Waukesha County Mental Health Ctr

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 42046 Based on observation, staff interviews, and review of maintenance records on 09/09/25, the facility did not construct, install and maintain the building systems to ensure life safety for patients. The cumulative effect of environment deficiencies are not compliant with 42 CFR 482.41(a) was NOT MET resulted in the Hospital’s inability to ensure a safe environment for the patients. Findings include: The facility was found to contain the following deficiencies: K345 Fire Alarm System - Testing and Maintenance K353 Sprinkler System - Maintenance and Testing K362 Corridors - Construction of Walls K511 Utilities - Gas and Electric K521 HVAC K712 Fire Drills K761 Maintenance, Inspection & Testing - Doors K918 Electrical Systems - Essential Electric Systems Refer to the full description at the cited K tags.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47413 Based on observation, record review and interview facility staff failed to provide a safe environment in 1 of 3 group rooms (Occupational Therapy Room) in a total of 3 group rooms observed. Findings Include: A review of the facility policy #CL 87109 titled, “Search of a Patient” last revised 02/19/2020 revealed, “...Contraband is broadly defined as any item that is forbidden and potentially hazardous to clients and staff...” During an observation of the facility’s Occupational Therapy room on 09/10/2025 at 12:12 PM, observed 11 pushpins on the tack board. During an interview on 09/10/2025 at 12:13 PM with RN (Registered Nurse) I and Occupational Therapist Supervisor H, both stated that pushpins would not be allowed on the unit.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 47413 Based on record review and interview the facility failed to review 91 of 117 policies every 3 years in 1 of 1 of policy review. Findings include: A review of the facility policy #HHS 8101 titled, “Policy on Policies” last revised 08/01/2023 revealed, “... policies will be reviewed within three (3) calendar years of last review or revision...” A review of the facility’s list of policies (no title) with columns titled, “Origination Date,” “Review Date- Most Recent,” and “Revision Date- Most Recent” revealed that 91 out of 117 policies were not reviewed every 3 years per facility policy. During an interview on 09/10/2025 at 9:06 AM, Compliance Analyst R stated that the facility is trying to get on a 3-year cycle for reviewing policies, per their policy.”

“MEDICAL STAFF RESPONSIBILITIES - H&P CFR(s): 482.22(c)(5)(i) [ The bylaws must:] Include a requirement that-- (i) A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(5)(iii) of this section. The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oral and maxillofacial surgeon, or other qualified individual in accordance with State law and hospital policy. This Standard is not met as evidenced by: 29963 Based on record review and interview, the facility staff failed to complete the History and Physical exam for patients admitted to the facility within 24 hours per policy for 2 of 30 medical records reviewed (Patients #17, 29) in a total universe of 30 medical records reviewed. Findings include: A review of the facility’s “Mental Health Center Bylaws, Rules, and Regulations, last approved 08/22/2024 revealed, “... All patients shall be given a physical examination by the General Medicine Consultant or their designee within 24 hours of admission, and the examination and patient’s medical history shall be completed and documented in the patient’s record within 24 hours of admission...” A review of Patient #17’s medical record revealed an admission date of 8/22/2025 at 5:35 PM, the history and physical exam was completed on 8/24/2025 at 1:07 PM. A review of Patient #29’s medical record revealed an admission date of 03/22/2025 at 1:00 AM, the history and physical exam was completed on 03/24/2025 at 11:29 AM. During an interview on 09/09/2025 at 3:30 PM, the medical record findings were discussed with and confirmed by Patient Care Coordinator C who stated the medical history, and the physical exam is expected to be completed within 24 hours of admission to the facility.”

