Ladd Memorial Hospital

“A standard critical access hospital recertification survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 01/20/2026 and 01/21/2026. Ladd Memorial Hospital, Inc. was found to NOT be in compliance with the following applicable regulations for Critical Access Hospital participation in Medicare-Medicaid: 42 CFR 485.623: Condition of Participation: Physical Plant was NOT MET. 42 CFR 485.623 (d)(1) Standard: Life Safety from Fire was NOT MET. NFPA 101- (2012 Edition) - Life Safety Code was NOT MET. Ladd Memorial Hospital, Inc. is a single-story slab-on-grade building, without a basement, built in 2008 and is classified as Type II (000) Unprotected Noncombustible. A health care addition to the original hospital was completed in 2011 to include an Emergency Department, Oncology Department, and MRI Suite. A 2-hour fire barrier wall separates the health care occupancy from the adjacent business occupancy of the clinic and the hospital administration wing. The building is protected throughout with a an NFPA 13 automatic sprinkler system. There is an exit access corridor smoke detection system. Additional smoke detectors are located in various use ares and inpatient rooms. The facility has a 350-kW diesel emergency generator that provides power to the life safety branch, critical branch, and the equipment branch. The facility includes (1) patient care wing and 3 smoke compartments along with the attached Rural Health Clinic of Type II (000) construction that is separated by a 2-hour fire barrier wall. Oncology and Rehab are located within the Rural Health Clinic. NOTE: The Type II (000) Unprotected Noncombustible Hospital is separated by a 2-hour fire barrier from the attached Type II (000) Unprotected Noncombustible fire barrier and walkway link from the fully sprinkler protected Type V (111) Wood Frame Protected Nursing Home. Ladd Memorial Hospital, Inc., is licensed for 25 beds, with a census of 14 inpatients at the time of survey. The facility was surveyed under the 2012 Life Safety Code, Chapter 19 for existing health care occupancies. Eleven (11) federal deficiencies of the Life Safety Code were cited.”

“Multiple Occupancies - Contiguous Non-Health CFR(s): NFPA 101 Multiple Occupancies - Contiguous Non-Health Care Occupancies Non-health care occupancies that are located immediately next to a Health Care Occupancy, but are primarily intended to provide outpatient services are permitted to be classified as Business or Ambulatory Health Care Occupancies, provided the facilities are separated by construction having not less than 2-hour fire resistance-rated construction, and are not intended to provide services simultaneously for four or more inpatients. Outpatient surgical departments must be classified as Ambulatory Health Care Occupancy regardless of the number of patients served. 18.1.3.4.1, 19.1.3.4.1 This Standard is not met as evidenced by: 41202 Based on observation and interview, the facility did not provide a two-hour rated building separation between the hospital and the attached rural health clinic in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.1.3, 19.1.3.3, and 8.3.4.2. This deficient practice could affect 14 patients and an undetermined number of staff and visitors. Findings include: 1. On 01/21/2026 at 12:14 pm, observation above the door from Corridor 1B505 to Passage 1C600 revealed that the 2-hour occupancy separation wall was stopped at the bottom of the roof beam and did not provide 2-hour protection to the underside of the roof deck above. The steel beam is exposed. 2. On 01/21/2026 at 12:27 pm, observation above the ceiling in 1D607 Visit Psych room revealed that the 2-hour occupancy separation wall was stopped at the bottom of the roof beam and did not provide 2-hour protection to the underside of the roof deck above. The steel beam is exposed. These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff GGG.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 41202 Based on observation and interview, the facility did not maintain doors with self-closing or automatic closing devices complying with NFPA 101, 2012 edition, Sections 19.1.1.3.1, 19.2.2.2.7, 7.2.1.8.2, 4.6.12, and 4.6.12.3. This deficient practice could affect an undetermined number of staff and visitors. Findings include: On 01/21/2026 at 12:40 pm, observation at the door into 1D115 Mtls Mgmt was not self-closing or automatic closing. The door is in a 1-hour rated wall. The door closer has been removed. This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff GGG.”

“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: 41202 Based on observation and staff interview, the facility did not provide a sprinkler system as required by the code; with all sprinkler piping properly supported and free from supporting construction items that are not part of the sprinkler system in accordance with NFPA 101 (2012 edition) sections 19.3.5, and NFPA 13 (2010 edition) sections 8.1, 9.1, and 9.1.1.7. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors. Findings include: 1. On 01/21/2026 at 10:26 am, observation above the ceiling in the main corridor at the double door leading to Corridor 1C200 revealed plastic sprinkler piping that was not supported to maintain positioning. The piping was resting against insulation of the ductwork and was not level. Additionally, low voltage wiring was being supported by the sprinkler system. 2. On 01/21/2026 at 10:30 am, observation above the ceiling in the main corridor at the single door leading into Corridor 1C300 revealed that the sprinkler piping was sagging from inadequate support, evidenced by the concealed sprinkler heads being up to 1” below the ceiling tile. Several concealed heads in the main corridor have dropped as the piping has sagged. 3. On 01/21/2026 at 10:34 am, observation above the ceiling in the main corridor by the double doors leading into the sleep lab revealed that a sprinkler line pipe support was not installed around the pipe. It was unsupported and sagging. 4. On 01/21/2026 at 11:15 am, observation above the ceiling in room 1C105 revealed that the Unistrut holding the sprinkler piping was also being used to support the ceiling grid and tile. 5. On 01/21/2026 at 12:27 pm, observation above the ceiling in Room 1D607 Visit Psych revealed flexible armored cable being supported by the sprinkler piping. These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff GGG.”

“Corridors - Construction of Walls CFR(s): NFPA 101 Corridors - Construction of Walls 2012 EXISTING Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area. 19.3.6.2, 19.3.6.2.7 This Standard is not met as evidenced by: 41202 Based on observation and interview, the facility did not provide corridor walls forming a barrier to limit the transfer of smoke as required in NFPA 101 (2012 edition), sections 19.3.6.2 through 19.3.6.2.3. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors. Findings include: On 01/21/2026 at 12:10 pm, observation above the ceiling on the hospital side of the cross-corridor doors revealed that there was an 8” round hole in the gypsum board of the corridor wall separating the main corridor from Room 1C602. This does not provide a barrier to limit the transfer of smoke. This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff GGG.”

