Aspirus Tomahawk Hospital

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment This Condition is not met as evidenced by: 49038 Based on observation, record review and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital’s inability to ensure a safe environment for all patients and staff. Findings include: The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags: K-321 Hazardous Areas - Enclosure K-923 Gas Equipment - Cylinder and Container Storage”

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 50644 Based on record review, observation and interview, the facility failed to maintain safe operating conditions for blanket and fluid warmers in 2 out of 2 (Emergency Department and Inpatient) warmers observed in a total universe of 8 patient care areas observed. Findings Include: A review of facility’s policy #17681281 titled, “Warming and Cooling Cabinets: Management and Safety Policy” last revised 02/2025 revealed, “1. Solutions used for irrigation (e.g. during surgical/invasive procedures) are stored at room temperature and, for a limited time interval, in a warmed or cooled state. A tracking system guides usage and rotation of solutions so that the interval does not exceed the parameters set forth by the manufacturer...A. Warming Solution Parameters...Solutions in plastic over-pouches of volume greater than 150 ml (milliliters) to temperatures not exceeding 104 F (Fahrenheit) (40 C (Celsius)), and for a period no longer than manufacturer guidelines...D. Temperature Monitoring of the Solution Cabinets...The temperature of each solution warming cabinet will be logged on the temperature monitoring log each day. Fluid Warmer/ Cooling cabinets that fall outside of the range will be reported to department/unit manager with corrective action steps documented on the daily log...2. Blanket Warming: A. Blankets may be warmed for patient comfort and are stored at room temperature and for a limited time interval in a warmed state. Blankets will be warmed at a temperature no higher than the recommendation of the blanket warmer IFU (Information for Use).” A review of facility’s “User Manual” for “Getinge Models 5524, 5618 & 5624 Warming Cabinets” revealed, “Safety Precautions...Burn Hazard. Items heated to over 49 C (120 F) can burn skin. Keep items that may contact skin at temperatures below 49 C (120 F). A review of facility’s “Fluids and Blanket Warmer Record” from the Emergency Department (ED) from 12/2024 through 05/14/2025 revealed fluid temperatures out of range (exceeding 104 F) for 39 out of 165 days and blanket warmer temperatures out of range (exceeding 120 F) for 100 out of 165 days. A review of facility’s “Fluids and Blanket Warmer Record” from the Medical Inpatient Unit from 12/2024 through 5/14/2025 revealed blanket warmer temperatures out of range (exceeding 120 F) for 165 out of 165 days. During an observation in the ED on 5/13/2025 at 9:38 AM, the fluid and blanket warmer temperature in the Trauma ED room was fluctuating between 104-106 degrees Fahrenheit and the blanket warmer at 122 degrees Fahrenheit. During an observation in the Medical Inpatient Unit on 5/14/2025 at 7:40 AM, the blanket warmer temperature was at 147 degrees Fahrenheit. During an interview on 5/13/2025 at 9:48 AM, Environmental Care Manager J stated that they have noticed a gap throughout the divisions in the policies for the temperatures on the warmers.”

“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: 49038 Based on observation, record review and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital’s inability to ensure a safe environment for all patients and staff. Findings include: The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags: K-321 Hazardous Areas - Enclosure K-923 Gas Equipment - Cylinder and Container Storage”

