Tomahawk Health Services

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance devices to prevent elopement or falls for 2 of 3 residents reviewed (R23, R5). R23 has a history of elopement attempts on and was assessed to be at risk for wandering and elopement. R23 wears a Wanderguard that alerts staff to her attempts to elope. On 02/24/26, R23 exited the facility without staff knowledge and without the Wanderguard alarm sounding. R23 was found by a citizen approximately 0.7 miles from the facility with approximately 1 inch of snow on top of her head. Police were called and were able to determine resident was from the facility. The facility's failure to provide adequate supervision created a finding of immediate jeopardy that began on 02/24/26. [...]

Inspectors wroteBased on observation and interviews, the facility did not ensure the safety of food handling in accordance with professional standards for food service safety. This had the potential to affect all 48 residents that eat orally. Prepared food placed in the walk-in cooler had been covered but was not labeled or dated, food in dry storage was not covered or dated, and 2 opened containers of milk were in milk cooler without indication of when they were open or when they should be used by resulting in the potential for foodborne illnesses to spread.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for all 44 residents in the facility. The facility failed to protect residents from risk of transmission of communicable disease as follows: No airborne precaution signs posted on residents diagnosed with COVID Certified nursing assistant (CNA) staff not using proper N95 masks when entering rooms of positive COVID residents PPE carts stocked with one size N95 masks for all staff to use, despite FIT testing recommendations. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility did not provide care adhering to accepted standards of practice for 4 of 5 residents reviewed. (R2, R6, R21, and R39)Faciity did not follow manufacturer guidelines for proper placement of continuous glucose monitoring device for R2, R6, R21, and R39. Nursing did not prime insulin pens before administering insulin to R2, R6, R39. Nursing administered a dose of Ferrous Sulfate to R21 without confirming with phsyician what the dose was. Order in R21's medical record did not state dosage. Example 1The facility policy with a revision date of 08/05/2022, titled, NSG - Blood Glucose Monitoring, states, The nurse will perform the blood glucose test utilizing the facility's glucometer as per manufacturer's instructions. On 03/17/26 at 9:28 AM. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure medication error rates are not 5 percent or greater for 4 of 5 residents reviewed during medication pass. The facility error rate was 22.22%. Example 1 The facility policy titled, Medication Orders, revised 01/23, states the elements of the medication orders include dose and dose form and any dose or order that appears inappropriate, considering the resident's age, condition, allergies or diagnosis, is verified by nursing with the prescriber. On 03/18/2026 at 7:25 AM, Surveyor observed LPN H administer Ferrous Sulfate to R21 without confirming the physician order contained a dosage for R21. R21's physician's orders dated 10/19/25 notes: Ferrous Sulfate one tablet by mouth every other day. Surveyor reviewed R21's notes and found that the dosage was not clarified with the physician. [...]

Inspectors wroteBased on interview and record review, the facility did not notify the physician as indicated by parameters in physicians' orders for a significant weight increase for 1 out of 13 residents (R) R46. This is evidenced by:R46 was admitted to the facility 12/21/21 with a diagnosis that included atrial fibrillation. R46 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognitively intact. R46's Quarterly Minimum Data Set (MDS) with an end date of 2/26/26, Section K: weight 128#.R46's care plan initiated 2/24/26, with a target date of 4/18/26, states, Actual dehydration or risk for alteration in hydration related to diuretic use. Goal: Will maintain adequate hydration as evidenced by good skin turgor, moist oral mucosa, and stable weights. [...]

Inspectors wroteBased on interview and record review, the facility failed to report events which had the potential to cause serious harm or injury for 1 of 3 residents reviewed (R23). R23 is cognitively impaired, eloped without facility knowledge, and the alarm system was not working properly.

