Tomah Nursing and Rehab

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an allegation of misappropriation for 1 of 2 abuse allegations (R1). On 1/16/26 R1 reported to CNA C (Certified Nursing Assistant) that she was having pain after CNA C assisted her with cares. CNA C reported R1's concern to RN D (Registered Nurse). R1 told RN D, That CNA was rough and She didn't mean to hurt me. R1 was sent to the ED (emergency department). The ED physician indicated, I suspect that R1 likely has a right elbow sprain. The facility failed to interview other residents to determine the scope of the concern. Therefore, this incident has not been thoroughly investigated. This is evidenced by:Facility policy, titled Abuse Prevention Program Policy and Procedure, includes: Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by staff or anyone. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 48 residents who reside in the facility. Surveyor observed dishwashing process. Dietary Aide failed to ensure proper hand washing was complete before going from dirty items to clean items in the kitchen. Evidence by:The facility policy, Machine Dishwashing Racking Procedure, Reviewed 1/25, states, in part;.To prevent cross-contamination when one employee is operating the dish machine, strict hand washing procedures must be adhered to between the soiled dish and clean dish handling. The facility policy, Hand washing/Hand Hygiene, Reviewed 1/25, states, in part;.Procedure:.3. Scrub your hands for at least 20 seconds. Need a timer? Hum the Happy Birthday song from beginning to end twice. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that garbage and refuse was disposed of properly. This has the potential to affect all 48 residents who reside at the facility. Surveyor observed the facility's main dumpster lid open and garbage outside of the dumpster. Surveyor observed a garbage bag, multiple disposable gloves, a hairnet, food wrappers, and cardboard outside of the dumpster. Evidenced by:The facility policy, Sanitizing Garbage Cans and Dumpsters, Revised 1/25, states, in part;.8. Dumpsters provided by the local refuge vender will be maintained by the facility and kept covered at all times. 9. Area around the dumpster will be kept clean, free of debris, foul odors, and free of harboring/feeding of pests. On 1/7/26 at 10:06 AM, During the initial walk through of the kitchen, Surveyor observed the facility dumpsters. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to the administrator of the facility and to other officials including the State Survey Agency for 2 of 2 incidents (R10 & R5) reviewed. R10 voiced an allegation of neglect to CNA O (Certified Nursing Assistant) of being left in her wheelchair for around 6 hours, left in a wet brief, left without colostomy care, and left without a call light or a way to summons assistance. The facility failed to follow the facility's abuse policy and failed to report allegation to NHA A and to state agency. R5 reported an allegation of abuse via a grievance form. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation or mistreatment, that all alleged violations are thoroughly investigated for 1 of 2 sampled Residents (R10). R10 voiced an allegation of neglect to CNA O (Certified Nursing Assistant). The facility failed to investigate the allegation thoroughly, including gathering staff interviews, gathering resident interviews, and recording an interview with R10. Evidenced by: Facility policy, titled Abuse Prevention Program Policy and Procedure, includes: Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by staff or anyone. The facility will provide a safe resident environment and protect residents from abuse. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that each resident had a baseline care plan developed and implemented, within 48 hours, with needed instructions to provide effective and person-centered care for 1 of 6 residents (R5) reviewed. R5's baseline care plan did not include R5's diagnosis of PTSD (Post- traumatic stress disorder), triggers, or interventions. Evidenced by:The facility's policy titled Resident Baseline Care Plan Development updated on 1/17/18 states in part .Policy: The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person- centered care of the resident that meet professional standards of quality care. The baseline care plan must-.ii. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- .e. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 sampled resident (R5) reviewed for dialysis. Facility staff were not fluent in the emergency plan for a resident bleeding from their dialysis access site. This is evidenced by:The facility's policy titled Dialysis Services last reviewed on 1/2025 does not include an emergency plan. According to Clinical Journal of the American Society of Nephrology article titled Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies dated February 2017, .Vascular Access Hemorrhage: [...]

Inspectors wroteBased on record review and interview, the facility did not ensure 1 of 1 resident (R5) who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. R5 has a diagnosis of PTSD (Post Traumatic Stress Disorder) and does not have a complete trauma assessment or a care plan addressing triggers, resident specific approaches, or interventions. Evidenced by:The facility's policy titled Trauma Informed Care revised 9/2022 states in part, .Policy Explanation and Compliance Guidelines: .2. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. [...]

