Trempealeau Cty Hcc Imd

Based on observation, interview, and record review, the facility failed to secure controlled substances in a locked container separate from containers for any non-controlled medications, and to linit access to authorized personnel consistent with state or federal requirements and professional standards of practice for all 31 residents in the facility.Surveyor observed a medication refrigerator inside the locked medication room that did not have a lock in place securing entry to medications. Surveyor observed a box of liquid oral lorazepam and a vial for IV injection of lorazepam. Both packages were unopened.This is evidenced by:Facility policy, titled Controlled Substances, with a reviewed date of 10/29/25, states in part: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation: 5. Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must always remain locked, except when it is accessed to obtain medications for residents.On 03/09/26 at 10:06 AM, Surveyor toured the locked medication storage room on [name of unit] with Registered Nurse (RN) H. Surveyor observed a medication refrigerator inside that did not have a lock in place securing entry to medications. Surveyor asked RN H to open the refrigerator door and observed a box of liquid oral lorazepam and a vial for IV injection of lorazepam. Both packages were unopened. Surveyor asked RN H about the lorazepam. RN H stated it was for emergency supply and not prescribed for a specific resident. Surveyor asked RN H if there was a lock for the refrigerator. RN H stated no.On 03/09/26 at 1:12 PM, Surveyor interviewed Director of Nursing (DON) B regarding observation. DON B stated not being aware of the requirement to store the controlled medication in refrigerator in a separate locked compartment. DON B stated that this would be addressed and fixed immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (R)(R5) observed during cares.Certified Nursing Assistant (CNA) C and CNA D did not use Enhanced Barrier Precautions (EBP) when providing direct care for R5.This is evidenced by:Facility policy, titled Enhanced Barrier Precautions, with a reviewed date of 01/06/26, states in part: Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves use during high contact resident care activities. 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be initiated for residents with any of the following: i. wounds (e.g., chronic wounds such as pressure ulcers.) even if the resident is not known to be infected or colonized with a MDRO. 4. High-contact resident care activities include: a. dressing, b. bathing, c. transferring, d. providing hygiene, e. changing linens, f. changing briefs or assisting with toileting, g. device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, h. wound care: any chronic skin opening requiring a dressing.R5 was admitted to the facility on [DATE] with pertinent diagnoses of pressure ulcer of sacral region stage 3 (09/25/23) and MRSA wound (03/09/25).R5's physician orders include:Dressing change order: Cleanse area with mild soap and water or wound wash, Pat Dry. Apply Vaseline to wound edges. Cut a piece of Hydrofera Blue, (Just lightly larger the wound). Moisten it with normal saline or sterile water. Squeeze out excess and place OVER wound bed. Cover with Gauze. Hold in place with tape. Change daily.- No orders for EBP noted.R5's care plan was reviewed and noted no EBP for care of R5's chronic pressure wound or during high-contact cares.On 03/10/26 at 6:56 AM, Surveyor observed R5's room door to have a sign posted stating EBP precautions. The EBP sign noted use of gown and gloves required when providing high-contact care. A large bag was hanging on R5's door filled with personal protective equipment (PPE) including disposable gloves and gowns. At 7:12 AM, Surveyor observed CNA C and CNA D providing morning cares for R5 in bed. CNA C and CNA D completed hand hygiene and donned gloves. CNA C and CNA D then removed R5's sleep clothes, washed R5's face and upper body, provided peri-care, and applied a new incontinent brief. CNA C and CNA D then transferred R5 from the bed to wheelchair. CNA C and CNA D did not use a gown at any point during R5's high-contact cares.On 03/10/26 at 7:26 AM, Surveyor interviewed CNA C and CNA D regarding observation. Both CNAs stated that they were under the impression that gown and glove use with EBP for R5 only needed to be used during wound care and not with other personal cares.On 03/10/26 at 8:35 AM, Surveyor interviewed CNA E and CNA D regarding EBP usage. Both CNAs stated that use of gowns was only needed if providing direct wound care or providing catheter care, otherwise only gloves were needed as PPE.On 03/10/26 at 8:40 AM, Surveyor interviewed Infection Preventionist (IP) G regarding observation and interviews. IP G stated that staff would be expected to use EBP when providing high-contact care for residents with wounds if they were not covered or were draining, based on CDC guidance. Surveyor then reviewed the facility's procedure/policy regarding EBP with IP G. Surveyor pointed out the facility's policy guidelines outlining that EBP was required with all high-contact care for all residents with chronic wounds and dressing changes. IP G stated having some confusion about this and stated recognition of the error in practice. IP G stated this would be addressed, and staff would be educated to use EBP in all high-contact cares with EBP residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (R) observed for morning cares (R16 and R24).
