Wheatland Memorial Hospital

“Subsistence Needs for Staff and Patients CFR(s): §403.748(b)(1), §418.113(b)(6)(iii), §441.184(b)(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1), §483.475(b)(1), §485.542(b)(1), §485.625(b)(1) [(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal. This Standard is not met as evidenced by: 40068 Based on interview and record review the facility failed to plan and implement a provision of subsistence needs for the staff and the residents. This affects all occupants in the facility. Findings include: During an interview on 3/6/24 at 12:20 p.m., staff member C stated the facility’s emergency preparedness plan did not include information on how the facility will utilize alternate sources of energy to maintain temperatures and lighting in the facility, as well as how the facility will manage sewage and waste disposal. Review of the EP plan, policies, and procedures on 3/6/24, reflected the facility’s emergency plan lacked policies and procedures for subsistence needs for staff and residents, particularly specific policies describing how alternate sources of energy will maintain proper temperatures, emergency lighting, keep sprinkler and alarm systems online, as well as sewage and waste disposal in the event of a loss of water.”

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 40068 Based on interview and record review, the facility failed to complete a system to track the location and availability of on-duty staff and patients during an emergency. The deficiency affects all the occupants in the facility. Findings Include: Review of EP plan on 3/6/24, reflected a lack of documentation that the facility had established a system to track on-duty staff and the patients during an emergency. The system must be effective to track on-duty staff and the residents during evacuation or sheltering in place. If there is an evacuation, there must be a system to document the specific name and location of where they are evacuated to. During an interview on 3/6/24 at 12:25 p.m., staff member C stated the facility did not have a method for tracking staff and patients during an emergency.”

“Policies/Procedures-Volunteers and Staffing CFR(s): §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: 40068 Based on interview and record review, the facility failed to develop and implement emergency preparedness (EP) policies and procedures, addressing the use of volunteers in an emergency. This deficiency affects all staff and patients in the facility. Findings include: During an interview on 3/6/24 at 12:30 p.m, staff member C stated the facility’s emergency preparedness plan did not include a policy for the use of volunteers in an emergency. Review of the facility’s Emergency Preparedness plan on 3/6/24 showed the facility did not include a policy and procedure for the use of volunteers in an emergency.”

“Emergency Officials Contact Information CFR(s): §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: 40068 Based on record review, the facility failed to develop and implement an emergency preparedness (EP) communications plan which includes contact information for the Certification Agency as well as the Ombudsman. This deficiency has the potential to affect all staff and patients at the facility. Findings include: 1. Review of the facility emergency preparedness plan on 3/6/24 showed the facility’s communications plan lacked contact information for the State Certification agency as well as the Ombusman.”

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 40068 Based on interview and record review the facility failed to maintain a emergency training and testing program based on the facility’s Emergency Preparedness Plan. This deficiency affects all staff and patients at the facility. Findings Include: During an interview on 3/6/24 at 12:40 p.m., staff member C stated the facility’s emergency preparedness training program was outdated and they are in the process of updating the program. Review of facility’s emergency preparedness plan on 3/6/24 showed the facility did not have a training and testing program for their Emergency Preparedness Plan.”

“EP Training Program CFR(s): §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: 40068 Based on record review the facility failed to implement the initial and annual training of the EP program to all staff members, consistent with each team members’ expected roles during an emergency or a disaster. This deficiency affects all of the occupants and staff in the facility. Findings include: 1. Record review of the facility EP plan and training documents on 3/6/24 revealed, the facility did not have documentation that staff training for the EP plan was conducted initially for new staff and every other year for all current staff.”