“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: 29972 Based on observation, interview and record review the facility staff failed to address high food temperatures to ensure patients receive safe food in 3 of 3 Food and Nutrition Test Tray Evaluations reviewed (March 2025, April 2025, May 2025), in a total of 3 months of test tray evaluations reviewed, and failed to ensure patient food is properly stored to prevent cross contamination and ensure food quality in 1 of 2 patient food storage areas observed (Kitchen), in a total of 2 patient food storage areas observed. Findings include: A review of the facility’s policy and procedure #12419969 titled, “Hazard Analysis--HACCP (Hazard Analysis Critical Control Points) Storage” last revised 09/2022 revealed: - “Non-food grade items will be stored separately from food items...” - “All opened foods will be kept in containers that prevent cross contamination.” - “Frozen foods will be wrapped or otherwise containerized in a manner that prevents oxidation (freezer-burn).” A review of the facility’s policy and procedure #16507610 titled, “Infection Control Plan--Food Service” last revised 10/2022 revealed: - “Food not in its original container shall be stored...covered...” Food Temperatures: On 05/13/2025 beginning at 11:45 AM, observed Cook U in the kitchen, checking the food temperatures before preparing the patient’s food trays. The Pork Roast was 206 degrees Fahrenheit (F), Mash Potatoes 212 degrees F, and the Gravy was 202 degrees F. A review of the “Food and Nutrition Test Tray Evaluation” for May 2025, April 2025, and March 2025 revealed: -On 05/06/2025 the “Point of Serv (service) Temp (temperature)” (when the patient receives the tray) for the hot cereal was 176 degrees F. -On 04/01/2025 the “Point of Serv Temp” was 178 degrees F for the “Starch,”; on 04/02/2025 the “Point of Serv Temp” was 174 degrees F for the “Soup” and 177 degrees F for the “Starch”; On 04/28/2025 the “Point of Serv Temp” was 177 degrees F for the “Hot Entree” and 181 degrees F for the “Starch.” -On 03/20/2025 the “Point of Serv Temp” was 175 degrees F for the “Hot Entree,” 180 degrees F for the “Starch,” and 190 degrees F for the “Hot Beverage.” During an interview on 05/13/2025 at 9:09 AM with Patient #17 when asked if he received warm food, Patient #17 responded, “Yes” and that the food was sometimes “too hot.” During an interview on 05/13/2025 at 11:45 AM with Cook U, Cook U stated that test trays are done to ensure patients are receiving quality food at appropriate temperatures. When asked what temperature would be considered too hot and how staff ensure the food temperature is safe for the patients, Cook U responded, “I’m not sure.” During an interview on 05/14/2025 at 8:10 AM with Dietary Director W, Dietary Director W stated that the facility does not have a policy and/or procedure addressing a maximum food temperature range to ensure patient food is not too hot. Dietary Director W stated that food and/or beverage more than 170 degrees F is “too hot” for patients. Food Storage: On 05/13/2025 beginning at 10:56 AM, while touring the kitchen, observed multiple cardboard shipping boxes on a 4 tiered metal cart stored over and next to patient food items; including but not limited to, large soup cans, packaged noodles, packaged crackers, fruit cups, and cookie boxes. During an interview on 05/14/2025 at 8:05 AM with Infection Control RN V, she stated that cardboard shipping boxes should not be stored with patient food. On 05/13/2025 beginning at 11:40 AM, while touring the kitchen, observed the following: -Open plastic bag containing grilled chicken breasts in the freezer. -Uncovered celery and bell peppers in the cooler. During an interview on 05/13/2025 at 11:40 AM with Cook U, Cook U stated that the food should be covered.”

“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: 29972 Based on observation, interview and record review, facility staff failed to remove gloves and/or perform hand hygiene as per policy in 1 of 1 patient care observations (Patient #16), 1 of 1 observations of dietary staff preparing patient food (Cook U), and 1 of 1 housekeeping staff observed cleaning a patient room (Housekeeper T), in a total sample of 3 observations of glove changes and/or hand hygiene; failed to disinfect/discard supplies and equipment to prevent potential cross contamination in 3 of 3 patient observations of care (Patient #16, 23, 24), in a total sample of 3 observations of supplies/equipment disinfection; and failed to wear personal protective equipment appropriately to protect from potential cross contamination in 1 of 1 housekeeping staff observed (Housekeeper T), in a total sample of 1 observation of housekeeping staff cleaning a patient room. Findings Include: A review of the facility’s policy and procedure #17404137 titled, “Hand Hygiene Policy” last revised 01/2025 revealed, “Wet hands first with water...Apply an amount of product...and rub hands together vigorously covering all surfaces of the hands and fingers...Wash for twenty seconds...” A review of the facility’s policy and procedure #12470366 titled, “Cleaning of Patient Care Areas Policy” last reviewed 10/2022 revealed, “Personal Protective Equipment must be worn to prevent occupational exposure to body substances or chemical hazards.” A review of the facility’s policy #13594207 titled, “Infection Control Plan- Therapies” dated 05/2023 revealed, “D. Supplies/Equipment 5. Reusable equipment will be cleaned by Physical Therapy Aides or department specific personnel per recommendations of manufacturer using approved detergent disinfectant... Outpatient Therapy Cleaning Matrix.. Item: Private treatment rooms and tables Frequency: After each use Responsibility: Aide staff Cleaning Material: Virex TB... Item: Bikes Frequency: After each use Responsibility: Therapists or Aide staff Cleaning Material: Purple Wipe, Virex TB...” A review of Directions for Use on bottle of “Virex TB” revealed, “For use of a Cleaner/Disinfectant: Spray evenly over surface. Be sure to wet all surfaces thoroughly. Let product remain on surface for 3 minutes... Wipe with clean cloth...” A review of the “Safety Data Sheet” for “All Purpose Virex Disinfectant Cleaner” last revised 07/31/2024 revealed, when using Virex disinfectant staff should wear “Chemical-splash goggles.” On 05/13/2025 beginning at 9:50 AM, Registered Nurse (RN) F prepared to administer antibiotics to Patient #16 via an intravenous (IV) line (Patient #16 was observed to be on Contact Precautions for MRSA--Methicillin resistant Staphylococcus Aureus, so a gown and gloves were required while staff was in the room). Observed the following: -RN F dropped a package containing supplies on the floor, then proceeded to pick up the package and remove the supplies without first removing the potentially contaminated gloves, performing hand hygiene, and donning clean gloves. Using the same gloves, RN F proceeded to connect the tubing to Patient #16’s IV and administer IV antibiotics allowing for potential cross contamination. -RN F reached into his pockets for supplies and observed RN F touch a normal saline syringe (in the package) that was in RN F’s pocket. RN F did not discard the supplies before exiting Patient #16’s room, to ensure the potentially contaminated supplies were not used on a different patient. -RN F used a “Rover” device to scan Patient #16’s wrist band and medication, RN F placed the Rover device back into his pocket. RN F did not clean and disinfect the Rover device before exiting Patient #16’s room. -RN F removed gloves and washed his hands for 6 seconds, not 20 seconds as per policy. During an observation on 05/13/2025 beginning at 10:00 AM, Housekeeper T was observed cleaning the bathroom in a patient room. Housekeeper T donned gloves and proceeded to clean the grab rails in the bathroom and the outside of the tissue dispenser. Wearing the same gloves, Housekeeper T touched the roll of tissue to fold under the tissue paper, allowing for potential cross contamination of the toilet tissue. Housekeeper T did not wear eye protection while cleaning the patient bathroom as per manufacturer guidelines for Virex. During an observation on 05/13/2025 beginning at 10:56 AM, Cook U began preparing patient food trays. Cook U washed her hands for 15 seconds, not 20 seconds as per policy. During an observation on 05/13/2025 at 1:45 PM, Occupational Therapist (OT) P was changing the sheets on a private treatment room table after patient (Patient #23) use. OT P disposed of the sheets in the dirty laundry bin. OT P then put new sheets on the table and pillow without disinfecting the surfaces. During an observation on 05/13/2025 at 2:00 PM, Physical Therapist (PT) O was wiping down the stationary bike after patient (Patient #24) use. PT O sprayed Virex TB onto a cloth. PT O then used the cloth to wipe the surfaces of the bike. Per interview with Housekeeping Manager X on 05/13/2025 at 1:12 PM, Manager X stated that Housekeeping staff should use eye protection when cleaning patient bathrooms. Manager X stated housekeeping staff use Virex Plus to clean the bathrooms. During an interview on 05/13/2025 at 2:10 PM, Therapy Manager N stated the tables should be wiped down with the Virex or the purple top Sani-wipes. Therapy Manager N stated the equipment including the bikes should be sprayed with the Virex TB, let sit for 3 minutes and then wipe the surfaces. Per interview with Director of Quality and Patient Safety R on 05/14/2025 beginning at 8:21 AM, Director R stated that staff should not store supplies in their pockets. She stated that the Rover device should be cleaned and disinfected after using in the patient’s room and that staff need to follow the policy for hand washing.”

