Muskego Health Care Center

F-F609).

Surveyor reviewed a 30 day look back for Resident R235's task documentation. Surveyor noted Resident R235 did not have any documentation indicating incontinence cares had been done every two hours on 1/8/2025 and 1/9/2025 under the bowel and bladder incontinence task, or the toileting task.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 25 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525686 B. Wing 01/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 On 1/23/2025, at 7:36 AM, Surveyor interviewed CNA-M who stated CNA-M met Resident R235's family member in

the hallway and asked if they needed anything. CNA-M stated Resident R235's family member walked right past and Level of Harm - Minimal harm or stated Resident R235's family had been calling but CNA-M could not recall the phone ringing. CNA-M walked with potential for actual harm Resident R235's family member to the room and Resident R235's family member stated Resident R235 needed to be changed and new gown put on. CNA-M stated that Resident R235 was not assigned to her, but CNA-M grabbed the necessary supplies Residents Affected - Few and started to assist Resident R235. CNA-M stated that Resident R235's CNA that was assigned came in to help and Resident R235's family member was trying to tell them how to do cares on Resident R235 because it was how Resident R235's family member wanted it done. Surveyor asked if tasks get documented anywhere indicating it was done. CNA-M stated that when tasks are completed, they get documented in PCC (Point Click Care- Healthcare software). CNA-M stated that Resident R235 was not assigned to her so CNA-M would not have charted on Resident R235.

Surveyor notes that the CNA on Resident R235's assignment 1/8/2025 - 1/9/2025 was no longer employed at the facility and was not available for interview.

On 1/23/2025, at 12:27 PM, Surveyor interviewed NHA-A who stated staff and nursing reported rounds were being done on residents. Surveyor asked how that was verified. NHA-A stated NHA-A would have to look and see. Surveyor asked if the phone was looked at or verified that it had no missing calls. NHA-A stated LPN-L stated there were no calls made to the phone that night but did not look. NHA-A stated that CNA-M was already in the room when Resident R235's family member came to the facility. Surveyor stated that CNA-M stated to Surveyor that CNA-M had met Resident R235's family member in the hallway and walked to Resident R235's room with them and then completed incontinence cares.

On 1/27/2025, at 9:00 AM Surveyor interviewed LPN-L who stated Resident R235's family member came the facility and stated Resident R235 needed to be changed and CNA-M assisted with the cares. LPN-L stated LPN-L did not get

a call that night on the phone and showed Resident R235's family member that the phone had no missed calls.

On 1/27/2025, at 10:38 AM, Surveyor shared concern with NHA-A and DON-B that Resident R235's family member concern that Resident R235 was not changed the night of 1/8/2025 into 1/9/2025 was not thoroughly investigated. Surveyor asked how it was verified that Resident R235 was being rounded on and check and changed every two hours. DON- B stated that CNAs are to document when tasks are completed, that includes repositioning, incontinence cares, hygiene, etc. Surveyor requested to see the documented tasks completed for Resident R235.

Surveyor was provided a 3 day bowel and bladder tracker for Resident R235. Surveyor noted staff documented two times at 6:00 AM and 7:00 AM on 1/5/2025. DON-B stated there was no other documentation regarding tasks being completed for Resident R235 for incontinence cares or hygiene cares that DON-B could find.

49845

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 25 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525686 B. Wing 01/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 2.) On 12/16/2024 the facility submitted a facility reported incident (FRI) regarding a resident to resident altercation between Resident R7 and Resident R30. The FRI documents that an incident occurred on 12/14/2024 involving Resident R7 Level of Harm - Minimal harm or and Resident R30. The report documents, Resident R30 was in the restroom in Resident R30's room. Resident R30's roommate, Resident R7, entered the potential for actual harm room to use the restroom. Upon Resident R7 entering the room Resident R30 was exiting at the same time and Resident R30's hand connected with Resident R7's shoulder. Resident R7 then reported to RN that Resident R30's hand connected with Resident R7's shoulder. Residents Affected - Few Surveyor noted there are documented statements from Nursing Home Administrator (NHA)-A, Licensed Practical Nurse (LPN)-D, and LPN-C. Surveyor noted Interviews documented with Resident R7 and Resident R30, documented by NHA-A. Surveyor noted there were no other interviews with facility staff or residents as part of the investigation.

