Vernon Manor

F-F3502-21 requirements including Workplace Performance and Workplace Performance Plus masks, OR

- A well-fitting facemask.

When used solely for source control, any of the options listed above could be used for an entire shift unless

they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH Approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH Approved particulate respirators with N95 filters or higher during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions), they should be removed and discarded after the patient care encounter and a new one should be donned

Source control is recommended for individuals in healthcare settings who:

- Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or

- Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure

Source control is recommended more broadly as described in CDC's Core IPC Practices in the following circumstances:

- By those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation measure once

the outbreak is over (e.g., no new cases of SARS-CoV-2 infection have been identified for 14 days); or

NIOSH Approved particulate respirators with N95 filters or higher used for:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 12 525562 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 525562 B. Wing 07/31/2024

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

Vernon Manor 310 Fairlane Dr Viroqua, WI 54665

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 o All aerosol-generating procedures.

Level of Harm - Minimal harm or o All surgical procedures that might pose higher risk for transmission if the patient has SARS-CoV-2 potential for actual harm infection (e.g., that generate potentially infectious aerosols or involving anatomic regions where viral loads might be higher, such as the nose and throat, oropharynx, respiratory tract). Residents Affected - Many o NIOSH Approved particulate respirators with N95 filters or higher can also be used by HCP working in other situations where additional risk factors for transmission are present, such as when the patient is unable to use source control and the area is poorly ventilated. They may also be considered if healthcare-associated SARS-CoV-2 transmission is identified and universal respirator use by HCP working in affected areas is not already in place.

- Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) worn during all patient care encounters.

Environmental Infection Control

- Dedicated medical equipment should be used when caring for a patient with suspected or confirmed SARS-CoV-2 infection.

o All non-dedicated, non-disposable medical equipment used for that patient should be cleaned and disinfected according to manufacturer's instructions and facility policies before use on another patient.

Example 1:

Facility line listings were not completed contemporaneously and there were no line lists for residents or staff from July 2023.

On 7/31/24 at 1:30 PM, ADON/IP C (Assistant Director of Nursing/Infection Preventionist) approached Surveyor with line listing for staff and residents. ADON/IP C stated, Resident R4 was the only resident that had any symptoms of COVID-19 and tested negative. Resident R4 ended up having bilateral pleural effusions. Resident R5 was diagnosed with pneumonia but no symptoms are listed on the line list and line list does not indicate if Resident R5 was ever tested for COVID-19.

On 7/31/24 at 3:30 PM, Surveyor interviewed ADON/IP C via phone. Surveyor asked ADON/IP C if infection control line lists should be updated daily. ADON/IP C stated, infection control should be conducted daily for tracking. Surveyor asked ADON/IP C if line listings should be completed contemporaneously. ADON/IP C stated, yes, I was just following what the following IP was doing before she left.

Of Note: During chart review surveyors noted at least two residents that were not placed on the line list who were experiencing symptoms. One of those residents was tested and tested negative but was never added to the line list.

Example 2:

During the survey, staff were observed throughout the facility not wearing any type of PPE.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 12 525562 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 525562 B. Wing 07/31/2024

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

Vernon Manor 310 Fairlane Dr Viroqua, WI 54665

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 7/31/24 at 12:25 PM, Surveyor interviewed ADON/IP C. Surveyor asked ADON/IP C if facility staff should be wearing PPE or utilizing source control during an outbreak. ADON/IP C stated, yes staff should be Level of Harm - Minimal harm or wearing masks if we are in an outbreak. potential for actual harm Example 3: Residents Affected - Many

The facility did not track community transmission rates and hospital admission rates.

On 7/31/24 at 11:10 AM, Surveyor interviewed ADON/IP C. Surveyor asked ADON/IP C if she was aware of what the community transmission rate was. ADON/IP C stated, the local health department advised to use

the state transmission rates and those are below baseline. ADON/IP indicates she does not track hospital rates.

Note: Surveyor reviewed current transmission rates in the region and state. Surveyor notes that the entire state is listed in as growing number of COVID-19 hospitalization across the State. Wastewater and hospital admission rates growing for the Western part of the State where the facility is located.

Example 4:

The facility failed to identify the outbreak and implement their COVID-19 policies and procedures.