“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: 41202 Based on observation and interview, the facility did not maintain smoke barriers in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.7, 19.3.7.1, 19.3.7.3, 8.5, 8.5.2 and 8.5.6. This deficient practice could affect all 14 patients, as well as an undetermined number of staff and visitors. Findings include: 1. On 01/21/2026 at 10:24 am, observation above the ceiling in the main corridor at the double door leading to Corridor 1C200 revealed penetrations that were not properly fire and smoke stopped. This included a 3/4” sleeve with low voltage wiring running through it, a 1/2” pipe, and a 3” sleeve. 2. On 01/21/2026 at 10:37 am, observation above the ceiling in Corridor 1C500 Sleep Lab at the double door to the main corridor revealed (2) 3/4” sleeves for low voltage wiring not properly fire and smoke stopped. 3. On 01/21/2026 at 10:45 am, observation above the ceiling at the cross-corridor doors going into Med-Surg revealed a 3” metal sleeve with low voltage wiring in it was not properly fire and smoke stopped. These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff GGG.”

“Evacuation and Relocation Plan CFR(s): NFPA 101 Evacuation and Relocation Plan There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2. 18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3 This Standard is not met as evidenced by: 41202 Based on record review and interview, the facility did not maintain a written evacuation plan that contained all the elements of a fire safety plan with staff trained adequately on evacuation of smoke compartment in accordance with the requirements of NFPA 101 (2012 edition) sections 19.7.2, 19.7.2.1, 19.7.2.2, 19.7.2.3, and 4.6.1.1. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors. Findings include: On 01/20/2026, during record review, staff could not provide a plan showing the locations and number of smoke compartments within the hospital. When requested to obtain a plan, staff notified the hospital designers for a Life Safety Code (LSC) Plan. This was provided later in the day. On 01/21/2026, during an interview with Staff GGG, the locations of the smoke barrier walls were pointed out and observation of stenciling on these walls verified the accuracy. The facility is not providing an accurate LSC Plan in the Fire Plan. This deficient practice was confirmed during multiple interviews with Staff GGG and Staff HHH.”

“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: 41202 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, 4.7.6, 19.7.1, 19.7.1.4, 19.7.1.5, 19.7.1.6, & 19.7.1.7. This deficient practice could affect 14 patients as well as an undetermined number of staff and visitors. Findings include: On 1/20/2026 and 01/21/2026 at various times, record review and interview revealed that fire drill documentation was provided for a drill from the first quarter day shift and the 2nd quarter but the shift was not designated. No other documentation was provided. This deficient practice was discussed with Staff GGG.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 41202 Based on record review and interview, the facility failed to annually inspect door leaves equipped with panic hardware or fire exit hardware, door assemblies in exit enclosures, electrically controlled egress doors and door assemblies with special locking arrangements per NFPA 101 - 2012 edition section 7.2.15.1 and fire, smoke and fire/smoke door assemblies with written records of inspection and testing in accordance with NFPA 101(2012 edition), sections 19.2.2.2.1, 19.7.6, 4.6.12, 7.2.1.15, 8.3.3. This deficient practice could affect all 14 patients and an undetermined number of staff and visitors. Findings include: On 01/20/2026 at 3:43 pm, record review and interview revealed that only coiling fire doors and two other rated doors were being inspected as required. Staff GGG and Staff III stated that the records only included these doors. Staff did not have an accurate Life Safety Code plan showing locations of opening protectives that require inspections. This was verified in interview with Staff GGG. The actual number of doors requiring inspection is more than 25. This deficient practice was confirmed at the time of discovery by a concurrent interview and during an interview on 01/21/2026 with Staff GGG.”

“Gas and Vacuum Piped Systems - Maintenance Pr CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Maintenance Program Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040. 5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99) This Standard is not met as evidenced by: 41202 Based on observation and interview, the facility did not maintain the zone valve boxes in accordance with NFPA 101 2012 Edition, Section 19.3.2.4 and NFPA 99 - 2012 edition, section 5.1.4.8.4. This deficient practice could affect 3 patients and an undetermined number of staff. Findings include: On 01/20/2026 at 4:19 pm, observation in the corridor outside of OR 1, OR 2 and the Procedure Room revealed carts for medical supplies, linens and various items used within the OR’s were stationed in the corridor. These carts blocked access to the Zone Valve boxes for the piped medical gasses. The zone valve box for the procedure room is located behind the door at the entrance to this corridor. The door is limited to 90 degrees open and stops approximately 3 feet from the valve box. The box is accessible if carts or other objects are not stored behind this door leaf. This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff GGG.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 41202 Based on observation and interview, the facility did not provide correct door hardware on the electrical room door in accordance with NFPA 101 - 2012 edition, Section 19.5.1.1, 9.1.2 and NFPA 70 - 2011 Edition, Section 110.26 (c)(3) and NFPA 110 - 2010 Edition, Section 7.2. This deficient condition could affect an undetermined number of maintenance personnel. Findings include: 1. On 01/21/2026 at 12:56 pm, observation in the MDP Electrical Room 1D102a revealed that the egress door going to the corridor did not include a panic device. This door is within 25 feet of the main electrical panel that exceeds 1200 Amps. 2. On 01/21/2026 at 12:53 pm, observation in the electrical room containing the EPSS equipment revealed the storage of step ladders, shovels, several boxes of lighting tubes and miscellaneous storage items. This type of room cannot include storage. These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff GGG and Staff III.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 41202 Based on record review and interview, the facility did not perform testing of the emergency generator in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.5.1 and 9.1.3; and NFPA 110 (2010 edition) Sections 8.3.7.1, 8.3.8, and 8.4.9. These deficient practices could affect 14 patients, as well as an undetermined number of staff and visitors. Findings include: 1. On 01/20/2026 at 2:52 pm, record review and interview revealed that there was no record of an annual diesel fuel quality test approved by ASTM Standards. 2. On 01/20/2026 at 3:05 pm, record review and interview revealed that there was no record of a four-hour continuous operational test of the EPSS within the last 36 months. 3. On 01/20/2026 at 3:00 pm, record review and interview revealed that there was no record of the monthly testing and recording of the electrolyte specific gravity or of a conductance test of the lead-acid batteries for the past 12 months. These deficient practices were confirmed at the time of discovery by a concurrent interview with Staff GGG, Staff HHH and Staff III.”