On 01/22/2025, at 10:06 AM, Surveyor interviewed Resident R7 regarding the incident. Surveyor noted Resident R7 has bilateral lower extremity amputations, and independently moves around in wheelchair. Resident R7 indicated Resident R30 use to be Resident R7's roommate. Resident R30 indicated to Surveyor that on the day of the incident, Resident R7 went back to Resident R7's room

after leaving the shower room. Resident R7 indicated Resident R30 was in Resident R7's bed. Resident R30 got out of Resident R7's bed and hit Resident R7 in the left shoulder with a fist but denies injuries. Resident R7 indicated Resident R7 then went and told the nurse and had Resident R30 removed from his room. Resident R7 indicated Resident R30 would always go through Resident R7's things and would try to put Resident R7's clothes on. Resident R7 indicated that he told Resident R30 that if Resident R30 keeps touching Resident R7's clothes, Resident R7 would cut Resident R30's hands off. Resident R7 indicated that Resident R30 eats off his and other residents' trays. Resident R7 informed Surveyor that Resident R30 has been moved to another room, but still comes into Resident R7's room occasionally. Resident R7 informed Surveyor Resident R30 was last in Resident R7's room yesterday, Resident R7's new roommate confirmed this as well. Resident R7 denies any further altercations occurring Resident R30. Surveyor noted Resident R7's description of what occurred is different than what the facility documented in the FRI.

On 01/22/2025, at 03:19 PM, Surveyor interviewed LPN-C regarding the FRI. LPN-C indicated she received

a call from NHA-A and DON-B that an incident between Resident R7 and Resident R30 had occurred and was asked to come in to the Facility to submit the report due to NHA-A and DON-B being unavailable. LPN-C indicated LPN-C came into the Facility and spoke with the two nurses on shift, RN-P and LPN-D. LPN-C indicated that Resident R7 was going in while Resident R30 was coming out of the bathroom, Resident R30 was startled, Resident R7 and Resident R30 bumped into each other. LPN-C indicated Resident R7 and Resident R30 were immediately separated and Resident R30's room was changed. Resident R30 was put

on 1:1 supervision for 2 days, with no further incidents. LPN-C indicated Resident R7 just does not like people in his space. LPN-C indicated LPN-C interviewed Resident R7 and Resident R30, no other residents were around. LPN-C indicated

the next day NHA-A started the investigation, then completed and submitted the report. LPN-C indicated statements were obtained from LPN-D and RN-P, but only has LPN-D's statement documented.

On 01/22/2025, at 03:37 PM, Surveyor interviewed DON-B, in the presence of Director of Operations-E, regarding the FRI. DON-B indicated the incident was reported due to the allegation of resident-to-resident abuse. DON-B indicated that while information came in and the investigation was conducted Resident R7 and Resident R30 were separated, and Resident R30 was put on 1:1 supervision. DON-B indicated that Resident R30 moves about the Facility freely and has attempted to go back to his old room on multiple occasions but is easily redirected. DON-B indicated interviews with Resident R7 and Resident R30 were conducted by NHA-A and LPN-C.

On 01/23/2025, at 03:37 PM, Surveyor informed NHA-A, DON-B, and Director of Operations-E of concerns regarding the investigation, interventions and reporting time of the FRI.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 25 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525686 B. Wing 01/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 On 01/27/2025, at 08:45 AM, Surveyor interviewed LPN-D regarding the FRI involving Resident R7 and Resident R30. LPN-D informed Surveyor that Resident R7 came to the nurses' station saying Resident R30 hit Resident R7. LPN-D indicated that they think Resident R7 Level of Harm - Minimal harm or was trying to hurry to the bathroom and Resident R30 was startled and accidentally hit Resident R7. LPN-D indicated Resident R30 is not potential for actual harm known to hit. LPN-D indicated the residents were separated and Resident R30 was moved to another room. LPN-D indicated no other residents were talked to. LPN-D indicated Resident R30 will occasionally wander into other resident Residents Affected - Few rooms, no previous incidents of hitting and is easily redirected.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 25 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525686 B. Wing 01/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47094

Residents Affected - Some Based on interview and record review, the facility did not ensure that residents remain as free of accident hazards as is possible and that each resident received adequate supervision and assistance devices to prevent accidents for 5 (Resident R8, Resident R12, Resident R23, Resident R29, and Resident R31) of 6 residents reviewed for falls and 1 (Resident R29) of 2 residents reviewed for smoking.

* Resident R29 had a fall on 8/31/2024 that was not thoroughly investigated and Resident R29's care plan was not revised until 9/3/2024.

* Resident R29 had a smoking evaluation completed on 8/13/2024. The smoking evaluation indicated that the facility holds onto Resident R29's smoking supplies and should be a supervised smoker. Resident R29 did not have a smoking care plan and had smoking supplies located in Resident R29's purse in her room. Resident R29 did not have any additional smoking evaluation assessments completed.

* Resident R23 had a fall on 10/29/2024 that was not thoroughly investigated. The facility failed to revise the plan of care post Resident R23's fall on 10/29/2024.

* Resident R31 had a fall on 1/5/2025 that was not thoroughly investigated.

