Ssm Health St Clare Meadows Care Ctr

F-F880 states in part; Water Management .

Facilities must be able to demonstrate its measures to minimize the risk of Legionella and

other opportunistic pathogens in building water systems such as by having a documented

water management program. Water management must be based on nationally accepted

standards (e.g., ASHRAE (formerly the American Society of Heating, Refrigerating, and

Air Conditioning Engineers), CDC (Center of Disease Control), or U.S. Environmental Protection Agency (EPA) and

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 46 525317 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525317 B. Wing 05/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

St Clare Care and Rehab Center 1414 Jefferson St Baraboo, WI 53913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 include:

Level of Harm - Potential for o An assessment to identify where Legionella and other opportunistic waterborne minimal harm pathogens (e.g., Pseudomonas, Acinetobacter) could grow and spread; and Residents Affected - Many o Measures to prevent the growth of opportunistic waterborne pathogens (also

known as control measures), and how to monitor them.

According to the CDC Water Management Toolkit . monitor to ensure control measures are performing as designed. Control limits, in which a chemical or physical parameter must be maintained, should include a minimum and a maximum value.

Per Centers for Disease Control and Prevention (CDC), 3/15/24 documents, in part: .Cold water guidance: Store and circulate cold water at temperatures below 77 F, although Legionella may grow at temperatures as low as 68 F (20 C). Hot water guidance: Store hot water at temperatures above 140 F (60 C). Ensure hot water in circulation doesn't fall below 120 F (49 C) and recirculate hot water continuously, if possible .

Example 1

On 5/13/25 at 7:32 AM, Surveyor interviewed MDir M (Maintenance Director) and MntT N (Maintenance Tech) and asked about how the facility monitors the WH and HWT outlet temperatures. MntT N stated the last maintenance director had done some form of temperature testing, prior to leaving employment about a month ago, but no record logs had been found. MDir M stated there is a work order in the maintenance management computer system assigned for the 15th day of each month which states to check multiple locations for water temperature readings (must be between 110-115 degrees, document finding.). MDir M stated that MDir M has been unable to locate a report of any documented temperature readings. Surveyor asked if there was monitoring of the water temperature at the WH or HWT. MDir M stated no, there are no documented temperatures.

Of note, 140 degrees is the temperature required to prevent Legionella.

On 5/13/25 at 8:24 AM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked about temperature testing of the water heater outlet. NHA A stated that the past maintenance director had put a robust plan into place and NHA A believed that there had been testing at the boiler. Surveyor asked NHA A if documentation of temperature testing would be expected. NHA stated yes.

The facility was not able to provide documentation of monitoring the temperature of the water heater or hot water storage tank to show they're monitoring their control measures per their water management plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 46 525317 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525317 B. Wing 05/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

St Clare Care and Rehab Center 1414 Jefferson St Baraboo, WI 53913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50228 potential for actual harm Based on interview and record review the facility failed to ensure they followed standards of practice for an Residents Affected - Some antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 17 sampled residents (Resident R42) and 3 of 4 supplemental residents (Resident R300, Resident R16 and Resident R11) reviewed for antibiotic stewardship.

Resident R300 had documented urinary symptoms. The facility did not verify that infection criteria was met or monitor symptoms and effectiveness of treatment following the start of an antibiotic.

Resident R42 started an antibiotic for urinary tract infection (UTI). The facility did not verify that infection criteria were met, monitor symptoms through time of order for antibiotic treatment, or monitor symptoms and effectiveness of treatment following start of antibiotic.

Resident R16 started an antibiotic for UTI. The facility did not verify that infection criteria were met, monitor symptoms through time of order for antibiotic treatment, or monitor symptoms and effectiveness of treatment following start of antibiotic.

Resident R11 had change in respiratory status and was started on an antibiotic for pneumonia. The facility did not verify that infection criteria were met or monitor symptoms and effectiveness of treatment following start of antibiotic.