Inspectors wroteBased on interview, and record review, the facility did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (R13) of 5 residents reviewed for medications. R13 was prescribed Buspirone for anxiety and failed to receive the medication. This is evidenced by:The facility's policy Care Standards, Standards of Nursing Practices, dated 1/25, includes: Responsibility with Medications and Physicians Orders 1. The licensed nurse that receives an order and notes the order is responsible to carry the order through by placing in achieve [Electronic Health Record], on the MAR (Medication Administration Record), TAR (Treatment Administration Record), ordering the medication from pharmacy, communicating order specifics to appropriate departments. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure it was free of medication error rates of 5% or greater. There were 8 errors in 25 opportunities that affected 1 resident (R50) out of a sample of 5 residents observed for medication administration. This results in an error rate of 16%. R50's medications were scheduled for 6:00 PM- 10:00 PM and R50 received their medications at 4:10 PM. Additionally, R50 was administered the wrong dose of hydroxyzine. Evidenced by: The facility's policy titled Medication Administration Procedures dated 4/2020 states in part A. Designated Times: .4. All medications must be passed within one hour on either side of the designated time. B. Dosage: 1. Give the exact number of tablets/ capsuled ordered. On 1/8/26 at 4:10 PM, Surveyor observed RN N (Registered Nurse) administer medications to R50. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident's environment remained as free of accident hazards as possible for 5 of 8 residents (R3, R7, R9, R10, and R11) by failing to have a system in place for monitoring the surface temperature of baseboard heaters to prevent burns. R3 is a resident with impaired mobility and cognition. On 10/29/25, R3 fell out of bed onto the baseboard heater. R3 was stuck between the wall and the bed. R3 sustained partial thickness (2nd Degree) burns. R7 is a resident with impaired mobility, who was observed by Surveyors to have her bed next to the baseboard heater, with the foot of the bed touching the baseboard heater, and the head of the bed less than 6 inches away from the baseboard heater. R7's base board heater temperature was 130.6. R7 has had a prior fall out of bed. [...]

Inspectors wroteBased on interviews, record review, and review of professional standards of practice, the facility did not ensure that the services provided by nursing personnel met the professional standards of quality for 1 of 3 residents (R1). Facility received orders to get a UA (urinalysis) on R1. Facility did not obtain the UA for R1 as ordered by the physician. Evidenced by:Surveyor requested a copy of all policies that reflect following the physicians orders and what to do if unable to complete physicians orders. Facility was unable to provide Surveyor with a policy that addressed following physicians orders or what to do if unable to follow physicians orders. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections such as COVID-19 and gastroenteritis. This had the potential to affect all 49 residents residing within the facility at the time of the outbreaks. As of 4/10/25 the facility was having a gastroenteritis outbreak with 3 staff with signs and symptoms. As of 4/20/25 the facility was having a COVID-19 outbreak with 4 residents positive for COVID-19. - Facility line listings were not completed contemporaneously. - Facility failed to recognize or ensure they routinely screened all residents for signs and symptoms of COVID-19 daily and increase screening to every shift once the outbreak was identified. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 3 sampled residents (R) R8, reviewed for abuse. Facility did not report an allegation reported by R8 that Certified Nursing Assistant (CNA) I is always so rough and is giving R8 bruises to state survey agency or law enforcement. Evidenced by: The facility's Abuse Prevention 7 Components, Reviewed 01/2025, includes, in part, the following: VII. Reporting/Response: [...]

Inspectors wroteBased on interview and record review, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for 2 of 3 residents (R) R1 and R8 reviewed for abuse. Facility did not fully investigate an allegation that Certified Nursing Assistant (CNA) I flipped R1 off when leaving R1's room and R1 does not feel safe with CNA I in his room. Facility did not fully investigate an allegation that CNA I was rough with R8 and left bruises. Evidenced by: The facility's Abuse Prevention Program 7 Component, Reviewed 01/2025, includes, in part, the following: V. Investigation. 1. The Administrator and or Director of Nursing are to initiate and coordinate completion of a thorough investigation. Investigations must be initiated immediately and concluded as soon as possible not to exceed (5) days. Forms are available to assist the investigator and may utilized. [...]

Inspectors wroteBased on interview and record review, 1 of 3 sampled residents' (R1) care and treatment to heal stasis ulcers was not provided in accordance with professional standards. R1's treatments of venous stasis ulcers were not completed as ordered by the physician. This is evidenced by The facility policy and procedure entitled Skin Care dated last reviewed 01/25 states in part Initiate treatment in accordance with facility protocols, standing orders, or physician orders. R1 was admitted to the facility in January 2025 with diagnoses including chronic venous hypertension with ulcer of bilateral lower extremity, myocardial infarction, and type 2 diabetes mellitus. R1 has physician ordered treatments to right and left lower leg venous ulcers. Cleanse with NS (Normal Saline) pat dry. Apply skin prep to peri wounds. Apply Medihoney to wound beds, followed by Calcium Alginate. [...]

Inspectors wroteBased on interview and record review, 1 of 3 sampled residents (R) care and treatment of pressure ulcers was not provided in accordance with professional standards (R1). R1's pressure ulcer treatments were not completed as ordered. This is evidenced by: The facility policy and procedure titled Pressure Injury Prevention and Care, dated last reviewed 01/25, states in part: Initiate treatment in accordance with facility protocols, standing orders, or physician orders. R1 was admitted to the facility in January 2025 with diagnoses including pressure ulcer left heel, stage 3, chronic venous hypertension with ulcer of bilateral lower extremity, myocardial infarction, and type 2 diabetes mellitus. R1 has physician ordered treatments to Skin treatment to left heel, Cleanse wound with NS (Normal Saline), pat dry. Apply skin prep to peri-wound. Apply Medihoney to wound bed. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure new care planned fall interventions were implemented post falls to prevent accidents for 1 of 3 residents (R) R3, reviewed for falls. R3 was at risk for falls and had a fall on 09/16/24. Facility did not implement the new interventions put into place post fall.

