Marshfield Medical Center - Neillsville

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment This Condition is not met as evidenced by: 12316 Based on observation, staff interviews, and review of maintenance records between August 05 through August 07, 2025, the facility failed to 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 02 K131 Multiple Occupancies-Sections of Health Care Occupancies K200 Means of Egress - Other K341 Fire Alarm System - Installation K920 Electrical Equipment - Power Cords and Extension Cords C930- Life Safety from Fire As a result of these deficiencies, 42 CFR 485.623 Condition of Participation: Physical Plant and Environment was NOT MET. See C930, and K-tags for details of the specific findings.”

“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: 29972 Based on record review and interview the facility staff failed to ensure that patient care equipment is maintained in safe operating condition in 1 of 11 patient care areas observed (Rehabilitation Department), in a total sample of 11 patient care departments observed. Findings Include: On 08/05/2025 beginning at 11:10 AM, observed the Physical Therapy department containing exercise equipment used by patients during therapy. Review of user manuals for the patient exercise equipment used in Physical Therapy revealed the following: -Treadmills Preventative Maintenance Schedule required inspections weekly, monthly, quarterly, bi-annual, and annual. Per user manual, “Follow the schedule...to ensure proper operation of the product.” -Versa Climber Maintenance Instructions revealed, “In order to maintain highest safety level of equipment, a regular examination is required for damage and wear. This requires a visual inspection of connectors, cables, chains, sprockets, pedals, handles etc. on a regular basis. -Upper Body Cycle Maintenance Instructions revealed that Annual Maintenance is required, including; adjusting Axial Play, Lube Chain, Lube Idler Rollers, Lube locking Knobs, Lube Chair Slide Rail, and Chair inspection. -Tru-Kinetics Uppercycle Maintenance instruction revealed, “...periodic inspection should be performed on high use components: crank arm assemblies (hand grips, detents, locking knobs), gas spring, and height adjustment lever.” Per interview with Rehabilitation Manager J on 08/05/2025 at 11:34 AM, Manager J stated that staff do not do safety checks/inspections on the patient exercise equipment in the Physical Therapy department. Manager J stated there was no policy and procedure for equipment inspections. Per interview with the Director of Rehabilitation EE on 08/05/2025 at 4:45 PM, Director EE stated that staff use manufacturer guidelines for machine maintenance and stated that there is no regular maintenance/inspections required for the exercise equipment. This is inconsistent with the equipment user manuals reviewed.”

“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: 12316 Based on observation, staff interviews, and review of maintenance records between August 05 through August 07, 2025, the facility failed to construct, install and maintain the building systems to ensure life safety to patients. Findings include Building 02 K131 Multiple Occupancies-Sections of Health Care Occupancies K200 Means of Egress - Other K341 Fire Alarm System - Installation K920 Electrical Equipment - Power Cords and Extension Cords As a result of these deficiencies, 42 CFR 485.623(c) Life Safety from Fire was NOT MET. See K-tags for details of the specific findings.”

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 29972 Based on observation, record review and interview the facility staff failed to ensure staff have access to emergency equipment for use as per policy in 1 of 1 eyewash station observed (Emergency Department), in a total of 1 eyewash station observed. Findings Include: Review of policy and procedure titled, “Eyewash Stations and Emergency Shower Policy” revised 07/01/2025 revealed: -“All installed emergency showers and eyewash stations must be located within 55 feet (no more than 10 seconds travel time) from the hazard that requires the installation.” -“Emergency shower and eyewash stations must be located on the same level as the hazard and the path of travel must be free of obstructions that may inhibit the immediate use of the equipment.” On 08/06/2025 at 9:55 AM, while touring the Emergency Department (ED) with Building Services Manager DD, observed the Eyewash Station in the Ambulance Bay of the ED. Per observations, there were 2 automatic opening doors that staff would need to wait for and go through to access the eyewash station, which could delay immediate use of the equipment. Per interview with Manager DD at the time of the observation, Manager DD stated that there was only 1 Eye Wash Station in the ED. Manager DD performed a distance check and stated that the distance from some of the ED rooms and areas to the Ambulance Bay eyewash station was more than 55 feet and could pose a concern with immediate use of the eye wash station.”