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 44431 Based on record review and interview, the facility failed to have a written process for reviewing new medication orders during off hours when a pharmacist is not immediately available for 22 of 22 patients (Pt’s #2, 3, 8, 9, 11, 13, 15, 18, 19, 23, 24, 30, 4, 6, 7, 10, 17, 25, 26, 27, 28, 29) in a total of 30 records reviewed. Findings include: A review of facility policy #CL 87097 last revised 09/04/2025 titled, “Prescriber Orders,” revealed no evidence of a process in place for reviewing medications prior to administering the first dose of medication after hours when a pharmacist is not immediately available. A review of 30 medical records revealed 12 patients (Pt’s. #2, 3, 8, 9, 11, 13, 15, 18, 19, 23, 24, 30) were all admitted to the facility after 4:30 PM Monday through Thursday and there was no evidence of a review of orders being completed prior to the potential first dose of medication(s) given. A review of 30 medical records revealed 10 patients (Pt’s #4, 6, 7, 10, 17, 25, 26, 27, 28, 29) were all admitted to the facility after 4:30 PM on a Friday or the weekend and there was no evidence of a review of orders being completed prior to the potential first dose of medication(s) given. During an interview on 09/09/2025 at 2:20 PM, Pharmacist N stated that for patients admitted after 4:30 PM, a pharmacist would not review the medications until next business day or, if admitted on the weekend, would review on Monday. During an interview on 09/10/2025 at 1:15 PM, Administrator A stated there was not a policy in place for review of medications when patients are admitted during off hours.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 47413 Based on record review, observation, and interview, facility staff failed to discard 5 of 5 expired medications and 4 of 4 expired supplies in 2 of 2 medication rooms observed. Findings include: A review of the facility’s policy titled, “Medication Disposal for Inpatient...” last revised 10/2010 revealed, “... 1.3 Quantities of expired oral or injectable meds (medications)... should be bagged and marked expired and returned to Nursing Administrators for disposal... Ointments, creams... can be disposed of in the garbage...” During a tour and observation of medication rooms 1 and 2 with RN (Registered Nurse) Supervisor S on 09/09/2025 at 10:45 AM observed the following expired medications and supplies in medication rooms 1 and 2: -One (1) 100 count bottle of Vitamin C capsules with an expiration date of 08/2025. -Nine (9) tablets of Denture Cleaner with an expiration date of 07/2025. -One (1) tube of 1 ounce (oz) Preparation H with an expiration date of 08/2025. -One (1) tube of 3.5 oz Icy Hot Balm with an expiration date of 05/2025. -One (1) Tubersol TB Test, 5 Tu/0.1mL, 1mL Vial with a “do not use” date of 08/26/2025. -One (1) 100 count box of 3 milliliter (mL) syringes with an expiration date of 07/31/2025. -Twenty-one (21) 1 mL 27 g (gauge)x ½” Tuberculin syringes with an expiration date of 10/28/2024. -One (1) 18 oz bottle of Hand Sanitizer with Aloe with an expiration date of 03/2025. -One (1) 67.6 oz bottle of Purell Hand Sanitizer with an expiration date of 07/2023. During an interview on 09/09/2025 at 11:15 AM, RN Supervisor S stated that she would discard the expired supplies and medications since they are past expiration date.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 42046 Based on observation, staff interviews, and review of maintenance records on 09/09/2025, the facility did not construct, install and maintain the life safety systems for patients. The cumulative effect of environment deficiencies with 42 CFR 482.41(b) Standard: Safety from Fire was NOT MET resulted in the Hospital’s inability to ensure a safe environment for the patients. Findings include: The facility was found to contain the following deficiencies. K345 Fire Alarm System - Testing and Maintenance K353 Sprinkler System - Maintenance and Testing K362 Corridors - Construction of Walls K511 Utilities - Gas and Electric K521 HVAC K712 Fire Drills K761 Maintenance, Inspection & Testing - Doors K918 Electrical Systems - Essential Electric Systems Refer to the full description at the cited K tags.