Superior Rehabilitation Center Llc

F-F588 for reasonable accommodation of needs).

Surveyor asked Resident R7 how she was able to attend her appointment on 03/10/25 if she did not have a wheelchair. Resident R7 stated staff borrowed Resident R43's w/c, as it is a bariatric w/c. Surveyor noted Resident R43 was currently on contact precautions related to a C. diff infection.

Surveyor immediately interviewed CNA I. CNA I stated, Ok, I had nothing to do with this. I helped [Resident R7] get ready for her appointment yesterday morning. I don't know why she doesn't have a w/c. I asked Nursing Home Administrator (NHA) and DON what I should do, and they told me to use [Resident R43's] w/c, as [Resident R7] needed a bariatric w/c. I knew [Resident R43] had C. Diff. They told me to clean the w/c before I used it. I was not going to be responsible for someone getting C. diff because I didn't clean the chair properly. I mean, I don't have time to be cleaning w/c's with bleach. I told them to clean it. NHA and [Nurse Manager (NM) BB] cleaned the w/c and brought it to [Resident R7's] hallway for me. When I got the w/c, I know they did not clean it with bleach because I could not smell bleach. I could smell the purple top wipes. I know what those smell like.

Example 8

SHOWER ROOM

On 03/11/25 at 8:16 AM, Surveyor observed clean linens in shower room on railings, inside shower stall, and

on shower bench. Personal care items including a bar of soap and disposable razor were present inside shower in an open metal rack.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 53 525397 Department of Health & Human Services Printed: 09/04/2025 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 525397 B. Wing 03/13/2025

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

Dove Healthcare - Superior 1800 New York Ave Superior, WI 54880

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 On 03/11/25 at 8:27 AM, Surveyor observed clean linens lying on a shower cot and on top of a cabinet, as well as a personal sweatshirt. Level of Harm - Minimal harm or potential for actual harm On 03/11/25 at 9:09 AM, Surveyor interviewed CNA Y. CNA Y reported staff get the items they need prior to giving a shower. Resident personal items are taken in the shower room for use and taken back to their Residents Affected - Many rooms after. The facility items are kept on shelves in the shower room.

On 03/11/25 at 9:17 AM, Surveyor interviewed CNA H. CNA H stated personal items and linens are taken in at the time of the shower. Dirty linens and personal care items are also removed when done. CNA H stated at times, clean linens that are extra get left in the shower room, but if they remove them, then they would have to be considered dirty and put into laundry. CNA H also reported any disposable razors get placed in sharps containers after use. When asked about facility soaps, CNA H only stated they retrieve them from the supply room.

On 03/12/25 at 10:09 AM, Surveyor interviewed DON B. DON B made a note of Surveyor's observations of

the shower room. DON B did not offer additional information.

48793

Example 9

On 03/11/25 at 7:35 AM, Surveyor observed CNA T enter bath house to assist CNA U with transfer of Resident R57. CNA U and CNA T began pushing stand lift to Resident R57 and instructed Resident R57 to help stand. Surveyor observed CNA U take a dry towel and wipe Resident R57's groin and buttock area without wearing gloves. CNA U then dropped

the dry towel as Resident R57 was in the process of sitting down. Surveyor observed CNA U don gloves, and CNA U and CNA T began standing Resident R57 again. CNA U then used dry towel again to dry off groin area and buttock area. Surveyor observed Resident R57 in the process of sitting on bath chair. CNA U then readjusted Resident R57's hair out of Resident R57's face with the soiled gloves on. CNA U then instructed Resident R57 to stand again while CNA U pulled brief and pants up for Resident R57 with soiled gloves. Surveyor observed CNA U grab wheelchair and place under Resident R57. Resident R57 sat down in wheelchair. Surveyor observed CNA U exit bath house with soiled gloves on and wheeled Resident R57 to

the dining room. Surveyor observed CNA U rearrange two dining room chairs to make room for Resident R57 with same soiled gloves on. Surveyor observed CNA U lock wheelchair brakes on Resident R57's wheelchair with soiled gloves and then placed a clothing protector/towel on Resident R57. Surveyor observed CNA U then take soiled gloves off in dining room and throw in the trash. Surveyor observed CNA U walk back to the bath house and started cleaning the bath house. Surveyor did not observe CNA U sanitize hands.

