Gundersen Moundview Hospital and Clinics

“A standard Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 04/07/2026 to 04/08/2026. Gundersen Moundview Hospital and Clinics was found to be NOT in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid: 42 CFR 485.623 Condition of Participation: Physical Plant and Environment is NOT met. 42 CFR 485.623(d) Standard: Life Safety from fire is NOT met. NFPA 101, Life Safety Code 2012 edition. Gundersen Moundview Hospital and Clinics is composed of four buildings built in different periods but attached to each other. Building 01 is a one story structure with a basement built in 1964, with Type II (111) construction type. A one story Nursing Home addition, with slab on grade structure built in 1976, with Type II (111) construction type. The facility has complete wet pipe and propylene glycol antifreeze sprinkler protection and smoke detection in all corridors. The facility closed the Nursing Home on 08/01/2008 and started using that area for swing bed patients starting in April of 2009. The facility has one diesel 170 kW 3 Ph (212.5 KVA pf =0.8) generator that provides power to the emergency loads. Gundersen Moundview Hospital and Clinics is licensed for 25 beds, with a census of 8 patients at the time of the survey. The facility was surveyed under the 2012 Life Safety Code, Chapter 19 for an existing health care occupancy. One federal deficiency of the Life Safety Code was cited for building number one.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 40659 Based on observation and interview, the facility did not protect a hazardous area as required in NFPA® 101 Life Safety Code® 2012 Edition, Sections 19.3.2.1.3 and 19.3.2.1.5. This deficient practice could affect 1 of the 8 patients. Findings include: 1. On 04/08/2026 at 11:00 AM, observation revealed at clean supply, one of two doors did not have self-closing hardware present. 2. On 04/08/2026 at 12:55 PM, observation revealed at room L1465, one precast horizontal assembly with great stuff foam insulation did not have a listed penetration firestop assembly. These findings were confirmed at the time of discovery by a concurrent interview with Staff W.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 40659 Based on observation and interview, the facility did not provide pendant sprinklers in accordance with their listing as required in NFPA® 101 Life Safety Code® 2012 Edition sections 8.7, 9.7, 9.7.1.1(1), and 19.3.2.2; NFPA® 13 2010 edition Sections 8.1 and 8.6. This deficient practice had the potential to affect 1 of the 8 patients. Findings include: On 04/08/2026 at 11:12 AM, observation revealed at laboratory, one pendant sprinkler head was obstructed 11 inches below the sprinkler head by one removable overhead cabinet. This finding was confirmed at the time of discovery by a concurrent interview with Staff W.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 40659 Based on observation and interview, the facility did not provide smoke barriers as required in NFPA® 101 Life Safety Code® 2012 Edition sections 8.5 and 19.3.7.3. This deficient practice had the potential to affect 1 of the 8 patients. Findings include: 1. On 04/07/2026 at 2:43 PM, observation revealed at the lower level elevator 3 smoke barrier, one CMP communication cable bundle overfilled within 2 inch diameter metallic sleeve did not have a listed penetration firestop assembly. 2. On 04/07/2026 at 2:50 PM, observation revealed at the materials management smoke barrier, three communication cable bundles multicolored orange great stuff foam insulation over red material did not have a listed penetration firestop assembly. 3. On 04/07/2026 at 2:57 PM, observation revealed at the doctor’s sleep room smoke barrier, one gypsum scab patch was not repaired as listed in UL System No. W-L-0020 or GA-225-2019 Repair of fire rated gypsum panel product systems. 4. On 04/07/2026 at 3:14 PM, observation revealed at the med surge smoke barrier, one ¾ inch EMT conduit through one 1 inch diameter hole and one CMP communication cable bundle through one 1 inch diameter hole did not have a listed penetration firestop assembly. 5. On 04/07/2026 at 3:20 PM, observation revealed at the CT smoke barrier, one ¾ inch EMT conduit through one 1 inch diameter hole and one CMP communication cable bundle through one 1 inch diameter hole with light brown colored foam insulation did not have a listed penetration firestop assembly. These findings were confirmed at the time of discovery by a concurrent interview with Staff W.”

“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: 40659 Based on observation and interview, the facility did not provide operating rooms with two low sidewall return grilles spaced at opposite corners as required in NFPA® 101 Life Safety Code® 2012 Edition, Sections 9.2, 9.2.1, 19.5.2.1; ANSI/ASHRAE/ASHE Standard 170-2017, Ventilation of Health Care Facilities section 7.4. This deficient practice could affect 1 of the 8 patients. Findings include: 1. On 04/08/2026 at 10:45 AM, observation revealed at Operating Room 1 (OR1), two low sidewall return grilles spaced at adjacent corners were obstructed by one stainless utensil stand and one stainless steel table. There was no marking and identification to provide clearance in front of the HVAC low sidewall return grilles. 2. On 04/08/2026 at 10:50 AM, observation revealed at Operating Room 2 (OR2), one low sidewall return grille weas obstructed by one stainless utensil stand. There was no marking and identification to provide clearance in front of the HVAC low sidewall return grilles. These findings were confirmed at the time of discovery by a concurrent interview with Staff W.”