“A standard critical access hospital recertification survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on May 13, 2025. Aspirus Tomahawk Hospital was found to NOT be in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid: 42 CFR 485.623 Condition of Participation: Physical Environment was NOT MET 42 CFR 485.623(D)(1) Standard: Safety from Fire was NOT MET NFPA 101 (2012 edition) - Life Safety Code was NOT MET Aspirus Tomahawk Hospital is a single-story structure built in 2002, with Type II (000) construction. The building has a clinic that is attached to the health care occupancy that is separated with 2-hour fire rated construction. The hospital billing numbers are not used in the clinic; therefore it was not surveyed as part of the hospital facility. The facility is fully sprinkler protected and has smoke detection in patient rooms and storage rooms. The facility has an emergency generator that provides power to the emergency loads. The facility was surveyed under the 2012 Life Safety Code, Chapter 19 for an existing health care occupancy. Two (2) Federal deficiencies of the Life Safety Code were cited.”

“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: 49038 Based on observation and interview, the facility failed to protect hazardous areas in accordance with the requirements of NFPA 101 (2012 edition), sections 19.3.2, 19.3.2.1.2, 19.3.2.1.3, 19.3.2.1.5, 8.3, 8.3.1.2, 8.3.2, 8.3.2.1, 8.4, 8.4.3, 4.6.12.1, and 4.6.12.2. These deficient practices could affect an undetermined number of patients, staff, and visitors. Findings include: 1. On 05/13/2025 at 1:06 pm, observation in the Maintenance shop revealed the 3/4-hour fire-rated double doors to the room were not equipped with coordinating hardware and if not released to close in the correct sequence, the door with the metal astragal remained opened. 2. On 05/13/2025 at 1:14 pm, observation above the ceiling on the west side of the 1-hour fire barrier wall between the Kitchen and the corridor revealed an approximate 8-inch by 8-inch gypsum scab patch that does not meet the tested and listed fire-rated wall assembly and was not protected in accordance with the listed penetration firestop assembly Gypsum Association GA-225-2019. These findings were confirmed at the time of discovery by a concurrent interview with Staff J, Staff Y, Staff Z, Staff AA, and Staff CC.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 49038 Based on observation and interview, the facility failed to store oxygen cylinders in accordance with the requirements of NFPA 101 (2012 edition), sections 19.3.2.4; NFPA 99 (2012 edition), sections 11.3.2, 11.3.2.3, 11.3.2.6, and 11.6.2.3. These deficient practices could affect an undetermined number of patients, staff, and visitors. Findings include: On 05/13/2025 at 2:30 pm, observation in ACU Room 329-Storage revealed (1) E-sized oxygen cylinder was not secured in a rack or in a cylinder cart. This finding was confirmed at the time of discovery by a concurrent interview with Staff J, Staff Y, Staff Z, Staff AA, and Staff CC.”