St Croix Regional Medical Center

“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-0311 - Vertical Openings - Enclosure K-0346 - Fire Alarm System - Out of Service K-0353 - Sprinkler System - Maintenance and Testing K-0372 - Smoke Barrier Construction K-0712 - Fire Drills 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.”

“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-0311 - Vertical Openings - Enclosure K-0346 - Fire Alarm System - Out of Service K-0353 - Sprinkler System - Maintenance and Testing K-0372 - Smoke Barrier Construction K-0712 - Fire Drills K-0918 - Essential Electric System Maintenance and Testing 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: 50643 Based on record review, observation and interview the facility failed to remove expired food items and failed to label food expiration dates in 1 (Kitchen) of 3 food storage areas observed. Findings Include: A review of facility policy “Food Storage” dated 9/2024 revealed, “...All stock must be rotated with each new order received. Rotating stock is essential to ensure freshness and highest quality of all foods. 1. Place new items behind stock already on shelf... 2. Date all items when shelved...” A review of facility policy “Food Handling” dated 9/2024 revealed, “...Inspect all foods thoroughly freshness... Check for expiration dates...” During an observation on 3/10/2026 at 11:00 AM, in the walk-in freezer, the following items were observed to be not dated: (21) loaves of bread, (4) packages of hamburger buns, (4) packages of hot dog buns, and (5) decorated cakes. During an observation on 3/10/2026 at 11:10 AM in the stand-alone freezer, the following items were observed to be out of date: (4) Belgian Waffles dated 11/2021. During an observation on 3/10/2026 at 11:17 AM in the dry food storage area, the following items were observed to not have a date: (16) containers/packages of cake decorating sprinkles. During an observation on 3/10/2026 at 11:40 AM in the deli area refrigerator, the following items were observed: (2) Glucerna nutrition shakes with expiration date of 3/1/2026, (1) Soy Chocolate Shake with expiration date of 3/5/2026, and (1) opened tube of whipped topping with no date. During an interview on 3/10/2026 at 11:06 AM, Dietary Manager N stated that the loaves of bread, buns, and cakes in the walk-in freezer are obtained from a local bakery and are not dated when received. Dietary Manager N stated that they do not date the items when they receive them because everything is used within a few months. Dietary Manager N stated that all other items in all storage areas of the Kitchen should be dated. Dietary Manager N stated that the Belgian waffles should not have been stocked as they were expired. Dietary Manager N stated that the Glucerna and Soy Chocolate Shakes should have been disposed of on their expiration dates.”

“RECORDS SYSTEM CFR(s): (1) The CAH maintains a clinical records system in accordance with written policies and procedures. This Standard is not met as evidenced by: 44431 Based on record review, observation and interview, the facility failed to protect the security of medical records in 1 (Medical Records) department out of a total universe of 3 departments where medical records are stored. Findings: A review of the facility policy #18243501 effective date of 07/2025 titled, “Filing of Medical Records Procedure,” revealed, “Background:...Paper records are filed in a locked storage....accessible by designated....personnel only.” On 03/10/2026 at 9:36 AM a tour and observation was conducted of the facility medical records department. Observed medical records in manilla folders sitting on a metal cart between office cubicles that was unable to be locked. Observed an 8 shelf metal bookshelf containing patient medical records that was unable to be locked against a wall. An interview was conducted on 03/10/2026 at 9:45 AM with Medical Records Lead BB. Lead BB was asked if these charts were secured and locked after medical records staff left at night and Lead BB stated, “No they are not.” When asked who has access to the department after hours Lead BB stated, “Everyone that works here and EVS (Environmental Services) cleans then.” On 03/11/2026 at 1:20 PM in an interview with EVS manager OO when asked when EVS staff clean the medical records department, EVS Manager OO stated, “They vacuum after hours when no one is there and they collect the trash during business hours.””