“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 3/6/24. 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 CAH is made up of two buildings as follows: Building 01 - Main Hospital Building Building 02 - Old Nursing Home Building 01, Main Hospital Building, is construction type Type III (211) and contains two smoke compartments and two floors. No new construction has occurred since the last survey of the facility on 10/20/16. The facility had 11 swing bed patients/residents and inpatient patient at the time of survey. There is a 2 hour barrier that serves as a horizontal exit between both buildings. There is a 2 hour barrier which separates a rural health clinic from the CAH on the upper floor. These requirements were not met as evidenced by the following deficiencies:”

“Discharge from Exits CFR(s): NFPA 101 Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7 This Standard is not met as evidenced by: 40068 Based on observation, the facility failed to maintain the exit discharge to the public way with respect to keeping a level walking surface free of obstruction in accordance with NFPA 101, 2012 Edition, Section 7.1.6.2.and These deficiencies affect 1 of 4 smoke compartments. Findings Include: During an observation on 3/6/24 at 12:27 p.m., the roof top exit egress path was inspected. The walkway was found to have multiple sections of the concrete chipped and broken. The hard-surface path to the public way cannot have more than a 1/4” variation in tread height.”

“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: 1. Review of the facility records for testing of the emergency lighting documentation on 3/6/24, showed the facility had not performed the required 30 second monthly lighting tests for the whole year. During an interview on 3/6/24 at 12:15 p.m., staff member B stated he had completed the monthly tests from January 2023 - May of 2023 but had not completed them June 2023 - January 2024. He stated he started doing the 30 second monthly tests in February 2024.”

“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 ensure all exit passageways were marked in accordance with NFPA 101 2012 Edition, Section 7.7.3.2 This deficiency affected 1 out of 4 smoke compartments in the facility. Findings include: 1. During an observation on 3/6/24 at 1:17 p.m., the exit signage to the roof top exit was inspected. There were no exit signs located on the exit door to the public way. There were several doors which could be confused as a way out of the area. It would not be obvious in times of darkness, smoke, or panic.”

“Vertical Openings - Enclosure CFR(s): NFPA 101 Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box. This Standard is not met as evidenced by: 40068 Based on observation and review of previous surveys, the facility failed to enclose an exit stairway in the means of egress from the second to the first floor in accordance with NFPA 101, 2012 Edition, Sections 19.3.1., 19.3.1.1 and 8.6.2. The deficiency affects 2 of 4 smoke compartments at the facility. Findings include: 1. During an observation on 3/6/24 at 1:32 p.m., the stairway adjacent to the laboratory at the second floor level was open to the corridor. Required means of egress, including stairways, should be separated from other parts of the building with at least 1 hour construction.”

“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: 40068 Based on an observation, and interview the facility failed to assure hazardous rooms/areas had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1, 19.3.2.1.3 and 19.3.2.1.5 (7). This deficiency affects 1 of 4 smoke compartments. Findings include: During an observation on 3/6/24 at 1:04 p.m., room 211 was inspected. the room was being used as storage, was over 50 square feet and did not have a self-closure on the door.”

“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 on record review, the facility failed to maintain the kitchen hood extinguishing system in accordance with NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition, Section 11.2.1. This deficiency affects all residents in the facility. Findings include: 1. Record review of the kitchen hood system inspection records reflected a lack of documentation to show the contractor had performed services on a semi-annual basis for the last year. The kitchen hood inspection documents were not located at the facility during the time of the survey.”

“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 This deficiency affects all smoke compartments at the facility. Findings include: 1. During a review of the most recent facility fire alarm inspection on 3/6/24, the fire alarm report was inspected. 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.”