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment This Condition is not met as evidenced by: 40659 Based on observation, staff interviews, and review of maintenance records between 04/07/2026 to 04/08/2026, the facility did not construct, install and maintain the building systems to ensure life safety to patients. Findings include: The facility was found to contain the following deficiencies. Building 01 K0372 Subdivision of Building Spaces - Smoke Barrier Construction Building 02 K0351 Sprinkler System - Installation Building 03 K0321 Hazardous Areas - Enclosure K0521 HVAC As a result of these deficiencies, 42 CFR 485.623 Condition of Participation: Physical Plant and Environment was NOT MET. See K-tags for details of the specific findings”

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 47413 Based on observation, interview, and record review, facility staff failed to lock the emergency code cart in 1 of 3 (Inpatient/Swing Bed) code carts observed in a total of 11 patient care departments observed. Findings Include: A review of the facility’s policy #18140024 titled “Crash Cart Check, GMHC-30029” last revised 04/2024 revealed, “...Each emergency cart is equipped with a lock and kept locked unless in use...” During an observation on 04/07/2026 at 10:00 AM, the Inpatient/Swing Bed emergency code cart had a red plastic tag lock on the cart that was not sealed and no evidence of a padlock to lock the medications. During an interview on 04/08/2026 at 8:49 AM, Clinic Manager G stated that the red tag should be intact on the code cart.”

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 40659 Based on observation, staff interviews, and review of maintenance records between 04/07/2026 to 04/08/2026, the facility did not construct, install and maintain the building systems to ensure life safety to patients. Findings include: The facility was found to contain the following deficiencies. Building 01 K0372 Subdivision of Building Spaces - Smoke Barrier Construction Building 02 K0351 Sprinkler System - Installation Building 03 K0321 Hazardous Areas - Enclosure K0521 HVAC As a result of these deficiencies, 42 CFR 485.623(d) Standard: Life Safety from fire is NOT met. See K-tags for details of the specific findings.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 44431 Based on observation, interview and record review the facility failed to maintain the integrity of patient care supplies in 2 (Inpatient/Swing Bed and Surgery) of 11 patient care departments; failed to remove expired supplies in 2 (Central Supply/Clean Storage and Surgery) of 11 patient care departments; and failed to remove expired medication in 2 (Emergency Department (ED) and Pulmonary Function Test (PFT) lab) of 5 areas where medications are stored in a total universe of 11 patient care departments observed. 47413 Findings Include: Supply Integrity: A review of the facility’s policy titled, “Stock Rotation, GMHC - 4529” last revised 02/2024 revealed, “...5. Items will be stored in an environment free of moisture, excessive heat, or contamination...” Examples in Inpatient/Swing Bed: On 04/07/2026 at 10:00 AM, observed the following supplies with yellowed packaging/tubing (no expiration dates): (2) 6 mm (milimeter) cuffed endotracheal (ET) tubes (2) 9 mm cuffed ET tubes (3) 12 French (Fr) Yankeur suction tip (1) 8 Fr Yankeur suction tip (1) 14 Fr Yankeur suction tip During an interview on 04/08/2026 at 8:49 AM, Registered Nurse Manager G stated that yellow supplies looked “tarnished” and should be thrown out since they did not have an expiration date. Examples in Surgery: On 4/8/2026 between 9:39 AM and 12:00 PM, observed the following supplies that were open and exposed to air/moisture: (1) medium concentration oxygen mask (1) extra large face mask, size 6 (2) child/adult small air masks (1) child/adult face mask (1) medium adult face mask During an interview on 4/7/2026 at 11:07 AM, RN A stated, “The open items shouldn’t be there.” 51278 Expired Supplies: A review of the facility’s policy titled, “Stock Rotation, GMHC-4529” last revised 02/2024 revealed, “...6. Expired items will be adjusted accordingly in Lawson and disposed of properly...” Examples in Central Supply/Clean Storage: On 04/08/2026 between 9:39 AM and 12:00 PM, observed the following expired supplies: (5) suction catheters,exp (expiration) 11/01/2023 (1) suction catheter, exp 03/01/2022 (2) Bacterial/viral filters, exp 04/01/2026 (1) box of alcohol pads, exp 06/2024 (31) tongue blades, exp 07/27/2024 (1) box of purple exam gloves, exp 02/28/2026 (7) Iso-gard HEPA (type of filter)-light, exp 12/28/2024 (2) boxes of culture media, exp 05/12/2022 Examples in Surgery: (1) bottle of alcohol hand sanitizer, exp 01/2026 (7) tongue blades, exp 07/27/2024 (1) box of blue nitrile exam gloves, exp 06/14/2024 (1) tube of surgical lubricant (opened with no open date), exp 02/29/2024 During an interview on 04//07/2026 at 11:07 AM, when asked about the expired items, RN A stated, “They should be tossed.” Expired Medications: A review of the facility’s policy titled “Medication Administration, GMHC - 29000” last revised 05/2025 revealed, “...Responsibilities. Staff administering medications...visually inspects...and verfies the medication is not expired...” Example in the ED: On 04/07/2026 at 1:35 PM, observed (1) epinephrine (medication) pen in the ED crash cart with an expiration date of 02/2025. During an interview on 04/07/2026 at 1:10 PM, Manager M confirmed one of the two epinephrine pens in the crash cart was expired. Example in the PFT Lab: On 04/07/2026 at 1:35 PM observed (4) Albuterol 0.083% (medication) in the PFT cart with an expiration date of 01/2025. On 04/07/2026 at 1:35 PM, when asked about the expired medications, Respiratory Therapist N stated, “They shouldn’t be there. We get them from Pyxis (medication storage unit) now.””