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment This Condition is not met as evidenced by: 41202 Based on observation, record reviews 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-0132 - Multiple Occupancy - Contiguous Non-Health K-0223 - Doors with Self-Closing Devices K-0351 - Sprinkler System - Installation K-0362 - Corridors - Construction of Walls K-0372 - Smoke Barrier Construction K-0711 - Evacuation and Relocation Plan K-0712 - Fire Drills K-0761 - Maintenance, Inspection & Testing - Doors K-0907 - Maintenance of Piped Gas Systems K-0911 - Electric Systems - Other K-0918 - Essential Electric System Maintenance and Testing As a result of these deficiencies, 42 CFR 485.623 Condition of Participation: Physical Plant and Environment was NOT MET.”

“PROVISION OF SERVICES CFR(s): §485.635 Condition of Participation: Provision of Services This Condition is not met as evidenced by: 50643 Based on record review, observation and interview, the facility failed to provide a safe quality food program for all patients, staff and visitors in 1 out of 1 kitchen observed and failed to review and revise facility policies every 2 years in 1 of 1 policy indexes reviewed. Findings Include: The facility failed to remove expired food items, failed to label food expiration dates, failed to dispose of dented food tins, failed to provide resources to staff for identifying outdated food and failed to follow the facility policy for dishwasher temperature and chemical monitoring. See Tag 1020. The facility failed to review and revise facility policies every 2 years. See Tag 1008.”

