Prairie Ridge Hospital and Health Services

“A Life Safety Code Survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on May 22, 2024. At the time of the survey the Prairie Ridge Hospital and Health Services was found not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR, Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care and the 2012 edition of NFPA 99, Health Care Facilities Code. THE FACILITY’S POC WILL SERVE AS YOUR ALLEGATION OF COMPLIANCE UPON THE DEPARTMENT’S ACCEPTANCE. YOUR SIGNATURE AT THE BOTTOM OF THE FIRST PAGE OF THE CMS-2567 FORM WILL BE USED AS VERIFICATION OF COMPLIANCE. UPON RECEIPT OF AN ACCEPTABLE POC, AN ONSITE REVISIT OF YOUR FACILITY MAY BE CONDUCTED TO VALIDATE THAT SUBSTANTIAL COMPLIANCE WITH THE REGULATIONS HAS BEEN ATTAINED IN ACCORDANCE WITH YOUR VERIFICATION. PLEASE RETURN THE PLAN OF CORRECTION FOR THE FIRE SAFETY DEFICIENCIES (K-TAGS) TO: IF PARTICIPATING IN THE E-POC PROCESS, A PAPER COPY OF THE PLAN OF CORRECTION IS NOT REQUIRED. Healthcare Fire Inspections State Fire Marshal Division 445 Minnesota St., Suite 145 St. Paul, MN 55101-5145, OR By email to: FM.HC.Inspections@state.mn.us THE PLAN OF CORRECTION FOR EACH DEFICIENCY MUST INCLUDE ALL OF THE FOLLOWING INFORMATION: 1. A detailed description of the corrective action taken or planned to correct the deficiency. 2. Address the measures that will be put in place to ensure the deficiency does not reoccur. 3. Indicate how the facility plans to monitor future performance to ensure solutions are sustained. 4. Identify who is responsible for the corrective actions and monitoring of compliance. 5. The actual or proposed date for completion of the remedy. The Prairie Ridge Hospital and Health Services building was built in 2014 and is a 1 story building without basement that was determined to be of Type II(111) construction. The facility is fully fire sprinkler protected. The facility is also equipped with a fire alarm system with full corridor smoke protection to include spaces that are open to the corridors. The facility’s fire alarm system is monitored for fire department notification. At the time of this initial life Safety Code inspection the facility is licensed for 10 beds and had a census of 1at the time of the survey. The requirement at 42 CFR, Subpart 482.41(b) is NOT MET as evidenced by:”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 34764 Based on observation and staff interview, the facility failed to maintain hazardous storage room doors per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.1, 19.3.2.1.3, and 8.7.1.1. This deficient finding could have an widespread impact on the patients within the facility. Findings include: On 05/22/2024 at 11:30 AM, it was revealed by observation patient room 113 has been converted into combustible storage and did not have door closers and was not labeled as storage. An interview with the Maintenance Tech verified this deficient finding at the time of discovery.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 34764 Based on observation and staff interview, the facility failed to maintain the sprinkler system per NFPA 101 (2012 edition), Life Safety Code, section 9.7.5, and NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, sections 5.2.1.1.1, 5.2.1.2 and 5.3.2.1. These deficient findings could have a patterened impact on the patients within the facility. Findings include: 1. On 05/22/2024 at 12:00 PM, it was revealed by observation dust covered sprinkler heads in the therapy treatment rooms. 2. On 05/22/2024 at 12:10 PM, it was revealed by observation dust covered sprinkler head in the walk in cooler. 3. On 05/22/2024 at 12:10 PM, it was revealed by observation storage of boxes in the freezer were stored within 18” of a sprinkler head. An interview with the Maintenance Tech verified these deficient findings at the time of discovery.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 34764 Based on a review of available documentation and staff interview, the facility failed to inspect fire doors per NFPA 101 (2012 edition), Life Safety Code section 8.3.3.1, and NFPA 80 (2010 edition), Standard for Fire Doors and Other Opening Protectives, section 5.2.1. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On 05/22/2024 at 09:40 AM, it was revealed by a review of available documentation at the time of the survey the facility could not provide an annual fire door inspection report. An interview with the Maintenance Tech verified this deficient finding at the time of discovery.”

