Big Sandy Medical Center

“Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 485.623(d) for Critical Access Hospitals (CAHs), a life safety code survey was performed on 3/20/24. Under this regulatory requirement, the facility must meet the applicable provisions of the National Fire Protection Association’s (NFPA) 101 Life Safety Code, 2012 Edition, and those mandatory Codes referenced by that edition. The building construction type was found to be Type V (111) and contains two smoke compartments in the basement and four on the main level. An addition was built in 2023 off of the kitchen for dry food storage. The facility is connected to a Critical Access Hospital and a two hour separation is not present; therefore, the entire facility was surveyed. The facility is licensed for 22 long term care beds eight hospital beds and at the time of survey 22 residents was the census plus 4 swing beds. These requirements were not met as evidenced by the following deficiencies:”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 40068 Based on an observation, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Sections 7.1.10.1 and 19.2.1. This deficiency affected 1 of 6 smoke compartments in the facility. Findings include: 1. During an observation on 3/20/24 at 1:25 p.m., The long-term care exit was inspected. There was a wet floor sign and a wheel chair blocking the means of egress and exit door to the public way.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 40068 Based on observation, the facility failed to maintain an egress door with only one releasing operation in accordance with NFPA 101, 2012 Edition, Section 7.2.1.5.10.2. This deficiency affected 1 out of 4 smoke compartments. Findings include: During an observation on 3/20/24 at 1:37 p.m., two egress doors from the kitchen had a dead-bolt lock located on the door. The two doors require more then one motion to open the door.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 40068 Based on observation, the facility failed to ensure doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7. This deficiency affects 1 out of 6 smoke compartments at the facility. Findings include: During an observation on 3/20/24 at 1:40 p.m., the kitchen storage room door had a rubber stopper fastened to the door. The door was fitted with a self-closure, and would not self-close with the use of the door stopper.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 40068 Based on interview and record review, the facility failed to provide emergency lighting per NFPA 101-2012, Sections 19.2.9.1 and 7.9.3.1.1. This deficiency affects the entire facility. Findings include: Review of the facility records for testing of the emergency lighting documentation on 3/20/24, showed the facility had not performed the required 30 second monthly lighting tests for the whole year or the annual 90 minute test. During an interview on 3/20/24 at 11:06 a.m., staff member B stated he was unaware he needed to complete emergency lighting tests for a certain amount of time. He stated he just made sure they turned on when he tested them.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 40068 Based on observation, the facility failed to maintain continuous illumination for all exit signs in accordance with NFPA 101, 2012 Edition, Section 7.10.5.1, and 7.10.5.2.1. This deficiency affected 1 out of 6 smoke compartments in the facility. Findings include: During an observation and interview on 3/20/24 at 1:45 p.m., the rear loading dock exit was inspected. The exit sign was not illuminated. Staff member B stated the exit sign needed a new bulb.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 40068 Based record review, the facility failed to maintain the wet chemical extinguishing system for the kitchen hood in accordance with NFPA 17A, 2009 Edition, Section 7.5.1. This deficiency affects 1 out of 6 smoke compartments in the facility. Findings include: Review of the maintenance records on 3/20/24 showed the last hydro test on the main cylinder for the kitchen hood was completed 12/22/2011. The hydrostatic test should have been completed in December of 2023.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 40068 Based on record review and interview, the facility failed to ensure that load voltage tests were conducted on the batteries of the fire alarm control panel (FACP) semi-annually, as required per NFPA 72-2010, Table 14.4.5 (6). This deficiency affects all smoke compartments at the facility. Findings include: During a review of the most recent facility fire alarm inspection on 3/20/24, the fire alarm system was inspected on 6/28/23. There was no indication either written on the batteries or in the panel that the six-month voltage test had been completed by the facility semi-annually.”

“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: 40068 Based on observation, interview and record review the facility failed: a) to maintain the sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Table 5.1.1.2, b) failed to ensure sprinkler piping was fee from external loads in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2, and c) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1 (3). These deficiencies affected all smoke compartments in the facility. Findings include: 1. During an interview on 3/20/24 at 11:08 a.m., staff member B stated the sprinkler inspections were not being completed on a quarterly basis. Review of the facility’s sprinkler inspections on 3/20/24 showed, only one sprinkler inspection was completed in the last year dated 6/22/23. The following quarterly sprinkler inspections were missing: First quarter of 2023 (January - March 2023) Third quarter of 2023 (July - September 2023) Fourth quarter of 2023 (October - December 2023) 2. During an observation on 3/20/24 at 1:03 p.m., the boiler room was inspected. A wire was hanging off the sprinkler piping. 3. During an observation on 3/20/24 at 1:11 p.m., the water closet was inspected. Cords were hanging off the sprinkler piping. 4. During an observation on 3/20/24 at 1:26 p.m. the atrium was inspected. There was a significant gap around the sprinkler piping that was coming out of the wall. 5. During an observation on 3/20/24 at 1:51 p.m., the atrium by the front entrance was inspected. There was a significant gap around the sprinkler piping that was coming out of the wall.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 40068 Based on observation, the facility failed to ensure latching fire/smoke barrier doors were maintained per NFPA 101-2012, Section 19.3.7.8., 4.2.3, and 4.6.12.1. This deficiency affected 2 out of 6 smoke compartments. Findings include: During an observation on 3/20/24 at 1:33 p.m., the dinging room double doors were inspected. The fire hardware on the door was not latching after being exercised multiple times.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 40068 Based on record review the facility failed to ensure all employees were kept informed with respect to their duties during a fire drill, ensuring competency per NFPA 101. 2012 Edition, section 19.7.1.2., and 19.7.1.6. This deficiency affects all facility occupants. Findings include: Review of the facility fire drills on 3/20/24 showed, the second quarter of 2023 (April - June 2023) did not have staff sign in sheets of who attended, to ensure competency with the fire drill protocol.”