* Resident R12 had a fall on 11/24/2024 that was not thoroughly investigated.

* Resident R8 had a fall on 11/3/2024 that was not thoroughly investigated. No interventions were implemented after Resident R8's fall and hospice services were not notified of Resident R8's fall on 11/3/2024.

Findings include:

The facility policy entitled Accidents and Supervision implemented on 12/29/2029 documents: Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes:

1. Identifying hazard(s) and risk(s).

2. Evaluating and analyzing hazard(s) and risk(s)

3. Implementing interventions to reduce hazard(s) and risk(s)

4. Monitoring for effectiveness and modifying interventions when necessary.

Policy Explanation and Compliance Guidelines: .

2. Evaluation and Analysis- the process of examining data to identify specific hazards and risks to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 25 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525686 B. Wing 01/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 a. Analysis may include, for example, considering the severity of hazards, the immediacy of risk, and trends such as time of day, location, etc. Level of Harm - Minimal harm or potential for actual harm b. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, Residents Affected - Some and identifying or developing interventions based on the severity of the hazards and immediacy of risk.

c. Evaluations also look at trends such as time of day, location, etc.

3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes:

a. Communicating the interventions to all relevant staff.

b. Assigning responsibility.

c. Providing training as necessary.

d. Documenting interventions.

e. Ensuring interventions are put into action.

f. Interventions are based on the results of the evaluation and analysis of information about -hazards and risks and are consistent with relevant standards, including evidenced-based practice.

g. Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully.

h. Facility-based interventions may include, but are not limited to- educating staff .

i. Resident-directed approaches may include- implementing specific interventions as part of the plan of care .

4. Monitoring and Modification- Monitoring the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective

in addressing hazards and risks. Monitoring and modification processes include:

a. Ensuring that interventions are implemented correctly and consistently.

b. Evaluating the effectiveness of interventions.

c. Modifying or replacing interventions as needed.

d. Evaluating the effectiveness of new interventions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 25 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525686 B. Wing 01/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 The policy entitled Resident Smoking revised on 12/15/2023 documents: Policy: It is the policy facility to provide a safe and healthy environment for residents, visitors, and employees, including safety related to Level of Harm - Minimal harm or smoking. Safety protections apply to smoking and non-smoking residents. potential for actual harm Policy Explanations and Compliance Guidelines: . Residents Affected - Some 5. Residents will be asked about tobacco use during the admission process, reviewed quarterly and as needed.

6. Resident who smoke will be further evaluated using the Smoking Evaluation to determine supervision need and intervention.

8. Any resident who is deemed safe to smoke with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times and in accordance wit the individualized care plan.

10. All safe smoking measures will be documented on the care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on the care plan.

13. Smoking materials of residents requiring supervision with smoking will be maintained by facility staff.

a. Storage of cigarettes and lighters: Wall mounted lock box on [name of unit] at the nurse's station.

14. The interdisciplinary team (IDT), with guidance from the physician, will help to support the resident's right to make an informed decision regarding smoking by: .

d. Developing a safe smoking plan, or an individualized plan to quit smoking safely.

1.) Resident R29 was admitted to the facility on [DATE REDACTED] and has diagnoses that includes multiple sclerosis, generalized anxiety disorder, and recurrent depressive disorder.

Resident R29's quarterly minimum data set (MDS) dated [DATE REDACTED] indicated Resident R29 had intact cognition with a Brief

Interview for Mental Status (BIMS) score of 15 and the facility assessed Resident R29 being dependent on 1 staff member for personal and toileting hygiene, lower body dressing, and putting on/ off footwear, and Resident R29 had impairments to both right and left side upper and lower extremities. Resident R29 required a sit to stand device for transferring and required max assist with 1 staff member for repositioning in bed. The facility assessed Resident R29

on 7/16/2024 to be a moderate risk for falls with a fall risk assessment score of 11.

Resident R29's risk for falls, accidents and incidents related to medication use, poor functional mobility care plan initiated on 7/17/2024 with the following interventions:

- Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 25 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525686 B. Wing 01/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 - Follow facility fall protocol.

Level of Harm - Minimal harm or - Anticipate and meet the residents needs. (initiated 7/22/2024) potential for actual harm - Educate resident/ family/ caregivers about safety reminders and what to do if a fall occurs. Residents Affected - Some - Ensure that the resident is wearing appropriate footwear.

- Pt evaluate and treat as ordered or PRN (as needed).

On 8/31/2024, at 19:38 (7:38 PM) in the progress notes nursing documented Resident R29 was found on the floor by certified nursing assistant (CNA). Resident R29's vital signs taken . Resident R29 stated complains of pain in Resident R29's legs. Resident R29 stated hit Resident R29's head but denied pain, no signs of shortness of breath of chest pain. Resident R29 refuses to be sent to the emergency room and is Resident R29 own person.