“Fundamentals - Building System Categories CFR(s): NFPA 101 Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99) This Standard is not met as evidenced by: 34764 Based on a review of available documentation and staff interview, the facility failed to provide a Risk Assessment per NFPA 99 (2012 edition), Health Care Facilities Code, section 4.2. This deficient finding could have a widespread impact on the patients within the facility. Findings include: On 05/22/2024 at 09:50 AM, it was revealed by a review of available documentation that the facility could not provide a NFPA 99 Risk Assessment at the time of the survey. An interview with the Maintenance Tech verified this deficient finding at the time of discovery.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 34764 Based on a review of available documentation and staff interview, the facility failed to maintain generators per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.4.4.1.1.3, and NFPA 110 (2010 edition), Standard for Emergency and Standby Power Systems, sections 4.2, 8.4.9, 8.4.9.1 and 8.4.9.2. This deficient finding could have a widespread impact on the patients within the facility. Findings include: On 05/22/2024 at 10:20 AM, it was revealed by a review of available documentation that the facility failed to provide documentation of a 36-Month 4-hour generator load bank test. An interview with the Maintenance Tech verified this deficient finding at the time of discovery.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 34764 Based on observation and staff interview, the facility failed to maintain storage of an oxygen tank per NFPA 99 (2012 edition), Health Care Facilities Code, 11.6.2.3 (11). This deficient finding could have an isolated impact on the patients within the facility. Findings include: On 05/22/2024 at 1:24 PM, it was revealed by observation in oxygen storage room there were 3 oxygen tanks were not secured for tip resistance. An interview with the Maintenance Tech verified this deficient finding at the time of discovery.”

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 48583 Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital. Findings include: Please refer to the Life Safety Code inspection tags: K0923, K0321, K0353, K0761, K0901, and K0918 for additional information.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (vi) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. All patient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patients or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of § 483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care. This Standard is not met as evidenced by: 40614 Based on observation, interview and document review, the facility failed to ensure the acting dietary manager had appropriate education to oversee food preparation and service(s) in 1 of 1 main kitchen. This had potential to affect all patients, visitors and staff who consumed food from the kitchen. Findings include: During a tour of the kitchen on 5/21/24 at 10:15 a.m., eggs were present in the dry storage room and were not labeled as being pasteurized. The dietary manager (DM)-A indicated they were pasteurized and the facility cooked eggs to order for patients, staff and visitors including sunny side up and over easy eggs (undercooked eggs). Upon further examination of the eggs, DM-B stated the eggs were not pasteurized and confirmed the facility should have used pasteurized eggs when serving undercooked eggs. During an interview on 5/22/24 at 10:50 a.m., DM-A indicated she began her duties in October 2023 (was unsure of exact date) however, had not completed any safe food handling education yet. DM-A indicated she had some training in safe food handling in the past however, her previous experience was in restaurants. During a follow-up interview on 5/23/24 at 1:20 p.m., DM-A indicated she supervised six staff members at the facility. DM-A stated the facility was short staffed and as a result, she has not had time to start the classes. During an interview on 5/23/24 at 1:50 p.m., DM-B confirmed DM-A had been enrolled in AAA Food Handler, manager training and examination on 12/1/23, however, had not completed any of the training yet. DM-B confirmed the training was required to manage the facility kitchen and supervise staff members. A policy and procedure for dietary manager qualifications was requested and none received. A Dietary Site Manager job description included: - The Dietary Site Manager (DSM) planned, directed and coordinated activities of the dietary department to provide dietetic services to patients, hospital employees and guests. - The DSM assisted in establishing policies and procedures for the site and supervises all dietary staff, plans menus, inspects work areas and meal service. -Requirements included Certified Dietary Certificate or willing to obtain certificate within 2 years of employment. Bachelors or advanced degree with major in Food Service Administration preferred however, not required.”