“Engineer Smoke Control Systems CFR(s): NFPA 101 Engineer Smoke Control Systems 2012 EXISTING When installed, engineered smoke control systems are tested in accordance with established engineering principles. Test documentation is maintained on the premises. 19.7.7 This Standard is not met as evidenced by: 40068 Based on observation, interview, and record review the facility failed to inspect, test and document the testing and inspection of fusible link dampers in accordance with NFPA 80, Standard for Fire Door and Other Opening Protectives, 2010 Edition, Section 19.4.1.1 This deficiency affects all smoke compartments in the facility. Findings include: During an observation and interview on 3/20/24 at 1:20 p.m., the fusible link damper in the lower level storage room by the crawlspace was inspected. Staff member B stated the facility had multiple fusible link dampers in the facility but he did not know when they were last tested. Review of the facility’s maintenance records did not show a fusible link damper test was completed.”

“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: 40068 Based on interview and record review, the facility failed to have evidence of the generator weekly visual documentationin accordance with NFPA 110 Standard for Emergency and Standby Power Systems, 2010 Edition, Sections 8.4.1 and 8.4.2.4. This deficiency affects all smoke compartments. Findings include: During an interview on 3/20/24 at 11:05 a.m., staff member B stated he did not have documentation of the weekly visual inspections of the generator, and was not aware he needed to complete, and document a weekly visual inspection. Record review of the generator information on 3/30/24 did not include any weekly visual documentation of the generator in the last year.”

“INFECTION PREVENT & CONTROL & ABT STEWAR PROG CFR(s): The CAH must have active facility-wide programs, for the surveillance, prevention, and control of HAIs and other infectious diseases and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic-resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in coordination with the facility-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 47752 Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Infection Prevention and Control. Based on interview and record review the facility failed to: - Ensure the individual employed as the primary Infection Preventionist and Control Specialist was qualified through training, experience, and/or certification in infection prevention and control practices. (see C1204) -Ensure all Healthcare Associated Infections, Antibiotic Stewardship and other infectious diseases were integrated and followed though the facilities QAPI leadership and program. (see C1229) - Ensure the Infection Preventionist was involved in the development and implementation of the infection prevention, control, and surveillance policies and procedures. (see C1231) - Provide education to all staff related to infection prevention and control practices in the facility. (see C1237) - Establish methods used by the Infection Preventionist to review all Healthcare Associated Infections and ensure all staff are following infection control practices. (see C1240) - Ensure the Antibiotic Stewardship Program was based on nationally recognized guidelines for improvement and monitoring the use of Antibiotic use in the facility. (see C1244)”

“QAPI CFR(s): Condition of Participation: Quality Assessment and Performance Improvement Program The CAH must develop, implement, and maintain an effective, ongoing, CAH-wide, data-driven quality assessment and performance improvement (QAPI) program. The CAH must maintain and demonstrate evidence of the effectiveness of its QAPI program. (a) Definitions. For the purposes of this section- Adverse event means an untoward, undesirable, and usually unanticipated event that causes death or serious injury or the risk thereof. Error means the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems; and Medical error means an error that occurs in the delivery of healthcare services. This Condition is not met as evidenced by: 45448 Due to the manner and degree of the deficient practice, the facility failed to meet the Conditions of Participation for Quality Assessment and Performance Improvement. Based on interview and record review, the facility failed to: - Implement a QAPI program that represents the services it provided. (See C1302) - Maintain an ongoing QAPI program. (See C1306) - Develop a QAPI program that used objective measures to evaluate the facilities processes, functions, and services. (See C1309) - Appoint qualified leadership to provide oversight and direction in maintaining a comprehensive, ongoing, inclusive, and data driven QAPI program. (See C1313)”

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 45448 Based on observation, interview, and record review, the facility failed to establish and implement a procedure for ensuring expired supplies in the pediatric emergency kit were replaced prior to the expiration date. This deficient practice had the potential to affect any pediatric patient requiring the need for these supplies. Findings include: During an observation and interview on 3/12/24 at 9:34 a.m., the Broselow pediatric emergency bag was observed to have the following expired items: -Pink/Red Intubation Module, expiration 6/30/23, -Purple Intubation Module, expiration 8/31/23, -Yellow Intubation Module, expiration 7/31/23, -White Intubation Module, expiration 8/31/23, -Blue Intubation Module, expiration 8/31/23, -Orange Intubation Module, expiration 8/31/23, and -Green Intubation Module, expiration 8/31/23. Staff member AA said nursing staff was responsible for checking for outdated medication and staff member BB was responsible for outdated medical supplies During an interview on 3/12/24 at 11:38 a.m., staff member B said the department had a system in place for checking and replacing outdated supplies. Staff member B stated the night shift was responsible for checking the items. Staff member B said the items had been ordered and the items were on backorder. Staff member B did not know which items within the modules were outdated and had not attempted to order those items individually. Record review of a facility provided purchase order showed the above items were ordered on 2/13/24 and were on backorder. No purchase orders were provided for the expired items prior to their expiration date.”