“SURGICAL SERVICES CFR(s): If a CAH provides surgical services, surgical procedures must be performed in a safe manner by qualified practitioners who have been granted clinical privileges by the governing body, or responsible individual, of the CAH in accordance with the designation requirements under paragraph (a) of this section. This Condition is not met as evidenced by: 50644 Based on record review, observation and interview, facility staff failed to maintain integrity of sterile instruments by not removing chipped tape and adhesives from sterile packaged instruments in 1 out of 1 central sterile department observed; failed to clean instruments at the point of use in 1 out of 1 (OR (operating room) 1) surgical instrument cleaning observations; failed to label dirty instruments as biohazard and/or cover dirty instruments and scopes when transporting in 3 out of 4 (ED (Emergency Department), Surgery Procedure room, OR 1) observations of dirty instruments being transported to Central Sterile (CS); failed to remove expired supplies in 1 of 1 surgical services department observed; failed to label drawn up medications in 1 out 2 anesthesia carts observed; and failed to maintain a clean and sanitary surgical environment to prevent cross contamination in 1 out of 1 surgical service department observed. Findings Include: Examples of chipped tape/adhesives on instruments: A review of facility policy, “Use and cleaning of equipment/instruments” last reviewed 9/2021 revealed, “All equipment and/or instruments used within the department shall have recommended preventative maintenance, be cleaned, disinfected and properly disinfected or sterilized according to the manufacturers instruction for use ...” A review of “ANSI (American National Standards Institue)/AAMI (Association for the Advancement of Medical Instrumentation) ST79:2017/(R)2022 Comprehensive guide to steam sterilization and sterility assurance in health care facilities” reaffirmed 1/3/2023 revealed, “Maintenance: Inspect tape for peeling, cracking, or discoloration; immediately remove damaged, chipped, or peeling tape from service...Old tape must be completely removed, and all residue cleaned off...Improperly applied or damaged tape can trap microorganisms, leading to sterilization failures...” During an observation in the sterile supply room on 1/20/2026 at 11:35 AM, observed the following instruments with chipped/peeling tape or visible adhesive on the sterile instruments which was observed through the peel packaged wrap: -Needle holder -Large Haneys -Carmalt forceps - Allis clamps -Kockers -Tenotomy scissors -uterine sounds -tenaculums During an interview on 1/20/2026 at 11:35 AM, ST (Surgical Technologist) P stated that in CS they follow AAMI guidelines. ST P stated that they are in the process of “taking all the tape off instruments because it’s peeling and chipping.” She stated that there is currently no process in place to maintain the tape integrity which is “why they are working to remove it.” Example of failing to spray instruments at point of use: A review of facility policy, “Transportation of dirty instruments” last reviewed 4/2025 revealed, “...spray with Prepzyme, ensuring the instruments are completely saturated...” A review of AORN (Association of Perioperative Registered Nurses) “Guidelines for Perioperative Practice, 2025 Edition...Guidelines for cleaning and care of surgical instruments” revealed, “Treat instruments with an instrument cleaner according to the instrument or device manufacturer’s written IFU (Instructions for use) before transport.” During an observation of breaking down a surgical table on 1/20/2026 at 11:05 AM in OR 1, observed ST K place used instruments on the surgical table in the room and cover with a table cover. There was no evidence that ST K sprayed the instruments with a pre-cleaner in the room before transporting the instruments to Central Sterile. During an interview on 1/20/2026 starting at 11:05 AM, ST P stated that they follow AORN and AAMI guidelines. She stated that they do not spray their instruments at point of use in the OR rooms before bringing to CS. Example of transportation of dirty instruments/scopes: A review of facility policy, “Transportation of Dirty Instruments” last reviewed 4/2025 revealed, “...Put instruments in red biohazard container and take red biohazard container to soiled utility room...” A review of AORN Guidelines, “Guidelines of cleaning and care of surgical instruments” 2025 Edition, revealed, “Transport soiled instruments to the decontamination area in a closed container or enclosed transport cart that is leak-proof, puncture-resistant...labeled with fluorescent orange or orange-red label containing a biohazard legend that is securely affixed...” During an observation of breaking down a surgical table and transferring the instruments to CS on 1/20/2026 at 11:05 AM observed ST K place dirty instruments on surgical table and place a blue table cover over top. There was no evidence of a biohazard label anywhere on the table cover. ST K then transported the instruments down the surgery hallway, out of the surgery department and through a main facility hallway before arriving to the central sterile department. During an observation of a scope transport and cleaning starting on 1/20/2026 at 11:50 AM, observed ST JJJ bring the dirty scope to the cleaning area in a wrapped unlabeled table cover. There was no evidence of this being transported in a red biohazard bin per policy. During a tour of the ED dirty utility room on 1/21/2026 at 10:10 AM, observed a cart for dirty instruments with 2 clear unlabeled containers for transporting of dirty instruments. There was no evidence that these instruments were marked with biohazard labels or in a red bin per policy. During an interview on 1/20/2026 at 10:18 AM when asked how we would know if the scopes or instruments are dirty when transported ST P stated, “You wouldn’t know if it was clean or dirty. There’s no label to identify that.” During an interview on 1/20/2026 starting at 11:05 AM, ST P stated that instruments coming from other departments such as ED and OB (obstetrics) should be transported in red biohazard buckets. Example of expired supplies: A review of facility policies revealed no policy for the outdating of surgical supplies. During a tour starting on 1/20/2026 at 10:18 AM, observed the following expired supplies in the surgical services department: -(1) Opti Fix absorbable fixation system, expired 12/28/2025 -(1) Endo Jaw disposable biopsy forceps, expired 6/30/2025 -(6) 22-guage IV catheters, expired 10/31/2024 (3), 4/30/2025, 8/31/2025, and 9/30/2025 -(18) 25-guage 1.5-inch needles, expired 10/31/2025 -(1) 24-inch tourniquet cuff, expired 1/14/2026 During an interview on 1/20/2026 at 10:30 AM, Surgery RN (Registered Nurse) I stated that outdates are completed monthly by the department RNs. She stated that anesthesia carts and supplies are stocked by the material management department. In an interview on 1/21/2026 at 3:23 PM, Operations/Quality Director V confirmed there is no policy for expired supplies in the hospital. Example of unlabeled drawn up medications: A review of facility policy, “Labeling of Medication Syringes and Other Containers” reviewed 3/13/2020 revealed, “All medication shall be stored in original manufacturer’s containers so as to maintain the proper labeling of name, strength, concentration, amount, preparer’s initial and date (if applicable), and beyond use (expiration) date. If drawn into a syringe or other container, the labeling of the immediate container must contain all information listed above as well as patient name...” During a tour of the procedure room on 1/20/2026 starting at 10:40 AM, observed a drawn up syringe of white medication which was labeled “Propofol 1/20” in the anesthesia cart. There was not a patient in the procedure room, there was no staff in the room and the anesthesia cart was unlocked. The label did not have all the information on the label as required per facility policy. During an inteview on 1/20/2026 at 10:40 AM, CRNA L acknowledged finding and stated, “I just drew it up.” Example of failing to maintain a clean and sanitary environment to prevent cross contamination: A review of facility policy, “Infection Prevention Program” (no date) revealed, “...Minimizing the risk of transmitting infections associated with the use of procedures, medical equipment, and devices...Promote the application of organizational and departmental policies relating to infection preventing and control involving but not limited to isolation procedures and techniques, sterilization procedures, the safe disposal of infectious or contaminated waste, and prevention of cross infection through equipment use...” During a facility tour starting on 1/20/2026 at 10:18 AM observed a linen cart in the main surgery hallway between OR 1 and OR 2 where patients and staff pass through, with clean linen on it, uncovered. During a facility tour starting on 1/20/2026 at 10:18 AM observed the following carts in the main surgery hallway where patients and staff pass through with sterile supplies and instruments on them, exposed to patient and staff traffic: - Anesthesia supply cart - Emergency bucket cart - Emergency C-section cart - Emergency Bowel Resection cart During a tour of the surgery department starting on 1/20/2026 at 10:18 AM observed 4 GI procedure kits set up in the surgery hallway with the sterile procedure items including the scope wrapped in the procedure table cover. The kits were not covered or protected from cross contamination from staff and patients traveling in that hallway. ST P confirmed they take the kits out of their original packages to prepare for the day’s cases. During a facility tour starting on 1/20/2026 at 10:18 AM observed an equipment cart with positioning supplies that included 5 large gel axillary rolls. 4 of the gel rolls had tears that were sticky to the touch and unable to be cleaned fully because of the tears in them. During an observation in OR 1 on 1/20/2026 at 11:05 AM, observed the wall next to the time-out white board with a tear to the surface of the wall which made it unable to be fully wiped down. During an interview on 1/20/2026 at 10:18 AM, Director Clinical Services G acknowledged these findings and confirmed that both patients and staff go through the main surgery hallway.”

“INFECTION PREVENT & CONTROL & ABT STEWAR PROG CFR(s): The CAH must have active facility-wide programs, for the surveillance, prevention, and control of HAIs and other infectious diseases and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic-resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in coordination with the facility-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 50644 Based on record review, observation and interview the facility failed to develop an antibiotic stewardship program; failed to monitor patient antibiotic use; failed to follow facility policy for annual staff Tuberculosis (TB) screening; failed to complete an infection risk assessment; failed to perform hand hygiene where indicated per facility policy; and failed to safely administer medications to patients in 1 of 1 infection control programs reviewed. Findings Include: The facility failed to follow infection prevention and control guidelines for annual staff TB medical screenings. See Tag 1206. The facility staff failed to perform hand hygiene per policy to mitigate potential risks of contamination and healthcare-associated infections. See Tag 1208. The facility failed to safely administer medications through an IV (intravenous catheter) per policy to prevent spread of infection. See Tag 1208. The facility failed to complete an infection risk assessment. See Tag 1210. The facility failed to develop and implement a facility-wide antibiotic stewardship program. See Tag 1244. The facility failed to monitor and collaborate regarding patient antibiotic use throughout the facility. See Tag 1248.”