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 50644 Based on record review and interview, facility staff failed to assess the ongoing risk of the spread of Tuberculosis (TB) in 14 out of 14 (Dietary Supervisor J, Dietician AA, Dietary Aide BB, Medical Director CC, Patient Care Coordinator C, Ocupational Therapist (OT) Y, OT Supervisor H, Registered Nurse (RN) L, Social Worker DD, Psychiatric Service Coordinator B, RN M, RN Supervisor S, Psychiatric Tech EE, Medical Nurse Practitioner (NP) Z and Psychology NP FF) employee files reviewed and failed to maintain employee vaccination records for 11 out of 14 (Dietary Supervisor J, Dietician AA, Dietary Aide BB, OT Y, OT Supervisor H, RN L, Social Worker DD, Psychiatric Service Coordinator B, RN M, RN Supervisor S, Psychiatric Tech EE and Medical NP Z) direct patient care staff in a total sample of 14 personnel files reviewed. A review of facility policies revealed no active policies in place to monitor ongoing risk/assessment for TB. A review of facility policy, “Administrative Policy and Procedure Manual Vol.II, Ch.1 Recruitment and Selection” last revised August 2025 revealed, “... Individuals hired for certain County positions must have completed specific physical examinations and other tests prior to the commencement of their employment. Examples of these examinations and evaluations include ...Rubella, Rubeola, and Hepatitis B Titer ...” A review of personnel files on 9/10/2025 at 9:00 AM revealed no documented evidence for ongoing assessment of TB risk in employees for Dietary Supervisor J, Dietician AA, Dietary Aide BB, Medical Director CC, Patient Care Coordinator C, OT Y, OT Supervisor H, RN L, Social Worker DD, Psychiatric Service Coordinator B, RN M, RN Supervisor S, Psychiatric Technician EE, Medical NP Z and Psychology NP FF. A review of personnel files on 9/10/2025 at 9:00 AM revealed no documented evidence of vaccination records for Dietary Supervisor J, Dietician AA, Dietary Aide BB, OT Y, OT Supervisor H, RN L, Social Worker DD, Psychiatric Service Coordinator B, RN M, RN Supervisor S, Psychiatric Technician EE and Medical NP Z. During an interview on 9/10/2025 at 1:11 PM, Patient Care Coordinator C stated that there is a yearly questionnaire that should be filled out to assess TB risk. During an interview on 9/10/2025 at 11:23 AM, Human Resources (HR) Representative X stated that required vaccinations are done at the health clinic and are not kept in the employee file. No evidence of the required vaccinations were provided. During an interview on 9/10/2025 at 2:00 PM, Administrator A stated that the “TB risk assessment policy is currently in draft form” and that there is no active policy that they are following to assess for ongoing TB risk in their employees.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and 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 perform hand hygiene per policy in 1 of 4 patient care observations (Patient #6) performed, failed to prevent potential exposure to blood borne pathogens in 1 of 1 injection (Patient #6) in a total of 4 observations of patient care observed, and failed to maintain a clean and sanitary environment free from sources of contamination in 1 of 1 nursing unit observed. A review of facility policy #CL 87139 titled, “Hand Washing and Hand Hygiene” last revised 12/9/2020 revealed, “1. Hand hygiene/hand washing to be performed before and after patient contact...” A review of facility policy #CL 87054 titled, “Disposal of Contaminated Syringes” last revised 1/8/2021 revealed, “... workforce members shall dispose of contaminated needles in a safe manner in accordance with Occupational Safety and Health Administration (OSHA) standards.” During a tour and observation of the nursing unit on 09/09/2025 at 11:20 AM with Patient Care Coordinator C, the following was observed: Patient room 146 and room 152 had multiple pencil eraser size areas of exposed sheet rock and chipped paint on the walls that did not allow the areas to be cleanable or wipeable. Multiple paper decorations and paper notices that were not cleanable or wipeable taped to the walls in the nursing unit. During an observation of care on 9/9/2025 at 4:20 PM, Registered Nurse (RN) O entered Patient #6’s room, placed gloves on and gave a subcutaneous injection in the right arm without performing hand hygiene. After completing the subcutaneous injection, RN O closed the safety needle device with her fingers putting her at risk of a needle stick injury. During an interview on 09/09/2025 at 11:30 AM, Patient Care Coordinator C stated they were not aware of the paint chips or exposed sheet rock and didn’t know who was responsible for checking for this problem. During an interview on 9/10/2025 at 7:51 AM, Patient Care Coordinator C stated that hand hygiene should be performed before starting, upon completion of medication administration, and upon entering and exiting a patient room. During an interview on 9/10/2025 at 10:55 AM, when asked if it would be appropriate to close a dirty needle after injection with your fingers, RN I stated, “No.” 44431”

