Orthopaedic Hospital of Wisconsin

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 42046 Based on observation, staff interview and review of maintenance records on May 19 to May 20, 2026, the Orthopaedic Hospital of Wisconsin failed to construct, install, and maintain the building systems to ensure safety of patients. Findings include: The facility was found to contain the following deficiencies. 1. K345 - Fire Alarm System 2. K353 - Sprinkler System - Maintenance and Testing 3. K511 - Utilities - Gas and Electric 4. K521 - HVAC 5. K712 - Fire Drills 6. A701 - Maintenance of Physical Plant 7. A709 - Life Safety from Fire As a result of these deficiencies, 42 CFR Subpart CFR 482.41 Condition of Participation: Physical environment was NOT MET.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 52395 Based on record review and interview staff failed to ensure all adverse patient events are investigated, analyzed for causes, and track and trend incidents in 6 (Pt #45, Pt. #46, Pt. #47, Pt. #48, Pt. #49, Pt. #50) of 6 event reports reviewed in a total of 1 of 1 QAPI programs reviewed. Findings Include: Review of policy and procedure titled, “Occurrence Reporting” last reviewed 7/1/2025 reveals, “All occurrences and unexpected events that result in actual or potential harm to patients or visitors of the organization or place the organization at risk shall be documented and reviewed via this Occurrence Reporting process...A. Patient Occurrence and Tracking Form is to be completed as soon as possible and no later than the end of the shift by the [Facility] employee who became aware of the occurrence... Occurrence Report data will be reviewed by [Facility] Administration for the identification of trends for quality improvement purposes...” Patient #45: Review of “Patient Occurrence and Tracking Form” on 4/14/26 at 11:45 PM revealed, a fall in the bathroom. No evidence of follow up or tracking of event. Patient #46: Review of “Medication Occurrence and Tracking Form” on 4/1/26 at 10:30 AM revealed, hit buttocks on cart and reported pain after, the MD was notified. No evidence of follow up or tracking of event. Pt. #47: Review of “Case Review Request” dated on 4/14/26 at 11:45 PM revealed, hypotension (low blood pressure) in PACU (post anesthesia care unit), MD notified, medication given with immediate effect. No evidence of follow up or tracking of event. Pt. #48: Review of “Case Review Request” dated on 4/09/2026, no time indicated on form revealed, pt. had redness from tape used during surgery. No evidence of follow up or tracking of event. Pt. #49: Review of “Case Review Request” dated on 05/02/2026, no time indicated on form revealed, “Pt. reported sore lip after assessment left lower lip was swollen with a small abrasion...” No evidence of follow up or tracking of event. Pt. #50: Review of “Patient Occurrence and Tracking Form” on 10/27/2025 at 2:22 PM revealed, an instrument tip broke off inside the shoulder, broken piece was removed and instrument tagged for repair, a second instrument was opened and removed off the sterile field, a third instrument was opened and used without failure. Evidence that all staff was made aware of this incident and education provided. There is no evidence of tracking of the event. During an interview with Coordinator of Quality Q on 5/19/2026 at 12:22 PM, when asked about the follow up documentation of these events, Coordinator of Quality Q stated, “they all get routed to me and I look into them and determine the level of severity and determine and if there is a risk, we bring to MEC (Medical Executive Committee) and watch for trends. Coordinator of Quality Q was asked to see the logs of events reported and what the follow up was for each event, and he stated “we don’t keep a log, but that is a good idea.” There is no evidence of a process for tracking and trending events.”

