Rocky Knoll Health Care

F-F689 where, under resident-to-resident altercations it notes: A resident-to-resident altercation should be reviewed as a potential situation of abuse which should be investigated under the guidance of 42 CFR 483.12. Willful means the individual intended the action itself, regardless of whether or not the individual intended to inflict injury or harm. Even though a resident may have cognitive impairment, he/she can still commit a willful act. The 2nd column on the form lists Wisconsin Administrative Code Chapter DHS 13 Caregiver Misconduct Definitions. The column provides

a definition of abuse as an act or repeated acts by a caregiver or non-client resident. The facility highlighted

in the DHS Caregiver Misconduct definitions column the following: Abuse does not include an act or acts of mere .incapacity.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 7 525337 Department of Health & Human Services Printed: 09/19/2025 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 525337 B. Wing 07/03/2024

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

Rocky Knoll Health Care N7135 Rocky Knoll Parkway Plymouth, WI 53073

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 On 7/3/24 at 3:57 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Assistant Administrator (AA)-C regarding reporting to the SA. NHA-A and AA-C indicated the facility did not report the Level of Harm - Minimal harm or allegation of sexual abuse to the SA because they determined the incident was not an abuse situation and potential for actual harm no harm occurred as indicated by Resident R5's skin assessment. When Surveyor asked if Resident R2 or Resident R5 suffered emotional or psychological harm in the days following the event, AA-C stated the facility completed a Social Residents Affected - Few Services Assessment for Resident R5 and provided Surveyor with a copy of the assessment. Surveyor noted the assessment was completed on 4/24/24 (which was more than 24 hours after the initial report was due to the SA). In addition, Surveyor requested any assessments related to capacity to consent for Resident R2 and Resident R5. The facility provided a Social Services Assessment, dated 4/24/24 (which was more than 24 hours after the incident occurred), which indicated Resident R5's decision making was severely impaired. The assessment indicated Resident R5 was able to make simple decisions as to whether Resident R5 preferred coffee or milk, but complex medical decisions were made by Resident R5's family. Section 12 of the assessment, titled Intimacy, assessed the following: Are you currently in a relationship? The assessment indicated Resident R5 was not in a current relationship. Do you have any interest in pursuing a relationship while at the facility? The assessment indicated Resident R5 did not have

an interest in pursuing a relationship while at the facility. Surveyor noted the check boxes for an intimacy care plan were not checked. AA-C and NHA-A confirmed official capacity to consent assessments were not completed for Resident R2 or Resident R5.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 7 525337 Department of Health & Human Services Printed: 09/19/2025 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 525337 B. Wing 07/03/2024

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

Rocky Knoll Health Care N7135 Rocky Knoll Parkway Plymouth, WI 53073

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43361 potential for actual harm Based on staff interview and record review, the facility did not thoroughly investigate an allegation of sexual Residents Affected - Few abuse for 2 residents (Resident R2 and Resident R5) of 3 sampled residents.

On 4/21/24, Resident R5 approached Resident R2 in the lobby. Resident R5 kissed Resident R2 on the mouth and Resident R2 touched Resident R5's breast. The facility did not thoroughly investigate the allegation of sexual abuse. The facility's investigation did not include interviews with Resident R5 and Resident R2, interviews with other resident interviews, and interviews with staff who were working at the time of the incident.

Findings include:

The facility's Freedom from Abuse, Neglect, and Exploitation policy, with a revised date of 10/23, indicates: Protection and Investigation: 6. Begin a thorough investigation. 7. Information will be collected that corroborates or disproves the incident and findings documented for each incident. 9. An analysis will be conducted as to why the situation occurred, risk factors that contributed to the abuse, and whether there is a need for systemic action. A thorough investigation may include the following: .3. Interviewing the alleged victim(s) witnesses(es): b. in cases of potential sexual abuse, evaluating and determining if the resident(s) has the capacity to consent and whether the resident actually consented to the sexual activity. Refer to Capacity to Consent policy and procedure. 4. Interviewing accused individuals. 5. Interviewing other residents to determine if they have been abused or mistreated. 6. Interviewing staff who worked the same shift .to determine if they witnessed any mistreatment by the accused; 7. Interviewing staff who worked other shifts to determine if they were aware of an injury or incident. 9. Involving regulatory authorities who may assist .