On 03/11/25 at 8:05 AM, Surveyor interviewed CNA U and asked CNA U what is the correct process for hand hygiene after peri cares are completed on resident. CNA U indicated that CNA U should have applied gloves the first time before cleaning Resident R57's peri area, then sanitized hands after and before placing gloves on. CNA U indicated that before leaving the shower room CNA U should have sanitized hands again before taking Resident R57 to the dining room for breakfast.

On 03/11/25 at 9:13 AM, Surveyor interviewed DON B and asked DON B what expectation does DON B have with staff and hand hygiene when staff are completing peri cares on a resident. DON B indicated hands should be sanitized before and after glove use, and when exiting resident care areas.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 53 525397 Department of Health & Human Services Printed: 09/04/2025 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 525397 B. Wing 03/13/2025

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

Dove Healthcare - Superior 1800 New York Ave Superior, WI 54880

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** 44863 potential for actual harm Based on interview and record review, the facility did not have documentation included in the resident's Residents Affected - Few medical record that the resident either received or did not receive the pneumococcal and/or the influenza vaccination for 2 of 5 residents (R) reviewed for immunizations (Resident R41 and Resident R53).

-Resident R41's record does not include evidence resident was offered pneumococcal vaccination.

-Resident R53's record does not include evidence resident was offered influenza or pneumococcal vaccination.

Findings include:

The facility's policy titled Pneumococcal Vaccine Series, read in part .2. Each resident will be offered a pneumococcal immunization unless it is contraindicated, or the resident has already been immunized. 4. The resident/representative retains the right to refuse the immunization. The facility will document in the clinical

record the reason for the refusal or the medical contraindication of the immunization.

The facility policy titled Influenza Exposure Control, read in part .2. The current season's influenza vaccine will be offered to residents and staff in accordance with facility's policy for influenza vaccination.

Resident R41

Resident R41 was admitted on [DATE REDACTED]. Diagnoses included dementia, Alzheimer's disease, traumatic brain injury, depression, and psychotic disorder.

Minimum Data Set (MDS) assessment completed on 01/27/25, confirmed a Brief Interview for Mental Status (BIMS) could not be conducted, and staff assessment of Resident R41's mental status indicated severe impairment.

Resident R41's MDS assessment indicated Resident R41 was offered and declined the pneumococcal vaccination.

On 03/11/25, Surveyor reviewed Resident R41's record and was unable to find evidence Resident R41 was offered and either received or declined the pneumococcal vaccination. There was no evidence in the record to support a contraindication to the pneumococcal vaccination.

On 03/12/25 at 10:09 AM, Surveyor interviewed Director of Nursing (DON) B. DON B reported the expectation is that residents will be offered immunizations annually. If a resident declines a vaccination, the facility will continue to offer the vaccination annually.

Surveyor requested documentation to support Resident R41 was offered and either received, declined, or evidence of

a contraindication to the vaccine. Surveyor did not receive any additional documentation.

Resident R53

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 53 525397 Department of Health & Human Services Printed: 09/04/2025 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 525397 B. Wing 03/13/2025

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

Dove Healthcare - Superior 1800 New York Ave Superior, WI 54880

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 Resident R53 was admitted to the facility on [DATE REDACTED]. Diagnoses included dementia, Alzheimer's disease, anxiety, and depression. Level of Harm - Minimal harm or potential for actual harm MDS assessment completed 02/19/25 confirmed Resident R53 scored 01/15 during BIMS, indicating severe cognitive impairment. Residents Affected - Few Resident R53's MDS assessment indicated Resident R53 was offered the influenza and pneumococcal vaccinations and declined.

On 03/11/25, Surveyor reviewed Resident R53's record and was unable to find evidence Resident R53 was offered and either received or declined the influenza and pneumococcal vaccinations. There was no evidence to support a contraindication to either vaccine.

Surveyor requested documentation to support Resident R53 was offered and either received, declined, or evidence of

a contraindication to the vaccines. Surveyor did not receive additional documentation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 53 525397