Marshfield Medical Center - Ladysmith

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment This Condition is not met as evidenced by: 46812 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 environmental 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-0372 - Smoke Barrier Construction As a result of this deficiency, 42 CFR 485.623 Condition of Participation: Physical Plant and Environment was NOT MET.”

“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: 50644 Based on observation, record review and interview, facility staff failed to remove expired supplies from emergency carts in 2 out of 6 (Cardiac rehab code cart, ED Broselow cart) emergency carts observed. A review of facility policy, “Emergency Carts Policy” last reviewed 12/8/2025 revealed, “...Staff are responsible for: Familiarizing and maintaining themselves with the list of emergency medications and supplies contained on each cart...” During a facility tour of the ED (Emergency Department) on 3/24/2026 starting at 3:36 PM, observed the following expired items in the Broselow (Emergency pediatric) cart: -1 CO2 (carbon dioxide) detector with expiration date of 12/18/2025 -1 Green pediatric emergency intubation kit with expiration of 1/31/2026 -2 -6.5 Endotracheal tubes with expiration of 1/29/2026 -1-Purple I-Gel with expiration of 1/31/2026 -2 Miller #2 laryngoscope blade with expiration of 12/1/2025 and 3/1/2026 -4 Vacutainer Safety Lok with expiration of 11/30/2025 -2-3.5mm Endotracheal tubes with expiration of 11/20/2025 and 1/29/2026 During a facility tour of the Cardiac Rehab Center on 3/24/2026 starting at 4:29 PM, observed the following expired items on the Emergency Code Cart: -2 Quik Combo Pads with expiration of 5/16/2025 During an interview on 3/24/2026 at 3:45 PM, Med Surg Supervisor T stated that the ED staff are responsible for outdating the Broselow cart and that supply chain is responsible for outdating the Code carts.”

“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: 46812 As a result of these deficiencies, 42 CFR 485.623(c) Life Safety from Fire was NOT MET. K-0372 - Smoke Barrier Construction See LSC K-Tags for details.”

“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: 53566 Based on observation, interview and record review, the facility failed to ensure the dishwasher’s wash temperature did not exceed the final rinse temperature during each run cycle and failed to calibrate food thermometers weekly in 3 (January, February, and March 2026) of 3 months reviewed in 1 of 1 kitchens observed in a total universe of 12 hospital departments. Findings include: Dishwasher Temperatures A review of facility policy #F019 “Sanitation and Infection Prevention/Control: Dishmachine Temperatures” revised 1/2026 revealed, “Dishmachine wash and rinse water should be maintained at temperatures that meet the guidelines established by the Food and Drug Administration...In no cases should the wash temperature exceed the final rinse temperatures..PROCEDURES:..Supervisor/Food and Nutrition Associate as assigned...Immediately brings any substandard temperatures to the attention of management. Supervisor. If documentation of the temperatures...has been assigned to a Food and Nutrition Associate, confirms that it is completed at each meal period. Director (in the event of inappropriate temperature). Determines if reading is due to malfunctioning temperature gauge or inappropriate temperature. Makes management decision concerning adequacy of sanitation of service ware. If due to inappropriate temperature...implements disposable service ware or use 3-compartment sink for sanitization. Notifies nursing units of use of disposable service ware. Contacts sources of repairs. Documents action taken on back of form. Director/Designee. Verifies completion of logs. Initials form weekly...” A review of “Dishmachine Temperature Record (High Temperature Machine)” forms from January 2026 to March 2026 revealed that the dishwasher’s wash temperature exceeded the final rinse temperature 14 out of 88 times recorded in January 2026, 12 out of 77 times recorded in February 2026, and 5 out of 55 times recorded in March 2026. No evidence was found of any weekly dishwasher temperature reviews by dietary management, maintenance notifications, completed repairs, or other corrective action taken regarding dishwasher temperatures during the months of January, February, or March 2026. During an interview on 3/24/2026 at 10:19 AM, Dietary Supervisor O stated that the dishwasher is to be run following each meal, and the wash temperature, final rinse temperature, and any associated interventions are to be documented according to policy and instructions on the “Dishmachine Temperature Record.” Calibration of Food Thermometers A review of facility policy #B007 “Production, Purchasing, Storage: Food Handling Guidelines” revised 1/2026 revealed, “...Verification of Food Thermometers. Pocket and digital thermocouple thermometers must be tested every week in an ice slurry to ensure that the readings are accurate (32+/- 2 degrees F). Complete the Thermometer Verification Sheet...” A review of “Thermometer Verification Sheet” forms from January 2026 to March 2026 revealed, “...All thermometers used in the department are verified weekly and documented on this form...” A review of the forms revealed that weekly thermometer calibration checks were missed 4 out of 5 weeks in Januray, 3 out of 4 weeks in February and 3 out of 4 weeks in March. On 3/24/2026 at 10:54 AM Cook S stated that food thermometers should be calibrated with recordings logged according to policy and instructions on the “Thermometer Verification Sheet.””