On 7/31/24 at 11:10 AM, Surveyor interviewed ADON/IP C. Surveyor asked ADON/IP C if the facility was currently in a COVID-19 outbreak as the facility had a positive staff member. ADON/IP C stated no. Surveyor asked ADON/IP C how many staff or residents need to positive to facilitate an outbreak. ADON/IP C stated, three. Surveyor showed ADON/IP C current guidance. Surveyor asked ADON/IP C based on current guidance would the facility be in an outbreak? ADON/IP C stated, yes.

Example 5:

The facility did not ensure they screened all residents for signs and symptoms of COVID-19 once a staff member tested positive.

On 7/31/24 at 11:10 AM, Surveyor interviewed ADON/IP C. Surveyor asked ADON/IP C if the facility was screening residents for signs and symptoms of COVID-19. ADON/IP C stated not at this time as we did not believe we were in an outbreak.

Example 6:

The facility failed to ensure that staff who tested positive for COVID-19 did not work.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 525562 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 525562 B. Wing 07/31/2024

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

Vernon Manor 310 Fairlane Dr Viroqua, WI 54665

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 7/31/24 at 11:10 AM, Surveyor interviewed ADON/IP C. Surveyor asked ADON C when the DON B (Director of Nursing) tested positive for COVID-19. ADON/IP C stated, last Thursday (7/25/24). Surveyor Level of Harm - Minimal harm or asked ADON/IP C when the last time DON B worked prior to testing positive. ADON/IP C stated DON B potential for actual harm worked Thursday morning from 2:00 AM to 6:00 AM on the floor. DON B tested at 6:00 AM prior to leaving from her shift and was positive at that time. Surveyor asked if DON B had worked since testing positive. Residents Affected - Many ADON/IP C stated DON B worked on Sunday (7/28/24) after testing positive due to Med Tech working and needing an RN (Registered Nurse) in the building. ADON/IP C states DON B worked from her office and did not come out on the floor. Surveyor asked ADON/IP C if an RN needed to be in the building with the Med Tech. ADON/IP C stated according to the facility policy an RN needs to be in the building. ADON/IP C pulled out policy and read, Med Tech to be supervised in the building by an LPN or RN. ADON/IP C stated, I guess

she didn't need to be.

Example 7:

Facility policies and procedures have not been reviewed or updated.

Surveyor reviewed facility policies provided which are undated and do not reflect current guidance from the CDC.

On 7/31/24 at 11:50 AM, Surveyor interviewed ADON/IP C. Surveyor asked ADON/IP C how often policies should be reviewed and updated. ADON/IP C stated, policies should be reviewed yearly at a minimum. Surveyor asked ADON/IP C should the infection control policies and procedures be up to date. ADON/IP stated she is new to the role and was going by what was done previously.

Example 8:

The facility failed to test residents and staff once there was a confirmed case of COVID-19.

On 7/31/24 at 11:10 AM, Surveyor interviewed ADON/IP C. Surveyor asked ADON/IP C if the facility is currently doing any testing of resident or staff. ADON/IP C stated, we are not testing widespread just staff and residents who would show signs and symptoms.

Note: Facility began testing residents and staff prior to survey team's exit with no positive residents or staff identified.

Example 9:

The facility Medical Director was not notified of outbreak of COVID-19.

On 7/31/24 at 11:10 AM, Surveyor interviewed ADON/IP C. Surveyor asked ADON/IP C if there has been any contact with the Medical Director regarding the outbreak. ADON/IP C stated, no contact has been made to anyone as we did not believe we were in an outbreak.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 525562 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 525562 B. Wing 07/31/2024

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

Vernon Manor 310 Fairlane Dr Viroqua, WI 54665

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 The facility failed to complete screening of residents for signs and symptoms of COVID-19 during the current outbreak, line listings did not include residents with symptoms and was not completed contemporaneously. Level of Harm - Minimal harm or Staff were not wearing the appropriate PPE. The facility did not ensure staff who were COVID-19 positive did potential for actual harm not work. The facility does not track community transmission rates and hospital rates. The facility did not ensure policies and procedures were up to date and reflect the current CDC recommendations. Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 525562