Inspectors wroteBased on interview and record review, the facility did not provide written information specifying bed-hold duration and payment policy to the resident or resident representative for 1 resident (R49) for 3 residents reviewed for bed-hold information in a sample of 13 residents. The facility failed to provide a written bed-hold agreement to R49's legal representative upon transfer to the emergency department (ED), or within 24 hours of transfer to the ED, or document in R49's medical record that bed-hold information was provided to a legal representative. This resulted in R49's legal representative to be uninformed of cost to resident to hold R49's bed, if desired, during R49's hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility did not implement the comprehensive care plan for accident prevention for 2 residents (R5, R43) of 3 residents reviewed for accidents in a sample of 13 residents. The facility did not implement care plan intervention of R5 always wearing grip socks or shoes when ambulating to prevent falls from occurring. This could result in R5 falling and sustaining serious physical injury. The facility did not implement care plan intervention providing gripper strips at R43's bedside to prevent falls when getting self out of bed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not revise resident's care plan following the completion of a Minimum Data Set (MDS) assessment for 1 of 13 residents reviewed. R2's care plan notes that R2 receives opioids, foot care, daily feet inspections, blue boot to right foot, hand splints, and assist with urinal. R2 is a double amputee, is no longer receiving opioids, refuses hand splints, and has a Foley catheter in place. R2 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, contractures of both hands and knees due to palmar fascial fibromatosis, left below the knee amputation, cervical neck pain, bow back pain, neuropathy, enlarged prostate, and urinary retention. R2's Minimum Data Set (MDS) dated [DATE] indicates R2 uses an indwelling Foley catheter. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident reviewed (R7). Facility staff did not obtain weights and vitals prior to or after dialysis appointments on several occasionsFindings include:Facility Policy titled, Hemodialysis, last revised 09/10/23, reads in part: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goas and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not follow the menu and did not notify residents of the menu change. This had the potential to affect all 43 residents in the facility. -The facility served a different meal than what was noted on the menu. The facility did notify residents of the menu change. -This resulted in residents complaining of the menu change. -This resulted in one resident (R28) requesting a bowl of cereal for lunch as he did not want what was posted on the menu. R28 was not notified of the menu change and was not given the option to receive the meal that was served.

Inspectors wroteBased on observation, interview and record review, the facility did not promote and facilitate resident self-determination through support of resident choice and preferences for 1 of 12 residents (R) reviewed. (R1). R1 was not given the right to choose to receive meal textures that R1 requested and prefers. This is significant to R1. This is evidenced by: According to Wisconsin State Statute GUIDANCE §483.60(d)(1)-(2) includes, in part, Providing palatable, attractive, and appetizing food and drink to residents can help to encourage residents to increase the amount they eat and drink. Improved nutrition and hydration status can help prevent, or aid in the recovery from, illness or injury. R1 was admitted to the facility on [DATE] for rehabilitation after falling and fracturing the right knee. [...]

Inspectors wroteBased on interview and record review, the facility charged a resident for a service covered under Medicaid. This effected 1 of 5 sampled residents (R41). -The facility charged R41 for transportation services to a medical appointment, which is a covered service under Medicaid. -The facility charged R41 for transportation services which were not specifically requested by R41. -The facility did not inform R41, orally and in writing, of a charge for a service and what that charge would be.

Inspectors wroteBased on interview and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 12 sampled residents (R1). The facility did not follow hospital discharge orders to complete daily blood glucose testing to ensure safe blood sugar levels.

Inspectors wroteBased 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 out of 8 residents on Enhanced Barrier Precautions (R23), staff did not change gloves or perform hand hygiene during observation of wound care. This is evidenced by: Facility policy titled, Enhanced Barrier Precautions, with most recent revised date of 08/08/24, stated in part: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities .high-contact resident care activities include: .wound care: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not store, prepare, distribute, and serve food by professional standards for food service safety. The facility distributed to residents eating in their rooms food that was uncovered and exposed to possible contamination. This has the potential to affect all 17 of 39 residents (R) (R36, R26, R3, R16, R25, R22, R31, R30, R24, R33, R18, R5, R28, R21, R10, R6, R19).