Evidenced by:

The facility's Antibiotic Stewardship Program policy, dated 4/2025, states, in part: Policy: It is the policy of

this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control Program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: Nursing staff shall assess residents who are suspected to have an infection . b. Monitoring antibiotic use: Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made. Antibiotic orders obtained upon admission, whether new admission or readmission to the facility shall be reviewed for appropriateness. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness . 5. Nursing will monitor the initiation of antibiotics on residents and conduct an antibiotic timeout within 48-72 of antibiotic therapy to monitor response to the antibiotic and review laboratory findings and will consult with the practitioner to determine if the antibiotic is to continue or if adjustmens need to be made based on findings .11. Documentation related to the program is maintained by the IP, including, but not limited to: .Assessment forms .data collection forms for antibiotic use, process, and outcome measures .

McGeer revised criteria indicates the following: . Urinary tract infection (UTI) surveillance definitions .

UTI without indwelling catheter. Must fulfill both 1 AND 2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 46 525317 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525317 B. Wing 05/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

St Clare Care and Rehab Center 1414 Jefferson St Baraboo, WI 53913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 1. At least one of the following signs or symptoms.

Level of Harm - Minimal harm or - Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate. potential for actual harm - Fever or leukocytosis, and greater than or equal to 1 of the following: Residents Affected - Some - Acute costovertebral angle pain or tenderness; suprapubic pain; gross hematuria; new or marked increase

in incontinence; new of marked increase in urgency; new or marked increase in frequency.

- If no fever or leukocytosis, then greater than or equal to 2 of the following:

- Suprapubic pain; gross hematuria; new or marked increase in incontinence; new of marked increase in urgency; new or marked increase in frequency.

2. At least one of the following microbiological criteria.

- Greater than 10^5 cfu/ml (colony forming unit per milliliter) of no more than 2 species of organisms in a voided urine sample.

- Greater than or equal to 10^2 cfu/ml of any organism(s) in a specimen collected by an in-and-out catheter.

Pneumonia MUST fulfill 1, 2, AND 3

1. Chest radiograph as demonstrating pneumonia or presence of a new infiltrate 2. At least 1 of the following:

2. At least 1 of the following:

- new or increased cough

- New or increased sputum production.

- O2 saturation <94% on room air or a reduction in O2 saturation of >3% from baseline.

- New or changed lung examination abnormalities

- Pleuritic chest pain

- Respiratory rate >25 breaths/min

3. at least 1 of the constitutional criteria

- fever

- leukocytosis

- Acute change in mental status from baseline

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 46 525317 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525317 B. Wing 05/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

St Clare Care and Rehab Center 1414 Jefferson St Baraboo, WI 53913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 - Acute functional decline.

Level of Harm - Minimal harm or Example 1 potential for actual harm Resident R300 admitted to the facility on [DATE REDACTED] and has diagnoses that include: cystitis (an inflammation of the Residents Affected - Some bladder); chronic kidney disease, stage 4 (moderate to severe kidney damage); gross hematuria (visible blood in the urine).

P300's Progress Notes include: 4/8/25 9:32 AM Situation: Resident has hematuria, extreme burning with urination, flank pain.May we check a UA and/or labs?

P300's Hospital Emergency Provider Note, date of service 4/8/25 6:12 PM, states, in part: Resident R300 has been having dysuria (painful urination) over the past approximate 24 hours .dysuria is really the only symptom at

this time .it is reasonable to send her home with outpatient p.o. (by mouth) antibiotics .Temperature 97.5

P300's April 2025 Medication Administration Record (MAR) includes: Cefdinir (antibiotic) oral capsule 300 mg (milligrams) by mouth every 12 hours two for UTI (urinary tract infection) for 6 days until finished. Order date 4/9/25

Surveyor requested progress notes regarding whether or not there are any further urinary symptoms or regarding antibiotic effectiveness through the end of this course of treatment. No progress notes were provided. Progress note was provided regarding a new episode of urinary symptoms beginning 4/25/25.

Resident R300's Progress Notes include:

*4/25/25: Resident with complaints I have a bladder infection. Reports burning with urination before and after urination. Also c/o nausea before Resident R300 urinates. Reports some frequency and only going in spurts. States s/s (signs and symptoms) for 3-4 days. Denies lower abdominal pain, denies hematuria. Afebrile (without fever). Fluids encouraged. MD to visit this afternoon.

*4/28/25: Resident had a UA (urine test) sent off Friday night and resident has burning, blood in urine also. Could we get her started on some treatment?

