Divine Rehabilitation And Nursing At St Croix

F-F887.

The facility failed to ensure the IP has specialized training in infection prevention and control.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 21 525532 Department of Health & Human Services Printed: 09/17/2025 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 525532 B. Wing 07/17/2024

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

Dove Healthcare - St Croix Falls 750 E Louisiana St St Croix Falls, WI 54024

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48793 potential for actual harm Based on interview, medical record review and facility document review, the facility did not have a Residents Affected - Some comprehensive system for ensuring residents received influenza and/or pneumococcal immunizations, for 9 of 13 sampled residents, (R). (Resident R40, Resident R24, Resident R11, Resident R1, Resident R2, Resident R21, Resident R42, Resident R37, and Resident R31)

This is evidenced by:

The CDC Influenza Vaccine Timing for Adults reads, in part:

One dose of Influenza vaccine is recommended for adults each flu season .

The CDC Pneumococcal Vaccine Timing for Adults reads, in part:

Administer 1 dose of PCV13 at least 1 year after the most recent pneumococcal vaccine dose. Administer a second dose of PPSV23 at least 8 weeks after PCV13 and at least 5 years after the previous dose of PPSV23 .

Surveyor requested a list of current residents and their influenza and pneumococcal immunization dates.

Resident R40 was admitted on [DATE REDACTED]. Resident R40's immunization record stated that influenza and pneumococcal vaccinations were recommended. Facility did not have documentation that the facility offered or educated Resident R40 of the influenza and pneumococcal vaccinations recommended. The facility did not have a declination form in Resident R40's record of the influenza and pneumococcal being declined.

Resident R24 was readmitted on [DATE REDACTED]. Resident R24's immunization record stated influenza immunization recommended. Facility did not have documentation that the facility offered or educated Resident R24 of the influenza vaccination. The facility did not have a declination form in Resident R24's record of the influenza vaccination being declined.

Resident R11 was admitted on [DATE REDACTED]. Resident R11's immunization record stated that influenza and pneumococcal were recommended. Facility did not have documentation that the facility offered or educated Resident R24 of the influenza vaccination or pneumococcal immunization. The facility did not have a declination form in Resident R24's record of the influenza vaccination or pneumococcal being declined.

Resident R1 was admitted on [DATE REDACTED]. Resident R1's immunization record stated influenza immunization and pneumococcal recommended. Facility did not have documentation that the facility offered or educated Resident R1 of the influenza vaccination.

Surveyor reviewed a consent form signed on 11/23/23 titled, Influenza vaccine consent form, signed by Resident R1's Power of Attorney (POA) which indicated the consent to receive the influenza vaccination from the facility.

The consent form does not specify that education was given, and the form does not have the screening questions answered to receive the vaccination appropriately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 21 525532 Department of Health & Human Services Printed: 09/17/2025 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 525532 B. Wing 07/17/2024

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

Dove Healthcare - St Croix Falls 750 E Louisiana St St Croix Falls, WI 54024

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 0883 Surveyor also reviewed a consent form signed on 11/23/23 titled, Pneumococcal Vaccine consent form, signed by Resident R1's Power of Attorney (POA) which indicated the consent to receive the pneumococcal Level of Harm - Minimal harm or vaccination from the facility. The consent form does not specify that education was given, and the form does potential for actual harm not have the screening questions answered to receive the vaccination appropriately.

Residents Affected - Some Resident R2 was admitted on [DATE REDACTED]. Resident R2's immunization record stated influenza vaccination was recommended. Facility did not have documentation that the facility offered or educated Resident R2 of the influenza vaccination.

Surveyor reviewed a consent form signed on 11/14/23 titled, Influenza vaccine consent form, signed by Resident R2 which indicated the declination of the influenza vaccination from the facility. The declination form does not specify that education was given.

Surveyor reviewed Resident R21, Resident R42, Resident R37, and Resident R31's immunization record which indicated influenza and pneumococcal vaccinations were not offered and/or kept up to date, and/or education was not given to residents or POAs regarding the vaccinations.

On 07/17/24 at 11:17 AM, Surveyor interviewed Resident R40 and asked if Resident R40 was offered or educated on influenza, pneumococcal, and COVID-19 vaccinations. Resident R40 indicated that no one has spoken to Resident R40 about vaccinations. Resident R40 indicated that Resident R40 was not offered an influenza vaccination or anything else while being admitted to the facility.