Staff did not perform hand hygiene with glove use when washing residents from a dirty location to a clean location or perform perineal care from clean to dirty for R16 and R24.
Findings:
Facility policy titled, Hand Hygiene revised 01/09/2024, stated in part, .5. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: .
F. Before moving from a contaminated body site to a clean body site during resident care .
Example 1
R16 was admitted to the facility on [DATE] with urologist diagnosis of retention of urine.
On 01/14/25 at 7:06 AM, Surveyor observed Certified Nursing Assistant (CNA) E perform morning cares with R16. CNA E performed proper hand hygiene and placed a gown and face shield per the facility's enhanced barrier precautions (EBP). CNA E took a clean wet washcloth from the basin of warm water, applied soap to washcloth then cleaned R16's groin and scrotum. CNA E then folded the washcloth using a clean area of the washcloth and began to clean the tip of the penis, the opening of the penis where the catheter comes out, without performing any glove changes and hand hygiene. CNA E then began to clean the catheter tube from the tip of the penis and away. When CNA E had finished this area CNA E noted that the resident was soiled with stool and began to clean that area. The rest of the observation was appropriate. Immediately after the observation, Surveyor asked CNA E, When you finished cleaning the arm pits, where should you start washing the perineal area and what infection control practice should be done when going from a dirty area to a clean area of the body? CNA E replied, I should have changed my gloves and washed my hands. Surveyor indicated that CNA E should start from the urethra and clean in a circular motion toward their scrotum, as the urethra is considered the cleanest part.
On 01/14/24 at 12:44 PM, Surveyor interviewed the Director of Nursing (DON) B about this observation made of CNA E. DON B indicated that the staff should be cleaning the residents from cleanest areas to dirty areas of the body, and they should change gloves and perform hand hygiene when going from dirty to clean areas of the body.
Example 2
R24 was admitted to the facility on [DATE] with diagnoses that include malignant neoplasm of the prostate (prostate cancer) and urine retention.
On 01/14/24 at 9:38 AM, Surveyor observed morning cares provided to R24 by CNA F. CNA F put on the proper personal protective equipment (PPE) for a resident with EBP as well as performed proper hand hygiene before entering the room. CNA F placed clean washcloths in a warm basin of water and then assisted R24 in taking R24's pants down to R24's knees. CNA F then took a clean washcloth and dipped in the basin of water, applied soap to washcloth then cleaned R24's scrotum. CNA F then placed the dirty/used washcloth back into the basin with the clean washcloths and took out an unused washcloth, that was in the dirty basin of water, put soap on it and began to wash R24's tip of his penis and catheter tube.
On 01/14/24 at 10:09 AM, Surveyor asked CNA F about this specific observation. CNA F indicated that she should not have put a dirty washcloth into the clean basin of water, and she should have removed her gloves and washed her hands and put new gloves on when washing the tip of the penis.
On 01/14/25 at 12:44 PM, Surveyor interviewed DON B about this observation of CNA F. DON B indicated that a dirty or used washcloth should not go back into the clean water, and they should clean from clean areas of the body to dirty. The CNAs should change gloves and perform hand hygiene when going from dirty to clean areas of the body.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not provide activities of daily living (ADLs) for residents who are dependent on staff. The facility practice affected 1 of 4 residents observed for care (R23).
