Clark County Rehabilitation & Living Center

F 0580 Level of Harm - Minimal harm or potential for actual harm

event.On 10/14/25 at 1:03 PM, Surveyor interviewed DON B regarding incident. DON B stated that she was pretty sure the guardian was notified but would double-check for documentation to provide the surveyor. No additional documentation was provided.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clark County Rehabilitation & Living Center

W4266 County Highway X Owen, WI 54460

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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident R1 into the recliner and told Resident R1 that CNA F will sit on you (Resident R1) if you don't take your meds. CNA G then observed CNA F then squat over Resident R1 to act like CNA F was going to sit on Resident R1. CNA G heard Resident R1 state ‘no, no' during this encounter. CNA G reported concerns the next day to the unit nurse manager, RN D. RN D stated to CNA G that this is bad and is abuse. Surveyor asked CNA G if Resident R1 would refuse medications if it was given in food or drink. CNA G stated no, that Resident R1 did not fight if it was in food.On 10/14/25 at 1:10 PM, Surveyor interviewed DON B regarding incident. DON B stated these two incidents were not reported to a supervisor immediately and became aware of it on 08/12/25. The dates of the two noted observations were determined to be 08/05/25 and 08/06/25 during the facility's investigation. DON B acknowledged facility staff used inappropriate physical restraints during the administration of Resident R1's medications and that CNA F was terminated due to the behavior.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clark County Rehabilitation & Living Center

W4266 County Highway X Owen, WI 54460

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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

may be staff with a lapse in annual training since trying to put this new system in place. CNA G's training was missed since CNA G was casual. RN E will be scheduled to complete trainings. Surveyor asked if the incident with Resident R1 was on 08/05/25 and 08/06/25 why did it take until 08/12/25 to report. Surveyor asked if there were written statements from staff or notes from interviews with staff. DON B stated on 08/12/25, RN D reported to RN C. RN D came to RN C in a panic about forgetting to report the incident with Resident R1. RN C immediately reported to DON B. RN E and CNA F were put on administrative leave on 08/12/25. DON B stated there were no staff written statements and did not keep notes of staff interviews after typing up the timeline. Surveyor asked if DON B reported RN E and CNA F to state agency of caregiver quality. DON B stated this incident was not reported. Surveyor asked if the incident was reported to the police and DON B stated it was not reported.Example 2R3 was admitted to the facility on [DATE REDACTED] with pertinent diagnoses of mild cognitive impairment of uncertain or unknown etiology, personality disorder, delusional disorders, unspecified psychosis not d/t a substance or known physiological condition, and depression.On 08/08/25 at 2:45 PM, local law enforcement was contacted by Resident R3's sister reporting an allegation of abuse.On 08/08/25 at 3:31 PM, law enforcement arrived at facility and informed staff purpose of visit was related to allegation of abuse concerning Resident R3. The facility did not submit a Facility Reported Incident (FRI) concerning allegation of abuse to the State Agency. On 10/14/25 at 1:10 PM, Surveyor interviewed DON B regarding incident.

DON B stated that Resident R3 and his sister have called the police and reported numerous allegations of abuse that were unfounded. DON B stated that on 08/08/25, Resident R3 had been threatening to call 911 numerous times for being held against his will and had notified the police that Resident R3 might call to report this. Surveyor asked why this allegation was not reported. DON B stated the facility already knew this allegation was not true due to the multiple prior reports and did not think it should be reported or investigated.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clark County Rehabilitation & Living Center

W4266 County Highway X Owen, WI 54460

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

you don't take your meds. CNA G then observed CNA F squat over Resident R1 to act like CNA F was going to sit on Resident R1. CNA G heard Resident R1 state ‘no, no' during this encounter. The following day, CNA G reported concerns to

the unit nurse manager, RN D. RN D stated to CNA G that this is bad and is abuse. RN D did not immediately report this to Director of Nursing (DON) B.On 08/12/25, DON B was notified and began an investigation. On 08/19/25, facility investigation determined abuse occurred and terminated CNA F. A FRI was not submitted to the State Agency to report allegation of abuse. No documentation was noted demonstrating local law enforcement was contacted to report allegation of abuse.On 10/14/25 at 1:10 PM, Surveyor interviewed DON B regarding reporting allegation of abuse. DON B stated this was not reported to State because it was late being reported to DON and State survey agency would be giving them a cite for reporting late so decided not to report.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clark County Rehabilitation & Living Center