“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 to: 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) document weekly sandpipe gauge readings weekly in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 6.2.2.2. and monthly standpipe gauge readings for the wet system per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 13.2.7.1. c) maintain sprinkler heads free of foreign materials per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.1.1.1, d) 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; e) Failed to maintain sprinkler heads free of foreign materials in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.1.1.1. This deficiency affects all smoke compartments at the facility. Findings include: 1. Review of the facility’s quarterly sprinkler inspections showed the first quarter of 2023 (January - March 2023) and the last quarter of 2023 (October - December 2023) were missing. During an interview on 3/6/24 at 11:17 a.m., staff member B stated he would need to call the sprinkler inspection company to have them send over the missing inspections. 2. Review of the facility’s documentation on 3/6/24 showed the sprinkler pressure guage documentation for the wet system and the dry system was not being completed. During an interview on 3/6/24 at 11:56 a.m., staff member B stated weeky dry sprinkler system and monthly wet sprinkler system documenttion was not being completed. 3. During an observation on 3/6/24 at 12:56 p.m., the laundry room was inspected. There was a waterline ziptied to the sprinkler piping. 4. During an observation on 3/6/24 at 12:58 p.m., the bio room was inspected. There were cords hanging off the sprinkler piping. 5. During an observation on 3/6/24 at 12:58 p.m., the medical records room was inspected. The sprinkler head was loaded with dust. 6. During an observation on 3/6/24 at 1:08 p.m., the HR office was inspected. There was a cord hanging off the sprinkler piping. 7. During an observation on 3/6/24 at 1:12 p.m., the boiler room was inspected. There was a cord hanging off the sprinkler piping.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 40068 Based on observation, the facility failed to install portable fire extinguishers in accordance with NFPA 101 Life Safety Code 2012 Edition, Sections 19.3.5.12, and NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.8.1. This deficiency affects all smoke compartments. Findings include: 1. During observations throughout the facility on 3/6/24 there were multiple fire extinguishers mounted above 5 feet from the floor. During an interview on 3/6/24 at 1:30 p.m., staff member B stated almost all the extinguishers were mounted above 5 feet. He stated he would go around the facility and ensure they all get mounted at the correct height.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 40068 Based on an observation the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d). This deficiency affects 2 out of 4 smoke compartments in the facility. Findings include: 1. During an observation on 3/6/24 at 1:00 p.m., the bio room was inspected. A housekeeping cart was being stored in front of an electrical panel. 2. During an observation on 3/6/24 at 1:20 p.m. the server room was inspected. there was storage in front of the electrical pannel.”

“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: 40068 Based on observation, the facility failed to maintain the proper signage for the storage room for oxygen cylinders in accordance with NFPA 99, 2012 Edition, Section 5.1.3.1.9. This deficiency affects 1 out of 4 smoke compartments. Findings include: During an observation on 3/6/24 at 1:05 p.m., the oxygen storage closet was inspected. The signage on the door read, “NO SMOKING OXYGEN IN USE.” This verbiage is not compliant with NFPA standards.”

“DRUG AND BIOLOGICALS CFR(s): Drugs and biologicals commonly used in life-saving procedures, including analgesics, local anesthetics, antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids, antiarrythmics, cardiac glycosides, antihypertensives, diuretics, and electrolytes and replacement solutions. This Standard is not met as evidenced by: 47752 Based on observation, interview, and record review, the facility failed to implement a procedure for ensuring expired medications were not accessible and were removed from use in the emergency department. This deficient practice had the potential to affect all patients requiring medication in the emergency department. Findings include: During an observation on 2/27/24 at 9:12 a.m., staff member Q unlocked the crash cart located in the emergency department. A 250 ml bag of IV fluids containing Heparin 25,000 units was observed. The expiration date on the bag was 1/2024. There were no other IV bags containing heparin located in the crash cart. During an interview on 2/27/24 at 9:45 a.m., staff member Q stated, “From what I understand, either the pharmacy tech or the Director of Nursing checks for expired medications, and removes them from use. I have not checked for expired medications since I have been here.” During an interview on 2/27/24 at 9:50 a.m., staff member H stated she was being trained as a pharmacy technician by the Director of Nursing. Staff member H stated she had not checked for expired medications in the emergency department. During an interview on 2/27/24 at 1: 21 p.m., staff member B stated she was ultimately responsible for the pharmacy. Staff member B stated there was a pharmacist on site once a month, but most duties were completed by her. Staff member B stated she should have been checking the emergency department more frequently for expired medications. Review of a facility document titled, “Omnicell-DISPOSAL OF EXPIRED MEDICATIONS,” with an approval date of 12/22/22, showed: “Expiration of medication stocked in the Omnicell and Emergency Room should be checked on a monthly basis by the pharmacy technician.””