“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 observation, interview and record review the facility failed to clean therapy equipment after patient use in 1 out of 2 (Cardiac Rehab) therapy departments observed; and failed to follow the surgical services dress code policy in 1 of 1 surgical departments observed in a total universe of 12 hospital departments. Findings include: A review of facility policy, “Routine Cleaning/Disinfection of Modality Carts Process-Rehabilitation Services” last reviewed 12/10/2024 revealed, “...Laminated color coded card or other indicator will be placed on each cart to indicate whether the equipment is clean or dirty...Once a modality cart is selected, the therapist will flip the indicator or card from Clean to Dirty...After the machine is used with a patient...placed in the hallway for cleaning...” During an observation on 3/25/2026 at 8:10 AM in the Cardiac Rehab department, observed 2 patients get off the NuStep machines and move to the next therapy machine. There was no evidence of indicator cards on the machines to determine if they are dirty and there was no evidence that those machines got cleaned after use. During an interview on 3/25/2026 at 8:15 AM, Cardiac Rehab Assistant GG stated that equipment is cleaned after the end of each class, not after each patient. She stated that there is a possibility that patients could go on a machine that was already used and not cleaned. 44431 A review of the facility policy #4FAR5N4RSFP7-3-400 last reviewed 04/25/2024 titled, “Dress Code Policy-Surgical Service,” revealed, “Purpose:...To reduce the potential of the human body as a source of pathogens and to reduce the spread of OR (Operating Room) acquired pathogens outside the OR...artificial nails shall not be worn by any personnel providing direct patient care...Any artificial enhancements or resin bonding products are considered artificial.” A review of the facility policy #3PE3E66MX2CW-2-1106 last reviewed 02/16/2026 titled, “Infection Prevention and Control Services Policy,” revealed, “Purpose of IP [Infection Prevention] is to provide a safe environment for patients...through...institution of appropriate infection prevention and control precautions...education...provides education for employees regarding infection prevention and control. Education focuses on risk of infection and practices to decrease risk...methods of employee education include orientation.” On 03/25/2026 from 08:00 AM to 09:30 AM during an observation of an OR dental procedure being completed for Patient #16, Dental Assistant Z was observed not wearing gloves, touched patient #16 to provide care, removed equipment from a surgical supply cabinent and added equipment to the surgical tray that was located above Pt. #16. Dental Assistant Z was observed to be wearing artificial nails. An interview was conducted with Surgery Director Y on 03/25/2026 at 9:39 AM. When asked if artificial nails were allowed in the OR, Y stated, “No. Contracted staff are expected to follow our policies and procedures.””