“COMPETENT DIETARY STAFF CFR(s): 482.28(a)(3) There must be administrative and technical personnel competent in their respective duties. This Standard is not met as evidenced by: 52276 Based on observation, interview and record review the facility failed to ensure food was labeled upon opening and not expired per facility policy in 3 of 3 kitchens, failed to temperature check food delivered to patients in 1 (main kitchen where patient food is prepared) of 3 kitchens observed, failed to follow manufacturers instructions for use of sanitation product in 1 (main kitchen where patient food is prepared) of 3 kitchens observed, and failed to check temperature of freezers in 2 (inpatient kitchenettes) of 3 kitchens where patient food is stored. Findings include: Examples of expired and opened, unlabeled food: A review of facility policy #FS247 titled, “Food and Beverage Storage and Rotation for Kitchen” last revised 09/2024 revealed, “...3. Store foods in their original packages. Food that must be opened and partially used should be stored labeled and dated in a NSF (National Sanitation Foundation) approved container with a tight fitting lid...” During an observation in the kitchen starting on 5/19/2026 at 9:30 AM, observed the the following items in the freezer, refrigerator and dry storage areas in the kitchen and inpatient kitchenette that were opened and not labeled: Examples in dry storage: 4 bags of pasta 13 containers of seasoning 1 bag of croutons 2 -1-gallon jugs of vinegar 1 container soy sauce 1 jar orange glaze Examples in freezer: 9 slices of angel food cake 1 bag of frozen biscuits 1 bag frozen spinach 1 bag frozen potatoes 1 bag frozen chicken Examples in refrigerator: 1 bottle of caramel sauce 1 bottle of chocolate sauce 1 container shredded cheese 1 container shredded lettuce 1 jar horse radish sauce 12 bottles of salad dressing Examples in the Kitchenettes: 2 bags of individual creamers expiration date of 10/21 (no year documented) 1 bag of individual honey packets expiration date 12/30 (no year documented) 2 bags of individual syrup packets expiration date 9/03 (no year documented) 2 bags of individual jelly packets expiration date 10/30 (no year documented) During an interview on 05/20/2026 at 9:00 AM Chef Manager G stated nothing gets labeled when opened because they “have a good system of ordering and rotating.” During an interview on 05/20/2026 at 10:00 AM with Dietary Aide X when asked how she would know when something without a date on it was opened she stated “I don’t really know when it was opened.” During an interview on 05/20/2026 at 10:30 AM, Nursing Supervisor V stated the kitchenette items were out dated and the year should be added to the date. Examples of food temperature monitoring and improper use of sanitizing cloths: A review of facility policy FS206 titled, “Infection Control: Temperature Standards For Food” last revised 09/2024 revealed, “...4.2 Temperature Control of Finished Products 4.2.1 The temperature of cooked products must be checked regularly. Products shall not be permitted to leave the kitchen for serving units unless they are at or slightly above the prescribed temperature. 4.2.2 Serving units are responsible for checking temperature of each product received from the kitchen and for rejecting products which are substandard in temperature. They shall also be responsible for insuring that cooked foods and cold foods are held at the temperatures prescribed in the Enclosure (1)...” Review of Manufacturers Instruction for Use for “Super Sani-cloth” (the disinfectant wipes used at the facility) revealed, “...for non-invasive medical devices and non-porous surfaces...Ensure the surface remains visibly wet for 1 minute for complete disinfection... Caution...avoid release to the environment.” During an observation in the kitchen starting on 5/19/2026 at 9:30 AM, Sous Chef Y prepared a patient’s lunch tray with hot and cold foods and beverages. Sous Chef Y did not check the temperatures of the food on the tray. During an interview on 05/20/2026 at 9:00 AM Chef Manager G stated, “We temp food on the line every hour to make sure the temp is above 165 degrees ...we do not temp food on patient trays.” During an observation on 05/20/2026 at 9:00 AM Chef Manager G demonstrated how temperatures were taken. The food thermometer was wiped with a “Super Sani-Cloth” and immediately placed into a pan of food, temperature taken, thermometer removed wiped with “Super Sani-cloth” and immediately placed into another pan of food without following the manufacturers recommendations of waiting 1 minute wet time and allowing time to dry. This was completed for 5 pans of hot food. The food thermometer was still visibly wet when placed into the pan of food, potentially contaminating food with disinfectant. During an interview on 05/20/2026 at 10:00 AM Dietary Aide X, who delivers the trays to the patients, stated temperatures are not taken on food served to patients. Examples of freezer temperature monitoring: A review of facility policy #FS206 titled, “Infection Control; Temperature Standards for Foods” last revised 09/2024 revealed, “Temperature of food storage areas and cold food vendors are monitored and action is taken to maintain temperatures within ranges recommended by licensing and surveying agencies. Frozen storage: minimum minus 10 degrees F (Fahrenheit) maximum zero degrees F...” During an observation of the inpatient kitchenette on 05/20/2026 at 10:30 AM, observed 2 refrigerator/freezer units for patient food. There were no thermometers to monitor temperatures in the freezers. During an interview on 05/20/2026 at 10:30 AM, Nursing Supervisor V stated freezer temperatures were not monitored.”