“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: 47752 Based on observation and interview, the facility failed to implement a procedure for ensuring expired supplies were replaced prior to the expiration date. This deficient practice had the potential to affect any patient receiving care in the emergency department. Findings include: During an observation on 2/27/24 at 9:12 a.m., staff member Q unlocked the crash cart and storage cupboards in the emergency room. The following supplies were found outdated or had no open or use by dates placed on them: - Eight (8) pink oral foam swabs with dentifrich: Expiration date of 4/15/2023, - One (1) pink oral foam swab: Expiration date of 11/1/2023, - Seventeen (17) pink oral foam swabs laying in the bottom of a zip lock bag unpackaged, and no expiration date noted, - Five (5) size 18 French 5 cc, ribbed balloon foley catheter: Expiration date of 10/31/23, - One (1) bottle of Alcon Sterile Eye Irrigation Solution: Expiration date of 11/2023, - One (1) open bottle hydrogen peroxide, one quarter full: No dates noted, - One (1) open bottle of betadine solution, one half used: No dates noted, and - Three (3) open packages of 3M red dot monitoring electrodes: No dates noted. During an interview on 2/27/24 at 9:45 a.m., staff member Q stated, “From what I understand, either the pharmacy tech or the Director of Nursing checks for expired supplies. I have not checked for expired supplies since I have been here.” During an interview on 2/27/24 at 9:50 a.m., staff member H stated she had not checked for expired supplies in the emergency department. During an interview on 2/27/24 at 1: 21 p.m., staff member B stated she was ultimately responsible for ensuring supplies were not expired in the emergency department and she should have been checking more frequently for expired supplies.”

“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: During an observation in the emergency department on 2/27/24 at 9:12 a.m., 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: - One (1) Welch Allyn head lamp, with an engraved metal facility plate with number 1027, - Two (2) DOT (brand name) thermometers, - One (1) ultra-violet exam light, - Traction splints with a handwritten facility number, 59036, and - LUCAS chest compression machine. During an interview on 2/28/24 at 3:05 p.m., staff members A and D stated the facility did not have a complete inventory of equipment required to meet patient needs or identify critical-care equipment or equipment essential to patient care. During an interview on 2/29/24 at 8:35 a.m., staff member D stated there was not a record of the DOT thermometers, ultra-violet exam light, traction splints, or the LUCAS chest compression machine having been inspected, tested, and maintained by the facility or by their contracted alternative equipment maintenance (AEM) contractor. During a phone interview on 2/29/24 at 8:57 a.m., NF1 stated they did not have a record of the head lamp, DOT thermometers, ultra-violet exam light, traction splints, or the LUCAS chest compression machine in their list of equipment to be maintained for the facility. Review of a facility document titled, “Preventative Maintenance Program,” with an approval date of 9/30/2021, showed: “PURPOSE: To provide for routine and preventative maintenance for the facility’s plant, electrical systems, and mechanical systems, and to ensure all essential equipment and systems are maintained in a safe operation [sic] condition. POLICY: The routine and preventative maintenance program will be provided by the Maintenance Department either directly or through a contact service or the equipment vendor. PROCEDURE: Inspections, routine maintenance, preventative maintenance, and testing of equipment shall be carried out on a regularly scheduled basis ...The [Facility] Maintenance Check List Schedule will be reviewed and updated periodically by the Facility Manager. Check List and Logs will be maintained and kept in the Maintenance Office or at the site of inspection ...” An initial request for the facility’s complete inventory list was made on 2/27/24, with a second request made on 2/28/24. None was received prior to the end of the survey.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 47752 Based on observation, interview, and record review, the facility failed to store medications in a temperature-controlled room. This deficient practice had the potential to affect any patient who received medications stored in the pharmacy. Findings include: During an observation and interview on 2/26/24 at 4:20 p.m., a thermometer gauge was observed sitting on a shelf in the pharmacy. The thermometer was not easily readable. Staff member H stated she was not aware what the temperature parameter was for the medication storage area in the pharmacy. Staff member H stated there was not a way to control the temperature in the pharmacy. During an interview on 2/28/24 at 8:06 a.m., staff member B stated there was no way to control the temperature in the pharmacy. Staff member B stated the only policy about medication storage was in the swing bed policy. Review of the facility policy titled, “STORAGE OF DRUGS-INTERMEDIATE SWING BED,” with an approval date of 12/22/22, showed: “PURPOSE: To comply with the proper storage of drugs and pharmaceutical regulations under State and Federal law. ... 3. Drugs should be stored at appropriate temperature. Drugs required to be at room temperature shall be stored at a temperature of not less than 15 degrees C (59 degrees F) or more than 30 degrees C (86 degrees F). Drugs requiring a ‘cool place’ shall be stored in the refrigerator.””