On 9/3/2024, at 9:04 AM, in the progress notes IDT documented review of Resident R29's fall on 8/31/2024. Resident R29 had

an unwitnessed fall in room. Resident R29 was found on the floor next to Resident R29's bed. Resident R29 stated she just fell . Resident R29 stated hitting Resident R29 but wished not to be sent out. Neurological checks completed and assessment indicated no injuries. Resident R29 was assisted off the floor with a Hoyer lift. Physician, director of nursing (DON), and Resident R29's family were updated. Root cause analysis revealed that Resident R29 was trying attempting to self-transfer. Interventions include encouraging Resident R29 to call for assistance prior to transferring.

On 1/23/2025, at 9:00 AM, Surveyor observed Resident R29 lying in bed watching TV. Resident R29 stated Resident R29 had a couple falls but could not remember any details as to when or why. Resident R29 stated Resident R29 usually calls if needs assistance with anything in between staff checking on Resident R29.

Surveyor reviewed Resident R29's Falls care plan and notes Resident R29's care plan was not revised until 9/3/2024 with the following intervention:

- Encourage resident to call for assistance with all transfers.

- Encourage resident to call for assistance when needed objects are out of reach. (initiated 9/16/2024).

Surveyor reviewed the fall investigation for Resident R29's fall on 8/31/2024. Surveyor notes that resident statement documented Resident R29 saying Resident R29 just fell . There were no staff interviews included to determine when Resident R29 was last checked on or toileted, or what the environment was like when Resident R29 was found on the floor. Surveyor noted no indication what interventions were in place or what interventions were implemented after the fall.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 25 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525686 B. Wing 01/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 1/27/25, at 8:59 AM, A Surveyor interviewed licensed practical nurse (LPN)-L, Surveyor asked what LPN-L would do if a resident had an unwitnessed fall. LPN-L stated that LPN-L would get an RN to assess Level of Harm - Minimal harm or the resident. LPN-L would start neurological checks, vital signs and assess range of motion. If everything potential for actual harm was okay, LPN-L would get help to move the resident with the Hoyer lift back into bed/chair. LPN-L would notify the MD (medical doctor), DON and POA (if necessary). Surveyor asked if there was a fall packet that Residents Affected - Some staff can use to guide them after a residents fall. LPN- stated, I'm not sure about that. Surveyor asked if CNA's give statements. LPN-L stated that they usually give verbal statements. Surveyor asked what happens after the nurse does her part in documenting the fall. LPN-L stated that management will do the full investigation and the root cause analysis.

On 1/27/2025, at 10:38 AM Surveyor shared concerns nursing home administrator (NHA)-A and DON-B that

the investigation for Resident R29's fall on 8/31/2024 was not thoroughly investigated and did not include interviews indicating when Resident R29 was last checked and changed, what interventions were in place at time Resident R29 was found

on the floor, or what interventions were implemented right away to prevent another fall.

2.) Resident R29's admission MDS dated [DATE REDACTED] documents under section J on the MDS under current tobacco use,

the answer no was checked indicating Resident R29 did not currently use tobacco.

Resident R29's quarterly MDS dates 12/19/2024 documents under section J on the MDS under tobacco use, there was no documentation marked under current tobacco use.

On 8/13/2024 a smoking evaluation assessment was completed and documented Resident R29 smokes cigarettes 1-2 times a day, cannot light own cigarettes, the facility was to store Resident R29's lighter and cigarettes, and that Resident R29 was not safe to smoke independently and was a supervised smoker.

On 1/23/2025, at 9:00 AM, Surveyor observed Resident R29 lying in bed watching TV. Resident R29 stated Resident R29 goes outside once in a while to smoke. Resident R29 stated Resident R29 used to go out 1 time a day depending on the weather and what staff was working. Surveyor asked Resident R29 if Resident R29 had own smoking supplies. Resident R29 stated that Resident R29's smoking supplies are in her purse. Surveyor asked if Resident R29 smokes alone or if staff stay with Resident R29. Resident R29 stated staff stay with Resident R29 when she smokes.

On 1/23/2025, at 9:44 AM, Surveyor reviewed the facility list with resident's that smoke. Resident R29 was not listed

on the smoking list.

Surveyor reviewed Resident R29's care plan and noted there was not a care plan for smoking.

Surveyor reviewed Resident R29's CNA care card and noted there was no interventions or indications that Resident R29 smoked.