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 47752 Based on observation, interview, and record review, the facility failed to ensure all essential mechanical, electrical, and patient-care equipment was identified and included in an inventory list; and failed to ensure all essential medical equipment was identified and maintained through a facility established maintenance strategy. This deficient practice had the potential to affect all patients provided care services by the facility. Findings include: 1. During an interview on 3/12/24 at 11:40 a.m., staff member X stated he was responsible for the maintenance of the facility and the facilities equipment. Staff member X stated he did not have a master list of all the equipment requiring facility evaluation, but provided a list of all the equipment serviced by the bio-medical contractor. Staff member X stated he monitored the facilities mechanical lifts, beds, recliners, tub, and any other equipment that the bio-medical service contract did not service. Staff member X stated he did not have a way to identify critical care equipment, or regular use equipment. Staff member X stated, “I don’t even know what critical equipment is.” A request for an inventory list including all equipment in the facility was requested and was not received prior to the end of the survey. 2. During an observation on 3/14/24, the following equipment was observed to not have a periodic maintenance sticker, which identified the equipment had an initial safety inspection prior to being used and/or had received periodic maintenance to ensure the equipment was inspected, tested, and maintained to ensure patient safety: Located in the emergency department: -one (1) Homemedic Thermometer, serial number A2309010AD03425, -two (2) Welch Allyn otoscopes, serial number 71670, -one (1) Welch Allyn charging stand, serial number 71140, -one (1) Welch Allyn speculum light and charger, serial number 71040 and -one (1) 3M surgical clipper and stand, serial number 9660. Located in an alcove adjacent to the nurse’s station: -one (1) Manitowoc ice machine. No serial number accessible. Located in patient care areas: -twelve (12) electric recliners. No serial number accessible -two (2) EZ way smart stand mechanical lifts, serial number 201643 and the other serial number was unreadable. Review of a facility policy titled, “Emergency Medical Services: Supplies and Equipment,” with an effective date of 10/1/19, showed: “ ... [Job title], or his/her designee shall see that such an inventory of supplies and equipment is stored in an orderly manner, periodically and regularly inspected, and tested, as appropriate and periodically and regularly reviewed for completeness.” A review of a facility policy titled, “Preventative Maintenance,” with a revised date of 4/9/21, showed: “ ... equipment used in direct patient care is checked for electrical safety prior to use and than semi-annually. Tags are applied to each piece of equipment noting the date of the inspection ... ... The preventative maintenance program is provided by the maintenance department ...”[sic] A review of the job description for staff member X showed: “Duties and responsibilities: ... Drafts and implements preventative maintenance schedules for buildings and equipment. Following the manufacturers guidelines, state and federal life safety regulations, and environment of care regulations.””

“PERIODIC REVIEW OF CLINICAL PRIVILEGES CFR(s): §485.631(d) Standard: Periodic review of clinical privileges and performance. The CAH requires that- (1) The quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners, clinical nurse specialist, and physician assistants at the CAH are evaluated by a member of the CAH staff who is a doctor of medicine or osteopathy or by another doctor of medicine or osteopathy under contract with the CAH. (2) The quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH are evaluated by- (i) One hospital that is a member of the network, when applicable; (ii) One Quality Improvement Organization (QIO) or equivalent entity; (iii) One other appropriate and qualified entity identified in the State rural health care plan; (iv) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH’s patient under an agreement between the CAH and a distant-site hospital, the distant-site hospital; or (v) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH’s patients under a written agreement between the CAH and a distant-site telemedicine entity, one of the entities listed in paragraphs (d)(2)(i) through (iii) of this section. (3) The CAH staff consider the findings of the evaluation and make the necessary changes as specified in paragraphs (b) through (d) of this section. This Standard is not met as evidenced by: 45448 Based on interview and record review, the facility failed to provide periodic performance evaluations of mid-level providers by a doctor of medicine or osteopathy. This deficient practice had the potential to affect all patients receiving care at the facility. Findings include: Record review of a credentialing file for staff member S did not contain a competency appraisal. Privileges were granted on 3/21/23. Record review of a credentialling file for staff member T did not contain a competency appraisal. Privileges were granted on 10/26/22. During an interview on 3/13/24 at 4:11 p.m., staff member Q said the facility did not have a written process in place for formal evaluations on the mid-level providers after the credentialing process.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (v) Procedures for reporting adverse drug reactions and errors in the administration of drugs. This Standard is not met as evidenced by: 47752 Based on observation, interview, and record review, the facility failed to complete a thorough investigation after controlled medication patches were not found on two separate patients (#s 27 and 33) of 3 sampled patients involving incident reports; failed to label medications with a use by date and an open date; and failed to complete a self-administration of medication assessment for 1 (#28) of 7 sampled patients during a medication pass. Findings include: 1. Review of a facility document titled, “Accident/Incident Report,” dated 3/29/23, showed: Patient #27’s Fentanyl pain patch was unable to be located by staff. Staff placed a new Fentanyl patch on resident #27 per the MAR schedule. No vital signs assessed after the incident. No investigation or interventions were completed by the facility. The incident report was signed by staff member B on 3/30/23. Review of a facility document titled, “Accident/Incident Report,” dated 5/24/23, showed: Resident #27 was due for a scheduled Fentanyl patch change, and the nurse could not locate the old Fentanyl patch. No vital signs assessed after the incident. Staff member B was notified. No investigation or interventions were completed by the facility. The incident report was signed by staff member B on 5/25/23. Review of a facility document titled, “Accident/Incident Report,” dated 7/15/23, showed: Resident #33 was due for a scheduled Fentanyl patch change, and the nurse could not locate the old Fentanyl patch. No vital signs assessed after the incident. Staff member B was notified. No investigation or interventions were completed by the facility. The incident report was signed by staff member B on 7/15/23. During an interview on 3/13/24 at 4:05 p.m., staff member B stated staff member Y investigated the incidents regarding the missing Fentanyl patches. Staff member B stated she was told by staff member Y, “There was no diversion on patient #27.” Staff member B stated she did not know what happened to patient #33’s Fentanyl patch because, “she is alert and oriented.” Staff member B stated she did not do any follow up with the incident reports, but they were now using a different system for incidents. During an interview on 3/13/24 at 4:20 p.m., staff member Y stated she had never received any incident reports from the facility regarding missing Fentanyl patches. Staff member Y stated, “The facility does not notify me of any incidents or issues that involve medications. I have met with staff member A about my concerns but that is as far as it went.” Staff member Y stated she had not done any investigations into the missing Fentanyl patches because she had not been aware of them. Review of a facility policy titled, “Incident Reporting,” with an effective date of 10/1/20, showed: “ ...The purpose of incident reports is to identify safety hazards and develop interventions to mitigate these hazards in order to reduce harm in health care.” A review of a facility document titled, “Investigation of Missing Transdermal Patches from the Patient’s body Following the Original Application,” dated, March 2024, showed: “ ...C. If the patch is not found ... 1. The nurse first calls the provider ... 2. If the transdermal patch is not found on the patient’s body, a new transdermal patch will be applied. 3. ...our pharmacists will be notified per phone or fax. 4. A thorough investigation continues followed by a written incident report. The DON is notified and reviews the incident report and nurse’s findings. The DON will document a summary of the investigation. 2. During an observation on 3/13/23 at 8:00 a.m., the medication cart contained medications that did not contain an open date, or a use by date. Medications included: - Acetaminophen 325 mg bottle, - Tums bottle ¾ empty, - 24-hour arthritis, 325 mg bottle, - Ibuprofen 200 mg bottle, - Acetaminophen Extra strength 500 mg bottle, - one (1) tube Voltaren Gel, - one (1) bottle debrox ear solution, - one (1) Metamucil bottle, - one bottle tobramycin eye drops, - one (1) bottle Flurbiprofen sodium 0.03% eye drops, - one (1) bottle Prednisone AC 1% eye drops, - one (1) bottle Refresh 1.4/0.6% eye drops, - one (1) bottle Fluticasone propinate nasal spray 50 mcg, - one (1) bottle Systane eye drops, and - one (1) tube of glucose tablets. During an interview on 3/13/24 at 8:15 a.m., staff member G stated, “All medications were to be dated when they are opened, and it was the responsibility of nursing staff to make sure the medications were labeled.” Review of a facility policy titled, “Labeling of Medication Containers,” undated, showed: “All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. ...” 3. During an observation and interview on 3/13/24 at 8:00 a.m., staff member G was doing the morning med pass in the dining room. Staff member G stated patient #29 was the only patient that was able to self-administer her medications. During an interview 3/13/24 at 8:50 a.m., patient #29 stated the nurse gave her medications but she was able to take them on her own without the nurse watching her. During an inteveiw on 3/13/24 at 2:30 p.m., staff member B stated there were no patients in the facility that self-administer medications. A review of patient #29 electronic medical record did not show a self-administration of medications assessment had been completed. A request was made for patient #29’s self-administration of medications assessment and was not received prior to the end of the survey. A review of a facility document titled, “Self-Administration of Medications,” with an effective date of November 2014, showed: “A. If a resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team...””