“RECORDS SYSTEM CFR(s): For each patient receiving health care services, the CAH maintains a record that includes, as applicable-- (i) Identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient; This Standard is not met as evidenced by: 52395 Based on record review and interview the facility failed to obtain a witness date and time in 4 of 6 (Pt. #27, Pt. #28, Pt. #30, Pt. 31) patients and failed to certify that the form has been fully explained in 4 of 6 (Pt. #27, Pt. #28, Pt. #29, Pt. 31) patients of 6 patients requiring consent for an invasive or surgical procedure in a total universe of 30 medical records reviewed. During a medical record review on 3/11/2026 with Interim Director AA and OR RN PP between 11:35 AM-12:47 PM the medical records revealed, no evidence of witness date and time for the following: -Pt. #27- Consent on 3/10/2026 for “Colonoscopy (examination of the intestine) with possible polypectomy (polyp removal) and/or biopsy (tissue sample). Possible HCT (CT Colonography- virtual colonoscopy).” Consent had an RN signature with no date and time. -Pt. #28- Consent on 03/11/2026 for “Laparoscopic (surgery using small incisions) Cholecystectomy (gall bladder removal) with umbilical herniorrhaphy (surgery to repair a hole in the stomach at the belly button) x 2.” Consent had an RN signature with no date and time. -Pt. #30- Consent on 12/19/2025 for “Arthroplasty Hip (removal of damaged bone in the hip) Anterior (front) Approach -Left.” Consent had an RN signature with no date and time. -Pt. #31- Consent on 3/10/2026 for “Colonoscopy with possible polypectomy and/or biopsy.” Consent had an RN signature with no date and time. During a medical record review on 3/11/2026 with Interim Director AA and OR RN PP between 11:35 AM-12:47 PM the medical record revealed, no evidence to certify form has been fully explained, checking the box (#8 on the consent form that states: “I certify this form has been fully explained to me, that I have read it or had it read to me...” -Pt. #27- Consent on 3/10/2026 for “Colonoscopy with possible polypectomy and/or biopsy. Possible HCT (CT Colonography- virtual colonoscopy).” Consent had no evidence to certify form has been fully explained, checking the box (#8 on the consent form that states: “I certify this form has been fully explained to me, that I have read it or had it read to me...” -Pt. #28- Consent on 3/11/2026 for “Laparoscopic Cholecystectomy with umbilical herniorrhaphy x 2.” Consent had no evidence to certify form has been fully explained, checking the box (#8 on the consent form that states: “I certify this form has been fully explained to me, that I have read it or had it read to me...” -Pt. #29- Consent on 12/5/25 for “Laparoscopic Cholecystectomy with intraop cholangiogram (a procedure to check for obstructions in the liver, gallbladder or bile duct).” Consent had no evidence to certify form has been fully explained, checking the box (#8 on the consent form that states: “I certify this form has been fully explained to me, that I have read it or had it read to me...” -Pt. #31- Consent on 3/10/2026 for “Colonoscopy with possible polypectomy and/or biopsy.” Consent had no evidence to certify form has been fully explained, checking the box (#8 on the consent form that states: “I certify this form has been fully explained to me, that I have read it or had it read to me...” An interview was conducted on 3/11/2026 at 11:35 AM with the Interim Director of OR AA. Director AA stated, “If the patient gets a pre consent in the clinic, the RN would document in the verification of surgery section on the consent. If they start in the hospital, they should be checking the box (#8 on the consent form that states: “I certify this form has been fully explained to me, that I have read it or had it read to me ...)” and patient should sign and date it with the RN to witness.” When asked why there is no date or time for the witness, she stated she wasn’t sure because she just started a few months ago. An interview was conducted on 3/11/2026 at 2:15 PM with OR RN PP, when asked why some people are signing in different areas on the consent and some check the box in #8 and some use #9 OR RN PP stated, “I am not sure who signs where, it is usually RN preference.” During an interview on 3/11/2026 at 2:48 PM with CAO (Chief Administrative Officer) F, when asked if she was aware of these issues with consents she stated, “I am aware we have some work to do.””