On 7/3/24, Surveyor reviewed Resident R2's medical record. Resident R2 was admitted to the facility on [DATE REDACTED] with diagnoses including vascular dementia with moderate behavioral disturbance, major depressive disorder, and anxiety disorder. Resident R2's Minimum Data Set (MDS) assessment, dated 3/1/24, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated Resident R2 had moderately impaired cognition. Resident R2 had an activated Power of Attorney for Healthcare (POAHC) and passed away at the facility on 6/25/24.

On 7/3/24, Surveyor reviewed Resident R5's medical record. Resident R5 was admitted to the facility on [DATE REDACTED] with diagnoses including Alzheimer's disease with late onset, dementia in other diseases with mood disturbance, generalized anxiety disorder, and major depressive disorder. Resident R5's MDS assessment, dated 4/24/24, had a BIMS score of 4 out of 15 which indicated Resident R5 had severely impaired cognition. Resident R5 had an activated POAHC.

Resident R2's medical record contained an incident note, dated 4/21/24 at 1:05 PM, that indicated: Resident R2 was wheeling Resident R2's self back from the dining room when Resident R5 sought out Resident R2, pulled back Resident R2's wheelchair, and kissed Resident R2 on

the mouth. Resident R2 responded by caressing Resident R5's right breast. Resident R5 removed Resident R2's hand from Resident R5's breast and stated, No, no. We can't do that. Resident R2 and Resident R5 were separated and supervised when Resident R2 and Resident R5 were out of their rooms. Administrative staff and Resident R2 and Resident R5's POAHC were updated. All were in agreement with the separation/supervision plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 525337 Department of Health & Human Services Printed: 09/19/2025 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 525337 B. Wing 07/03/2024

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

Rocky Knoll Health Care N7135 Rocky Knoll Parkway Plymouth, WI 53073

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 Resident R5's medical record contained an incident note, dated 4/21/24 at 11:16 AM, that indicated: Late Entry: Resident R5 sought out Resident R2 who used the railing to assist Resident R2 when wheeling out of the dining room. Resident R5 pulled Resident R2 around Level of Harm - Minimal harm or in Resident R2's wheelchair and kissed Resident R2 on the mouth. Resident R2 responded by caressing Resident R5's breast. Resident R5 removed Resident R2's potential for actual harm hand from Resident R5's breast and stated, No, no. We can't do that. Staff assessed Resident R5's right breast and noted no injury, bruising, or pain. Resident R5 and Resident R2 were separated and supervised when Resident R5 and Resident R2 were out of their rooms. Residents Affected - Few Administrative staff and Resident R5 and Resident R2's POAHC were updated. All were in agreement with the separation/supervision plan.

When Surveyor requested to review the facility's investigation, the facility provided a risk management report, dated 4/21/24, that indicated Resident R5 and Resident R2 were immediately separated and supervised. The report also indicated Resident R5 and Resident R2's POAHC were updated and in agreement with the interventions put in place. Resident R2's care plan was updated to include a stop sign banner across Resident R2's door so Resident R5 did not enter Resident R2's room. Resident R5's care plan was updated with the following intervention: (Resident R5) seeks affection from male residents and needs to be kept separate from male residents. Closely monitor (Resident R5) when out of room and redirect (Resident R5) away from male peers when attempting to touch or kiss others. The facility also provided staff education regarding updates to Resident R2 and Resident R5's care plans.

On 7/3/24 at 3:57 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Assistant Administrator (AA)-C regarding interviewing other residents as part of the investigation. AA-C stated Resident R2 and Resident R5 were the only 2 residents involved in the situation and AA-C was unsure what other residents should have been interviewed.