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (vi) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. All patient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patients or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of § 483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care. This Standard is not met as evidenced by: 52276 Based on observation, interview and record review the facility failed to ensure patients receive safe, quality food by failing to label open food per facility policy in 1 (Dietary kitchen) of 4 areas where food is stored. Findings include: A review of facility policy #18330017 titled, “Sanitation Practices, GMHC -23018” last revised 06/2025 revealed, “...Labeling of Food and Supplies...2. Once packages are opened and not used completely they will be labeled with the date that they are opened and given a new expiration date if needed/as appropriate...” During an observation starting on 4/7/2026 at 10:30 AM, observed the following freezer and dry storage items opened and not labeled. Freezer items: -One (1) bag raspberries -One (1) bag strawberries -One (1) bag cooked chopped chicken -One (1) bag chicken tenders -One (1) bag meatballs -One (1) bag egg omelets -One (1) bag macaroni bites -One (1) bag cod fillets -One (1) bag fish sticks -One (1) bag pork sausage links -One (1) bag pork sausage patties Dry Storage Items: -One (1) bag dried mashed potatoes -One (1) bag brown sugar -One (1) bag beef gravy -One (1) bag country gravy During an interview on 04/07/2026 at 11:41 AM, Cook K stated all food should be labeled when opened.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also 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 maintain a clean and sanitary environment free from the risk of infection by failing to maintain integrity of Operating Rooms in 2 of 2 ORs (Operating Rooms) observed; failed to adhere to aseptic techniqe during medication administration for 1 (Patient #5) of 1 patients observed receiving meds; failed to perform hand hygiene and glove changes between clean and dirty tasks for 2 (Housekeeping and Lab) of 11 departments observed; failed to clean surfaces contaminated between patients in 1 (Lab) of 11 departments observed; and failed to complete annual TB (tuberculosis) screening for employees per policy for 12 (Physician Assistant X, Certified Nursing Assistant H, Registered Nurse I, Registered Nurse F, Director Business Operations BB, Dietary Aide K, Dietician JJ, Infection Prevention Y, Operating Room Supervisor C, Nuclear Medicine Physician KK, Physical Therapist KK, and Surgical Technologist BB) out of 19 employee files reviewed. Findings Include: Clean and Sanitary Enviroment: A review of facility policy #17992518 titled, “Infection Control Plan, GMHC-26000” last approved 06/2025 revealed, “...To provide a safe environment for patietns, employees and visitors...To construct, review, update and enforce policies and procedures related to infection control...” Examples of OR room integrity: A review of “AORN Guidelines for Perioperative Practice” 2026 Edition revealed, “...13.10 Maintain the integrity of structural surfaces (eg, doors, floors, walls, ceilings, cabinets) and repair surfaces when they are damaged...Damaged structural surfaces can create a reservoir for the collection of dirt and debris that cannot be removed during cleaning...” During a tour and observation of the surgery department with Surgery RN (Registered Nurse) A on 04/07/2026 between 09:39 AM and 12:00 PM, observed in OR (Operating Room) 1 and OR 2 multiple areas of rust, exposed sheetrock, chipped paint, and chipped wood; multiple areas of chipped and flaking paint on the walls; and brown, discolored ceiling lights. During an interview on 04/07/2026 at 10:30 AM, RN A stated, “Maintanence is aware of the chips and we have put in work orders.” 47413 Examples of Medication Administration: A review of the facility’s policy #18231121 titled, “Medication Administration, GMHC-29000” last revised 05/2025 revealed, “...4. The rubber diaphragms of medication vials will always be swabbed with an alcohol prep pad before withdrawing a dose...” During an observation on 04/07/2026 at 1:10 PM, Registered Nurse I administered IV (intravenous: into the blood stream) Bumex (a diuretic medication to remove fluid) to Patient #5. Registered Nurse I opened an alcohol prep pad, swabbed the two rubber diaphragms of the medication vials, scrubbed Patient #5’s IV hub with the same alcohol prep pad, administered a saline flush, scrubbed Patient #5’s IV hub again with the same alcohol prep pad, administered IV Bumex, and then opened a new alcohol prep pad to scrub Patient #5’s IV hub and administered another saline flush. During an interview on 04/08/2026 at 8:51 AM, Registered Nurse Manager G stated that a new alcohol swab should be used for each surface scrubbed. 