“PROTECTION OF RECORD INFORMATION CFR(s): The CAH maintains the confidentially of record information and provides safeguards against loss, destruction, or unauthorized use. This Standard is not met as evidenced by: 48583 Based on observation, interview and document review, the critical access hospital (CAH) failed to maintain the safeguards against potential loss, destruction, or unauthorized use in the CAH medical record storage area. Findings include: On 5/22/24 at 1:00 p.m., quality and safety director (QSD) indicated very few medical records were being stored as medical information was being placed into the the patients electronic health record (EHR). QSD stated patient records were being stored in the basement at the fitness center downtown and would speak with the health information management (HIM) for a tour. During an interview and observation on 5/22/24 at 3:49 p.m., QSD indicated HIM personnel had left for the day and the tour was going to be completed with QSD. Arrival at Anderson Fitness located at 15 East Division Street Elbow Lake, MN 56531 with QSD for clinical record storage tour. Anderson Fitness required access to the main entrance with a key fob. CAH did not have access to the building with the current key fob provided by the HIM department. The basement door was locked and only able to be accessed by a push button code. QSD received the code from HIM department and stated the code would need to be changed after the tour was completed. Entered the basement and walked down the steps into the storage area. Patient records were being stored in white and brown boxes on wooden and metal shelving units. Patient file boxes were dated from 2019, through earlier years. Patient file boxes were labeled with information that stated, “patient records, deceased patient records, patient payments, patient refunds, and additional items”. Shelving units were approximately four to six inches from the floor and extended four to six inches from the ceiling. Each shelving unit had boxes stacked three to four high and contained approximately 30-35 boxes stacked. A total of 27 shelving units and four smaller shelving units were counted. The basement felt damp and had a foul wet damp smell. A cord was observed plugged in on the back wall and was laying the length of the basement. A dehumidifier was sitting at the bottom of the basement steps however, was not plugged in and the water reservoir was full. No sprinklers or fire reducers were present. Standing water was observed on the floor in the front part of the basement and extended to the back of the basement. The large puddle of water extended approximately two feet wide by ten feet long and extended under the shelving against the back wall of the basement. A small area on the floor noted to be higher where water was not standing. A puddle of water began again and was approximately one inch deep and extended the width of the walkway and extended under shelving units on both sides. Walked to the right and entered another room with more patient files being stored on shelving that extended the entire length of the room. Turning to the right again, another room was filled with shelving units that contained boxes of patient records. When entering that room, there was a puddle of water that extended through the middle of the room and under the storage shelves in the entire room. QSD indicated HIM staff could not recall the last time any staff had been in the basement. QSD confirmed the current storage area for patient records was concerning and needed to be addressed. Review of facility policy titled Medical Record Confidentiality, Security and Access Medical Records/HIM last review date 12/31/18, to provide guidelines for the confidentiality, security and access of medical records. Prairie Ridge Hospital & Health Services (PRHHS) assured any patient records containing clinical, social, financial or other data was treated in a confidential manner. Records were reasonably protected from loss and destruction. Deceased medical records were stored at the PRHHS Fitness Center in the basement in a secured area. Requested for facility agreement with Anderson Fitness as PRHHS no longer owned the fitness center, however one was not provided.”