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 42046 Based on record review and interview, the facility failed to maintain an emergency preparedness plan in accordance with the requirements of 42 CFR 403.748(a). This deficient practice could affect all 11 patients and an undetermined number of staff and visitors. Findings include: On09/09/2025 at 4:00 pm, review of the facility’s Emergency Preparedness Plan revealed that the plan including the All Hazards Risk Assessment was not updated/reviewed within the past year. Most recent update was 02/13/2020. This deficient practice was confirmed by Staff D and Staff S at the time of discovery.”

“Development of Communication Plan CFR(s): §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This Standard is not met as evidenced by: 42046 Based on record review and staff interview, the facility did not have a communication plan as part of their emergency preparedness plan in accordance with the requirements of 42 CFR 485.625(c). This deficiency has the potential to affect all patients and an undetermined number of staff and visitors. Findings include: On 09/09/2025 at 3:55 pm, record review revealed that the facility did not have an updated written emergency communication plan. The plan’s policy CL87024 Communication Plan was last updated on 02/13/2020. The plan had an origin date of 10/01/2017, a reviewed date of 02/13/2020 and a revision date of 00/00/00. This deficient practice was confirmed by Staff D and Staff S.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 42046 Based on record review and staff interview, the facility did not participate and document two Emergency Preparedness exercises in the past 12 months to test the plan per 42 CFR section 483.73(d)(2). This deficient practice could affect all residents as well as undetermined number of staff and visitors. Findings include: On 09/09/2025 at 4:10 pm, record review of the emergency preparedness plan over the past 18 months revealed that the facility did not participate or conduct two exercises to test their emergency plan by participating in a facility based, tabletop or full-scale, community-based exercise or an actual event within the past year. The last recorded exercises included a Chemical Emergency Surge Table-Top which was an exercise held on 01/31/2024 and Medical Response surge on 02/29/2024. Both exercises were held beyond the required 12 month period. This deficient practice was confirmed at the time of discovery with Staff D and Staff S.”

“A Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 09/09/2025. Waukesha County Mental Health was found to be NOT in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid: 42 CFR 482.41(a) Condition of Participation: Physical Environment was NOT MET 42 CFR 482.41(b)(c) Standard: Safety from Fire was NOT MET NFPA 101- Life Safety Code was NOT MET The Waukesha County Mental Health Center is a 1-Story structure built in 1993, with Type II (000) noncombustible construction, including structural steel framing, CMU smoke barrier walls, and a brick exterior. There are two roof-top mechanical penthouses and a partial basement under the center core of the building. The facility was fully-sprinklered and had smoke detection in all corridors, inpatient sleeping rooms, and hazardous spaces. Most exit doors were consistently locked as staff possessed keys at all times. The facility had a 500kW emergency generator that provided power to the emergency loads. The facility contained (2) patient care wings (the A and B Units) and (5) smoke compartments, including the basement. Waukesha County Mental Health Center is licensed for 16 beds, with a census of 9 patients at the time of the survey. The hospital facility was surveyed under the 2012 Life Safety Code, Chapter 19 Existing Health Care Occupancies. Eight (8) federal deficiencies of the Life Safety Code were cited.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 42046 Based on record review and interview, the facility did not perform the semi-annual testing and inspections of the fire alarm system in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.4.1, 9.6.1.3, and 9.6.1.5; as well as NFPA 72, 2010 edition, Sections 14.1, 14.1.4, 14.3.1, 14.3.3, 14.4.2.2, 14.4.5, and 14.6. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: 1. On 09/09/2025 at 09:34 am, observation of the FACP at the entrance area of the facility revealed that there was a trouble alarm on the panel. When Staff was asked about the alarm Staff were unaware that there was a trouble alarm on the panel. 2. On 09/09/2025 at 12:00 pm, record review of fire alarm inspection and testing documents revealed that the semi-annual visual inspection of notification devices (horns, strobes, bells, chimes, or combination thereof), was not conducted by the facility or Action Fire and Alarm within the past 18 months. Staff W stated via phone that the facility does not do semi-annual inspections of the fire alarm system. This deficient practice was confirmed by Staff U and Staff V at the time of discovery.”

“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: 42046 Based on observation and interview, the facility did not maintain an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems 2010 edition as required in NFPA 101: Life Safety Code, 2012 edition sections 9.7, 9.7.1.1(1), 19.3.5.1; NFPA 13 (2010 edition) Sections 6.2.9.1, 6.2.9.7 and 6.2.9.7.1. This deficient practice could affect all residents and an undetermined number of staff and visitors. Findings include: On 09/09/2025 at 3:14 pm, observation at the Sprinkler Riser revealed one spare sprinkler head box mounted on the wall near the sprinkler supply riser did not include a list of sprinkler heads installed with sprinkler identification number or the manufacturer model, orifice, deflector type, thermal sensitivity, pressure, type installed, sprinkler identification number and other required information consisting of general description, quantity of each type to be contained in the cabinet and the issue or revision date of the list. This condition was confirmed at the time of discovery by Staff U and Staff V.”