“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: 45448 Based on interview and record review, the facility failed to develop individualized therapeutic diets based on patient needs and preferences. This deficient practice had the potential to affect all patients/residents in the facility with specific dietary requirements. Findings include: On 3/11/24, a request was made for a copy of all therapeutic diets offered within the facility. A handwritten note was received with a list of residents requiring a therapeutic diet for textures. During an interview on 3/11/24 at 1:50 p.m., staff member V said the facility had switched vendors for their meal planning and was now using USDA. The USDA meal rotation did not provide alternate therapeutic diets. Staff member W said the facility provided the different textures for patients, but the providers only ordered regular diets for the patients. If a patient requests or requires a substitute item, the facility would provide the item requested by the patient. During an interview on 3/13/24 at 11:06 a.m., staff member V said the facility did not have prescription diets at this time. Staff member V stated the new system required each individual patient to be built, to include their dietary needs and preferences. The system will print out a meal ticket for their meal. Staff member V said she has been provided training on the system, but had not had time to build each patient into the system. She stated all patients receive regular diets currently. During an interview on 3/13/24 at 1:33 p.m., staff member S said she only orders regular diets for swing bed patients. Staff member S said she has ordered sodium restricted diets for inpatients. Staff member S said she was not aware the facility did not have therapeutic diets available. During an interview on 3/13/24 at 1:50 p.m., staff member Z stated she was contracted by the facility for nutritional assessments and dietary management. She stated she visits the facility once a month. Staff member Z said she was not aware the facility no longer had therapeutic diets available, as they had therapeutic diets with the previous vendor. Staff member Z said she was not familiar with the USDA system and did not know a diet needed to be built individually for every resident/patient. During an interview on 3/14/24 at 9:02 a.m., staff member A said he thought the dietary program was switched to USDA 6 months ago. Staff member A stated he was not aware of the change in menus, or change in the process for therapeutic diets.”