Important to note: there are no progress notes regarding urinary symptoms between 4/25/25 and 4/28/25.

Resident R300's April 2025 MAR includes: Cefprozil (antibiotic) Tablet 250 mg Give 1 tablet by mouth every 12 hours for infection for 7 days. Order date: 4/29/25

Surveyor requested facility documentation of infection meeting criteria, documentation regarding urinary symptoms for the time frame of 4/25 and 4/28/25 and documentation of and whether or not there were any further symptoms after start of and through completion of antibiotic treatment. No documentation was provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 46 525317 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525317 B. Wing 05/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

St Clare Care and Rehab Center 1414 Jefferson St Baraboo, WI 53913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 On 5/13/25 at 10:10 AM, Surveyor interviewed MDS/IP D (Minimum Data Set / Infection Preventionist) and asked if there was monitoring of Resident R300's urinary symptoms between 4/25/25 and 4/28/25. MDS/IP D stated Level of Harm - Minimal harm or there is no documentation of this. Surveyor asked how the facility determines infection. MDS/IP D stated potential for actual harm McGeer's Criteria. Surveyor asked if this was reviewed for meeting McGeer's. MDS/IP D stated McGeer's was not checked due to the resident being seen at the hospital. MDS/IP D stated if a resident admits on Residents Affected - Some antibiotic or has antibiotic prescribed in the emergency room that McGeer's is not verified by the facility. Surveyor asked if there was monitoring of the resident's symptoms and antibiotic effectiveness following start of antibiotic. MDS/IP D stated no documentation was noted.

Example 2

Resident R42 admitted to the facility on [DATE REDACTED] and has diagnoses that include encephalopathy ( a dysfunction or disease of the brain that alters its function or structure); adult failure to thrive (a state of decline in older adults that manifests as a downward spiral of health and activity); need for assist with personal care.

Resident R42's April 2025 MAR includes: Cefdinir oral capsule 300 mg Give 1 capsule by mouth two times a day for uti until 4/12/25. Order date 4/4/25.

Resident R42's Provider Telephone Encounter, dated 4/4/25, states, in part: nitrofurantoin (antibiotic) is generally not recommended for complex or complicated UTIs [for example fever, somnolence (drowsiness)], given its poor tissue penetration. I will order cefdinir.fever has improved and Resident R42 became less somnolent with acetaminophen (medication used to reduce fever). So will monitor closely.

Surveyor requested facility documentation of infection meeting criteria and documentation related to resident assessment of symptoms of UTI and whether or not there were any further symptoms after starting antibiotic and through completion of antibiotic treatment. No documentation was provided.

On 5/13/25 at 10:10 AM, Surveyor interviewed MDS/IP D (Minimum Data Set / Infection Preventionist) and asked if Resident R42 met McGeer's Criteria. MDS/IP D stated that it had been reviewed at time of antibiotic order, but there was no documentation of the review. Surveyor asked if there was monitoring of the resident's symptoms and antibiotic effectiveness following the start of the antibiotic. MDS/IP D stated no documentation was noted.

Example 3

Resident R16 admitted to the facility on [DATE REDACTED] and has diagnoses that include: multiple sclerosis (a chronic, neurological disease, affecting communication between the brain and body, leading to a wide range of symptoms that may include bladder dysfunction), overactive bladder (a condition where the bladder squeezes urine out involuntarily at the wrong time, leading to sudden and strong urge to urinate), urge incontinence (a condition where there is a sudden, strong urge to urinate which is difficult to control, often resulting in leakage).

Resident R16's Provider Progress Note dated 3/27/25, states, in part: .noted to be more confused by nursing home staff. Resident R16 denies urinary changes but has been noted to have frequency, incontinence, and foul-smelling urine per staff observation, history of sepsis (a life-threatening condition caused by the body's extreme response to an infection) secondary to UTI in the past. UA with culture reflex (laboratory test that identifies microorganisms, like bacteria, in a urine sample) has been ordered .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 46 525317 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525317 B. Wing 05/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

St Clare Care and Rehab Center 1414 Jefferson St Baraboo, WI 53913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Resident R16's Provider Telephone Encounter Note dated 3/28/25, states, in part: .urinalysis concerning for UTI. Since afebrile and no systemic symptoms to suggest complicated cystitis, recommend Macrobid 100 mg Level of Harm - Minimal harm or twice daily for 5 days. potential for actual harm Resident R16's Progress Note dated 3/28/25 3:09 PM, states, in part: Situation: with results of lab and urine will start Residents Affected - Some resident on Macrobid (antibiotic) for UTI .