“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 record review, observation and interview, facility staff failed to complete hand hygiene per policy in 4 of 4 dietary staff (Dietary Staff K, L, M, J) observations of food preparation, in 1 of 1 surgical staff (RN U) observations of surgical procedures, and in 1 of 1 patient care staff (RN R) observations of patient care in a total of 9 hand hygiene opportunities observed. Examples of hand hygiene/infection control in Dietary: Review of the facility policy titled, “Food handling” dated 9/2024 revealed, “...Observe good grooming and hygiene practices... wear clean work clothes... wash hands thoroughly...” During an observation on 3/10/2026 at 11:23 AM Dietary Staff K was observed washing her hands for 6 seconds while preparing hospital patient lunch trays. During an observation on 3/10/2026 at 11:24 AM Dietary Staff L was observed washing her hands for 6 seconds while preparing hospital patient lunch trays. During an observation on 3/10/2026 at 12:00 PM Dietary Staff M was observed washing her hands for 7 seconds while preparing hospital patient lunch trays. During an observation on 3/10/2026 at 12:04 AM Lead Cook J was observed washing her hands for 10 seconds while preparing hospital patient lunch trays. During on interview on 3/10/2026 at 11:25 AM, Dietary Manager N stated, “Dietary staff should be washing their hands for 20 seconds.” Examples of hand hygiene/infection control in Surgical Services: Review of the facility policy titled, “Infection Prevention Practices Policy” dated 8/2025 revealed, “if gloves are worn during patient cares, perform hand hygiene immediately after gloves are removed.” During an observation of a lap chole (cholecystectomy) gallbladder removal on 3/11/2026 at 8:30 AM RN U was observed taking the gloves off after getting patients prepped and putting new gloves on without hand hygiene. During an interview with the Infection Preventionist (IP) CC on 3/11/2026 at 8:42 AM, when asked if IP CC saw RN U complete hand hygiene she stated “No.” Examples of hand hygiene/infection control on the Medical Surgical unit: During an observation on 3/11/2026 at 8:45 AM RN R was observed doing personal cares and a dressing change for Pt. #33 who was on enteric precautions due to a stool infection. Pt. #33 was incontinent of stool. RN R assisted in changing and bathing. Gloves were changed during cares and prior to dressing change without hand washing.”

“NOTICE OF RIGHTS CFR(s): A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under state law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible This Standard is not met as evidenced by: 44431 Based on record review and interview the facility failed to provide an Important Message from Medicare (IMM) notice upon admission for 2 (Patient #1 and Patient #21) patients and failed to provide an IMM notice no later than 2 days prior to discharge for 2 (Patient #1 and #21) patients of 11 medicare patients in a total universe of 30 medical records reviewed. Findings: A review of Pt. #1’s medical record revealed Pt. #1 was admitted to the facility on 12/6/2025 and was discharged on 12/13/2025. There is no evidence that Pt. #1’s activated Power of Attorney (POA) received an IMM upon Pt. #1’s admission to the facility and no evidence the POA received an IMM notice prior to Pt. #1’s discharge. These findings were confirmed in an interview with RN (Registered Nurse) Discharge Planner O on 03/11/2026 at 3:00 PM. A review of Pt. #21’s medical record revealed Pt. #21 was admitted to the facility on 03/03/2026 as an observation patient and was changed to an inpatient on 03/06/2026 and discharged on 03/11/2026. There is no evidence that Pt. #21 received an IMM upon their admission to the facility. Ongoing review of Pt. #21’s medical record revealed an IMM notice was given on 03/11/2026 at discharge and no time was written on the notice. An interview was conducted with Nurse Manager Y on 03/11/2026 at 1:10 PM. Nurse Manager Y stated, “We don’t have a policy on when to give the IMM.””