“RECORDS SYSTEM CFR(s): The records are legible, complete, accurately documented, readily accessible, and systematically organized. This Standard is not met as evidenced by: 45448 Based on interview and record review, the facility failed to have a process in place to verify the completeness of medical records for 4 (#s 2, 4, 14, and 19) of 27 sampled patients. This deficient practice had the potential to affect all medical records for patients receiving care at the facility. Findings include: A review of patient #2’s EMR, with an admission date of 1/4/23, showed a nutritional assessment on 12/12/23 that was not entered into the medical record until 1/24/24. Nutritional information was not available for patient #2, within the EMR, until 6 weeks after the assessment was completed. A review of patient #4’s EMR, with an admission date of 5/6/23, failed to include a history and physical. A review of patient #14’s EMR, with an admission date of 9/23/23, failed to include a consent for inpatient treatment. A review of patient #19’s EMR, with an admission date of 10/22/23, failed to include a consent for inpatient treatment. During an interview on 3/12/24 at 2:56 p.m., staff member C stated nursing staff should have obtained a separate consent to treat when a patient changed from ER status to inpatient status. During an interview on 3/14/24 at 10:00 a.m., staff member C stated she scanned documents into the patient’s medical records and checked to make sure the scan was completed. She stated she was not aware of a process to verify patient medical records were completed. Staff member C stated she did not know who would be responsible for checking the EMR for complete record entries. Staff member C said she would assume nursing staff was responsible for making sure all orders and entries were completed.”

“INFECTION PREVENT & CONTROL ORG & POLICIES CFR(s): Infection prevention and control program organization and policies. The CAH must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body, or responsible individual, as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure the individual employed as the primary Infection Preventionist and Control Specialist was qualified through training, experience, and/or certification in infection prevention and control practices. This deficient practice had the potential to affect all patients receiving care and staff providing care at the facility. Findings include: During an interview on 3/13/24 at 8:30 a.m., staff member D stated he assisted with Infection Prevention, but staff member S was appointed by the governing board as the Infection Preventionist. Staff member D stated he had not received any education on Infection Prevention, and he had not taken any Infection Prevention classes or seminars. Staff member D stated, “What I have learned, I have learned off of the APIC website.” During an interview on 3/13/24 at 10:35 a.m., staff member B stated she used to be the Infection Preventionist and held an APIC certificate. Staff member B stated, “I have too much on my plate, so I am not the infection Preventionist currently, but I do help with Infection Prevention.” During an interview on 3/13/24 at 10:50 a.m., staff member S stated she was who the governing board appointed as the Infection Prevention provider. Staff member S stated she was appointed because she happened to attend that particular board meeting. Staff member S stated she does not have any Infection Prevention certificates or extra training. Staff member S stated, “I am a PA so that is what education I have had.” A review of a facility document titled, “[Facility] Board of Directors Meeting,” dated 2/16/23, showed: “ ...CMS requires a practitioner to be approved by the board for infection control in the facility. It was recommended that [Staff member S’s Name] be approved.” The motion was seconded and “staff member S was approved as the infection control practitioner.””

“LEADERSHIP RESPONSIBILITIES CFR(s): (ii) All HAIs and other infectious diseases identified by the infection prevention and control program as well as antibiotic use issues identified by the antibiotic stewardship program are addressed in collaboration with the CAH’s QAPI leadership. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure all Healthcare Associated Infections, Antibiotic Stewardship, and other infectious diseases were integrated and followed though the facilities QAPI leadership and program. This deficient practice had the potential to affect all patients recieving care at the facility. Findings include: During an interview on 3/13/24 at 8:30 a.m., staff member D could not verbalize how HAI’s, Antibiotic Stewardship, and other infections were addressed with QAPI leadership or the QAPI program. Staff member D stated, “I just print off a report and give it to staff member A.” During an interview on 3/13/24 at 10:35 a.m., staff member B stated the only people who look at HAI’s, Antibiotic Stewardship, and other infections are herself and staff member D. During an Interview on 3/13/24 at 10:50 a.m., staff member S stated, “I don’t know how staff members B and D handle that.” Staff member S stated she did not attend any QAPI meetings and was unsure what QAPI was. A review of a facility document titled, “Antibiotic Stewardship-Staff and Clinician Training and Roles,” undated, showed: “ ... 4. The IP will report to the Pharmacy Review and the QAPI committee ...”.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for: (i) The development and implementation of facility-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure the Infection Preventionist was involved in the development and implementation of the infection prevention, control and surveillance policies and procedures. This deficient practice had the potential to affect all patients receiving care and all staff providing care in the facility. Findings include: During an interview on 3/13/24 at 8:30 a.m., staff member D stated, “I write all the policies and procedures for Infection Prevention. Staff member B looks at them and staff member S signs off on them.” During an interview on 3/13/24 at 10:35 a.m., staff member B stated, “As a clinical person, I get the clinical policies implemented.” During an interview on 3/13/24 at 10:50 a.m., staff member S stated, “I do not have a role in the development and implementation of policy and procedure for Infection Prevention. I just review the minutes from the infection control committee.” A review of a facility document titled, “Infection Prevention and Control Program,” undated, showed: “ ... C. The program is under the direction of the Infection Preventionist (IP) assigned by administration and the Board of Directors, to provide oversight ...””