“THERAPEUTIC DIET MANUAL CFR(s): 482.28(b)(3) A current therapeutic diet manual approved by the dietitian and medical staff must be readily available to all medical, nursing, and food service personnel. This Standard is not met as evidenced by: 52276 Based on record review and interview, the facility failed to have a current therapeutic diet manual reviewed and approved by the dietician and medical staff in 1 of 1 nutrition manual reviewed (Therapeutic Diet Manual). Findings include: Review of the facility’s therapeutic diet manual revealed the dietary manual had a copyright date of 2005. The last dietitian approval with signature was signed on 7/25/2018. There was no additional evidence found that the Therapeutic Diet Manual had been reviewed or approved by the dietician and medical staff since 2018. During an interview on 5/19/2026 at 9:00 AM, Chef G stated, “it’s not really needed, we have not changed the menu since 2012.””

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 42046 Based on observation, staff interview and review of maintenance records on May 19 to May 20, 2026, the Orthopaedic Hospital of Wisconsin failed to construct, install, and maintain the building systems to ensure safety of patients. Findings include: The facility was found to contain the following deficiencies. 1. K345 - Fire Alarm System 2. K353 - Sprinkler System - Maintenance and Testing 3. K511 - Utilities - Gas and Electric 4. K521 - HVAC 5. K712 - Fire Drills As a result of these deficiencies, 42 CFR Subpart CFR 482.41(b) Standard: Life safety from fire was NOT MET. See K tags.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 44431 Based on observation, record review and interview the facility failed to remove expired supplies from 2 (Surgical and Post Anesthesia Unit (PACU) patient care departments out of a total of 7 patient care departments observed. Findings: A review of the facility policy #SS359 last reviewed 03/01/2026 titled, “Infection Control for Perioperative...” revealed, “Purpose: To outline strategies to prevent and control infections within the hospital....Shelf life:..Always check commercially prepared items for expiration dates.” A review of the facility policy #AD154 last reviewed 07/01/2025 titled, “Supply Expiration Dates,” revealed, “The [Hospital] employs an ongoing process that allows all supplies in the hospital to be checked for expiration dates. [Hospital] will eliminate expired inventory from the facility and dispose of each item in a proper manner. All items that are found to be past the use by dates will be considered expired...all items that are considered expired will be removed from the facility immediately.” On 05/19/2026 at 11:00 AM during a tour, observation and interview with DON (Director of Nurses) C of the PACU area observed in the cardiac crash cart 2 packages of IV (Intravenous) tubing with an expiration date of 01/01/2026. DON C stated, “They are expired and shouldn’t be here.” On 05/19/2026 at 11:40 AM during a tour, observation and interview with DON C of the Surgical Malignant Hypothermia cart, observed an anesthetic gas breathing circuit with an expiration date of 02/23/2026. DON C stated, “That is expired too.””