“LICENSURE, CERT., OR REG OF PERSONNEL CFR(s): Staff of the CAH are licensed, certified, or registered in accordance with applicable Federal, State, and local laws and regulations. This Standard is not met as evidenced by: 44431 Based on interview and record review the facility failed to ensure the Chief Nursing Officer (CNO) was licensed as a registered nurse in the state the facility is located in for 1 (CNO B) of 1 CNO personnel files reviewed. Findings Include: A review of Wisconsin State Statute Chapter 440, Department of Safety and Professional Services, on 01/21/2026 revealed, “...440.094(2): Practice by Health Care Providers from Other States...(a)...a health care provider may provide services within the scope of the credential that the health care provider holds and the department shall grant the health care provider a temporary credential to practice under this section if all of the following apply...1. The health care provider applies to the department for a temporary credential under this section within 30 days of beginning to provide health care services for a health care employer...b. That the health care provider holds a valid, unexpired credential granted in another state. c. The health care provider is not currently under investigation and no restrictions or limitations are currently placed on the health care provider’s credential by the credentialing state or any other jurisdiction. d. The health care provider has applied for a permanent credential granted by the department or an examining board...2...the health care employer of the health care provider attests to all of the following to the department within 10 days of the date on which the health care provider begins providing health care services in this state under this section: a. The health care employer has confirmed that the health care provider holds a valid, unexpired credential granted by another state. b. To the best of the health care employer’s knowledge and with a reasonable degree of certainty, the health care provider is not currently under investigation and no restrictions or limitations are currently placed on the health care provider’s credential by the credentialing state or any other jurisdiction...” A review of the facility policy effective date January 1, 2025 titled, “Nursing Administration Policy,” revealed, “Policy statement: The organization maintains a central Nursing Administration structure led by a qualified Chief Nursing Officer (CNO)...The Chief Nursing Officer is the senior executive responsible for the oversight, direction, and coordination of all nursing services. All nursing staff report under the direction of the CNO. The CNO shall be a licensed Registered Nurse with education and experience consistent with regulatory and accreditation requirements...The CNO has authority and accountability for: Nursing practice standards...compliance with regulatory and accreditation standards...Scope of Practice...All nursing and clinical support staff shall practice within: State Nurse Practice Act...Regulatory...standards...References: State Nurse Practice Act...Accreditation Standards (e.g. CMS (Centers for Medicare and Medicaid Services), DHS [Department of Health Services], WI Nursing Board of Licensing).” A review of CNO B’s personnel file revealed B was appointed as the facility’s CNO B in November, 2025. Further review of the file revealed CNO B had a current nursing license for another state. There was no evidence CNO B had applied for a Wisconsin state nursing license or had obtained a temporary license within 30 days of employment as the CNO. In an interview with CNO B on 01/21/2026 at 2:30 PM, CNO B stated, “All of nursing reports to me. I’ll be getting my Wisconsin nursing license. I have 12 months to get it.” In an interview on 01/21/2026 at 3:00 PM with CEO Y when asked why CNO B was not licensed as a nurse in Wisconsin (where the hospital is located), CEO stated, “He has a Minnesota license and we have given him 12 months to obtain his license.””

“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: 50643 Based on observation, interview, and record review the facility failed to document crash cart monitoring checks daily in 2 of 4 emergency crash carts (Adult Emergency Department (ED), Pediatric (Peds) ED Cart) in a total of 4 emergency code carts observed; and failed to ensure non-expired formalin spill kits were available and staff were educated to use spill kits in 2 (surgery and lab) of 2 departments requiring spill kits. Findings include: Examples of failed crashed cart monitoring: Review of the facility policy titled, “Crash Cart Defibrillator and Suction Quality Assurance” dated 12/2023 revealed, “ ...Observe for intact tie locks on each cart and/or drawer every shift. Document...on the daily check list...” Review of the checklist titled, “Peds Cart Checklist: November 2025” revealed no documented checks performed on November 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 20,22,24,26,27,29, and 30. Review of the checklist titled, “Peds Cart Checklist: December 2025” revealed no documented checks performed on December 1, 9, 10, 11, 15, 16, 21, 30, and 31. Review of the checklist titled, “Peds Cart Checklist: January 2026” revealed no documented checks performed on January 1, 5, 10, 11, and 15. Review of the checklist titled, “Crash Cart Checklist: January 2026” revealed no documented checks performed on January 4 and 5. During an interview on 1/21/2026 at 8:40 AM, ED Manager EE stated, “ED staff should be documenting that they checked the crash carts daily.” Example of expired/outdated spill kits: During an observation with Lab Manager SS on 1/21/2026 at 09:10 AM, a Formalin spill kit was found under a sink in the lab that had a date of 2012 written on the box (when the box was placed in service). Observed 5 plastic sheets that were torn open in the box. The mask in the box was in a plastic bag and was ripped open and integrity seal broken. During an interview with Lab Manager SS on 1/21/2026 09:20 AM, when asked when the last time the Formalin spill kit was replaced or what the process was, he stated, “ I am not sure, I just started a few months ago.” When asked when was the last time they received training on how to use the kit, he stated he didn’t know and could not retrieve any record of training. During an observation in surgery with Director G on 1/21/2026 at 1:40 PM the Formalin spill kit was also labeled 2012 (when the box was placed in service). During an interview with Director G, when asked about education and training for the Formalin spill kit, he stated that they had no orientation in the last few years on the spill kit. When asked if there was a policy about how often this box is replaced, Director G stated “No.””