On 07/17/24 at 11:45 AM, Surveyor interviewed Director of Nursing (DON) B, Registered Nurse (RN) D, and VP of Clinical Operations Q and asked about the process for admission and up to date on current immunizations. DON B and RN D indicated the process for following up with vaccinations after residents are admitted is a working process at this time. RN D indicated the facility has recognized the process for updating immunizations, offering, and educating on vaccinations was not being completed throughout the whole facility. RN D indicated this task had fallen through the cracks. RN D indicated the staff did not administer or educate on influenza and/or pneumococcal vaccinations appropriately to Resident R40, Resident R24, Resident R11, Resident R1, Resident R2, Resident R21, Resident R42, Resident R37, and Resident R31.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 21 525532 Department of Health & Human Services Printed: 09/17/2025 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 525532 B. Wing 07/17/2024

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

Dove Healthcare - St Croix Falls 750 E Louisiana St St Croix Falls, WI 54024

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 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48793

Residents Affected - Some Based on staff interview and record review, the facility did not ensure 8 residents (R) of 13 sampled were offered a COVID-19 vaccine as indicated. (Resident R40, Resident R24, Resident R1, Resident R2, Resident R21, Resident R42, Resident R37, and Resident R31)

This is evidenced by:

The CDC COVID-19 vaccine Timing for Adults reads, in part:

One dose of COVID-19 vaccination booster is recommended for adults every 6 months unless immunocompromised .

Surveyor requested a list of current residents and their COVID-19 immunization dates.

Resident R40 was admitted on [DATE REDACTED]. Resident R40's immunization record stated that COVID-19 vaccinations were recommended. Facility did not have documentation that the facility offered or educated Resident R40 of the COVID-19 vaccination recommendation. The facility did not have a declination form in Resident R40's record of the COVID-19 vaccination being declined.

Resident R24 was readmitted on [DATE REDACTED]. Resident R24's immunization record stated COVID-19 vaccination recommended. Facility did not have documentation that the facility offered or educated Resident R24 of the COVID-19 vaccination.

The facility did not have a declination form in Resident R24's record of the COVID-19 vaccination being declined.

Resident R1 was admitted on [DATE REDACTED]. Resident R1's immunization record stated COVID-19 vaccination recommended. Facility did not have documentation that the facility offered or educated Resident R1 of the COVID-19 vaccination.

Surveyor reviewed a consent form signed on 11/23/23 titled, COVID-19 vaccine consent form, signed by Resident R1's Power of Attorney (POA) which indicated the consent to receive the COVID-19 vaccine from the facility.

The consent form does not specify that education was given, and the form does not have the screening questions answered to receive the vaccination appropriately.

The immunization record does not indicate that Resident R1 received the COVID-19 vaccination as requested.

Resident R2 was admitted on [DATE REDACTED]. Resident R2's immunization record stated that COVID-19 vaccination was recommended. Facility did not have documentation that the facility offered or educated Resident R2 of the COVID-19 vaccination.

Surveyor reviewed a consent form signed on 11/14/23 titled, COVID-19 vaccine consent form, signed by Resident R2 which indicated the declination of the COVID-19 vaccination from the facility. The declination form does not specify that education was given.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 21 525532 Department of Health & Human Services Printed: 09/17/2025 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 525532 B. Wing 07/17/2024

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

Dove Healthcare - St Croix Falls 750 E Louisiana St St Croix Falls, WI 54024

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 0887 Surveyor reviewed Resident R21, Resident R42, Resident R37, and Resident R31's immunization record which indicated COVID-19 vaccinations were not offered and/or kept up to date, and/or education was not given to residents or POAs regarding the Level of Harm - Minimal harm or vaccinations. potential for actual harm

On 07/17/24 at 11:17 AM, Surveyor interviewed Resident R40 and asked if Resident R40 was offered or educated on Residents Affected - Some COVID-19 vaccinations. Resident R40 indicated that no one has spoken to Resident R40 about vaccinations. Resident R40 indicated that Resident R40 was not offered an COVID-19 vaccination while being admitted to the facility.

On 07/17/24 at 11:45 AM, Surveyor interviewed Director of Nursing (DON) B, Registered Nurse (RN) D, and VP of Clinical Operations Q and asked about the process for admission and up to date on current immunizations. DON B and RN D indicated the process for following up with vaccinations after residents are admitted is a working process at this time. RN D indicated the facility has recognized the process for updating immunizations, offering, and educating on vaccinations was not being completed throughout the whole facility. RN D indicated this task had fallen through the cracks. RN D indicated the staff did not administer or educate on COVID-19 vaccinations appropriately to Resident R40, Resident R24, Resident R1, Resident R2, Resident R21, Resident R42, Resident R37, and Resident R31.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 21 525532