Cody Regional Health Spirit Mountain Hospice

“Based on medical record review, and staff interview, the facility failed to ensure the POC included all pertinent information for 5 of 14 sample patients (#1, #2, #4, #5, #6). The findings were: 1. Review of the POC for patient #1 showed diagnoses that included dementia, anxiety, radiculopathy and osteoarthritis. The care needs and goals addressed skin integrity, comfort care, spiritual, and pain management. The following concerns were identified. a. Observation during the home visit on 6/4/25 at 11:30 AM showed the patient was assisted by the spouse and nurse to stand and ambulate. The nurse donned gloves and assessed an open wound to the coccyx area. The nurse duffed gloves and performed hand hygiene. The spouse revealed they were applying ointment to the coccyx wound. b. Interview during a home visit on 6/4/25 at 11:30 AM with the spouse revealed the patient fell this morning into a desk. Further, she revealed the patient had more frequent falls in the last couple of weeks.c. The facility failed to ensure falls was addressed on the care plan. The POC showed under DME and supplies: “None at this time.” Under safety measures: it showed “Safety measures, precautions, and/or restrictions are in place.” The facility failed to include in DME’s gloves, and ointment. In the safety measures the facility failed to state what safety measure, precautions, and/or restrictions were in place.2. Review of the POC for patient #2 showed diagnoses that included malignant neoplasm of thyroid gland, atrial fibrillation pneumonia and retention of urine. The care needs and goals addressed skin integrity, comfort care, spiritual care, pain management, fall prevention, medication management. The following concerns were identified: a. Observation during the home visit on 6/4/25 at 9:30 AM showed the patient had a bedside commode, incontinent briefs, grip bars in shower and by toilet, wheelchair, incontinent pads, cane, gloves and tegaderm dressings. The POC under DME and supplies only showed “Walker”.3. Review of the POC for patient #4 showed diagnoses that included chronic obstructive pulmonary disease, anxiety, chronic respiratory failure with hypoxia, personal history of nicotine dependence and altered mental status. The care needs and goals showed comfort care, spiritual, pain management, skin integrity, and oxygen management. The following concerns were identified: a. The DME and supplies showed “as needed at CRH Hospice House”. The facility failed to include what supplies were needed. b. The safety measures showed “Safety measures, precautions, and/or restriction are in place.” The facility failed to state what safety measure, precautions, and/or restrictions were in place.4. Review of the POC for patient #5 showed diagnoses that included secondary malignant neoplasm of brain, lung, bone, and large intestine and rectum, neoplasm related pain. The care needs and goals showed comfort care, spiritual, pain management, skin integrity, urinary catheter management, oxygen management. The following concerns were identified: a. The DME and supplies showed “DME and supplies as needed.” The facility failed to showed what DME and supplies were needed. b. The safety measures showed “Safety measures per Hospice House protocol”. The facility failed to showed what the safety measures were.5. Review of the POC for patient #6 showed diagnoses that included acute kidney failure, systemic inflammatory response syndrome of non-infectious origin with acute organ dysfunction, dementia, malignant neoplasm of bladder and benign prostatic hyperplasia without lower urinary tract symptoms. The care needs and goals showed comfort care, pian management, skin integrity, urinary catheter management. The following concerns were identified: a. The DME and supplies showed “DME and supplies as needed per the Hospice House.” The facility failed to show what DME and supplies were needed. b. The safety measures showed “Safety measures, precautions, and/or restrictions are in place.” The facility failed to showed what the safety measures were.6. Interview with RN #2 on 6/4/25 at 12:30 PM revealed if a new staff were to take care of the patient, they would not know what the DMEs and safety measures were, based off the care plan.7. Interview with RN #4 on 6/4/25 at 1:45 PM revealed she did the care plans for the patients. She stated the staff would not know what DMEs were needed and what safety measures were needed.”

“Based on document review and staff interview, the facility failed to test and maintain the fire alarm system in accordance with the 2010 NFPA 72, National Fire Alarm and Signaling Code. Failure to properly test and maintain the fire alarm system could result in a malfunction or failure of the system, resulting in injury or death in the event of a fire. The deficiency affected the fire alarm system, and could affect all residents, staff, and visitors. Document review on 06/03/25 starting at 12:10 PM revealed that the facility failed to perform all required testing of the fire alarm system. No documentation was available at the time of the survey to confirm that the annual inspection and testing of the annunciator panels, notification devices, pull stations, heat detectors, smoke dampers, or smoke detectors had been completed in the last twelve (12) months. Documentation was available to confirm the fire alarm batteries had been inspected and tested in June of 2024, but no additional documentation was available to confirm any additional inspections or testing had been conducted in the last twelve (12) months. Interview with facility personnel revealed that the annual inspection and testing of the system was supposed to take place in January, but had not been completed as of the time of the survey. The annunciator panels, notification devices, pull stations, heat detectors, smoke dampers, and smoke detectors shall be inspected and tested annually, and the fire alarm system batteries shall be inspected and tested semi-annually. Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated that they were aware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency. Ref: 2010 NFPA 72 Table 14.4.5(15)(i), Table 14.4.5(20), Table 14.4.5(15)(f), Table 14.4.5(15)(e), Table 14.4.5(15)(i), NFPA 90A 4.4.1, Table 14.4.5(6)(3), Table 14.3.1(3)(d)”