“ORGAN, TISSUE, & EYE PROCUREMENT CFR(s): Ensure that the CAH works cooperatively with the designated OPO, tissue bank and eye bank in educating staff on donation issues, reviewing death records to improve identification of potential donors, and maintaining potential donors while necessary testing and placement of potential donated organs, tissues, and eyes takes place. §485.643(f) For purpose of these standards, the term “organ” means a human kidney, liver, heart, lung, pancreas, or intestines (or multivisceral organs). This Standard is not met as evidenced by: 48583 Based on interview and document review, the critical access hospital (CAH) failed to collaborate and communicate with the Organ Procurement Organization (OPO) to ensure every patient’s death was being reviewed. Findings include: Review of the facility’s patients expired dated 5/21/23 to 2/16/24, revealed nine patient deaths. Review of the facility’s 2023 Tissue & Eye Donation Activity Report and LifeSource referral data dated 12/31/23, the facility contacted the OPO for 10 facility deaths. During an interview on 5/20/24 at 3:59 p.m., director of nursing (DON) confirmed the above findings and stated she received a quarterly and yearly report from the OPO. The DON stated she reviewed the report and would bring the reports to the quality meetings and annual meetings for review. DON indicated the report was reviewed for 100% calls from the facility to the OPO. DON indicated she had never cross referenced the OPO report with the facility’s death report to ensure every death was reported. DON stated there were no QAPI goals associated with OPO at the time of survey. During document review and interview on 5/22/24 at 1:15 p.m., P12 was pronounced deceased on 7/18/23, while admitted as a swing bed patient. P12’s electronic health record (EHR) lacked documentation OPO had been contacted after P12 had been pronounced deceased. Quality and Safety Director (QSD) reviewed P12’s record and confirmed the EHR lacked documentation OPO had been contacted. QSD verified the P12’s medical record number (MRN) was not included in facility’s 2023 Tissue & Eye Donation Activity Report and LifeSource referral data dated 12/31/23. QSD indicated documentation about the OPO was difficult to find and was not always being recorded in the record of death checklist for organ, tissue and eye donation form. Review of facility policy titled Death in Hospital last reviewed 5/1/24, contact LifeSource within one hour of death. Complete the Record of Death Checklist for Organ, Tissue and Eye Donation form.”

“ADMISSION, TRANSFER, & DISCHARGE RIGHTS CFR(s): Admission, Transfer and Discharge Rights (§483.5 definition of transfer & discharge, §483.15(c)(1), (c)(2), (c)(3), (c)(4), (c)(5), (c)(7), (c)(8), and (c)(9) of this chapter). “ §483.5 definition of transfer & discharge: Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. “ §483.15(c)(1) Transfer and discharge-(1) Facility requirements- (i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (A) The transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility; (B) The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility would otherwise be endangered; (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Non-payment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. (ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to §431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to §431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. “ §483.15(c)(2) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident’s medical record and appropriate information is communicated to the receiving health care institution or provider. (i) Documentation in the resident’s medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by- (A) The resident’s physician when transfer or discharge is necessary under paragraph (c)(1)(A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. (iii) Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident (B) Resident representative information including contact information. (C) Advance Directive information. (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals, (F) All other necessary information, including a copy of the resident’s discharge summary, consistent with §483.21(c)(2), as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. “ §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident’s representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident’s medical record in accordance with paragraph (c)(2) of this section; and (iii)Include in the notice the items described in paragraph (c)(5) of this section. “ §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii)Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident’s health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident’s urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. “ §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident’s appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. “ §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. “ §483.15(c)(8) Notice in advance of facility closure. In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at §483.70(l). “ §483.15(c)(9) Room changes in a composite distinct part. Room changes in a facility that is a composite distinct part (as defined in §483.5) are subject to the requirements of §483.10(e)(7) and must be limited to moves within the particular building in which the resident resides, unless the resident voluntarily agrees to move to another of the composite distinct part’s locations. This Standard is not met as evidenced by: 27955 Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure Medicare Beneficiaries were provided the Important Message from Medicare regarding their rights as a patient for 10 of 10 medical records reviewed. Findings include: On 5/22/24 at 1:30 p.m., clinical analyst (CA-C) assisted with medical record review of patient’s. During the process of medical record review ten patients medical records lacked evidence of an Important Message from Medicare provided to the patients. On 5/22/24 at 2:45 p.m., CA-C stated the Important Message from Medicare should have been provided to Medicare Beneficiaries, so they were aware of their rights when they admitted to the hospital. CA-C stated the nurses provided the admission packets to the Medicare Beneficiaries. On 5/22/24 at 4:38 p.m., two facility admission packets were reviewed. The admission packets lacked the Important Message from Medicare. On 5/22/24 at 4:40 p.m., registered nurse (RN)-A stated the nurses prepared the packets for admission. RN-A stated she just learned the Important Message from Medicare could have been printed out and provided to the patients when they were admitted. RN-A confirmed the Important Message from Medicare had not been added to the admission packets. A facility policy was requested however, was not provided.”