“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 label medications with a use by date and an open date; failed to ensure that expired medications were replaced; and failed to follow physician’s orders resulting in medications errors for 2 (#s 7 and 14) of 16 sampled swing bed patients. This deficient practice had the potential to affect all swing bed patients who receive their medications from staff, and have medications stored in the medication cart. Findings include: 1. During an observation on 2/26/24 at 4:30 p.m., the medication cart in the swing bed area had the following medications which did not have an open date, a use by date, or were expired: - ondansetron 4 mg, with an expiration date of 1/2023, - dorzolamide timolol ophthalmic solution, - timolol maleate 0.05% solution, - Icy Hot ointment, - betamethasone 0.05% cream, - triamcinolone 0.025% cream, - two (2) Nystatin powder 100,000 units, - Tylenol 325 mg bottle, - chewable calcium bottle, 500 mg, - senna 8.6 mg bottle, - baby aspirin 81 mg bottle, - iron 325 mg bottle, - fluticasone/salmeterol 250 mcg/50 mcg inhaler, - albuterol inhaler 90 mcg, and - fluticasone propionate nasal spray 50 mcg. 2. During an observation on 2/27/24 at 7: 50 a.m., staff member P was passing medications in the dining area. Staff member P opened the medication cart and pulled out resident #7’s medications and began to pop them out of the bubble pack, into a clear medication cup. Staff member P was not logged into the computer and did not verify the physician’s orders for medication administration. Staff member P opened the side drawer of the medication cart and grabbed a large bottle of Metamucil. The Metamucil bottle did not have a pharmacy label in place. The only patient identifier was a first name, written on the lid in marker. Staff member P stated patient #7 received 3.4 grams daily. Staff member P grabbed a plastic teaspoon off the medication cart and placed two spoonfuls into a clear, plastic cup, resulting in approximately 10 mls of the medication. The directions on the bottle stated a 3.4 gram dose was two tablespoons. Two tablespoons was approximately 30 mls. Staff member P took the medications over to where resident #7 was sitting, placed the medications in front of her and walked away. During an interview at 7:55 a.m., staff member P stated, “She (patient #7) is with it, so I can leave her medications with her and she will take them.” Review of patient #7’s EMR, dated February 2024, refelcted patient #7 did not have a physician order for self-administration of medication, or an assessment for self-administration of medications. 3. During an observation and interview on 2/27/24 at 9:05 a.m., staff member P took patient #14’s insulin out of the top drawer of the medication cart and took it to patient #14’s room. The open date on the insulin pen was 1/22/24. Insulin is good for 28 days after opening. Staff member P attached the insulin needle to the insulin pen and stated she had primed the needle with 1 unit of insulin. No residual insulin was noted on the needle, showing it had not been properly primed. Staff member P turned the dial on the insulin pen to 10 units and handed patient #14 the insulin pen. Staff member P cleaned patient #14’s abdomen with an alcohol wipe and patient #14 injected the insulin into his abdomen. The insulin pen was eight days past the use by date. Staff member P stated, “It is the nurse’s responsibility to check the dates and the medications, not mine.” A request for staff evaluations on medication pass and insulin procedures was requested but was not received prior to the end of the survey. A request for the facilities policy and procedure for insulin administration and priming was requested but was not received prior to the end of the survey. A request for the policy and procedure for expired medications for swing bed was requested but was not received prior to the end of the survey. Review of the facility document titled, “STORAGE OF DRUGS-INTERMEDIATE SWING BED,” with an approval date of 12/22/22, showed: ... “5. Drugs shall not be kept on hand after the expiration date ...” A review of a facility document titled, “ Medication And/or Treatments-Self Administered by Swing Bed Patients,” with an approval date of 6/23/21, showed: “ ...A. Self-administration of medications or treatments by patients is permitted only by a provider order that includes dosage, route, and any special instructions. ... Procedure: A. The admitting nurse will assess intermediate swing bed patient competency to self-administer using “Assessment of Self-Administering of Medications” form... B. A decision to permit self-administering is made by the Interdisciplinary Care Plan Conference and written order by the Provider after the ‘Assessment to Self-Administration of Medication’ is completed.” [sic]”