On 1/23/2025, at 10:31 AM, Surveyor interviewed registered nurse (RN)-O who stated Resident R29 does not go out very often to smoke, not even once a week. Surveyor asked if Resident R29 had to be supervised and where Resident R29's smoking supplies are kept. RN-O stated staff need to stay with Resident R29 while smoking and that Resident R29 had her own smoking supplies.

On 1/23/2025, at 2:01 PM, Surveyor interviewed CNA-N who stated Resident R29 needs someone to stay with her while smoking and that Resident R29 has her own smoking supplies. CNA-N stated that Resident R29 does not go out a lot to smoke, somedays she will and then there will be several days she does not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 25 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525686 B. Wing 01/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 1/27/2025, at 8:42 AM, Surveyor interviewed CNA-S who stated Resident R29 does not go out often to smoke, maybe once a week if that. CNA-S stated Resident R29 has her own smoking supplies and staff are to stay with Resident R29 Level of Harm - Minimal harm or while smoking. potential for actual harm

On 1/27/2025, at 10:38 AM, Surveyor shared concerns with NHA-A and DON-B that Resident R29 did not have a Residents Affected - Some smoking care plan, no other smoking assessments had been completed since 8/2025, and that Resident R29 has smoking supplies which the smoking assessment completed 8/2024 indicated the facility should hold onto her smoking supplies.

No additonal information was provided.

49011

3.) Resident R23 was admitted to the facility on [DATE REDACTED] from the hospital with diagnoses that includes paraplegia, chronic obstructive pulmonary disease, type 2 diabetes mellitus, chronic pain syndrome, neuromuscular dysfunction of bladder, neurogenic bowel, and major depressive disorder.

Resident R23's Quarterly Minimum Data Set (MDS) with an assessment reference date of 1/15/2025 indicated Resident R23 had a Brief Interview for Mental Status score of 02 (severe cognitive impairment). Resident R23 has an activated Power of Attorney (POA). Resident R23's MDS was coded that for toileting Resident R23 has an indwelling catheter and an ostomy bag. The MDS noted no falls since admission or reentry.

Surveyor reviewed Resident R23's care plan and noted the following: The resident is at risk for falls, accidents and incidents r/t (related to) antidepressant use, NWB (non-weight bearing) d/t (due to) paraplegia. Revision on: 08/27/2024.

The goal set is the resident will be free of falls through the review date. Revision on: 01/15/2025, with a target date of 04/15/2025.

Interventions are:

- Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.

Date Initiated: 08/15/2024

- Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs.

Date Initiated: 08/27/2024

- Follow facility fall protocol.

Date Initiated: 08/15/2024

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 25 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525686 B. Wing 01/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 01/22/25, at 11:16 AM, Surveyor reviewed a progress note written on 10/29/2024, at 07:45 AM, which documents: Vss (vital signs stable). Resident had no issues most of the night. Resident bed was lowered to Level of Harm - Minimal harm or the floor resident fell out of the bed he denied any complaints of pain or discomfort he denied hitting his potential for actual harm head. Resident was assessed got him back up and put in bed Resident was also educated on his safety and

the falling out of the bed falling. DON (Director of Nursing) notified, will continue to monitor. Residents Affected - Some Surveyor requested the fall investigation information from the Facility and reviewed it. Under the category of Statements it reads no statements found. No post fall statements were obtained from staff or the resident about the resident or their condition post fall. There was no information documented as to when the resident was last seen. There is a statement IDT (Interdisciplinary Team) Fall: Resident had an unwitnessed fall from bed. He was found lying next to his bed. He stated that he rolled from bed. He denies hitting his head. Assessment WNL (within normal limits). VSS. No complaints of pain. Neuro check completed and negative. Resident was assisted from the floor back into bed. Resident was last rounded on around 6am. He has a catheter and ostomy. Resident had call light within reach. Root cause analysis revealed that resident rolled from bed. Intervention include education about using call light when needing repositioning help.

Surveyor noted the invention was not added to the care plan. Surveyor notes the information of resident was last rounded on at 6am is included, but no statements are included to know where this time came from.

On 01/23/25, at 09:50 AM, Surveyor interviewed Registered Nurse (RN)-O regarding when a resident has a fall, what are the next steps. RN-O stated with an unwitnessed fall, the nurse would assess to make sure the resident is okay, then with help get them up. The nurse then should contact the doctor, family, and case manager if resident has one. Surveyor asked how the fall is investigated and RN-O stated that the Director of Nursing (DON)-B does post investigation and they look at risk management. Surveyor asked about interviews or statements after the fall and RN-O stated that there are no interviews unless there are questions about cause of the fall.

On 01/23/25, at 01:40 PM, Surveyor interviewed (DON)-B and asked about witness statements. DON-B stated they get statements if there are witnesses. For unwitnessed falls the DON speaks with Certified Nursing Assistants (CNA) to determine when they last rounded and if there is any other information.