Certified Nursing Assistants (CNA) C and D did not provide ADLs of washing, rinsing and drying R23's face, hands or body as part of R23's morning ADLs.
This is evidenced by:
Surveyor reviewed R23's most recent annual Minimum Data Set (MDS) dated [DATE] which notes he sometimes understands, sometimes is understood and is cognitively impaired. R23 is dependent on staff for transfers and bed mobility. R23 requires substantial assistance to wash, rinse and dry self, for hygiene.
Surveyor reviewed R23's care plan and noted:
Problem: This is my usual performance of my functional abilities for my ADLs.
Category
ADLs Functional Status/Rehabilitation Potential
Start Date
10/11/2023
Last Reviewed/Revised
01/09/2025
Goal(s)
I want to remain as independent as I can while performing my ADLs.
Target Date: 04/22/2025 (Long Term Goal)
Approach: PERSONAL HYGIENE (from the neck up and washing hands): Setup/Touch assist is my usual performance for personal hygiene. Assist of 1
BATHING (washing, rinsing and drying): Substantial is my usual performance for showering/bathing Assist of 1
Surveyor requested and received the facility policy for expected ADLs for residents who are dependent on staff for care. Surveyor was provided Standard Protocol for ADL's dated as effective July 2012 and most recently reviewed/revised on 1/2024. The protocol in part read: Encourage resident to complete hygiene, grooming and dressing tasks as independently as possible .assist as listed on plan of care.
On 1/14/25 at 6:51 AM, Surveyor observed CNA C and D assist R23 with morning cares. CNA C and D rolled R23 side to side in bed to remove a soiled brief, provide peri care and donned a clean brief. CNA C and D dressed R23's lower body in bed and transferred R23 with a mechanical lift to his wheelchair. Once in wheelchair CNA D exited R23's room and CNA C wiped under R23's arms, applied deodorant, sprayed R23 with body spray and donned a clean shirt. CNA C brushed R23's dentures and placed them in his mouth, provided R23 with his glasses and baseball cap and wheeled him from his room.
On 1/14/25 at 7:04 AM, Surveyor spoke with CNA C about the observation. Surveyor asked CNA C if the care provided to R23 was his morning care and what R23's morning cares consist of. CNA C indicated this was R23's morning care and she should have washed R23's hands, face and body along with his peri area when R23 was in bed. Surveyor asked CNA C why the care was not done. CNA C responded, It slipped my mind.
On 1/14/25 at 7:10 AM, Surveyor spoke with CNA D about the observation and what is expected with morning ADLs. CNA D explained care expectation would be to wash arms, face, hands body and peri care in bed, as well as do teeth or dentures and comb hair. Surveyor asked CNA D why R23 was not provided the ADLs of washing face, hands and body. CNA D responded, Should have, not sure why not done, maybe nerves.
On 01/14/25 at 7:18 AM, Surveyor spoke with Director of Nursing (DON) B about R23's expected morning ADLs. DON B expressed she would expect staff to wash, rinse and dry R23 top to bottom, face to bottom, clean to dirty. Surveyor asked DON B for the facility policy regarding ADL care. DON B responded expected ADLs is part of basic nurse aide training and nurse aide expectations to thoroughly wash resident top to bottom with morning cares. Face to peri care, all areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure the resident environment remained as free of accidents as possible for 1 of 4 residents reviewed for accidents (R23).
Certified Nursing Assistant (CNA) C and D did not remain at bedside when R23's bed was in a high position when providing morning care.
This is evidenced by:
Surveyor requested and received the facility policy titled Falls and Fall Risk Management dated as most recently reviewed 1/2024. The policy in part read:
Policy Statement: Preventing falls requires a substantial interdisciplinary team effort. Such efforts should focus on minimizing fall risk and risk of fall-related injuries .