“DENTAL SERVICES CFR(s): Dental Services (§483.55(a)(2), (3), (4), and (5) and (b) of this chapter). “ §483.55 Dental services. The facility must assist residents in obtaining routine and 24-hour emergency dental care. (a) Skilled nursing facilities. A facility- (2) May charge a Medicare resident an additional amount for routine and emergency dental services; (3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility’s responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility’s responsibility; (4) Must if necessary or if requested, assist the resident- (i) In making appointments; and (ii) By arranging for transportation to and from the dental services location; and (5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay. (b) Nursing facilities. The facility- (1) Must provide or obtain from an outside resource, in accordance with §483.70(g), the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan); and (ii) Emergency dental services; (2) Must, if necessary or if requested, assist the resident- (i) In making appointments; and (ii) By arranging for transportation to and from the dental services locations; (3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay; (4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility’s responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility’s responsibility; and (5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan. This Standard is not met as evidenced by: 27955 Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure the dental services agreement was current and signed by the dental provider for swing bed patients to have available to them. This had the potential to affect all swing bed patients that were admitted to the hospital. Findings include: A Lake Region Healthcare, Corporation and Affiliates Business Associate Agreement was provided on 5/21/24 at 3:47 p.m., from the director of nursing (DON). The agreement was dated 5/21/24, and signed by the DON at 1:16 p.m. The agreement lacked the dental provider signature. On 5/22/24 at 9:10 a.m., the DON stated the dental provider received the new agreement to sign on 5/21/24. The DON confirmed the agreement had not been signed nor implemented yet. A policy was requested however, not provided.”

“Hospital CAH and LTC Emergency Power CFR(s): §482.15(e) Condition for Participation: (e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section. §483.73(e), §485.625(e), §485.542(e) (e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section. §482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1) Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated. 482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2) Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code. 482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2) Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates. *[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):] The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes. (1) National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169, www.nfpa.org, 1.617.770.3000. (i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011. (ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011. (iii) TIA 12-3 to NFPA 99, issued August 9, 2012. (iv) TIA 12-4 to NFPA 99, issued March 7, 2013. (v) TIA 12-5 to NFPA 99, issued August 1, 2013. (vi) TIA 12-6 to NFPA 99, issued March 3, 2014. (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011. (viii) TIA 12-1 to NFPA 101, issued August 11, 2011. (ix) TIA 12-2 to NFPA 101, issued October 30, 2012. (x) TIA 12-3 to NFPA 101, issued October 22, 2013. (xi) TIA 12-4 to NFPA 101, issued October 22, 2013. (xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.. This Standard is not met as evidenced by: 40614 Based on a review of available documentation and staff interview, the facility failed to maintain generators per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.4.4.1.1.3, and NFPA 110 (2010 edition), Standard for Emergency and Standby Power Systems, sections 4.2, 8.4.9, 8.4.9.1 and 8.4.9.2. This deficient finding could have a widespread impact on the patients within the facility. Findings include: On 5/22/2024 at 10:20 a.m., it was revealed by a review of available documentation the facility failed to provide documentation of a 36-Month 4-hour generator load bank test. An interview with the Maintenance Tech (MT)-A verified this deficient finding at the time of discovery.”