On 1/27/25 at 8:59 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-L. Surveyor asked what LPN-L would do if a resident had an unwitnessed fall. LPN-L stated that LPN-L would get an RN to assess the resident. LPN-L would start neuro checks, vital signs and assess range of motion. If everything was ok, LPN-L would get help to move the resident with the Hoyer lift back into bed/chair. LPN-L would notify the doctor, DON and POA (if necessary). Surveyor asked if there was a fall packet that staff can use to guide them after a residents fall. LPN-L stated, I'm not sure about that. Surveyor asked if CNA's give statements. LPN-l stated that they usually give verbal statements. Surveyor asked what happens after the nurse does her part in documenting the fall. LPN-L stated that management will do the full investigation and the root cause analysis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 25 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525686 B. Wing 01/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 01/27/25, at 10:52 AM, Surveyor informed the Nursing Home Administrator and the DON-B of the concerns of no care plan intervention added after the fall. The intervention was determined as to use call Level of Harm - Minimal harm or light when needing repositioning help but was not implemented. The lack of thorough investigation to include potential for actual harm post fall statements and when the resident was last rounded on.

Residents Affected - Some No additional information was provided.

4.) Resident R31 was admitted to the facility on [DATE REDACTED] from the hospital with diagnoses that includs chronic migraine without aura, morbid (severe) obesity, chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity, major depressive disorder, and type 2 diabetes mellitus.

Resident R31's Quarterly Minimum Data Set (MDS) with an assessment reference date of 11/15/2024 indicated Resident R31 had a Brief Interview for Mental Status score of 14 (cognitively intact). Resident R31 is responsible for self. Resident R31's MDS was coded that for toileting Resident R31 is frequently incontinent of bladder and always continent of bowel. The MDS noted no falls since admission or reentry.

Surveyor reviewed Resident R31's care plan and noted the following: The resident is at risk for falls, accidents and incidents r/t (related to) impaired mobility secondary to recent spinal surgery with complications, morbid obesity, asthma, acute respiratory failure with hypoxia. Revision on: 08/19/2024.

The goal set is the resident will be free of falls through the review date. Revision on: 08/26/2024, Target Date: 02/09/2025.

Interventions are:

- 1/6: Reeducation on using call light for all transfers.

Date Initiated: 01/06/2025

- Anticipate and meet the resident's needs.

Date Initiated: 08/19/2024

- Be sure the resident's call light is within reach and encourage the resident to use it

for assistance as needed. The resident needs prompt response to all requests for

assistance.

Date Initiated: 08/10/2024

- Educate the resident/family/caregivers about safety reminders and what to do if a

fall occurs.

Date Initiated: 08/19/2024

- Ensure that The resident is wearing appropriate footwear when ambulating or

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 25 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525686 B. Wing 01/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 mobilizing in w/c (wheel chair).

Level of Harm - Minimal harm or Revision on: 08/19/2024 potential for actual harm - Follow facility fall protocol. Residents Affected - Some Date Initiated: 08/10/2024

- Pt (physical therapy) evaluate and treat as ordered or PRN.

Date Initiated: 08/19/2024

On 01/22/25, at 12:38 PM, Surveyor reviewed a progress note dated 1/6/2025, written at 10:07 AM, IDT (Interdisciplinary Team) FALL: Resident had an unwitnessed fall within her room. Resident was found on the floor on the right side of her bed. She states that she did not hit her head. She was attempting to transfer back into bed. Assessment revealed no injuries. Resident had appropriate footwear on a time of fall. MD (medical doctor) and Notified. Root cause analysis revealed she was attempting to self transfer. Intervention include reeducation regarding using the call light before transfer.

Surveyor requested the fall investigation information from the Facility and reviewed it. Under the category of Statements it reads no statements found. No post fall statements were obtained about the resident or their condition post fall. There was no information documenting when the resident was last seen or last toileted.

Surveyor noted no information on when resident was last rounded or toileted was included in the fall investigation.

On 01/23/25, at 09:50 AM, Surveyor interviewed Registered Nurse (RN)-O regarding when a resident has a fall, what are the next steps. RN-O stated with an unwitnessed fall the nurse would assess to make sure ok, then with help get them up. The nurse then should contact the doctor, family, and case manager if resident has one. Surveyor asked how the fall is investigated and RN-O stated that the Director of Nursing (DON) does post investigation, they look at risk management. Surveyor asked about interviews or statements after

the fall and RN-O stated that there are no interviews unless there are questions about cause of the fall.