On 7/8/24 at 2:52 PM, the facility provided Surveyor with staff statements regarding the incident via email.

The facility did not provide other resident interviews or assessments.

On 7/9/24 at 3:50 PM, NHA-A indicated via email that the facility did not complete other resident interviews because the incident was a witnessed, singular event and abuse was ruled out. NHA-A stated residents on

the unit had dementia and memory deficits and many were not interviewable. NHA-A also stated because

the facility followed the flow sheet and ruled out abuse, the facility did not feel safety was a concern and indicated there were no other incidents beyond the witnessed incident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 525337 Department of Health & Human Services Printed: 09/19/2025 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 525337 B. Wing 07/03/2024

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

Rocky Knoll Health Care N7135 Rocky Knoll Parkway Plymouth, WI 53073

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** 43361

Residents Affected - Few Based on observation, staff interview, and record review, the facility did not ensure care plan interventions were followed which resulted in a resident-to-resident interaction between 2 residents (R) (Resident R2 and Resident R5) of 11 sampled residents.

On 4/21/24, Resident R5 approached Resident R2 and kissed Resident R2 on the mouth. Resident R2 then touched Resident R5's breast. The incident occurred while Resident R2 self-propelled Resident R2's wheelchair back from the dining room. Resident R2's care plan contained an intervention to escort Resident R2 to and from Resident R2's room and keep Resident R2 separate from female residents. The intervention was not consistently followed.

Findings include:

On 7/3/24, Surveyor reviewed Resident R2's medical record. Resident R2 was admitted to the facility on [DATE REDACTED] with diagnoses including vascular dementia with moderate behavioral disturbance, major depressive disorder, and anxiety disorder. Resident R2's Minimum Data Set (MDS) assessment, dated 3/1/24, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated Resident R2 had moderately impaired cognition. Resident R2 had an activated Power of Attorney for Healthcare (POAHC) and passed away at the facility on 6/25/24.

Resident R2 had a care plan intervention, initiated on 3/18/24, that indicated: Escort (Resident R2) to/from room. To be direct supervision at all times when out of room. To be seated near an exit and sit with all males when in dining room. To be kept separate from female residents.

On 7/3/24, Surveyor reviewed Resident R5's medical record. Resident R5 was admitted to the facility on [DATE REDACTED] with diagnoses including Alzheimer's disease with late onset, dementia in other diseases with mood disturbance, generalized anxiety disorder, and major depressive disorder. Resident R5's MDS assessment, dated 4/24/24, had a BIMS score of 4 out of 15 which indicated Resident R5 had severely impaired cognition. Resident R5 had an activated POAHC.

Resident R2's medical record contained an incident note, dated 4/21/24 at 1:05 PM, that indicated: Resident R2 was wheeling Resident R2's self back from the dining room when Resident R5 sought out Resident R2, pulled back Resident R2's wheelchair, and kissed Resident R2 on

the mouth. Resident R2 responded by caressing Resident R5's right breast. Resident R5 removed Resident R2's hand from Resident R5's breast and stated, No, no. We can't do that. Resident R2 and Resident R5 were separated and supervised when Resident R2 and Resident R5 were out of their rooms. Administrative staff and Resident R2 and Resident R5's POAHC were updated. All were in agreement with the separation/supervision plan.

Resident R5's medical record contained an incident note, dated 4/21/24 at 11:16 AM, that indicated: Late Entry: Resident R5 sought out Resident R2 who was using the railing to assist Resident R2 when wheeling out of the dining room. Resident R5 pulled Resident R2 around in Resident R2's wheelchair and kissed Resident R2 on the mouth. Resident R2 responded by caressing Resident R5's breast. Resident R5 removed Resident R2's hand from Resident R5's breast and stated, No, no. We can't do that. Staff assessed Resident R5's right breast and noted no injury, bruising or pain. Resident R5 and Resident R2 were separated and supervised when Resident R5 and Resident R2 were out of their rooms. Administrative staff and Resident R5 and Resident R2's POAHC were updated. All were in agreement with the separation/supervision plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 525337 Department of Health & Human Services Printed: 09/19/2025 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 525337 B. Wing 07/03/2024