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 44431 Based on observation and interview the facility failed to verbalize fire safety risk during time out in 2 (Patients #21 and #22) of 2 surgical procedures observed, failed to document fire safety risk in the time out process for 30 (Patient #1-#30) out of 30 surgical medical records reviewed and failed to have a policy to address fire safety for 1 (Surgery department) of 2 procedural areas observed in a total of 1 surgical suites observed. Findings: A review of the facility policy #SS113, last reviewed 03/01/2026 titled, “Surgical Safety and Universal Protocol/Time Out Process,” revealed, “The time out will include patient name, the planned surgical procedure (s) with laterality, the operative site (s) and the patient position. Allergies and antibiotics will be verbally verified as correct and availability of correct implants and any special equipment will be verbally verified by members of the surgical team.” There was no evidence that fire safety risk level was addressed in the time out policy. A review of “AORN (Association of Perioperative Registered Nurses) Guidelines for Perioperative Practice” 2026 Edition revealed, “...As part of the preprocedural briefing process, the perioperative team should initiate a fire risk assessment to assess for the presence of the three elements of the fire triangle...The perioperative team should collaborate to implement interventions that address the fire risks identified during the assessment...Prevent contact between fuel sources and ignition sources...” A review of patients’ #1 through #30 medical records revealed no documentation of surgical fire risk completed prior to the start of the surgical procedure. During an observation on 05/19/2026 at 10:47 AM, the surgical team completed a time out immediately prior to incision for Pt. #21’s surgical procedure. Surgical fire risk level was not addressed and no fire prevention interventions were discussed during the time out. During an observation on 05/19/2026 at 11:31 AM, the surgical team completed a time out immediately prior to incision for Pt. #22’s surgical procedure. Surgical fire risk level was not addressed and no fire prevention interventions were discussed during the time out. During an interview with Operating Room Manager F on 05/19/2026 at 12:20 PM, Operating Room Manager F stated the facility follows AORN guidelines. During an interview with Director of Nurses (DON) C on 05/20/2026 at 12:55 PM, DON C stated that currently fire safety is not part of the time out process. When asked if there was policy on fire safety for the operating room, DON C stated, “There isn’t a policy on fire safety in the OR.””

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 42046 Based on record review and staff interview, the facility did not participate in and document two Emergency Preparedness exercises in the past 17 months to test the facility-based plan per 42 CFR section 483.73(d)(2). This deficient practice could affect all residents, as well as undetermined number of staff and visitors. Findings include: On 05/19/2025 at 12:36 pm, record review of the emergency preparedness plan (EPP) revealed that the facility had no record of conducting a second exercise to test their emergency plan by participating in a full-scale facility-based exercise, mock-disaster drill, or an actual event within the past (17) months. Documentation was provided for a tabletop exercise titled, “Medical Response and Surge “ Southeast Wisconsin HERC Region 7 that was conducted on 04/14/2026. Staff WW was asked is there was a record of a second drill within the past year. Staff WW stated that no full-scale exercise or other qualifying drill had been completed in 2025 or 2026. This finding was confirmed at the time of discovery by a concurrent interview with Staff WW.”

“A standard Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on May 19 to May 20, 2026. The Orthopaedic Hospital of Wisconsin - Shorewood Physical Therapy Clinic was found to be in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid: 42 CFR 482.41 Condition of Participation: Physical Environment was MET 42 CFR 482.41(b) Standard: Safety from Fire was MET NFPA 101- Life Safety Code was MET The Orthopaedic Hospital of Wisconsin - Shorewood Physical Therapy Clinic is a mixed use, 7-Story office Building of Type I fire-resistive construction without a basement. The facility was located on the first floor and had three exits. The physical therapy facility and the rest of the building were not sprinkled. The therapy suite was protected by a smoke detection system. Orthopaedic Hospital of Wisconsin Shorewood Physical Therapy suite had 10 patients on the day of the survey and was surveyed as a satellite facility as part of the Orthopaedic Hospital of Wisconsin survey. The physical therapy suite was surveyed under the 2012 Life Safety Code, Chapter 39 Existing Business Occupancies. No federal deficiencies of the Life Safety Code were cited.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 42046 Based on record review, observation, and interview, the facility did not perform the annual testing, inspections, and maintenance of the fire alarm system in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.4, 9.6.1.3, 9.6.1.5, 4.6.1, 4.6.12, and 4.6.12.1 and NFPA 72 (2010 edition) Sections 10.12.1, 10.12.6, 10.12.7, 14.2.1.2, 14.2.1.2.2, 10.19, 14.3.1, 14.4.2.2, 14.4.5, 14.6, and 14.6.2.4. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: On 5/19/2026 at 3:41 pm, observation of the fire alarm control panel (FACP) revealed three trouble signals: “Trouble in System - Program Corrupted”, “Trouble Smoke IDF Elect/Room” and “Trouble 3rd Floor Damper Shutdown” on the FACP. No Fire Alarm technician was working on the system at the time and staff stated that they had recently left the facility. These deficient practices were confirmed at the time of discovery by a concurrent interview with Staff XX, Staff YY & Staff ZZ.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 42046 Based on record review and interview, the facility failed to ensure the fire department connection (FDC) was hydrostatic tested to 200 pounds per square inch (PSI) in accordance with NFPA 101 (2012 edition), sections 19.3.5.1, 19.3.5.4, 9.7.1.1, and 9.7.5; National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (2011 Edition) Section 6.3.2.1. This deficient practice had the potential to affect all 5 patients as well as undetermined number of staff and visitors. Findings include: 1. On 05/19/26 at 10:55 am, during record review of the Grunau Fire Protection’s “ Sprinkler Report” dated 02/13/26, 04/28/25, 07/30/25 & 10/27/25 it was revealed that the Fire Department Connection (FDC) was not hydrostatic tested every five years. The reports did not define which reports were quarterly and which report was annual. There was no additional information on the reports for the FDC testing. Interview with Staff WW & Staff YY revealed that no additional information was available on the facility maintenance computer or from calling Grunau Fire Protection. 2. On 05/19/26 at 10:57 am, during record review of the Grunau Fire Protection’s “ Sprinkler Report” dated 02/13/26, 04/28/25, 07/30/25 & 10/27/25 it was revealed that the reports used NFPA 25 (2023 edition) and NFPA 72 (2022 edition) as their reference codes. These deficient practices were confirmed by Staff WW, Staff XX, Staff YY and Staff ZZ at the time of discovery.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 42046 Based on observation and interview, the facility failed to maintain a clear working space in front of one electrical panel in accordance with NFPA 101 (2012 edition) Section 9.1.2; NFPA 70 (2011 edition) Sections 110.26 & 110.34 (A). The deficient practice could affect 2 patients, as well as an undetermined number of staff and visitors. Findings include: 1. On 5/19/2026 at 2:55 pm, observation in Operating Room #2 revealed that access to the electrical panel was less than the minimum required 3’-0” clearance. A blood pressure rack was stored 10 inches in front of the electrical panel. 2. On 5/19/2026 at 2:58 pm, observation in Operating Room #3 revealed that access to the electrical panel was less than the minimum required 3’-0” clearance. A wheeled table with a laptop computer was stored directly against the wall in front of the electrical panel. These deficient practices were confirmed at the time of discovery by a concurrent interview with Staff XX, Staff YY & Staff ZZ.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 42046 Based on observation and interview, the facility did not provide control of environmental ventilation per NFPA 101, 2012 edition, Sections 19.5.2.1, 19.7.6, 2.1, 4.5.8, 4.6.12, and 9.2; NFPA 99, 2012 edition, Sections 9.1.3 and 9.3.1.1; as well as ASHRAE Standard 170, 2008 edition, Section 7.1. These deficient practices could affect all 5 patients, as well as an undetermined number of staff and visitors. Findings include: 1. On 05/19/2026 at 3:20 pm, observation in the janitor’s closet room #2609 revealed that the closet exhaust fan was not operating properly as tested with a one ply tissue. This deficient practice had a potential to contaminate the air of clean spaces outside of the Janitor’s closet with undesirable contaminants. The pressure relationship between the closet and the corridor was not maintained. 2. On 05/19/2026 at 3:23 pm, observation inside the soiled utility room #2608 revealed that the room exhaust fan was not operating properly as tested with a one ply tissue. This deficient practice had a potential to contaminate the air of clean spaces outside of the soiled utility room with undesirable contaminants. The pressure relationship between the soiled utility room and the corridor was not maintained. These deficient practices were confirmed at the time of discovery by a concurrent interview with Staff XX, Staff YY & Staff ZZ.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 42046 Based on record review and interview, the facility failed to conduct fire drills in accordance with the requirements of NFPA 101 (2012 edition) Sections 4.7.1, 4.7.2, 4.7.4, 4.7.6, 19.7.1, 19.7.1.4 and 19.7.1.6. This deficient practice could affect all 5 patients, as well as an undetermined number of staff and visitors. Findings include: On 5/19/2026 at 1030 am, review of the fire drill records for the last twelve months revealed that the fire drills were not conducted at varied times. The facility performed fire drills during the 1st shift on 1/2/2026 at 7:00 am and 04/03/26 at 7:30 am. This condition was confirmed at the time of discovery by a concurrent interview with Staff WW, Staff YY and Staff ZZ.”