On 01/23/25, at 01:40 PM, Surveyor interviewed the Director of Nursing (DON)-B and asked about witness statements. DON-B stated they get statements if there are witnesses. For unwitnessed falls the DON speaks with Certified Nursing Assistants (CNA) to determine when they last rounded and if there is any other information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 25 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525686 B. Wing 01/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 1/27/25 at 8:59 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-L. Surveyor asked what LPN-L would do if a resident had an unwitnessed fall. LPN-L stated that LPN-L would get an RN to assess the Level of Harm - Minimal harm or resident. LPN-L would start neuro checks, vital signs and assess range of motion. If everything was ok, potential for actual harm LPN-L would get help to move the resident with the Hoyer lift back into bed/chair. LPN-L would notify the doctor, DON and POA (if necessary). Surveyor asked if there was a fall packet that staff can use to guide Residents Affected - Some them after a residents fall. LPN-L stated, I'm not sure about that. Surveyor asked if CNA's give statements. LPN-l stated that they usually give verbal statements. Surveyor asked what happens after the nurse does her part in documenting the fall. LPN-L stated that management will do the full investigation and the root cause analysis.

On 01/27/25, at 10:54 AM, Surveyor informed the Nursing Home Administrator and the DON-B of the concern regarding lack of thorough investigation to include post fall statements and when the resident was last rounded on or toileted.

No additional information was provided.

49435

5.) Resident R12 was admitted to the facility on [DATE REDACTED] with a diagnosis that includes Hemiplegia (muscle weakness or partial paralysis on one side of the body) following stroke affecting right dominant side, Aphasia (language disorder that affects ability to understand and express language), and Vascular Dementia.

Resident R12's Quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED], documents that Resident R12's cognition is moderately impaired. Resident R12 uses a wheelchair. Resident R12 mobility requires partial to moderate assistance. Resident R12 requires substantial/maximal assistance for transfers. Resident R12 has not had any recent falls since prior MDS assessment.

Resident R12's Fall Risk Care Area Assessment from Resident R12's Annual MDS assessment dated [DATE REDACTED] documents: According to documentation [Resident R12] triggered for falls. [Resident R12] has poor balance [due to] hemiparesis. He receives antidepressant medications which further increases his fall risk. Interventions are in place. No recent falls. Care plan reviewed and updated.

Resident R12's Fall risk care plan initiated on 9/25/22 includes the following pertinent interventions: Remind to use call light for assistance. Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. [Resident R12] needs a safe environment with: even floors free from spills and/or clutter; a working and reachable call light, the bed in low position at night; personal items within reach).

Resident R12's fall risk assessment dated [DATE REDACTED] documents Resident R12 is at moderate risk for falls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 25 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525686 B. Wing 01/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Resident R5's progress note entered by Licensed Practical Nurse (LPN)-L, dated 11/24/24 at 10:13 AM documents: [Resident R12] fell out of bed reaching for mints on end table next to bed. [Resident R12] was found face down on right side of Level of Harm - Minimal harm or bed. [Resident R12] stated [Resident R12] did not hit [Resident R12's] head. [Resident R12] stated [Resident R12] was trying to get [Resident R12's] mints. No potential for actual harm injuries were noted. [Resident R12] denied pain. [Director of Nursing (DON)] made aware of situation. MD was made aware of situation. [Range of Motion] was performed and [Within normal limits]. [Resident R12] was Hoyer lifted back Residents Affected - Some in bed and provided mints. Immediate intervention provided was putting mints and items within reach. No concerns noted at this time.

Surveyor reviewed Resident R5's Unwitnessed fall investigation dated 11/24/24. Surveyor noted the following: Predisposing environmental factors, the facility documents that poor lighting was a factor. Resident R12's mental status (whether Resident R12 was oriented to person, place, time or situation) was left blank and nothing was documented in investigation. Predisposing physiological factors (i.e. confused, drowsy, hypotensive, incontinent, weakness, impaired memory, etc.) was left blank and nothing was documented in investigation. Predisposing situation factors (i.e. ambulating without assist, improper footwear, other, etc.) was left blank and nothing was documented in investigation. Predisposing Situation Factors (i.e. using cane, side rails up, using walker, etc.) was left blank and nothing was documented in investigation. Statements-the facility documents no statements found.

On 11/25/24, Interdisciplinary Team (IDT) met and documented the following: [Resident R12] had an unwitnessed fall from bed. [Resident R12] stated that [Resident R12] was attempting to reach mints on [Resident R12's] beside stand. Assessment revealed no injuries. [Vital Signs Stable]. Resident was last rounded on around [9 PM]. [Resident R12] was dry at the time of fall. [Resident R12] is able to make needs known with adequate time given for response. MD, [Power of Attorney], and [Director of Nursing] notified. Root cause analysis revealed that resident was reaching for something to far out of reach. Intervention included encourage resident to keep items frequently needed near for easier reach.

