A list of the most recent deficiencies for Tomah Nursing and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-11-28 | 2023-12-22 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-07-19 | 2023-08-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-19 | 2023-08-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-18 | 2023-08-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-07-18 | 2023-08-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-18 | 2023-08-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-18 | 2023-08-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-18 | 2023-08-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-18 | 2023-08-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-18 | 2023-08-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-31 | 2023-06-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-31 | 2023-06-22 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-05-31 | 2023-06-22 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-31 | 2023-06-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-31 | 2023-06-22 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-10-03 | 2022-10-20 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-05-18 | 2022-06-24 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-05-18 | 2022-06-24 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-05-18 | 2022-06-24 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-05-18 | 2022-06-24 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-05-18 | 2022-06-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-18 | 2022-06-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-18 | 2022-06-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-18 | 2022-06-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-18 | 2022-06-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-05-18 | 2022-06-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-05-18 | 2022-06-24 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-06-01 | 2022-06-23 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-06-01 | 2022-06-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-01 | 2022-06-23 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-06-01 | 2022-06-23 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-01 | 2022-06-23 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-06-01 | 2022-06-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-01 | 2022-06-15 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-03-23 | 2022-04-15 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-23 | 2022-04-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-23 | 2022-04-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-23 | 2022-04-12 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-03-23 | 2022-04-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-23 | 2022-04-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-21 | 2022-01-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-21 | 2022-01-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-10-26 | 2021-11-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-12 | 2021-07-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-20 | 2021-06-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-11 | 2021-04-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-03-11 | 2021-04-08 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-03-11 | 2021-04-08 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-03-11 | 2021-04-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-11 | 2021-04-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-11 | 2021-04-08 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2021-03-17 | 2021-04-08 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-03-17 | 2021-04-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-03-17 | 2021-04-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-03-17 | 2021-04-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-03-17 | 2021-04-08 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2021-03-17 | 2021-04-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-03-17 | 2021-04-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-03-17 | 2021-04-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-17 | 2021-04-08 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-03-17 | 2021-04-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-17 | 2021-04-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-03-17 | 2021-04-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-03-17 | 2021-04-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-03-17 | Not Fixed | N |