“A standard Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 03/10/2026. St. Croix Regional Medical Center 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 Building #01 The original two-story above grade hospital, with an additional story below grade, was approved and built in the 1950’s and classified as Type II (1,1,1) protected non-combustible. Building additions were constructed in 1971 (Hospital), 2002 (Emergency Department) and 2007 (Lloyd Olson Surgery Center). All three additions are two-story above grade and one story below grade and classified as Type II (1,1,1) protected non-combustible. The 2007 addition also includes a Helipad on top of the Lloyd Olson Surgery Center. The building is partially protected with an NFPA 13-automatic sprinkler system. The facility has an NFPA 72 addressable, fire alarm system. The facility has two (2) emergency generators that provide power to the emergency loads. The stories are as follows: - Ground floor: Partially below grade, with multiple points of exit discharge. - First Floor: Main Entrance - Second Floor: Atrium partially connects First and Second Floors. - Third Floor: Helipad (unoccupied) Note: the Helipad third floor is not counted as a fourth story, as it is not an occupiable story. Occupancy Note: The Critical Access Hospital is separated from the Main Clinic by a two-hour fire-rated occupancy separation barrier. Three (3) Rural Health Clinics associated with the hospital were not included in the survey: The main clinic, the Unity Clinic, and the Frederic Clinic. St. Croix Regional Medical Center is licensed for 25 beds, with a census of 10 inpatients at the time of the survey. The facility was surveyed under the 2012 Life Safety Code, Chapter 19 for an existing health care occupancy. Six (6) federal deficiencies of the Life Safety Code were cited.”

“Vertical Openings - Enclosure CFR(s): NFPA 101 Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box. This Standard is not met as evidenced by: 46812 Based on observation and interview, the facility did not protect the atrium vertical opening in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.1, 8.3, 8.3.2, 8.3.5, 8.3.5.1, and 8.6.7. This deficiency has the potential to affect 6 patients, as well as an undetermined number of staff and visitors. Findings include: On 03/10/2026 at 3:47 pm, observation above the ceiling of the 1-hour fire-rated wall at the entry to Med/Surg revealed two gypsum scab patches, approximately 4-inch x 12-inch and 12-inch x 18-inch in size, that do not meet the tested and listed fire-rated wall assembly and was not protected in accordance with the listed penetration firestop assembly Gypsum Association GA-225-2019. Observation also revealed a 2-inch diameter penetration and a 2-inch x 4-inch penetration through the fire-rated wall that were not properly fire stopped. This wall and door are part of the one-hour fire-rated separation for the atrium. This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff I.”

“Fire Alarm System - Out of Service CFR(s): NFPA 101 Fire Alarm - Out of Service Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.6 This Standard is not met as evidenced by: 46812 Based on record review and interview, the facility did not provide a comprehensive fire watch policy and procedure in accordance with NFPA 101 (2012 edition) Section 9.6.1.6. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors. Findings include: On 03/10/2026 at 4:27 pm, record review of the fire watch policy revealed that the facility did not have wording stating that fire alarm outage rounds are to be continuous. The policy stated, “Fire watch members shall inspect all spaces in the affected area within 30 minutes of the outage and no less than every 30 minutes throughout the outage.” This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff I.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 46812 Based on observation and interview, the facility did not maintain the automatic sprinkler system in accordance with NFPA 101 (2012 edition) Sections 9.7.1.1, 9.7.5, and 19.3.5.1; NFPA 25 (2011 edition) Sections 5.1.1.2, 5.2.1.1, and 5.4.1; and NFPA 13 (2010 edition) Section 26.1. This deficient practice could affect 4 patients, as well as an undetermined number of staff and visitors. Findings include: On 03/10/2026 at 3:34 pm, observation in the corridor near the Administration smoke barrier doors revealed a concealed sprinkler head cover had been painted blue to match the ceiling. All other concealed sprinkler head covers were white. This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff I.”

“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: 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 6 patients, as well as an undetermined number of staff and visitors. Findings include: On 03/10/2026 at 3:31 pm, observation above the ceiling of the smoke barrier wall on the ground floor adjacent to the Marketing & Communications office revealed a 3-inch diameter penetration with wires and metal conduit running through it that was not properly fire stopped. This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff I.”