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for:] (iv) Competency-based training and education of CAH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the CAH, on the practical applications of infection prevention and control guidelines, policies and procedures. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to provide education to all staff related to infection prevention and control practices in the facility. This deficient practice had the potential to affect all staff providing care at the facility and all patients receiving care at the facility. Findings include: During an interview on 3/13/24 at 8:30 a.m., staff member D stated he was responsible for the education of facility staff. Staff member D stated he assigns videos for staff and all department heads are responsible for doing audits to ensure completion. Staff member D stated he had never done any education with the providers. During an interview on 3/13/24 at 10:35 a.m., staff member B stated staff member D was primarily responsible for staff education. During an interview on 3/13/24 at 10:50 a.m., staff member S stated she had not had any training related to infection prevention. During an interview on 3/13/24 at 3:12 p.m., staff member G stated she had not had any recent education on infection prevention. A review of a facility document titled, “Infection Control Committee,” undated, showed: “ The infection control committee shall oversee training programs for all employees ... A. Infection Prevention and Control in-service training records, indicating the dates of the training sessions, the content of those training sessions along with the names of all persons conducting the training, and the names of all those receiving the training. ...” A request was made for Infection Prevention training and a folder was brought to the surveyor. Review of the folder failed to include documentation of any Infection Prevention education and/or in-services provided to staff.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for:] (v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by CAH personnel. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to establish methods used by the Infection Preventionist to review all Healthcare Associated Infections and ensure all staff were following infection control practices. This deficient practice had the potential to affect all patients who received care in the facility and all staff providing care in the facility. Findings include: During an interview on 3/13/24 at 8:30 a.m., staff member D was unable to verbalize what methods were used to review HAI’s and ensure staff were following the infection control practices. During an interview on 3/13/24 at 10:35 a.m., staff member B stated, “We just add more infection control audits if needed.” During an interview on 3/13/24 at 10:50 a.m., staff member S was unable to verbalize what methods were used to review HAI’s and ensure staff were following the infection control practices. Staff member S stated, “I don’t know.” Review of a facility document titled, “Monitoring Compliance with Infection Control,” undated, showed: “[Facility Name] will conduct routine monitoring and surveillance of the workplace to determine compliance with infection prevention and control policies and practices. A. The Infection Preventionist or designee monitors the effectiveness of out infection prevention and control work practices. ...””

“LEADERSHIP RESPONSIBILITIES CFR(s): (3) The leader(s) of the antibiotic stewardship program is responsible for: (i) The development and implementation of a facility-wide antibiotic stewardship program, based on nationally recognized guidelines, to monitor and improve the use of antibiotics. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure the Antibiotic Stewardship Program was based on nationally recognized guidelines for improvement and monitoring the use of antibiotics in the facility. This deficient practice had the potential to affect all patients receiving care in the facility. Findings include: During an interview on 3/13/24 at 8:30 a.m., staff member D stated, “I don’t know if the Antibiotic Stewardship program is based on any national guidelines.” During an interview on 3/13/24 at 10:35 a.m., staff member B stated, “We are looking into that. We have an ICAR scheduled to try and help us.” During an interview on 3/13/24 at 10:50 a.m., staff member S stated, “I am not sure, I just use my clinical judgement as a PA.” A review of a facility document titled, “Antibiotic Stewardship,” undated, showed: “Antibiotics will be prescribed and administered under the guidance of [Facility Name] Antibiotic Stewardship Program.””

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (1) Be appropriate for the complexity of the CAH’s organization and services provided. This Standard is not met as evidenced by: 45448 Based on interview and record review, the facility failed to implement a QAPI program that represents the services it provided. This deficient practice had the potential to affect all areas providing services to patients receiving care. Findings include: During an interview on 3/12/24 at 1:52 p.m., staff member A said he had completed a facility quality assurance review on 6/30/22. Staff member A stated he had not completed the review annually because he was told it only needed to be performed every two years. During an interview on 3/14/24 at 9:02 a.m., staff member A said he was responsible for the QAPI program and had limited experience in QAPI program oversight. Staff member A said he had been “limping along” with the program and had just hired a new staff member to help the facility with their QAPI program. Review of a facility provided document, “[Facility Name] Critical Access hospital Annual Evaluation,” dated 6/30/22, representing July 2021 through June 2022, showed: “ ...Periodic Evaluation and Quality Assurance Review- [Facility Name] continues to meet the requirements of this section, which generally describes the requirement of the organization to perform a review of operations at least annually. ...” A request for policies and procedures for the facility QAPI program was made on 3/11/24 and 3/13/24. No policies or procedures were provided by the facility prior to the end of the survey.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (2) Be ongoing and comprehensive. (3) Involve all departments of the CAH and services (including those services furnished under contract or arrangement). This Standard is not met as evidenced by: 45448 Based on interview and record review, the facility failed to maintain an ongoing QAPI program. This deficient practice had the potential to affect all areas of the facility providing patient care. Findings include: A review of the facility QAPI notebook, containing multiple years of QAPI projects for individual departments, showed current process improvement projects for each department. Nursing, Education, and Social Services were the only departments indicating current process improvement projects, which were initiated in 2023. No process improvement projects were identified as implemented in 2024. A review of the facility QAPI meeting minutes for 1/24/24 showed, no QAPI updates were provided for Medical Records, Dietary, Maintenance, Nursing, Medical Staff, Organ Procurement, or Human Resources. Education provided an update, “continued improvement on obtaining general orientation checklist. No exact numbers at this time, but certainly an improvement.” No QAPI projects were discussed with possible project development, parameters, or adjustments made for compliance. During an interview on 3/14/24 at 9:02 a.m., staff member A said the facility did not include Pharmacy in the QAPI program because it was a contracted service. Staff member A said he was not aware of any safety, medication therapy, or infection control process improvement projects. Staff member A stated each service area was currently working to update policies and procedures. Staff member A said each service area was responsible for identifying, monitoring, and reporting current projects. 47752 During an interview on 3/11/24 at 2:35 p.m., staff member B stated, “ I do not believe it (organ procurement) is being followed in QAPI.” During an interview on 3/12/24 at 9:55 a.m., staff member C stated, OPO is not being followed in QAPI. A review of the facilities QAPI minutes showed no documentation for the inclusion of the OPO program.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (4) Use objective measures to evaluate its organizational processes, functions and services. This Standard is not met as evidenced by: 45448 Based on interview and record review, the facility failed to develop a QAPI program that used objective measures to evaluate the facilities processes, functions, and services. This deficient practice had to potential to affect the facilities performance based on national standards. Findings include: During an interview on 3/13/24 at 11:40 a.m., staff member B said she had not received any training on development of a process improvement project, and she used the forms provided by the facility. Staff member B states she was currently working on a falls project but had not set parameters for the project. During an interview on 3/14/24 at 9:02 a.m., staff member A said he was responsible for the QAPI program and had limited experience in QAPI program oversight. Staff member A said he had been “limping along” with the program and had just hired a new staff member to help the facility with their QAPI program. Staff member A said he did not feel he had the medical background required for QAPI oversight. A request for policies and procedures for the facility QAPI program was made on 3/11/24 and 3/13/24. No policies or procedures were provided by the facility prior to the end of the survey.”