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

Rocky Knoll Health Care N7135 Rocky Knoll Parkway Plymouth, WI 53073

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 7/3/24 at 12:52 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-G who stated CNA-G was working when the incident between Resident R2 and Resident R5 occurred but did not witness the incident. CNA-G was aware Level of Harm - Minimal harm or that Resident R2 should be escorted to and from the dining room and stated Resident R2 was seated at a table with all males potential for actual harm near the door. CNA-G saw Resident R2 leave the dining room and stated staff would have been a minute behind Resident R2 because staff intervened quickly. Residents Affected - Few

On 7/3/24 at 1:06 PM, Surveyor interviewed CNA-F who was a regular staff on the unit. CNA-F was aware that Resident R2 needed to be escorted to and from Resident R2's room. CNA-F stated staff were busy in the dining room assisting residents with eating during meal time. CNA-F confirmed Resident R2 was seated at an all male table near

the exit and stated Resident R2 did not always want to wait for staff to escort Resident R2 back to Resident R2's room. When asked if Resident R2 exited the dining room independently on 4/21/24, CNA-F stated Resident R2 probably did because Resident R2 was often impatient.

On 7/3/24 at 2:15 PM, Surveyor interviewed Registered Nurse (RN)-E who was working when the incident occurred and wrote the progress notes in R and Resident R5's medical records. RN-E stated RN-E witnessed part of

the incident. RN-E observed Resident R2 pull on the railing and head from the dining room toward Resident R2's room. RN-E was near the med cart and there were staff in the vicinity, but Resident R2 was not being escorted. RN-E stated Resident R2 was quick. RN-E heard commotion, looked up, saw Resident R2 and Resident R5's lips come apart, and saw Resident R2's hand touch Resident R5's breast. RN-E stated Resident R5 stopped Resident R2's hand right away. RN-E stated the interaction was unexpected and Resident R5 approached Resident R2 first. RN-E stated Resident R2's care plan interventions regarding female residents were well known to staff. RN-E stated RN-E would have called the on-call manager but could not recall the name of the manager. RN-E completed a skin assessment of Resident R5 to ensure there was no injury to Resident R5's breast and put interventions in place to ensure Resident R5 and Resident R2's safety.

On 7/3/24 at 2:45 PM, Surveyor interviewed CNA-D who was working at the time of the incident and intervened after the incident occurred. CNA-D said Resident R2 was often impatient and staff did not bring Resident R2 to the dining room until Resident R2's meal was ready because Resident R2 would not stay in the dining room. CNA-D stated Resident R2 sat at a table with 2 other male residents on 4/21/24 and CNA-D assisted the other male residents while Resident R2 ate. CNA-D stated Resident R2 ate quickly and wanted to leave the dining room as soon as Resident R2 was finished. CNA-D saw Resident R2 leave the dining room and told Resident R2 that CNA-D would be right there, however, CNA-D continued to assist

the other 2 residents and forgot to assist Resident R2 back to Resident R2's room. When CNA-D heard a staff state that Resident R5 was near Resident R2, CNA-D got up right away and saw Resident R5 lean over and kiss Resident R2 and saw Resident R2 touch Resident R5's breast. CNA-D stated Resident R2 stopped touching Resident R5 when Resident R5 pushed Resident R2's hand away and said Resident R2 and Resident R5 couldn't do that. CNA-D intervened and took Resident R2 to Resident R2's room. CNA-D was aware that Resident R2 should have been escorted from

the dining room to Resident R2's room and confirmed Resident R2 was not being escorted at the time the incident occurred.

On 7/3/24 at 3:57 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Assistant Administrator (AA)-C who stated NHA-A and AA-C expect staff to escort Resident R2 to and from the dining room as indicated in Resident R2's plan of care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 525337