“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: 42046 Based on observation and interview, the facility did not provide smoke barrier corridor wall separations as required in NFPA 101, 2012 edition, Sections 19.3.6.2.5, 19.3.6.2.6, 8.4.2, and 8.4.4. This deficient practice could affect an undetermined number of residents, staff and visitors. Findings include: On 09/09/2025 at 3:05 pm, observation above the lay in ceiling in the corridor outside of the CRC meeting room revealed a flexible metal BX cable pierced the 1-hour rated corridor wall and damaged the gypsum board around the opening and was not fire stopped according to an approved method. These deficient practices were confirmed by Staff U and Staff V at the time of discovery.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 42046 Based on observation and staff interview, the facility did not ensure the electrical wiring and equipment met the requirements of NFPA 101, 2012 Edition, Sections 19.5.1.1 and 9.1.2, as well as NFPA 70, edition 2011, Articles 110.8 and 110.27. This deficient practice could affect an undetermined number of staff and visitors. Findings Include: On 09/09/2025 at 2:45 pm, observation above the lay in ceiling in the corridor near smoke barrier wall and doors 1087A revealed that four, 4-inch by 4-inch metal electric junction boxes did not have cover plates leaving the raceway system open. The deficient practice was confirmed by Staff U and Staff V at the time of discovery.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 42046 Based on observation and interview, the facility did not provide control of environmental ventilation per NFPA 101, 2012 edition, Sections 19.5.2.1, 19.7.6, 2.1, 4.5.8, 4.6.12, and 9.2; NFPA 99, 2012 edition, Sections 9.1.3 and 9.3.1.1; as well as ASHRAE Standard 170, 2008 edition, Section 7.1. These deficient practices could affect 2 of 11 residents, as well as an undetermined number of staff and visitors. Findings Include: On 09/09/2025 at 2:15 pm, observation in Resident Rooms 152 and Room 153 revealed that the return grills were not returning air to the HVAC system resulting in an odor present in the room. The return air grills were completely blocked with dust. The pressure relationship between the resident room and the corridor was not maintained. The deficient practice was confirmed by Staff U and Staff V at the time of discovery.”

“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: 42046 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 and 19.7.1.6. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: 1. On 09/09/2025 at 11:20 am, review of the facility fire drills for the last twelve months revealed that fire drill record did not include the record of transmission of the alarm signal to the monitoring company. 2. On 09/09/2025 at 11:22 am, review of the fire drill records for the last twelve months revealed that the fire drills were not conducted at varied times. The facility performed fire drills during the 1st shift on 01/21/25 at 11:43 am, on 7/17/2025 at 11:30 am and on 12/16/24 at 10:43 am. The facility performed fire drills during the 2nd shift on 02/16/25 at 9:10 pm, on 05/19/25 at 9:41 pm, and on 08/25/24 at 9:25 pm. The facility performed fire drills during the third shift on 03/20/25 at 11:53 pm and on 06/24/24 at 12:15 am. 3. On 09/09/2025 at 11:23 am, review of the fire drill records for the last twelve months revealed that the time of the drill was not recorded for the drill held on 11/25/24. This condition was confirmed at the time of discovery by a concurrent interview with Staff U and Staff V.”

“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: 42046 Based on record review and interview, the facility did not inspect smoke and fire rated door assemblies at least annually with a written record of inspection and testing in accordance with NFPA 101, 2012 edition, Sections 21.7.3, 21.7.6, 4.6.12, 7.2.1.15, 8.2.2.4, 8.3.3.3, and 8.3.3.4; as well as NFPA 80, 2010 edition, Sections 5.2 and 5.2.4. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors. Findings include: On 09/09/2025 at 12:29 pm, record review revealed that the facility had no record that fire rated door assemblies, including any corridor, combination smoke and fire barrier, or other doors, had been inspected or tested within the past 12 months. This deficient practice was confirmed at the time of discovery with Staff U and Staff V.”

“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: 42046 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, 8.3.4, 8.3.7, 8.3.7.1, and 8.3.7.2. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: On 09/09/2025 at 12:37 pm, record review of the monthly emergency generator inspection and testing documentation over the past 12 months revealed that conductance or specific gravity tests of the generator batteries was not performed. This finding was confirmed at the time of discovery by a concurrent interview with Staff U and Staff V.”