“RESTRAINT AND SECLUSION CFR(s): The CAH must have written policies and procedures regarding the use of restraint and seclusion that are consistent with current standards of practice. This Standard is not met as evidenced by: 50644 Based on record review and interview the facility failed to obtain an order for patient restraints every 24 hours and when discontinued per policy; and failed to complete nursing care plans and documentation for restraint use per policy for 1 out of 3 (Patient #7) patients requiring restraints in a total universe of 26 patient medical records reviewed. Findings Include: A review of facility policy titled, “Restraints Policy” last reviewed 9/17/2025 revealed, “...Obtain an order. The provider must be notified of the application of the restraint immediately following application of the restraint. An order for restraints will be placed as soon as possible in the medical record by the provider OR the nurse...The patient’s need for restraints will be reflected in the plan of care...This includes: Initial documentation to reflect the necessity of a restraint. Ongoing review of the patient’s care plan that reflects the necessity of the restraint...” A review of Patient #7’s medical record from 6/24/2025 to 8/11/2025 revealed the following missing orders and care plans while Patient #7 was in restraints: -7/3/2025 at 12:57 PM through 7/6/2025 at 12:00 PM with no evidence of an order placed on 7/5/2026 to continue the restraints and no evidence of nursing care plans created for the duration of the restraint application. -7/8/2025 at 1:29 AM to 7/9/2025 at (unknown time) with no evidence of a discontinued order for when the restraints were removed and no evidence of nursing care plans created for the duration of the restraint application. -8/3/2025 at 10:19 PM to 8/4/2025 at (unknown time) with no evidence of a discontinued order for when the restraints were removed and no evidence of nursing care plans created for the duration of the restraint application. -8/6/2025 at 4:20 PM to 8/10/2025 at 9:53 PM with no evidence of an order placed for restraints on 8/6/2025, 8/7/2025, 8/8/2025, 8/9/2025 and 8/10/2025. 53566 During an interview on 3/24/2026 at 1:30 PM, Med/Surg (Medical/Surgical) Supervisor T stated that provider orders, nursing care plans, and documentation every two hours on the restraint flowsheet are all part of the required documentation when restraints are initiated for a patient on the Med/Surg unit. During an interview on 3/25/2026 at 8:30 AM, ED (Emergency Department)/Med/Surg Manager A stated that nursing care plans are not required for outpatients in the ED but are required for all inpatients and swing bed patients in the hospital. When asked if Patient #7 should have had a restraint care plan in place each day she was in restraints, ED/Med/Surg Manager A stated, “Yes, [Patient #7] should have.””

“A standard Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 03/24/2026. Marshfield Medical Center - Ladysmith was found to be NOT in substantial compliance with the following applicable regulations for Critical Access Hospital participation in Medicare-Medicaid: 42 CFR Subpart 485.623 - Condition of Participation: Physical Plant and Environment was NOT MET 42 CFR Subpart 485.623(c) - Standard: Life Safety from Fire was NOT MET NFPA 101 (2012 edition) - Life Safety Code was NOT MET This hospital facility is a two-story building constructed in 2023 and classified as Type II (1,1,1) protected non-combustible. The hospital occupancy is located on the lower level of this building. A Rural Health Clinic (business) occupancy occupies Level 1 of this building. The hospital occupancy and business occupancy are separated by a two-hour fire barrier. The hospital is fully protected with an NFPA 13 automatic sprinkler system and has an NFPA 72 addressable, fire alarm system. The facility has a diesel gas-fueled emergency generator that provides power to the emergency loads. Marshfield Medical Center - Ladysmith is licensed for 25 beds, with a census of 5 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. One (1) federal deficiency of the Life Safety Code was cited.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 NEW Smoke barriers shall be constructed to provide at least a one hour fire resistance rating and constructed in accordance with 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations of fully ducted HVAC systems. 18.3.7.3, 18.3.7.4, 18.3.7.5, 8.3 Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 46812 Based on observation and interview, the facility failed to maintain smoke barrier walls 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 8 patients, as well as an undetermined number of staff and visitors. Findings include: On 03/24/2026 at 12:47 pm, observation above the ceiling of the smoke barrier wall on the lower level, adjacent to patient room 104, revealed two (2) 2-inch diameter penetrations with metal conduit and wiring running through them that were not properly fire stopped. This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff C, Staff J, and Staff L.”