W4266 County Highway X Owen, WI 54460

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

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 of 3 (Resident R3) residents reviewed.On 08/08/25, an allegation of abuse was reported to local law enforcement regarding Resident R3. The facility did not investigate this allegation.This is evidenced by:Facility policy titled, Abuse, Neglect, Mistreatment & Misappropriation of Resident Property Policy & Procedure, with no implemented or reviewed date, states in part: E. Investigation: It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriate of property) are promptly and thoroughly investigated. Procedure: The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed.Resident R3 was admitted to the facility on [DATE REDACTED] with pertinent diagnoses of mild cognitive impairment of uncertain or unknown etiology, personality disorder, delusional disorders, unspecified psychosis not d/t a substance or known physiological condition, and depression.On 08/08/25 at 2:45 PM, local law enforcement was contacted by Resident R3's sister reporting concerns that Resident R3 was being abused at the facility and Resident R3 does not feel safe.On 08/08/25 at 3:31 PM, law enforcement arrived at facility and informed staff purpose of visit was related to allegation of abuse concerning Resident R3.Surveyor reviewed Resident R3's progress notes and noted:On 08/08/25, Resident R3 stated desire to call 911 for being held prisoner at facility and upset about guardianship and protective placement. At 2:45 PM, facility called local police to inform them that Resident R3 may call and was told that Resident R3's sister had already called to report brother being abused at facility. At 3:10 PM, Resident R1's guardian and county APS SW, DON, and supervisor notified of events and police involvement via email.No additional documentation of investigating allegation of abuse noted.On 10/14/25 at 1:10 PM, Surveyor interviewed Director of Nursing (DON) B regarding incident. DON B stated that Resident R3 and his sister have called the police and reported numerous allegations of abuse that were unfounded. DON B stated that on 08/08/25, Resident R3 had been threatening to call 911 numerous times for being held against his will and had notified the police that Resident R3 might call to report this. Surveyor asked why this allegation was not reported. DON B stated the facility already knew this allegation was not true due to the multiple prior reports and did not think it should be reported or investigated.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clark County Rehabilitation & Living Center

W4266 County Highway X Owen, WI 54460

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 0659

Provide care by qualified persons according to each resident's written plan of care.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility did not ensure prescription medications were administered by qualified staff for 1 of 3 residents (Resident R1) reviewed.Resident R1's medications were administered by a Certified Nursing Assistant (CNA).This is evidenced by:Facility policy titled, Medication Administration & Treatment by Certified Nursing Assistants, with no date, states in part: Policy: This facility will comply with all state and federal guidelines related to medication administration in order to ensure the safety of resident. Nursing assistants may NOT administer any medications or perform any treatments with the following exception as delegated by the nurse: 1. Nursing assistants can apply prescription and nonprescription topical creams and ointments to UNBROKEN skin during daily cares. 2. Nursing assistants can provide oral care with mouthwashes.Facility policy titled, Medication Administration, with no date, states in part: Policy: Medication administration will adhere to all federal and state regulations. All medications shall be administered by a licensed nurse or nurse technician per physician order.Resident R1 was admitted to the facility on [DATE REDACTED] with pertinent diagnoses of anxiety disorder, depression, personality disorder with other symptoms and signs involving cognitive functions and awareness, and unspecified psychosis not due to substance or known physiological condition.Resident R1's physician orders:-Haloperidol Lactate Oral Concentrate 2 MG/ML (Haloperidol Lactate) Give 2.5 ml by mouth one time a day for Behavior/agitation/mood.-Valium Oral Tablet 5 MG (Diazepam) Give 1 tablet by mouth every 8 hours as needed for anxiety.On 08/12/25, Director of Nursing (DON) B was made aware of an allegation of abuse regarding Resident R1 and began an investigation. Interviews were completed with Certified Nursing Assistant (CNA) F, CNA G, and Registered Nurse (RN) E, who were identified in the complaint. Facility's documentation noted CNA F admitted administering Resident R1's medications using food, ice cream, and a syringe. CNA F stated that someone would hold Resident R1's hand while CNA F held Resident R1's chin and squirted the syringe of medication into Resident R1's mouth. While CNA F administered Resident R1's medications using physical force, RN E would supervise.Surveyor reviewed CNA F's personnel file and noted no medication administration training completed.On 10/14/25 at 1:10 PM, Surveyor interviewed DON B regarding facility's investigation and the noted medication administration by CNA F. DON B stated it was common practice for the facility to allow CNAs to administer medications while under direct supervision of a nurse. Surveyor asked DON B if CNAs received additional training or competency evaluation to administer medications. DON B stated, no, that no competency would be needed if the nurse prepares the meds and directly observes the administration by the CNA. DON B further stated that as long as the nurse delegated

the medication administration task to the CNA, it was completely acceptable for unlicensed staff to administer medications as long as the RN directly supervised.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clark County Rehabilitation & Living Center

W4266 County Highway X Owen, WI 54460

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 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Based on interview and record review, the facility did not ensure staff received training regarding abuse, neglect, and exploitation and what activities constitute abuse, procedures for reporting and dementia management and resident abuse prevention. This has to potential to affect all 134 residents.This is evidenced by:The facility's policy titled Abuse, Neglect, Mistreatment & Misappropriation of resident property policy & procedure, which is not dated, states in part: .Staff and volunteers will receive education about resident mistreatment, neglect, and abuse, including injuries of unknown source, exploitation and misappropriation of property upon first employment and annually after that.Surveyor reviewed Certified Nursing Assistant (CNA) G, CNA F, and Registered Nurse (RN) E's education for abuse. CNA G completed abuse education on 07/05/23, and RN E completed abuse education on 01/30/24. CNA F did not have recorded abuse education training. On 10/14/25 at 11:50 AM, Surveyor interviewed CNA G about the abuse training. CNA G stated had received abuse education when they first took the CNA class at the facility in 2022.On 10/15/25 at 10:00 AM, Surveyor interviewed Director of Nursing (DON) B asking about monitoring for completion of staff education on abuse, neglect and misappropriation at time of hire and annually. DON B stated CNA F's abuse training upon hire was not completed. DON B stated it is the expectation new hire training to be completed before working with residents. Currently working on a system to ensure all staff are assigned training in the computer and to be completed by 10/31/25. DON B stated understanding there may be staff with a lapse in annual training since trying to put this new system in place. CNA G's training was missed since CNA G was casual. RN E will be scheduled to complete trainings. No additional information was provided.

Event ID:

Facility ID:

If continuation sheet