“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: 41202 As a result of these deficiencies, 42 CFR 485.623(c) Life Safety from Fire was NOT MET. K-0132 - Multiple Occupancy - Contiguous Non-Health K-0223 - Doors with Self-Closing Devices K-0351 - Sprinkler System - Installation K-0362 - Corridors - Construction of Walls K-0372 - Smoke Barrier Construction K-0711 - Evacuation and Relocation Plan K-0712 - Fire Drills K-0761 - Maintenance, Inspection & Testing - Doors K-0907 - Maintenance of Piped Gas Systems K-0911 - Electric Systems - Other K-0918 - Essential Electric System Maintenance and Testing See LSC K-Tags for details”

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 53566 Based on record review, the facility failed to review or revise policies at least every 2 years for 43 of 51 policies reviewed. A review of the facility policies revealed no policy regarding the review or revision of policies. Policies last reviewed/revised greater than two years ago, and those with no reviewed/revised date included: “Eyewash & Drench Shower Equipment Inspection & Testing Procedure” (no date) “Medication Administration Policy and Procedure” (no date) “Incentive Spirometry Procedure” (Revised 11/2013) “BiPAP (Bilevel Positive Airway Pressure) Use Procedure” (Revised 4/2017) “BiPAP/CPAP (Continuous Positive Airway Pressure) Setup and Download Procedure” (Effective 11/2013) “Arterial Blood Gas Analysis Procedure” (Revised 11/2013) “General Nursing Standards of Care” (no date) “Inventory Control” (Reviewed 12/23) “Ventilator Management Procedure” (Effective 6/01/13) “Oxygen Therapy Procedure” (Revised 11/2013) “Peak Flow Monitoring Procedure” (Effective 12/2013) “Nebulizer Use Procedure” (Revised 11/2013) “Mechanical Ventilation Policy/Procedure” (Effective 2/2022) “Allen’s Test Procedure” (Revised 11/2013) “Ventilator Weaning Procedure” (Effective 6/01/2013) “Use of Suctioning Procedure” (Effective 2013) “Release of Information” (Revised 1/4/2024) “Managing Hospital Discharge Planning Binder” (Reviewed 9/2017) “Health Care Directives (Health Care Power of Attorney and Living Will)” (Reviewed 11/2020) “Water Management Plan (Legionella)” (Reviewed 3/16/2022) “...Medical Center Medical Staff Bylaws...” (Reviewed 9/25/2023) “Safe Injection, Infusion, and Medication vial practices” (no date) “Analyzing Risk and Setting Goals/Objectives for Infection Prevention Program” (no date) “Infection Prevention Program” (no date) “Scope or Responsibility - Chairperson of Surgical and Anesthesia Services Departments” (Reviewed 9/2021) “Hand Hygiene/Glove Usage” (Reviewed 11/24/2020) “Labeling of Medication Syringes and Other Containers” (Reviewed 3/13/2020) “Use and cleaning of equipment/instruments” (Reviewed 9/2021) “Fluid Warming for use in IV Therapy and Wound/Surgical Site Irrigation” (Reviewed 11/2021) “Sterility Quality Indicators” (Reviewed 11/2021) “Returning used Equipment/Instruments to CSR for Reprocessing” (Reviewed 9/2021) “Cleaning and Disinfection of Patient Care Equipment” (no date) “Quality Assessment and Performance Improvement Policy” (no date) “Restraints/Seclusion” (no date) “Medication Reconciliation” (no date) “MINDS (Minnesota Detoxification Scale)-rev Assessment and Management based on ASAM (American Society of Addition Medicine) Criteria” (no date) “Policy on Assistants in Nursing” (no date) “OB/GYN (Obstetrics/Gynecology) Transfer - Infant Procedure” (Reviewed 6/2018)”