~Staff will seek to identify environmental factors .that may contribute to falling.
~Strategies for reducing the risk of falls:
Risk Factor: Environment. Strategy: Beds: low position and brakes on at all times.
Surveyor reviewed R23's record and noted:
R23's most recent annual Minimum Data Set (MDS) dated [DATE] notes he sometimes understands, sometimes is understood and is cognitively impaired. R23 is dependent on staff for transfers and bed mobility. R23 has range of motion limitations in one lower extremity. R23 has not experienced falls.
R23's most recent fall risk assessment dated [DATE] notes R23 is high risk for falls (19). Assessment notes 10 or higher represents a high risk for falls with R23 scoring a 19. Risk factors include R23's cognition, medications and osteoarthritis. R23 is unable to ambulate without assistance. At risk medications include antidepressants, antihistamines, antihypertensive, diuretics, cathartics and narcotics.
R23's care plan included:
Problem: I am at risk for falls r/t (related to) medications, right knee pain r/t osteoarthritis.
Falls
Start Date
10/25/2021
Last Reviewed/Revised
01/05/2025
Goal(s)
I will remain safe from injury r/t falls.
Target Date: 04/22/2025 (Long Term Goal)
Approach(s)
Approach: Reminder signs will also placed in room to remind to use the call light for assistance with transferring.
Approach: Follow Altered Mobility/Fall Protocols.
On 1/14/25 at 6:51 AM, Surveyor observed CNA C and CNA D provide peri care and dressing of R23 in bed. CNA C and D raised R23's bed to high position to provide care. CNA C went into R23's bathroom to gather supplies, and CNA D joined CNA C in the bathroom to wash his hands after going to R23's wardrobe closet to gather clothing for R23. R23 was left in bed with no staff at bedside with his bed in high position. CNA D walked across R23's room to remove his personal protective equipment and obtain a mechanical lift as CNA C went back to the bathroom to wash her hands. Again R23 was left with no staff at bedside as his bed was in high position. CNA C and D transferred R23 to his wheelchair after placing sling under R23 in bed.
On 1/14/25 at 7:10 AM, Surveyor spoke with CNA D about the observation. Surveyor asked CNA D if R23 is a fall risk and if leaving R23 in bed without staff at bedside was a safe practice. CNA D respond R23 does attempt to self transfer and relies on two staff to safely transfer him. CNA D stated, Oh god no, not a good practice to leave [R23] in bed in high position without staff at bedside.
On 1/14/25 at 7:04 AM, Surveyor spoke with CNA C about the observation. and R23's fall risk. CNA C expressed she was not aware of recent falls. Surveyor asked CNA C if leaving R23's bed in high position with resident in bed was a safe practice. CNA C responded, I can go and grab stuff. I think is ok to leave bed high. I think I can leave alone but not 100 percent sure.
On 01/14/25 at 7:18 AM, Surveyor spoke with Director of Nursing (DON) about the observation and if R23 was at risk for falling. DON B referenced R23's electronic record and explained R23 was last assessed for fall risk 10/2025 and the assessment deemed R23 scored (19) which indicated R23 was high risk for falling. Surveyor asked DON B if R23 is care planned for low bed. DON B explained R23 was admitted with his wife and slept in a recliner. Sleeping in a bed is new for resident and he has only slept in bed for approximately 6-9 months. R23 will attempt to self transfer and is a fall risk. DON B indicated R23's care plan does not indicate he needs a low bed, and it is not ok to leave bedside when his bed is in high position as it is an unsafe practice.

Based on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 of 8 employees reviewed.
The facility did not ensure their abuse policy was implemented when one employee's Criminal Background Check (CBC) was not reproducible.
Findings include:
The facility policy, entitled Background Screening Investigations, revised 12/22/22, states in part .Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on individuals making application for employment with this facility; either every two- or four-years during employment as required by CMS regulations .
On 11/08/23, Surveyor reviewed 8 random staff CBCs as part of the caregiver program compliance check.