Inspectors wroteBased on observation, interview and record review, the facility staff did not perform hand hygiene when warranted, did not follow current standards of practice for Transmission-based Precautions (TBP), and did not offer hand hygiene to residents prior to eating. This facility practice has the potential to affect 9 residents (R24, R26, R36, R16, R30, R31, R18, R22, and R24) who reside in the Alzheimer Care Unit (ACU). This is evidenced by: Example 1 On 11/20/23 at 11:48 p.m., Surveyor observed Certified Nursing Assistant (CNA) P assist residents with lunch meal in ACU unit by delivering meal trays to residents in rooms and those eating in the common dining room (R24, R36, R16, R22, and R31). Surveyor observed CNA P open food cart, pull out residents' meal trays for service, deliver food trays to residents without completing hand hygiene before, during, or after meal service delivery. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that each resident is free from physical restraints that are not required to treat the resident's medical symptoms for 1 of 1 residents reviewed for restraints (R21). R21 had a pommel cushion without a physician order for use, the medical symptom the cushion is being used to treat or an assessment to determine appropriateness of its use. Furthermore, the device was not indicated in R21's care plan. The facility did not consider this device as being a potential restraint. This is evidenced by: The facility's policy titled Restraint Free Environment dated 9/22/22 was reviewed. [...]

Inspectors wroteBased on interviews and record reviews, the facility did not complete and submit a Significant Change in Status (SCS) Minimum Data Set Assessment (MDSA) within 14 days after determining a SCS has occurred for 1 of 13 residents (R27) reviewed for assessments. This is evidenced by: R27 has medical diagnoses that include, but are not limited to, chronic obstructive pulmonary disease, protein-calorie malnutrition, diabetes mellitus-type II with neuropathy and peripheral vascular disease. In reviewing the Medical Record of R27, Surveyor noted the most recent MDSA completed was a quarterly assessment with the Assessment Reference Date of 8/27/23. R27 was admitted to hospice services 9/27/23 in which a SCS MDSA had not yet been completed. On 11/21/23 at 1:55 PM, Surveyor telephoned Staff C, who is the Corporate Director of Clinical Reimbursement. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not provide an ongoing individualized and meaningful program to support the residents in their choice of activities designed to meet their interests and support their physical, mental, and psychosocial well-being causing decreased social interaction. This affected 1 of 5 residents (R6) reviewed for activity programming.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice. A bowel regimen to prevent constipation was not implemented for 1 of 4 residents (R6).

Inspectors wroteBased upon observation, interview and record review the facility did not ensure R21's bladder continence program was followed , when toileting was not offered to R21. This is evidenced by: R21 has medical diagnoses that include, but are not limited to, severe dementia with behavioral disturbance, repeated falls, anxiety disorder and hypersexuality. The most recent Minimum Data Set Assessment (MDSA) was a Significant Change in Status assessment dated [DATE]. According to this assessment, R21 was scored a 4/15 on the Basic Interview of Mental Status (BIMS), indicating severe cognitive deficit. R21 also requires extensive staff assistance to meet her most basic daily tasks of bed mobility, transfers, dressing, personal hygiene, toileting and bathing. R21 was also listed as being non-ambulatory with no range of motion limitations and is frequently incontinent of bladder and bowel function. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure 1 of 4 residents reviewed for nutrition (R21), maintained acceptable parameters of nutrition, such as body weight. This is evidenced by: R21 has medical diagnoses that include, but are not limited to, severe dementia with behavioral disturbance, repeated falls, anxiety disorder and hypersexuality. The most recent Minimum Data Set Assessment (MDSA) was a Significant Change in Status assessment dated [DATE]. According to this assessment, R21 was scored a 4/15 on the Basic Interview of Mental Status (BIMS), indicating severe cognitive deficit. R21 also requires extensive staff assistance to meet her most basic daily tasks of bed mobility, transfers, dressing, personal hygiene, toileting and bathing. R21 required supervision with meals once the meal tray was set up. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure residents who are trauma survivors receive trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization for 1 of 1 resident (R6) reviewed for trauma informed care.