“QAPI CFR(s): (c) Standard: Governance and leadership. The CAH’s governing body or responsible individual is ultimately responsible for the CAH’s QAPI program and is responsible and accountable for ensuring that the QAPI program meets the requirements of paragraph (b) of this section. This Standard is not met as evidenced by: 45448 Based on interview and record review, the facility’s governing board failed to appoint qualified leadership to provide oversight and direction in maintaining a comprehensive, ongoing, inclusive, and data driven QAPI program. This deficient practice had the potential to affect all care provided to patients by all departments within the facility. Findings include: During an interview on 3/14/24 at 9:02 a.m., staff member A said he was responsible for the QAPI program and had limited experience in QAPI program oversight. Staff member A said he had been “limping along” with the program and had just hired a new staff member to help the facility with their QAPI program. Staff member A said he did not feel he had the medical background required for QAPI oversight. A request for policies and procedures for the facility QAPI program was made on 3/11/24 and 3/13/24. No policies or procedures were provided by the facility prior to end of the survey.”

“ORGAN, TISSUE, & EYE PROCUREMENT CFR(s): §485.643(a) Incorporate an agreement with an OPO designated under part 486 of this chapter, under which it must notify, in a timely manner, the OPO or a third party designated by the OPO of individuals whose death is imminent or who have died in the CAH. The OPO determines medical suitability for organ donation and, in the absence of alternative arrangements by the CAH, the OPO determines medical suitability for tissue and eye donation, using the definition of potential tissue and eye donor and the notification protocol developed in consultation with the tissue and eye banks identified by the CAH for this purpose; This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to notify the OPO (Organ Procurement Organization) upon the death of 2 (#s 12 and 27) of 5 sampled patients who expired in the facility; and failed to ensure their organ, tissue, and eye donation program (OPO) was integrated into their QAPI (Quality Assurance and Performance Improvement) program. This deficient practice had the potential to affect all patients with a requested organ donor and imminent death. Findings include: Review of patient #12’s electronic medical record, dated 7/18/23 to 7/24/23, showed the patient expired in the facility on 7/24/23. The electronic medical record showed the OPO was not notified of the patient’s death. Review of patient #27’s electronic medical record, dated 7/8/19 to 7/14/23, showed the patient expired in the facility on 7/14/23. The electronic medical record showed the OPO was not notified of the patient’s death. During an interview on 3/12/24 at 10:30 a.m., staff member C stated the facility was not aware of having to notify the OPO of the death of hospice patients. Staff member C stated, “We were under the understanding that hospice called the OPO.” Review of a facility policy titled, “Organ, Tissue, and Eye Donation,” with an effective date of 10/1/2019, showed: “ ... 1. [Facility] will notify LifeCenter Northwest (LCNW) as soon as possible of every death and imminent deaths in the critical access hospital or emergency room.” During an interview on 3/11/24 at 2:35 p.m., staff member B stated, “I do not believe it (organ procurement) is being followed in QAPI.” During an interview on 3/12/24 at 9:55 a.m., staff member C stated, OPO is not being followed in QAPI. A review of the facilities QAPI minutes showed no documentation for the inclusion of the OPO program.”