Inspectors wroteBased on observation, record review and interview, the facility did not prepare, store or distribute foods in a safe and sanitary manner. The facility practices had the potential to affect all 49 residents. Facility kitchen staff did not maintain proper personal hygiene to prevent contamination. Facility kitchen staff did not store food and equipment properly and did not prevent food contamination. This is evidenced by: Surveyor reviewed the facility policy titled Dietary Dress Code which is dated as most recently revised on 08/23. The policy in part read: Policy: All dietary employees will wear clean and safe apparel. Beard covers must be worn by staff presenting with facial hair. Surveyor reviewed the facility policy titled Storage Procedures which is dated as most recently revised on 08/23. The policy in part read: Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 4 of 4 residents (R48, R16, R5 and R2) who are unable to carry out activities of daily living receive the necessary services to maintain good nutrition, grooming, and personal hygiene. The facility did not assure R48, R5, and R16 were provided routine weekly minimum showers as part of their activities of daily living (ADL). The facility staff did not provide assistance with nutrition for R2 who is dependent on staff. This is evidenced by: The facility policy, entitled Activities of Daily Living (ADLs)/Maintain Abilities reviewed on 01/2024, states in part, 3. The facility will provide care and services for the following activities of daily living: a. Hygiene - bathing . Example 1 R48 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents receive adequate supervision and assistive devices to prevent accidents for 5 of 5 residents reviewed (R22, R43, R39, R32, R1). R22 and R43 maintained their own smoking materials which is not consistent with the facility policy for smoking. Staff did not ensure R39 and R32 were smoking safely in designated areas. R39 maintained their own smoking materials. R43's Feeding Precautions were not implemented and placed R43 at risk for aspiration. Staff did not provide R1 with meal assistance for safety as directed in the plan of care. This is evidenced by: The facility policy entitled, Smoking Policy, dated 01/2024, states: -Supervised smoking times will be designated by the facility and posted. -Residents will be alerted at the scheduled smoke time and assisted to designated location. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents (R) were treated with respect and dignity and cared for in a manner to enhance their quality of life. Facility staff stood over R34 while assisting to eat. This affected 1 of 3 residents observed.

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure 1 of 5 residents (R48) reviewed for high risk of pressure injury development, received the necessary treatment and services to promote healing of existing skin impairments. The facility did not ensure appropriate hand hygiene during wound care was conducted. This is evidenced by: The facility policy entitled Handwashing/Hand Hygiene last reviewed by facility on 01/2024 states in part: Practicing hand hygiene is a simple way to prevent infections by preventing the spread of germs. Wash hands and other skin surfaces when: 1. After immediate contamination with blood, other body fluids or potentially contaminated articles. 2. After removing gloves or other personal protective equipment. 4. Before and after nursing treatments or procedures (dressing changes). [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development and transmission of communicable diseases, and infections for 1 of 4 residents (R) observed. (R202) Facility staff did not wear a gown during high-contact care for a resident on enhanced barrier precautions (EBP). Facility staff did not sanitize lift after use on a resident with EBP.

Inspectors wroteBased on staff interviews and record review, the facility did not thoroughly investigate, determine root-cause, document details, and provide satisfactory resolution for 1 of 3 residents (R) R1's grievances.

Inspectors wroteBased on observation, interview and record review, the facility did not 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, infection, and Covid. This had the potential to affect 23 out of 38 residents (R) who resided on the Covid hall in the facility. The facility did not ensure staff wore the proper personal protective equipment (PPE) during a Covid outbreak in the facility. Universal Worker (UW) E was observed to pull their face mask down to speak to others multiple times, exposing their nose and mouth. This is evidenced by: The facility policy, entitled Isolation Categories of Transmission Based Precautions, dated 09/2022, stated in part: [...]

Inspectors wroteBased on staff interview and record review, the facility did not provide Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) for residents (R) whose Medicare Part A coverage was discontinued with benefit days remaining for 1 (R29) of 3 residents reviewed. R29 was discharged from Medicare Part A services with benefit days remaining and remained in the facility. The facility did not provide a SNFABN or NOMNC. This is evidenced by: The facility policy titled, Medicare Denial Notification SNFABN (CMS 10055) and NOMNC (CMS 10123), with a date of October 1, 2016, read in part, The original copy of the form is to be kept in the beneficiary's financial folder the form may be mailed certified to the family member or legal representative document your conversation - when was the call made, who did you talk to and any response. [...]