On 11/08/23 at 11:00 AM, Nursing Home Administrator (NHA) A stated the CBC for Registered Nurse (RN) H was completed in 2018 and then again in December 2022. The 2022 CBC was scanned into the Vidix human resources record system, which states that it was completed, but we are unable to see the CBC results. We called Vidix and they are trying to locate this CBC. NHA A said they will have RN H complete a new CBC today.
On 11/08/23 at 11:38 AM, NHA A provided RN H's new CBC completed today, 11/08/23.
On 11/08/23 at 1:04 PM, Surveyor interviewed Human Resources (HR) G Assistant concerning RN H's CBC completion in December 2022. HR G said RN H turned in the Background Information Disclosure (BID) form on December 15, 2022, and I ran the CBC on that date. RN H's CBC returned with no new findings from the 2018 report. If any CBC reports return with new information, I let the NHA review the results. I then scanned RN H's CBC into our HR record system Vidix. We have called Vidix to see if they can locate this CBC for us, but they said it could take a while to find it, if at all. Surveyor asked HR G what they do with the paper copy of the BID and CBC. HR G said they shred the BID and CBC once it was scanned into the system, so there was no hard copy of these documents.
Every four years a new CBC needed to be completed on each employee per the facility's policy. RN H needed a CBC completed in 2022. The facility was not able to reproduce the 2022 CBC for RN H.

Based on observation and staff interview, the facility did not follow proper food handling practice. This practice had the potential to affect all 34 residents residing in the facility.
Staff did not properly seal/cover and date open food items in the cold storage.
Findings include:
The facility policy entitled, Storage of Food and Supplies, revised December 7, 2020, which states in part, .Cover, label and date unused portions and open packages .
On 11/06/23 at 7:34 AM, Surveyor completed the initial tour of the kitchen with [NAME] E. [NAME] E took Surveyor into refrigerated storage. There was a gallon of white milk opened and over half full on the shelf in the refrigerator. Surveyor noted there was no date written on the milk container as to when it was opened. [NAME] E then took Surveyor into the walk-in freezer. There was a package of hotdogs on the shelf that were open to the air and no date placed on the hotdog package as to when it was opened or expires. Surveyor asked [NAME] E about the items not labeled. [NAME] E took the open package of hotdogs out of the freezer. Surveyor followed [NAME] E out to the main kitchen area. [NAME] E placed the hotdogs on the counter and said to the staff near [NAME] E, This needs to be thrown away.
On 11/07/23 at 11:16 AM, Surveyor interviewed Registered Dietician (RD) F about the observations made regarding foods opened, and not labeled. RD F replied, When items are opened they need to be labeled and food should not be left open to the air like the hotdogs in the freezer.
On 11/08/23 at 7:15 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. Surveyor asked NHA A, What is your expectation for open food in the kitchen as well as frozen food left open to the air? NHA A replied, The Executive Director (ED) C and I frequently walk through the kitchen, and we look for things that might not be ok. On Mondays we know that we are getting deliveries so we will give them a couple of hours to take care of the products then we go and see if there are any items on the floor or see if there are any items not labeled or open to the air. Our staff know that we are coming, and these things are not commonly found. Surveyor asked NHA A for a copy of the policy regarding dating open food in the kitchen.

Based on interview and record review, the facility did not ensure the mandatory submission of staffing data based on payroll data was completed. This had the ability to affect all 34 residents residing in the facility.
Payroll Based Journal (PBJ) data was not submitted by the facility since the last annual survey.
Findings include:
PBJ staffing data reports generated quarterly indicated the facility triggered for Failed to submit PBJ data for the fiscal year quarter 3 2023 (April 1 - June 30). Review of the past year PBJ reports show no reporting was completed by this facility.