“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, record review and interview the facility failed to dispose of outdated supplies in 4 patient care areas (Medical-Surgical Nursing Unit, Housekeeping, Post Anesthesia Care Unit and the Laboratory department) out of a total of 11 patient care departments observed. Findings Include: Review of facility policy #KT2N6QC5SZE5-3-3005, last review date 04/28/2025 titled, “Storage and Handling of Patient Care Supplies and Healthcare Facility Sterilized Products Policy,” revealed, “Supplies with expiration dates must be checked regularly to identify and remove items which have expired.” Examples on the Medical Surgical Unit: On 08/05/2025 from 9:45 AM-11:30 AM during a tour and observation of the medical surgical nursing unit observed the following: Room 109 nursing supply server 2 telemetry patch packages with an expiration date of 08/16/2024, 4 telemetry patch packages with an expiration date of 08/01/2025 and 1 telemetry patch package with an expiration date of 06/05/2025. Room 112 observed Sanicloth wipes on the counter with an expiration date of 05/2025. At 10:00 AM an interview on 08/05/2025 with RN (Registered Nurse) L, when asked if these supplies were expired, L stated, “Yes, Staff should be checking expiration dates, I will get rid of them.” Examples in Housekeeping: On 08/05/2025 from 2:00 PM-3:00 PM during a tour and observation of the housekeeping areas in the facility observed the following: In the Housekeeping supply room on the medical surgical unit observed 1 bottle of good sense cleaner with an expiration date of 09/25/2023 and a bottle of handsoap with an expiration date of 10/2024. On the housekeeping cleaning cart in the housekeeping storage area observed 2 bottles of hydrogen peroxide with an expiration date of 11/02/2023 and 08/21/2024, a bottle of hand sanitzer with an expiration date of 03/2025. At 2:30 PM in an interview on 08/05/2025 with Housekeeping Manager R, when asked about the expired products in the housekeeping areas, R said the expired products should have been removed. 50643 Example in Post Anesthesia Care Unit (PACU): On 08/05/2025 at 9:43 AM during a tour and observation of the PACU observed the following: Malignant Hyperthermia Cart: Two 55cc vials of Sterile Water with an expiration date of 08/01/2025. During an interview on 08/05/2025 at 09:44 AM Operating Room (OR) Manager F stated she will take care of the expired supplies. Example in Lab: On 08/05/2025 at 11:25 AM during a tour and observation of the Lab observed the following: Supply Drawer: Four Microtainer tubes with an expiration date of 07/31/2025. During an interview on 08/05/2025 at 11:26 AM Lab Manager D stated she will take care of the expired supplies.”

“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: 44431 Based on record review, observation and interview the facility failed to ensure patients receive safe quality food by failing to remove unlabeled and undated food items in 1 (Kitchen) of 3 food storage areas observed. Findings Include: Review of facility policy #E44FHF34YSFX-6-450, last reviewed 01/27/2025, titled, “Food and Nutrition-Nursing Unit Stock Policy-Acute Care,” revealed, “Complete an orange label for each type...of item and place the label on the outside of the zip lock bag...Discarding of expired items is the responsibility of Food Service staff and is done according to established guidelines.” On 08/05/2025 from 11:30 AM - 12:30 PM during a tour and observation of the facility kitchen observed the following in the kitchen freezer: 1 package of white diced meat that was not sealed, did not have an open date, and wasn’t labeled 1 package of white meat no date and no label 2 packages of green food with no date and no label On 08/05/2025 at 12:00 PM in an interview with Dietary Manager S, when asked if all frozen foods should be labeled and dated, S stated, “Yes, I’ll get rid of them.””

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 29972 Based on record review and interview the facility staff failed to ensure all staff received job orientation/education and were competent to perform their job duties in 2 of 14 personnel files reviewed (Operating Room Manager F, Surgical Technician UU), in a total of 14 personnel files reviewed. Findings Include: Review of policy and procedure titled, “Annual Competency Standards Policy” last revised 04/15/2022 revealed: -“Manager or designee is responsible for developing and maintaining a system for employee annual competency plans. -“Employee is responsible for completing the annual competencies and will work with a validator to complete.” Review of personnel files with Regulatory Coordinator FF and Education BB, on 08/06/2025 beginning at 10:00 AM revealed there was no documented evidence of Operating Room Manager F and Surgical Technician UU receiving a job orientation/education to ensure staff are competent to perform their job duties. Per interview with Manager F on 08/06/2025 beginning at 11:36 AM, Manager F stated that she was unable to find evidence of an orientation to the OR Manager role in her personnel files. Manager F stated that she was unable to find evidence of Surgical Technician UU’s receiving an orientation to the Surgical Technician position. Per interview with Educator BB on 08/06/2025 beginning at 11:00 AM, Educator BB stated that staff should have orientation/competencies completed on hire and annually.”