53566 Example of failing to clean a patient room after use: A review of facility policy #17365008 titled, “Cleaning of Patient Rooms, GMHC-14016” last approved 4/2025 revealed, “...To provide a clean and pleasant atmosphere for the patient while preventing the spread of infection and to thouroughly clean the room after discharge...” During an observation on 4/7/2026 at 10:11 AM, observed Phlebotomist P perform a blood draw for Patient #21 in the outpatient laboratory. After completeion of the blood draw, observed the draw supply cart, where Phlebotomist P then stated, “Be careful. I dripped some blood on the top of that cart.” Observed visible blood droplets on top of the clean supply cart. Phlebotomist P then left the draw room without wiping the blood off the supply cart. No evidence that the draw room was wiped down after patient use. During an interview on 4/7/2026 at 10:11 AM, when asked about the cleaning procedure for the lab draw rooms, Phlebotomist P stated, “Sometimes we wipe them down after every patient but we don’t always have time when it’s busy. We sweep, mop, and wipe down the rooms at the end of the day.” Examples of glove changes and hand hygiene: A review of facility policy #17992518 titled, “Infection Control Plan, GMHC-26000” last approved 06/2025 revealed, “...Frequent handwashing is essential between contacts with patients, patient care items or other contaminated items, especailly blood or other body fluids or stool...” During an observation on 4/7/2026 at 10:11 AM, observed Phlebotomist P perform a blood draw for Patient #21 in the outpatient laboratory. Phlebotomist P failed to perform hand hygiene prior to donning gloves. Phlebotomist P cleaned Patient #21’s skin at the draw site, touched the clean draw site with the same gloves he had worn to open supplies, and inserted the needle into Patient #21’s skin without first recleaning the site. After filling the blood tubes and disposing of the needle, Phlebotomist P continued to wear the same pair of gloves to touch the computer, reenter the clean supply cart for more items, and remove a pen from his pocket. Observed that the index finger on Phlebotomist P’s left glove had ripped and his skin was exposed. While still wearing the dirty and ripped gloves, Phlebotomist P left the draw room and walked Patient #21 down the hall to the bathroom to leave a urine sample. He walked to the bathroom and retrieved the urine sample left by Patient #21. Phlebotomist P carried the urine cup into the lab’s main processing area, still wearing the original pair of gloves he had donned before drawing Patient #21’s blood. No hand hygiene observed after Phlebotomist P removed the gloves. During an observation on 4/7/2026 at 1:10 PM, observed deep cleaning of a room following a patient discharge. Housekeeper T donned gloves, cleaned the outside of the toilet, returned to the patient room, and touched the previously sanitized pillows and bed without removing her gloves or performing hand hygiene. During an interview on 4/7/2026 at 10:58 AM, Lab Tech Q stated that any surfaces potentially contaminated by body fluids during a blood draw, including the arm table on the patient’s chair and the top of the supply cart, should be cleaned with Oxyvir wipes between patients. She stated each draw room gets a deep cleaning at the end of the day. When asked to describe the hand hygiene process surrounding blood collection, Lab Tech Q stated that she performs hand hygiene, dons gloves, collects the blood sample, removes gloves, and performs hand hygiene again before touching any other surfaces or leaving the room. Examples of Annual TB Screening: A review of facility policy #18116898 titled, “Tuberculosis (TB) Control Plan, GMHC-26021” last approved 06/2025 revealed, “Risk of exposure applies to all employees and all non-employees with privileges within the health care setting are considered at risk...To minimize or eliminate occupational exposure to tuburculosis (TB)...Annual employee questionnaire (online) for employees...” A review of personnel files revealed no evidence of annual TB questionnaires completed for Physician Assistant X, Certified Nursing Assistant H, Registered Nurse I, Registered Nurse F, Director Business Operations BB, Dietary Aide K, Dietician JJ, Infection Prevention Y, Operating Room Supervisor C, Nuclear Medicine Physician KK, Physical Therapist KK, and Surgical Technologist BB. During an interview on 4/8/2026 at 9:35 AM, Infection Prevention Y stated that TB assessments should be completed annually by all staff and have “fallen through the cracks.””