On 11/25/24 a new intervention was added to Resident R12's Fall risk care plan: Encourage resident to keep things frequently needed within reach.

Surveyor noted that investigation did not include whether Resident R12's call light was on at the time of the fall or if the call light was within reach at the time of the fall. Surveyor noted that there were no witness statements regarding the fall. Surveyor noted that multiple sections within the fall investigation template were left blank with no responses. Surveyor noted that poor lighting was identified as a predisposing environmental factor and was not addressed in Resident R12's fall risk interventions.

On 1/23/25 at 1:58 PM, Surveyor interviewed CNA-N. Surveyor asked what CNA-N would be responsible for

after a residents falls. CNA-N stated they would see if the residents was ok and go tell the nurse. CNA-N stated that CNA-N would help Hoyer lift the resident back into the bed or chair if directed by the nurse. Surveyor asked if CNA-N would provide a written statement after a fall. CNA-N stated that they would fill out

a statement sheet from the fall binder.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 25 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525686 B. Wing 01/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 1/27/25 at 8:59 AM, Surveyor interviewed (LPN)-L. Surveyor asked if LPN-L could describe what happened when Resident R12 was found on the floor on 11/24/25. LPN-L indicated that a Certified Nursing Assistant Level of Harm - Minimal harm or (CNA) informed LPN-L that Resident R12 was on the floor. LPN-L could not recall which CNA found Resident R12 on the floor. potential for actual harm LPN-L came to Resident R12's room and found that Resident R12 was face down on the side of his bed. LPN-L stated that Resident R12 was reaching for mints when Resident R12 fell . LPN-L stated that Resident R12 did not have any injury and after assessment, Residents Affected - Some Resident R12 was put back into bed with a Hoyer lift. Surveyor asked if the call light was on at time of the fall. LPN-L state LPN-L did not recall. Surveyor asked if Resident R12's call light was within reach. LPN-L stated that LPN-L did not recall. Surveyor asked who saw Resident R12 last and at what time Resident R12 was last seen. LPN-L stated that LPN-L did not recall. Surveyor asked what LPN-L would do if a resident had an unwitnessed fall. LPN-L stated that LPN-L would get a Registered Nurse (RN) to assess the resident. LPN-L would start neuro checks, vital signs and assess range of motion. If everything was ok, LPN-L would get help to move the resident with the Hoyer lift back into bed/chair. LPN-L would notify the doctor, DON and POA (if necessary). Surveyor asked if there was a fall packet that staff can use to guide them after a residents fall. LPN-L stated, I'm not sure about that. Surveyor asked if CNA's give statements. LPN-L stated that they usually give verbal statements. Surveyor asked what happens after the nurse does her part in documenting the fall. LPN-L stated that management will do the full investigation and the root cause analysis. Surveyor asked what type of interventions would be put in place if poor lighting was identified as a predisposing factor prior to a fall. LPN-L stated we could put an intervention like nightlight on or keep door open for more light on the resident's care plan.

Surveyor noted that LPN-L stated an unknown CNA informed LPN-L of Resident R12's fall and there is no statement or documentation from the CNA. Surveyor noted LPN-L was not aware of a fall packet or checklist. Surveyor noted LPN-L listed fall care plan interventions for poor lighting.

On 1/23/25 at 1:39 PM, Surveyor interviewed Registered Nurse (RN)-O. Surveyor asked if there was a fall packet or binder to help guide staff after a resident has a fall. RN-O stated yes. RN-O went to a cupboard and pulled out a binder.

Surveyor reviewed the binder and found stapled Fall Check List packets for staff to use to guide them after a fall.

The undated, Falls Check List included the following action items that the floor nurse is responsible for: 1. Call fall huddle- complete as a team to determine potential root cause and immediate intervention. 2. Initiate Neuro check if unwitnessed or hit head. 3. Notify Director of Nursing/Nurse Manager. 4. Update Care plan/Kardex with immediate intervention. 5. Notify MD. 6. Notify 1st Representative. 7. Complete Risk Management [user defined assessment] in [electronic medical record] . (Note: complete all interviews with staff using the note section. State who and when you took their statement.) 8. Complete initial wound assessment, if indicated. 9. Update 24-hour report. The Check list included the following action items that the IDT team is responsible for, in part: 1. Bring found down/fall packet to clinical meeting to review as IDT . The bottom of the check list documents: Complete fall check list and all items appropriate in Fall/Found Down Packet. Return to the Director of Nursing.

Surveyor noted that the check list gives instructions for staff interviews. Surveyor noted that the completed fall packet is to be taken to the IDT meeting to be reviewed.

On 1/23/25 at 1:52 PM, [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 25 525686