Resident R16's March 2025 MAR includes:

*Macrobid oral capsule 100 mg give one capsule by mouth two times a day for UTI for 5 days. Order date 3/28/25. D/C (Discontinue) date 3/31/25

*Macrobid oral capsule 100 mg give one capsule by mouth two times a day for UTI until 4/7/25 11:59 PM Take with morning and evening meal. Order date 3/31/25.

Surveyor requested facility documentation of infection meeting criteria and documentation related to resident assessment of symptoms of UTI and whether or not there were any further symptoms after the start of and through completion of the antibiotic treatment. No documentation was provided.

On 5/13/25 at 10:10 AM, Surveyor interviewed MDS/IP D (Minimum Data Set / Infection Preventionist) and asked if Resident R16 met McGeer's Criteria. MDS/IP D stated that it had been reviewed at time of antibiotic order, but there was no documentation of the review. Surveyor asked if there was facility documentation of symptoms prior to the provider assessment. MDS/IP D stated no documentation was noted. Surveyor asked if there was monitoring of the resident's symptoms and antibiotic effectiveness following the start of the antibiotic. MDS/IP D stated no documentation was noted.

Example 4

Resident R11 admitted to the facility on [DATE REDACTED] and has diagnoses that include chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs); paroxysmal atrial fibrillation (an irregular heart rhythm which can cause fluttering or pounding in the chest and shortness of breath); dependence on supplemental oxygen.

Resident R11's Progress Notes include:

*2/11/25 9:26 AM .residents vital signs taken. Oxygen saturation was 99% on 2.5L (liter flow of oxygen); however, her respirations were 38. Lung sounds diminished with some coarse crackles heard in the right base, very shallow breathing. Resident denied SOB (shortness of breath) sitting in her chair at the time. Supervisor updated.

*2/11/25 7:30 PM .spoke with daughter regarding chest xray which showed pneumonia and that Resident R11 was started on an antibiotic .

Resident R11's Provider Telephone Encounter note, dated 2/11/25, states, in part: .Mobile chest xray completed due to new basilar crackles (abnormal lung sounds) and tachypnea (abnormally rapid breathing), vital signs, no hypoxia, patient denies shortness of breath. Concerning for L (left) pneumonia, recommend treating empirically due to frailty .Levofloxacin (antibiotic) 750 mg po (by mouth) every 48 hours x (for)4 doses .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 46 525317 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525317 B. Wing 05/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

St Clare Care and Rehab Center 1414 Jefferson St Baraboo, WI 53913

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Resident R11's February 2025 MAR (Medication Administration Record) includes: Levofloxacin oral tablet 750 mg give 1 tablet by mouth every 48 hours for pneumonia for 4 administrations. Order date 2/11/25. Level of Harm - Minimal harm or potential for actual harm Surveyor requested facility documentation related to resident assessment of symptoms of pneumonia after starting the antibiotic and through completion of antibiotic treatment. No documentation was provided. Residents Affected - Some

On 5/13/25 at 10:10 AM, Surveyor interviewed MDS/IP D (Minimum Data Set / Infection Preventionist) and asked if Resident R11 met McGeer's Criteria. MDS/IP D stated that it had been reviewed at time of antibiotic order, but there was no documentation of the review. Surveyor asked if there was monitoring of the resident's symptoms and antibiotic effectiveness following start of antibiotic. MDS/IP D stated no documentation was noted.

On 5/13/25 at 1:16 PM, Surveyor interviewed DON B (Director of Nursing) and asked about facility protocol for resident's with new symptoms. DON B stated staff is expected to monitor for at least 72 hours or through course of antibiotic/wellness. Surveyor asked if this monitoring is documented. DON B stated yes. Surveyor asked how infections are determined. DON B stated through McGeer's Criteria. Surveyor asked if McGeer's Criteria is expected to be documented. DON B stated yes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 46 525317