“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: 46812 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, 4.7.4, 4.7.6, 19.7.1, 19.7.1.4, 19.7.1.6, & 19.7.1.7. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors. Findings include: On 03/10/2026 at 9:29 am, review of the facility fire drill reports for the last twelve months revealed that fire drills were not conducted at varied times. Two of the four quarterly fire drills done during first shift were at 1:00 pm. These drills were conducted on 02/26/2026 and 11/28/2025. The four quarterly fire drills done during second shift were all within an hour and a half of each other. The quarter one drill was conducted on 01/30/2026 was at 3:20 pm, the quarter two drill was conducted on 04/30/2025 at 3:25 pm, the quarter three drill was conducted on 07/29/2025 at 4:30 pm, and the quarter four drill was conducted on 10/30/2025 at 3:55 pm. This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff I.”

“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: 46812 Based on record review and staff 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; NFPA 99 (2012 edition) Section 6.4.3.1; and NFPA 110 (2010 edition) Section 8.4.6. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors. Findings include: 1. On 03/10/2026 at 11:01 am, review of the monthly generator documentation for the past 12 months for Generator #1 revealed that the time it takes for the automatic transfer switch to engage during monthly generator tests was greater than 10 seconds for the monthly reports dated 02/16/2026, 09/02/2025, and 11/14/2025. 2. On 03/10/2026 at 11:06 am, review of the monthly generator documentation for the past 12 months for Generator #2 revealed that the time it takes for the automatic transfer switch to engage during monthly generator tests was greater than 10 seconds for the monthly reports dated 02/16/2026, 05/01/2025, 06/24/2025, and 12/22/2025. These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff I.”

“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: 50643 Based on record review and interview, the facility staff failed to implement immediate actions outlined in the water management plan in response to a suspected case of hospital acquired legionella for 1 of 1 patients (Patient #1), and failed to identify mitigation opportunities to reduce the risk of growth of pathogens in 1 of 1 water management plan. Findings Include: A review of the “Water Management Plan” last revised 2/2024 revealed, “[Facility M] has developed and implemented a water management plan to ensure the safety of its water sources at the hospital and clinic in [Facility M.] Elements of the plan are based on the guidance of the ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) publication “Water Management in Healthcare Facilities: Complying with ASHRAE standard 188” which references CDC (Centers for Disease Control and Prevention) guidelines and is in compliance with CMS directive QSO-17-30... ·5. Process for reporting and responding to a suspected case of Legionella: a. [Facility M] have a suspected or verified case and cannot confirm its source (community based or facility based). b. Parties from Infection Prevention, Facilities, Quality, Laboratory, and the discovering clinical team will meet to discuss possible exposure possibilities. c. Decision may be made to test [Facility M] water sources that had been high likelihood for exposure/contact by that Individual (may be showers, spa, electric water coolers, etc.). d. Determine through external sources the best options for decontamination of domestic water system. Include testing of city source water. e. Activate incident command to manage the decontamination, notification, and resumption of normal services. f. If Legionella is present in [Facility M] water system, immediately cease the use of water that may lead to breathing of aerosolized vapors, such as the use of water coolers, showers, spa... g. Contact remediation firms that specialize in the discovery and abatement of Legionella in domestic water systems...” On 2/26/25, Patient #1 was readmitted to Facility M with concerns for fever, hypotension, tachycardia, hypoxia, and cough. On 2/26/25 Patient #1’s urine antigen test resulted positive for Legionella. Patient #1 was treated with Azithromycin (antibiotic that treats Legionella Pneumonia), and discharged in a stable condition to Facility N on 3/3/2025. A review of Facility M’s Legionella tracking timeline revealed the following: ·2/27/25: Facility M received Patient #1’s positive Legionella test results. ·2/28/25: Infection Preventionist RN F reported Patient #1’s positive Legionella test result to WEDSS (Wisconsin Electronic Disease Surveillance System). There was no evidence that incident command was implemented per the water management plan or further notifications and communication was completed. On 3/12/25: Water samples were collected by the State Department of Public Health and County Health Department P. The Facility was notified the water tested positive for Legionella on 3/20/25. On 3/17/25 leadership met to review “logistics for remediation strategies including hyper-chlorination and subsequent water shut down, mass flushing, filtration and ongoing testing.” There was no evidence of actions taken as a result of this meeting. On 4/1/25 (33 days after Patient #1 tested positive and 20 days after Water Testing Results) the facility began flushing of faucets throughout the facility. ·4/4/25: Signage was added to Facility M entrances notifying of Legionella in water. Point of use filters added to sinks in patient care areas and public restrooms. Signs were added to sinks without filters notifying users that sink does not have point of use filter. An interview was conducted on 4/8/25 at 2:00 PM with Infection Preventionist F. Infection Preventionist F stated that the action he took immediately following the notification of Patient #1’s positive Legionella result was to report it to Director of Quality D and to enter it in the WEDSS system. Infection Preventionist F stated that he did not take any other action until he received notification from County Health Department P.”