“GRIEVANCES CFR(s): § 485.614(a)(2) Grievances The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The hospital’s governing body must approve and be responsible for the effective operation of the grievance process and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. At a minimum: This Standard is not met as evidenced by: 45448 Based on interview and record review, the facility failed to inform all patients whom to contact to file a grievance for 26 (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27) of 27 sampled patients. This deficient practice had the potential to limit a patient’s right to submit a grievance to the facility. Findings include: A review of resident #1’s EMR, with an admission date of 7/14/21, showed no information was provided to the patient or the patient’s representative about filing a grievance. A review of resident #2’s EMR, with an admission date of 11/4/22 and 1/4/23 showed no information was provided to the patient of patient’s representative about filing a grievance. A review of resident #3’s EMR, with an admission date of 6/26/20, showed no information was provided to the patient of patient’s representative about filing a grievance. A review of resident #4’s EMR, with an admission date of 5/6/23, showed no information was provided to the patient or the patient’s representative about filing a grievance. A review of resident #5’s EMR, with an admission date of 3/8/24, showed no information was provided to the patient or the patient’s representative about filing a grievance. A review of resident #6’s electronic medical record, with an admission date of 3/5/24, failed to show documentation the patient or the patient’s representative was provided information about how to file a grievance or who to file a grievance with at the facility. A review of resident #7’s electronic medical record, with an admission date of 12/15/21, failed to show documentation the patient or the patient’s representative was provided information about how to file a grievance or who to file a grievance with at the facility. A review of resident #8’s electronic medical record, with an admission date of 11/9/22, failed to show documentation the patient or the patient’s representative was provided information about how to file a grievance or who to file a grievance with at the facility. A review of resident #9’s electronic medical record, with an admission date of 10/3/23, failed to show documentation the patient or the patient’s representative was provided information about how to file a grievance or who to file a grievance with at the facility. A review of resident #10’s electronic medical record, with an admission date 4/21/22, failed to show documentation the patient or the patient’s representative was provided information about how to file a grievance or who to file a grievance with at the facility. A review of resident #11’s electronic medical record, with an admission date of 11/5/23, failed to show documentation the patient or the patient’s representative was provided information about how to file a grievance or who to file a grievance with at the facility. A review of resident #12’s electronic medical record, with an admission date 4/21/22, failed to show documentation the patient or the patient’s representative was provided information about how to file a grievance or who to file a grievance with at the facility. A review of resident #13’s EMR, with an admission date of 9/12/23, showed no information was provided to the patient or the patient’s representative about filing a grievance. A review of resident #14’s EMR, with an admission date of 9/22/23, showed no information was provided to the patient or the patient’s representative about filing a grievance. A review of resident #16’s EMR, with an admission date of 12/26/23, showed no information was provided to the patient or the patient’s representative about filing a grievance. A review of resident #17’s EMR, with an admission date of 12/29/23, showed no information was provided to the patient or the patient’s representative about filing a grievance. A review of resident #18’s EMR, with an admission date of 9/30/23, showed no information was provided to the patient or the patient’s representative about filing a grievance. A review of resident #19’s EMR, with an admission date of 10/21/23, showed no information was provided to the patient or the patient’s representative about filing a grievance. A review of resident #20’s EMR, with an admission date of 12/28/23, showed no information was provided to the patient or the patient’s representative about filing a grievance. A review of resident #21’s EMR, with an admission date of 9/5/23, showed no information was provided to the patient or the patient’s representative about filing a grievance. A review of resident #22’s EMR, with an admission date of 10/28/23, showed no information was provided to the patient or the patient’s representative about filing a grievance. A review of resident #23’s EMR, with an admission date of 12/1/23, showed no information was provided to the patient or the patient’s representative about filing a grievance. A review of resident #24’s EMR, with an admission date of 1/13/24, showed no information was provided to the patient or the patient’s representative about filing a grievance. A review of resident #25’s EMR, with an admission date of 2/20/24, showed no information was provied to the patient or the patient’s representative about filing a grievance. A review of resident #26’s EMR, with an admission date of 3/6/24, showed no information was provided to the patient or the patient’s representative about filing a grievance. 47752 A review of resident #27’s electronic medical record, with an admission date 7/8/19, failed to show documentation the patient or the patient’s representative was provided information about how to file a grievance or who to file a grievance with at the facility. Review of a facility policy, “Grievances/Complaints, Filing,” revision dated 4/2017, showed: “ ...4. Upon admission, residents are provided with written information on how to file a grievance or complaint. A copy of our grievance/complaint procedure is posted on the resident bulletin board. ...” During an interview on 3/13/24 at 11:38 a.m., staff member B said grievance information for patients would be provided under the patients’ rights area of the medical chart. Staff member B stated she did not believe the information for filing of grievances was provided to patients. During an observation on 3/14/24 at 7:37 a.m., the resident information board was viewed and no listing of grievance policy or process was posted.”

“GRIEVANCES CFR(s): The hospital must establish a clearly explained procedure for the submission of a patient’s written or verbal grievance to the hospital. This Standard is not met as evidenced by: 45448 Based on interview and record review, the facility failed to establish a process which explained how to submit a verbal or written grievance to the facility for 26 (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27) of 27 sampled residents. This deficient practice had the potential to affect all patients who were provided care by the facility. Findings include: A review of resident #1’s EMR, with an admission date of 7/14/21, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #2’s EMR, with an admission date of 11/4/22 and 1/4/23, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #3’s EMR, with an admission date of 6/26/20, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #4’s EMR, with an admission date of 5/6/23, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #5’s EMR, with an admission date of 3/8/24, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #6’s electronic medical record, with an admission date of 3/5/24, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #7’s electronic medical record, with an admission date of 12/15/21, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #8’s electronic medical record, with an admission date of 11/9/22, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #9’s electronic medical record, with an admission date of 10/3/23, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #10’s electronic medical record, with an admission date 4/21/22, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #11’s electronic medical record, with an admission date of 11/5/23, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #12’s electronic medical record, with an admission date 4/21/22, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #13’s EMR, with an admission date of 9/12/23, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #14’s EMR, with an admission date of 9/22/23, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #16’s EMR, with an admission date of 12/26/23, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #17’s EMR, with an admission date of 12/29/23, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #18’s EMR, with an admission date of 9/30/23, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #19’s EMR, with an admission date of 10/21/23, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #20’s EMR, with an admission date of 12/28/23, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #21’s EMR, with an admission date of 9/5/23, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #22’s EMR, with an admission date of 10/28/23, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #23’s EMR, with an admission date of 12/1/23, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #24’s EMR, with an admission date of 1/13/24, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. A review of resident #25’s EMR, with an admission date of 2/20/24, failed to show documentation the patient or the patients representative was provided information about how to file a verbal or written grievance with the facility. A resview of resident #26’s EMR, with an admission date of 3/6/24, failed to show documentation the patient or the patients representitive was provided information about how to file a verbal or written grievance with the facility. 47752 A review of resident #27’s electronic medical record, with an admission date 7/8/19, failed to show documentation the patient or the patient’s representative was provided information about how to file a verbal or written grievance with the facility. During an interview on 3/11/24 at 3:00 p.m., patient #3 said she had not been given any information on how to file a grievance with the facility. Patient #3 said she had not seen any information posted within the facility or grievance forms available for patients to file a complaint. During an interview on 3/14/24 at 8:28 a.m., staff member A said he was responsible for the investigation of grievances. He was not aware the patients were not provided information for filing a grievance within the facility.”