“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: 50643 Based on observation, interview and record review, facility staff failed to remove gloves and/or perform hand hygiene as per policy in 2 of 4 patient care observations of hand hygiene/glove changes (Patients #11 and #24) and 1 of 3 (Sterile Processing (SP) Tech AA) equipment cleaning observations; and failed to maintain equipment integrity to prevent infection in 1 (Loyal Clinic) out of 11 hospital departments surveyed. Findings Include: A review of the facility’s policy titled, “Standard Precautions” last revised 08/27/2024 revealed, “...Gloves must be changed after contact with each patient...or when heavily contaminated...” During an observation on 08/05/2025 beginning at 11:27 AM, Lab Technician E was observed drawing blood on Patient #24 with gloves. Lab Technician E failed to remove gloves and perform hand hygiene before touching a clean surface. During an observation on 8/06/2025 at 09:45 AM, SP Tech AA was observed cleaning a colonoscope with gloves and then touched clean supplies without removing gloves or performing hand hygiene. During an observation on 08/06/2025 at 10:36 AM, Gastrointestinal (GI) Medical Doctor (MD) Z entered, made contact with, and left Patient #11’s Post Anesthesia Care Unit (PACU) bay without performing hand hygiene. During an observation on 08/06/2025 at 10:47 AM, PACU RN B entered, made contact with, and left Patient #11’s PACU bay without performing hand hygiene. During an interview on 08/05/2025 at 11:40 AM Lab Manager D stated that she would expect lab technicians to remove their gloves and performing hand hygiene before touching clean surfaces. During an interview on 8/06/2025 at 1:20 PM Operating Room (OR) Manager F confirmed there were missed opportunities for hand hygiene. 50644 During a facility tour starting on 8/6/2025 at 8:00 AM, observed 3 bean bag weights in the traction room (1.106) with torn edges and holes in them, not allowing for proper cleaning to prevent infection. During an interview on 8/6/2025 at 10:05 AM, Quality W stated, “Mock tracers are completed every 6 months to check for integrity of equipment such as tears and rips and a monthly accreditation readiness checklist is completed by department staff to check for this also.””

“A standard Recertification Survey of the Marshfield Medical Center Neillsville, Neillsville, for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 08/05-08/07/2025. Marshfield Medical Center Neillsville was found to be NOT in compliance with the following applicable regulations for Critical Access Hospital participation in Medicare-Medicaid: 42 CFR 485.623: Condition of Participation: Physical Environment was NOT MET. 42 CFR 485.623 (d)(1) Standard: Life Safety from Fire was NOT MET. NFPA 101 - Life Safety Code 2012 edition was NOT MET. Marshfield Medical Center Neillsville is a single-story, slab-on-grade structure of metal frame unprotected noncombustible construction Type II(000) built in 2021 without a basement. Construction plans were approved on 11/14/2019 and building was first occupied on 05/08/2021. A single-story outpatient therapy clinic attached to hospital building was also surveyed. The clinic building was separated by a 2-hour fire-resistance rated occupancy separation from the hospital building. The facility had one (1) operation room (OR #1), 16 patient rooms in the medical-surgical unit, post-anesthesia (PACU), 1 CT scan and imaging area, laboratory, sterile processing, scope cleaning and decontamination rooms, sterile storage, physical therapy and support spaces. Emergency department had 5 treatment, 1 trauma, and 1 triage rooms and support spaces. Kitchen and dining areas, storage, central plant, separate normal and emergency power electrical equipment rooms are on the main floor. The facility had one 600kW diesel Caterpillar emergency generator located outside. The facility is fully sprinkler protected with an NFPA 13 automatic supervised sprinkler system and had a corridor smoke detection system in the med-surg unit. System smoke detectors were installed within 5 feet of automatic closing smoke barrier, fire doors and vertical rolling steel doors that were electro-magnetically held open. The main fire alarm panel, sprinkler riser and control valves were located in the central plant room with boilers, pumps and domestic hot water heaters set at 140 deg F with a continuous recirculating pump. The facility had one bulk oxygen supply system with reserve cylinders located outdoor in addition to piped-in manifold CO2, nitrogen, vacuum, and medical air source equipment. The hospital is licensed for 25 beds and had an average census of 7 inpatients at the time of the survey. The facility was surveyed under the 2012 Life Safety Code, Chapter 18 for a new health care occupancy. Four (4) federal deficiencies of the Life Safety Code were cited.”