On 11/06/23 at 1:30 PM, Surveyor spoke with Nursing Home Administrator (NHA) A and Director of Finances (DF) D concerning the PBJ. NHA A and DF D said the facility had never reported PBJ data because they are an Institution for Mental Diseases (IMD) Nursing Facility. Surveyor asked NHA A and DF D who told them that they did not need to submit the PBJ data. DF D said she had the email response in her office and will provide this information.
On 11/07/23 at 10:05 AM, DF D provided the email dated 05/23/16 that the facility received from CMS Nursing Home Staffing concerning PBJ data submission. CMS responded with .Only long-term care facilities that are subject to meeting the requirements for participation as specified in 42 CFR Part 483, subpart B are subject to the PBJ reporting requirements .If your facility meets the definition of an institution for mental diseases .then you would not be subject to the PBJ reporting requirements . DF D said the response from this email was why the facility was not submitting PBJ data because they are an IMD nursing facility.
Surveyor reviewed the email that further read, For Medicare and Medicaid purposes (including eligibility, coverage, certification, and payment), the facility is always the entity that participates in the program, whether that entity is comprised of all of, or a distinct part of, a larger institution. For Medicare, and SNF (see section 1819(a) (1) of the Act) and for Medicaid an NF (see section 1919(a) (1) of the Act) may not be an institution for mental diseases as defined in 483.1010 of this chapter.
On 11/07/23 at 12:52 PM, Surveyor interviewed NHA A and Executive Director (ED) C concerning staffing schedules. Surveyor reviewed the recent working schedules along with looking at the triggered PBJ fiscal year (FY) Quarter 3 2023 indicated at least 1 Registered Nurse (RN) on staff per day for a 12-hour shift and at least a Licensed Practical Nurse (LPN) to cover the rest of the 24-hour period. There was always an RN available in the building 24/7, not to mention the Director of Nursing (DON), NHA, and ED are all RNs and available to help. Certified Nursing Assistants (CNA) coverage was sufficient with multiple ancillary staff who are CNA certified and will assist when needed. No concerns with staffing levels.
On 11/08/23 at 10:00 AM, Surveyor interviewed ED C asking if the nursing facility participates in the Medicaid program and certification and follows the 42 CFR 483, subpart b. ED C indicated the nursing facility does participate with the Medicaid program. Surveyor explained by participating with the Medicaid program and certification they would need to follow the 42 CFR 483, subpart b and this includes the PBJ reporting. ED C acknowledged understanding of the requirement and the need to complete the PBJ reporting.

Based on interview and record review, the facility did not maintain an infection prevention and control program according to professional standards of practice having the potential to affect all 34 residents residing in the facility at the time of survey.
The facility's Water Management Plan (WMP) was not based on current standards of practice and did not:
Include a comprehensive assessment of the facility's water system to identify all locations where Legionella could grow and spread.
Maintain acceptable ranges of control limits (temperature ranges) and corrective actions when control limits are not met.
Include a process to confirm the WMP is being implemented and is effective.
Findings include:
The facility policy entitled, Plant Operations-Legionella control and procedure, dated 11/05/2020 documented in part, Ensuring risk assessments are carried out at least every two years or as necessary.
On 11/08/23 at 10:00 AM, Surveyor interviewed Infection Preventionist (IP) I. Surveyor asked about the facility's program to prevent Legionnaire's disease. IP I stated that the facility has been working on a program but that the facility's maintenance personnel handle the majority of that program, and Surveyor should ask him about the details of the program.
On 11/08/23 at 11:10 AM, Surveyor interviewed Maintenance J. Surveyor asked to see the facility assessment of the water management system. Maintenance J provided the Surveyor with a binder of water management system printouts. Within this binder it contained an assessment of the water system, which was not completed. Surveyor asked if this was the facility's assessment of the water system to identify where Legionella could grow and spread, when to apply control measures and how to monitor, and when to intervene when control limits are not met? Maintenance J answered the facility has not completed the Legionella and water system assessment. It is a work in progress; he has been working with IP I on this, but it is not completed yet. Surveyor asked and was not provided any written documentation of inspections and control measures being completed.