“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: 50643 Based on record review, observation, and interview the facility failed to ensure patients receive safe quality food by failing to remove expired food items; failing to follow facility policy in clearly labeling food expiration dates; failing to dispose of dented food tins; failing to provide resources to staff for identifying outdated food; and failing to follow facility policy on dishwasher temperature and chemical monitoring in 1 of 1 kitchen areas observed. Findings Include: A review of facility policy “Food Storage” dated 5/2025 revealed, “...Food will be stored in an area that is clean, dry, and free from contaminants... All stock must be rotated with each new order received... Old stock is always used first... Food should be dated as it is placed on the shelves... Date marking should be visible... All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded...” A review of facility reference sheet “Food Storage Chart - Food storage Guide Lines” dated 2013 revealed, “All items need to be dated... Items kept in Refrigerator, Freezer, Room Temperature...” A review of facility policy “Clean Dishes/Dish Machine” dated 5/2025 revealed, “Prior to use, proper temperatures and/or chemical concentrations and machine function should be verified...” A review of USDA (United States Department of Agriculture) “Shelf-Stable Food Safety” guideline dated 10/24/2024 revealed, “...Discard deeply dented cans... A sharp dent on either the top or side seam can damage the seam and allow bacteria to enter the can. Discard any can with a deep dent on any seam...” A review of the manufacturer guidelines, “ES Series Door Type, Chemical Sanitizing, Single and Dual Rack Dish Machines” dated 12/5/2007 revealed, “...Daily Machine Preparation: Before proceeding with start-up, verify the following:... Check all chemicals... Titrate the rinse water using the chlorine titration test kit... Ensure that all chemicals being injected into the machine have been verified as being at the correct concentrations ...” A review of the facility adverse event log revealed, “Event #309177” dated 6/30/2025 by Staff Member EEE revealed, “...Patients daughter brought it to the writers attention that there were “white spots” on the top of her moms Jell-O... the patient had already taken a few bites and there were also at least 3 mold spots visible on top of the Jell-O... There was no date on the Jell-O.” During an observation on 1/20/2026 at 10:12 AM, in the dry food storage area, the following items were observed to be opened and not dated with an opened date: Rice Crispies, Fettuccini Noodles, Brown Sugar. During an observation on 01/20/2026 at 10:15 AM in the dry food storage area, the following deeply dented tins were observed: (5) 7.25 oz (ounce) Tomato Soup tins, (1) 3 lb (pound) 2 oz Cream of Mushroom Soup tins, (3) 1 lb 16 oz Mushroom tins, (7) 28 oz Roasted Pepper tins. During an observation on 1/20/2026 at 11:10 AM a large wire shelf was observed in the kitchen area with bottled spices. Multiple bottles were expired, multiple bottles did not have an opened date, and multiple bottles did not have a visible expiration date. A review of the “Dishwasher Temperature/Chemical Check Logs: November 2025” revealed that checks were missed on: November 3, 5, 10, 12, 13, 14, 16, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 31. A review of the “Dishwasher Temperature/Chemical Check Logs: December 2025” revealed that checks were missed on: December 1, 3, 4, 8, 9, 11, 12, 14, 15, 16, 17, 18, 20, 22, 23, 24, 26, 27, 29, 30, 31. A review of the “Dishwasher Temperature/Chemical Check Logs: January 2026” revealed that checks were missed on: January 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19. During an interview on 1/20/2026 at 10:20 AM, Dietary Cook TT stated that all food containers should be dated when they are opened. When asked what the opened date meant in regards to whether food could be used or not, Dietary Cook TT stated, “I’m not sure.” Dietary Cook TT stated that her Director had a sheet to refer to that states when food should be thrown away, but that she did not know where the sheet was. During an interview on 1/20/2026 at 11:00 AM, Dietary Cook TT stated that she uses almost all of the spices on the spice rack. During an interview on 1/21/2026 at 9:25 AM, Dietary Director Director WW stated all food items that are opened should be marked with the opening date, and that staff should refer to the “Food Storage Chart - Food storage Guide Lines” to know when food should be disposed of. Dietary Director WW stated that all dented food tins should be removed and not used to make patient food. Dietary Director WW stated that staff should dispose of all food items that have expired. Dietary Director WW stated that staff should be documenting dishwasher water temperatures and chemical concentration before washing dishes after every meal.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 50644 Based on record review and interview, the facility failed to complete annual TB screenings for staff to prevent possible transmission of disease in 15 out of 22 (ST P, OB RN Supervisor DD, ED Supervisor EE, Quality V, Dietary Aide GG, Dietary Aide HH, Food Services Director II, Dietician JJ, Surgery RN I, Nuc Med Director KKK, PT LLL, Rehab Director NN, RT OO, Radiology PP, Infection Control RN H, and General Surgeon O) personnel files reviewed. Findings Include: A review of facility policy titled, “Infection Prevention Program” (no date) revealed, “Employee Health provides a safe working environment for employees through the coordination of Infection Prevention and Control and Employee Health to identify potentially infectious conditions that may pose a risk for patients, visitors, and staff...” A review of employee personnel files on 1/21/2026 starting at 11:00 AM with HR Manager DDD revealed no evidence of an annual TB risk assessment completed in 2025 for ST P, OB RN Supervisor DD, ED Supervisor EE, Quality V, Dietary Aide GG, Dietary Aide HH, Food Services Director II, Dietician JJ, Surgery RN I, Nuc Med Director KKK, PT LLL, Rehab Director NN, RT OO, Radiology PP, Infection Control RN H, and General Surgeon O. HR Manager DDD confirmed these findings and stated that “there should be one for 2025.” During an interview on 1/20/2026 at 2:04 PM with Infection Control RN H, she stated that TB screening is done at hire and yearly for ongoing assessment.”

“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: 50644 Based on record review, observation and interview, facility staff failed to complete hand hygiene/glove usage per policy in 3 out of 5 (Patient #2, Patient #25, and Patient #32) patient care observations, 5 out 6 (EVS Staff UU, EVS Staff VV, ST MMM, ST NNN and ST JJJ) environmental cleaning observations in EVS and Surgery and 2 of 2 staff (Dietary Staff GG and HH) observations of food preparation. Findings Include: A review of facility policy, “Hand Hygiene/Glove Usage” last revised 11/24/2020 revealed, “...Use Alcohol-based hand rub in all recommended situations below unless hands are visibly soiled: 1. Before and after direct patient contact...4. After contact with patient’s intact skin...5. After removing gloves...7. When moving from a contaminated body site to a clean body site during patient care...Gloves...can become contaminated during care and must be removed or changed when moving from a contaminated site to a clean site on the same patient...” Examples of hand hygiene in Dietary: Review of the facility policy titled, “Personal Hygiene and Health Reporting” dated 5/2025 revealed, “...How to wash Hands:...Scrub for a minimum of 10 to 15 seconds within the 20-second hand washing procedure ...” During an observation on 1/20/2025 at 11:15 AM Dietary Staff GG was observed washing his hands for 8 seconds while preparing hospital patient lunch trays. During on observation on 1/20/2025 at 11:16 AM Dietary Staff HH was observed washing her hands for 6 seconds while preparing hospital patient lunch trays. During an observation on 1/20/2025 at 11:25 AM Dietary Staff GG was observed washing his hands for 6 seconds while preparing hospital patient lunch trays. During on observation on 1/20/2025 at 11:30 AM Dietary Staff HH was observed washing her hands for 7 seconds while preparing hospital patient lunch trays. During on observation on 1/20/2025 at 11:32 AM, Dietary Staff GG was observed washing his hands for 6 seconds while preparing hospital patient lunch trays. During on interview on 1/21/2025 at 8:55 AM, Dietary Director WW stated, “Dietary staff should be washing their hands for at least 20 seconds.” Examples of hand hygiene in Environmental Services: Review on the facility policy titled, “Environmental Services Cleaning Procedure: Infection Control” (no date) revealed, “...You should always wash your hands...after removing gloves...” During an observation on 1/21/2026 at 3:00 PM, EVS (environmental services) Staff UU and EVS Staff VV were observed cleaning in-patient room after the patient was discharged. Staff UU and VV removed their gloves at 3:06 PM, 3:15 PM, 3:20 PM, 3:22 PM, 3:25 PM, 3:27 PM, 3:31 PM, and 3:35 PM, and then put on new gloves without washing their hands. During an interview on 1/21/2026 at 4:10 PM, EVS Staff VV stated that there was hand sanitizer on the cleaning cart, and that it should be used after removing gloves. Examples of hand hygiene in patient care area: During an observation on 1/21/2026 at 8:15 AM, RN (registered nurse) T was observed performing laboratory speciman collection and medication administration for Pt. #2. RN T failed to wash hands before donning gloves, completed a bilateral nasal swab, placed a new pair of gloves over the dirty pair and continued with the medication pass. During an observation on 1/21/2026 at 9:00 AM, RN T was observed donning gloves without prior hand washing while discontinuing tube feeding for Pt. # 32 . During an observation on 1/21/2026 from 10:15 AM to 10:35 AM, RN T was observed donning gloves/ changing gloves without prior hand washing while doing a wound dressing change and G-tube site clean with dressing change a total of 5 times on Pt. # 32. Hand hygiene completed with soap and water one time for 10 seconds. During an observation on 1/21/2026 at 10:15 AM, CNA (certified nursing assistant) X was observed donning gloves without prior hand washing when assisting Pt. # 32 with cares. Example of hand hygiene in Surgery: During an observation of a surgical suite cleaning starting on 1/20/2026 at 9:44 AM in OR 2, observed ST (surgical technologist) MMM and ST NNN finish cleaning the OR suite, leave the OR room with dirty gloves on, discard the gloves in the garbage in the main surgery hallway and walk away without performing hand hygiene after removing gloves. Example of hand hygiene in Central Sterilization: During an observation of a scope cleaning on 1/20/2026 starting at 11:52 AM, observed ST JJJ complete a scope cleaning. At the end of the cleaning, ST JJJ grabbed a wipe out of the canister and wiped down the clean scope cart and place a clean towel on the cart all while wearing dirty gloves. ST JJJ then removed the top pair of dirty gloves, placed the clean scope on the cart, and washed down the sink with the gloves. After cleaning the sink, ST JJJ proceeded to place the clean scope into the sterilizer with the dirty gloves still on. Example of hand hygiene in Prep & Hold: During an observation on 1/20/2026 at 1:37 PM, General Surgeon O entered surgical prep room 6 to meet with Patient #25 prior to his planned surgical procedure. General Surgeon O performed a brief H&P (history and physical) update, during which he touched Patient #25’s arm. General Surgeon O then left the room. He failed to perform hand hygiene both before and after contact with Patient #25. Example of IV medication administration: A review of facility policy, “Safe Injection, Infusion, and Medication vial practices” (no date) revealed, “...Disinfect IV ports and vial stoppers by using friction and 70% isopropyl alcohol, an iodophor, or an approved antiseptic agent. Allow the port to dry before accessing...” During an observation on 1/20/2026 starting at 9:57 AM in OR 1, observed SRNA (student registered nurse anesthetist) N administering IV medication to Patient #24 on 5 separate instances without cleaning the access port on the patient’s IV tubing. SRNA N also drew IV medication out of a vial and failed to clean the septum of the vial prior to puncturing the vial with the needle. During an interview on 1/20/2026 at 2:26 PM, CRNA (certified registered nurse anesthetist) L confirmed that the anesthesia staff must follow any hospital policies regarding infection control. During an interview on 1/20/2026 at 2:04 PM, Infection Control RN H stated that they follow CDC (Centers for Disease Control) and APIC (Association for Professionals in Infection Control) guidelines for infection control practices.”