“Multiple Occupancies CFR(s): NFPA 101 Multiple Occupancies - Sections of Health Care Facilities Sections of health care facilities classified as other occupancies meet all of the following: o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access. o They are separated from areas of health care occupancies by construction having a minimum two hour fire resistance rating in accordance with Chapter 8. o The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served. 18.1.3.3, 42 CFR 482.41, 42 CFR 485.623 This Standard is not met as evidenced by: 12316 Based on observation and interview, the facility failed to provide 2-hour fire resistance rated occupancy separation in accordance with the requirements of NFPA 101, 2012 edition, Sections 18.1.3.3, 8.3.3.1, 8.3.3.3; NFPA 80, 2010 edition, Sections 5.2.13.1, 6.1.4.2.1. This deficient practice had the potential to affect all inpatients, as well as an undetermined number of staff and visitors. Findings include On 08/06/2025 at 12:18 P.M., observation revealed that the 90-minute fire-rated door in the 2-hour fire-rated occupancy separation wall was propped open with a wooden wedge causing obstruction to free operation of door. The door was located in the Consult Room HN 1.A105 in the pharmacy. The above finding was confirmed by interview with Staff DD (building services manager) and M4 (facilities system manager) at the time of discovery, and Staff A, NN, M, M5, YY, FF, R, XX, W, VV, WW, and Staff M2 and M3 in exit interview.”

“Means of Egress Requirements - Other CFR(s): NFPA 101 Means of Egress Requirements - Other List in the REMARKS section any LSC Section 18.2 and 19.2 Means of Egress 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. 18.2, 19.2 This Standard is not met as evidenced by: 12316 Based on observation, record review and interview, the facility failed to install one exterior door in accordance with NFPA 101, 2012 edition, Sections 18.2.1, 7.10.8.3.1. This deficient practice had the potential to affect all patients who receive care in Smoke Zone 2, and undetermined number of staff and visitors. Findings include On 08/05/2025 at 3:20 P.M., observation revealed that there was no “NO EXIT” sign posted on the exterior exit door of the Family Waiting Room HN 1.E151 adjacent to the Med-Surg Unit. The fully glazed door in the exterior wall was likely to be mistaken as an exit door. The above finding was confirmed by interview with Staff DD (building services manager) and M4 (facilities system manager) at the time of discovery, and Staff A, NN, M, M5, YY, FF, R, XX, W, VV, WW, and Staff M2 and M3 in exit interview.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 12316 Based on observation, record review and staff interview, the facility failed to provide a properly installed and tested fire alarm system in accordance with the NFPA 101 2012 edition 18.3.4.1, 9.6.1.3, NFPA 72, 2010 edition, Sections 10.7.5, 10.12, 10.12.6, 14.4.5.22, 14.4.2.2(18)(b). This deficient practice had the potential to affect all patients, and undetermined number of staff and visitors in the facility. Findings include 1. On 08/06/2025 between 1:30 and 3 P.M., interview with Staff DD (senior building services manager) revealed that the fire alarm main panel and three remote annunciator panels of the fire alarm system had been displaying trouble signals since the facility had started to replace the system from Banco to Johnson Controls (JCI) 6 to 9 months ago, and that there had been no change in display of signals. Staff DD further stated that main fire alarm control unit and remote annunciators did not display address of initiating device that activated or zone location of initiating device activating the alarm. 2. On 08/07/2025 between 8:55 A.M. and 9:05 A.M. observation revealed that the automatic dialer component of the facility fire alarm system, when placed in trouble by disconnecting the dedicated phone lines in the main fire alarm control unit located in the central utility plant room, did not annunciate a distinctive audible trouble signal nor a visible signal at the main fire alarm control panel (FACP). When interviewed on 08/07/2025 between 9 A.M. and 9:05 A.M, Staff M1 (electrical technician) stated that remote annunciator panels located in emergency department and two other locations, where the trouble signal is likely to be heard, did not annunciate visual and audible trouble signals. When Staff M1 was asked on 08/07/25 at 9:51 A.M. whether the fire alarm remote supervising station received a trouble signal from the phone line disconnection test performed on 08/07/25 at 8:55 A.M, Staff M1 stated that the Banco company, who monitored the fire alarm system, did not receive trouble signals from the phone line failure test. The above deficient practice was verified with Staff DD and M1 at the time of discovery.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 12316 Based on observation and staff interview, the facility failed to properly maintain electrical devices in accordance with NFPA 99, 2012 edition, 10.2.3.6; NFPA 101, 2012 edition, Sections 18.5.1.1 and 9.1.2, and NFPA 70, 2011 edition, Sections 400.8, 590.2(B). This deficiency could affect an undetermined number of staff and patients receiving care in the facility. Findings include On 08/06/2025 at 10:36 A.M., observation in the Exam Room HN 1.F106 adjacent to stress testing room revealed that the power supply cord of the Plethysmograph equipment was plugged into a multi-outlet power strip device, and not into the wall receptacles in fixed wiring of building structure. The above finding was confirmed by interview with Staff DD (building services manager) and M4 (facilities system manager) at the time of discovery, and Staff A, NN, M, M5, YY, FF, R, XX, W, VV, WW, and Staff M2 and M3 in exit interview.”