“Based on document review and staff interview, the facility failed to test and maintain the fire sprinkler system in accordance with the 2011 NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Failure to properly test and maintain the fire sprinkler system could result in a malfunction or failure of the system, resulting in injury or death in the event of a fire. The deficiency affected the fire sprinkler system, and could potentially affect all residents, staff, and visitors. Document review on 06/03/25 starting at 12:10 PM revealed that the facility failed to conduct all required inspections and tests of the fire sprinkler system. No documentation was available at the time of the survey to confirm that the internal inspection of the fire sprinkler system had been conducted in the last five (5) years. An inspection of piping and branch line conditions shall be conducted every five (5) years for the purpose of inspecting for the presence of foreign organic and inorganic material. Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated that they were aware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency. Ref: 2011 NFPA 25 14.2.1Document review on 06/03/25 starting at 12:10 PM revealed that the facility failed to correct identified deficiencies regarding the fire sprinkler system. Documentation review at the time of the survey revealed that the antifreeze branch had been tested for the freezing point within the last twelve (12) months. The test revealed that the antifreeze solution had a freeze point at +20 degrees F. The antifreeze system protects the attic and garage, and both areas have the potential to reach temperatures below 20 degrees F. The annual fire sprinkler testing took place in October of 2024, and it noted the solution needed to be drained and replaced. If test results indicate an incorrect freeze point the system shall be drained, the solution adjusted, and the systems refilled.Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated that they were aware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency. Ref: 2011 NFPA 25 5.3.4.3.2”

“Based on observation, document review, and staff interview, the facility failed to maintain the medical gas system in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to properly maintain the medical gas system could result in a malfunction of the system, resulting in injury or death. The deficiency affected the oxygen supply system, and had the potential to affect all residents that use that system. Document review on 06/03/25 starting at 12:10 PM revealed the oxygen supply was not being maintained at standard operating pressure. Documentation revealed that the medical gas system had been inspected in the last twelve (12) months. It was noted on the inspection report that the operating pressure for the oxygen supply was typically between 47 and 45 psi. Observation of the medical gas alarm panel revealed the oxygen supply pressure was at 47 psi. Standard operating pressure for oxygen supply shall be between 50 and 55 psi unless intentionally changed due to equipment or use that requires a different operating pressure. Where medical gas pressure is different from the standard operating pressure the gas piping system and shutoff valves shall be labeled with the nonstandard operating pressure used. Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated that they were aware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency. Ref: 2012 NFPA 99 Table 5.1.11; 5.1.11.2.2”

“Based on document review and staff interview, the facility failed to test and maintain the Essential Electrical System (EES) in accordance with the 2012 NFPA 99, Health Care Facilities Code, and 2010 NFPA 110, Standard for Emergency and Standby Power Systems. Failure to properly test and maintain the EES could result in a failure of the system, resulting in injury or death in the event of an emergency. The deficiencies affected the EES, and could affect all residents, staff, and visitors. Document review on 06/03/25 starting at 12:10 PM revealed that the facility failed to conduct all required testing of the emergency electrical generator. No documentation was available at the time of the survey to confirm that the four (4) hour load test had been conducted in the last three (3) years. Emergency electrical generators shall be tested every thirty-six (36) months for four (4) continuous hours under the available load. Interview with the facilities director at the time of the observation acknowledge the deficiency, but indicated that they were aware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency. Ref: 2012 NFPA 99 6.4.4.1.1.4; 2010 NFPA 110 8.4.9”

“Based on document review and staff interview, the facility failed to test and maintain the Patient Care Related Electrical Equipment (PCREE) in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to properly test and maintain PCREE could result in a failure in the equipment, resulting in injury or death. The deficiency affected PCREE in the facility, and could potentially affect any patients that utilize the equipment. Document review on 06/03/25 starting at 12:10 PM revealed that the facility failed to test all PCREE for electrical safety . Documentation was available at the time of the survey to demonstrate that the facility was conducting the required electrical safety testing on most PCREE in the facility including patient lifts and patient monitors. Documentation revealed that the electrical safety test was not being conducted for patient beds. Interview with facility staff confirmed the electrical safety test was not being conducted on patient beds. The physical integrity, resistance, leakage current, and touch current tests shall be conducted for all PCREE including patient beds. Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated that they were unaware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency. Ref: 2012 NFPA 99 10.3”

“Based on observation and staff interview, the facility failed to properly store oxygen cylinders in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to properly store oxygen cylinders could result in damage to the cylinders and a release of oxygen gas, which could propagate the spread of smoke and fire, resulting in injury or death in the event of a fire. The deficiency affected the garage, and has the potential to affect all residents, staff, and visitors. Observation on 06/03/25 at 11:31 AM revealed an oxygen storage tank that was being improperly stored. Observation of the garage revealed a large liquid oxygen dewar tank being stored. The liquid oxygen dewar tank was labeled as having a capacity of 5,250 cubic feet of oxygen gas. Oxygen storage containers exceeding 3,000 cubic feet shall be secured with lockable doors or gates, shall be stored in a 1-hour fire resistance-rated room, shall be heated by indirect means, and shall be provided with a means to secure from falling. Observation of the room revealed the liquid oxygen dewar tank was not secured, and was being stored alongside combustible materials. Interview with facility staff revealed the tank is typically empty when stored, but is at times partially full. Interview with the maintenance personnel at the time of the observation acknowledge the deficiency, and indicated that they were unaware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency. Ref: 2012 NFPA 99 5.1.3.3.2”