“INFECTION PREVENT & CONTROL SCOPE & SEVERITY CFR(s): The infection prevention and control program reflects the scope and complexity of the CAH services provided. This Standard is not met as evidenced by: 50644 Based on record review and interview the facility failed to complete an infection risk assessment for the facility to ensure the infection control program reflects the scope and services of the facility in 1 out of 1 infection control programs reviewed. Findings Include: A review of facility policy, “Analyzing Risk and Setting Goals/Objectives for Infection Prevention Program” (no date) revealed, “To evaluate infection risks for our organization and set goals and objectives based on the results of that assessment. A risk assessment is performed to identify key internal and external infection vulnerabilities ...The goal is to conduct and coordinate an organizational-wide Infection Prevention risk assessment ...The prioritized risks will be used as the basis for the Infection Prevention Plan ...The Infection Preventionist will have direct care managers complete an annual risk assessment at least annually or whenever significant changes occur ...” A review of facility policies/documents revealed no evidence of a facility wide risk assessment that prioritized risks to create an Infection Prevention plan for infection vulnerabilities. During an interview on 1/20/2026 at 2:04 PM, when asked if the hospital utilizes a risk assessment process to prioritize selection of activities and quality indicators, Infection Control RN H stated, “No, there is no assessment.””

“LEADERSHIP RESPONSIBILITIES CFR(s): (3) The leader(s) of the antibiotic stewardship program is responsible for: (i) The development and implementation of a facility-wide antibiotic stewardship program, based on nationally recognized guidelines, to monitor and improve the use of antibiotics. This Standard is not met as evidenced by: 50644 Based on record review and interview, the facility failed to establish a facility wide antibiotic stewardship program for 1 of 1 infection prevention program observed. Findings Include: A review of facility infection control policy list revealed no evidence of a policy that addressed a facility-wide antibiotic stewardship program based on recognized guidelines to monitor and improve the use of antibiotics. During an interview on 1/20/2026 at 2:04 PM, when asked about an antibiotic stewardship program at the facility, Infection Control RN H stated that they are “working towards creating an antibiotic stewardship program.” She stated that there is currently nothing in place for this program.””

“LEADERSHIP RESPONSIBILITIES CFR(s): (3) The leader(s) of the antibiotic stewardship program is responsible for:] (iii) Communication and collaboration with medical staff, nursing, and pharmacy leadership, as well as the CAH’s infection prevention and control and QAPI programs, on antibiotic use issues. This Standard is not met as evidenced by: 50644 Based on record review and interview, the facility failed to document antibiotic use for patients at the facility as part of an antibiotic stewardship program in 1 out of 1 infection control programs reviewed. Findings Include: A review of facility policies revealed no policy regarding tracking of antibiotic use in patients or an antibiotic stewardship program at the facility. A review of the facility’s quality plan revealed no evidence of tracking antibiotic use in patients or that antibiotic stewardship was being tracked. During an interview on 1/20/2026 at 2:04 PM, when asked if any tracking was being done with antibiotic usage of patients, Infection Control RN H stated, “No, not to my knowledge.””