“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 record review, interview and observation the facility failed to disinfect the water system by thermal or other disinfection method when the facility’s water tested positive for Legionella in 1 of 1 hot water system supply. The facility also failed to maintain hot water temperatures for prevention of future Legionella outbreaks. Based on record review, interview and observation the facility failed to disinfect the water system by thermal or other disinfection method when tested positive for Legionella and failed to maintain hot water temperatures for prevention of Legionella in 1 of 1 hot water system supply. A review of State Plumbing Code 382.50(3)(ag), 382.50(3)(b)(6) revealed that hot water supply temperature to be initiated and stored at 140 deg F in holding tank. Return water temperature is to be a minimum of 124 deg F. A review of ASHRAE 12 guidelines revealed, recommend 140 deg F supply and return water temperature of 124 deg F. Findings Include: Review of the facility Water Management Plan (WMP) revealed that the facility did not have a policy that provides for the temperature of hot water supply at the source i.e. starting point of hot water distribution piping based on CDC and ASHRAE 12 guidelines to maintain hot water circulation in distribution piping above a certain minimum to reduce the risk of growth of pathogens including the growth of legionella bacteria. Alternatively, the WMP did not provide for a disinfectant system to treat municipal water entering the building in accordance with CDC and ASHRAE. On 2/26/25, Patient #1 was readmitted to Facility M with concerns for fever, hypotension, tachycardia, hypoxia, and cough. On 2/26/25 Patient #1’s urine antigen test resulted positive for Legionella. Patient #1 was treated with Azithromycin (antibiotic that treats Legionella Pneumonia), and discharged home in a stable condition to Facility N on 3/3/2025. On 3/12/25: Water samples were collected by the State Department of Public Health and County Health Department P. The Facility was notified the water tested positive for Legionella on 3/20/25. The facility failed to disinfect the domestic hot water system piping and fixtures based on CDC and ASHRAE 12 guidelines - raising the hot water temperature to a recommended high and maintaining at that level while progressively flushing each outlet around the system, chlorination followed by flushing, or other approved disinfectant system. Recolonization is possible unless proper hot water temperature is maintained in the distribution piping, or if subsequent periodic chlorination is not carried out per ASHRAE 12 guidelines. On 04/08/2025 between 10 AM and 2 PM, observation, record review and staff interview revealed that the temperature gauge in the outlet pipe of hot water mixing valve in the mechanical room read water temperature of 118 deg F. The hot water at 118 deg F was supplied to the distribution line serving the 1972 building housing patient sleeping areas and treatment areas. Water returned to the holding tank in the mechanical room at 112 deg F - the temperature reading at temperature gauge in the return line to building. Review of hot water supply temperature log between 1:30 PM and 2:15 PM revealed that the hot water temperature supplied to 1972 building varied from 116 to 120 deg F. The above water temperature readings were confirmed by interview with Director of Facilities G, and Infection Preventionist RN F at the time of discovery. In an interview on 04/14/2025 at 11:27 A.M. State Legionella Hygiene Specialist J stated that because there has been an outbreak recently in the facility, it can be concluded that Facility M’s WMP did not provide for adequate control of the legionella bacteria in the hospital domestic hot water plumbing system by implementing proper remediation method in accordance with State Plumbing Code SPS 382.50 and ASHRAE 12 and CDC guidelines. Facility M failed to disinfect the water system by thermal or disinfection method when the Legionella outbreak was discovered.”