“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: 47752 Based on interview and record review, the facility failed to review death records with the OPO (Organ Procurement Organization) for 3 (#s 19, 20, and 26) of 3 sampled patients who expired in the facility. Findings include: Review of patient #19’s EMR, dated 9/14/23 to 10/6/23, showed the patient expired in the facility on 10/6/23. The EMR showed the OPO was notified of the death in the facility. Review of patient #20’s EMR, dated 5/14/23 to 7/11/23, showed the patient expired in the facility on 7/11/23. The EMR showed the OPO was notified of the death in the facility. Review of patient #26’s EMR, dated 10/26/23, showed the patient expired in the emergency department on 10/26/23. The EMR showed the OPO was notified of the death in the facility. During an interview on 2/27/24 at 1:40 p.m., staff member B stated she had not reviewed the death records or reviewed the death records with the OPO. Staff member B stated, “Should I be? I have not been doing that.” A review of a facility policy titled, “Organ and Tissue Donation,” with an effective date of 3/23/2023, showed: “In compliance State and Federal Laws, it is the policy of [Facility Name] to recognize the right of every individual to determine the disposition of his/her organs and tissue upon death. ... 10. [Facility Name] works cooperatively with the donation agencies in reviewing death records...” A request was made on 2/27/24, for the quarterly review of deaths with the OPO. None was received prior to the end of the survey.”

“COMP ASSESSMENT, CARE PLAN & DISCHARGE CFR(s): §485.645(d)(5) Comprehensive assessment, comprehensive care plan, and discharge planning (§483.20(b), and §483.21(b) and (c)(2) of this chapter), except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under §483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in §413.343(b) of this chapter). “ §483.20(b) Comprehensive assessments- (1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information. (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychosocial well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnoses and health conditions. (xi) Dental and nutritional status. (xii) Skin condition. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. (2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2) (i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. (For purposes of this section, “readmission” means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.) (ii) Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. (For purposes of this section, a “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both.) (iii) Not less often than once every 12 months. “ §483.21(b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25, or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25, or §483.40 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (i) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (ii) In consultation with the resident and the resident’s representative(s)- (A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident’s representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident’s needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident’s written plan of care. (iii) Be culturally-competent and trauma-informed. “ §483.21(c)(2) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident’s stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident’s status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative. (iii) Reconciliation of all pre-discharge medications with the resident’s post-discharge medications (both prescribed and over-the-counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to complete a comprehensive assessment containing the required elements, within 14 days of admission for 2 (#s 15 and 18) and failed to develop and implement a comprehensive, patient-centered care plan for 7 (#s 3, 4, 5, 6, 7, 8, and 14) of 16 sampled swing bed (skilled and intermediate) patients.This deficient practice had the potential to result in a lack of personalized, comprehensive care for individual patients. Findings include: 1. Review of the following EMRs failed to show a comprehensive assessment was completed within 14 days of the patient’s admission: - patient #15, skilled swing bed, dated from 2/8/24 to 2/23/24, and - patient #18, skilled swing bed, dated from 1/19/24 to 2/9/24. During an interview on 2/28/24 at 2:22 p.m., staff member B stated there was a form, titled, “LTC Comprehensive Assessment,” not dated, within the EMR system which prompted the nurse to assess all of the required areas of the comprehensive assessment. Staff member B stated the comprehensive assessment was done annually, but she was not sure if staff were aware the comprehensive assessment also needed to be completed within 14 days of admission to a swing bed (skilled or intermediate). A request for the initial comprehensive assessment, for patient #s 15 and 18, was made on 2/28/24. Neither of the assessments were received prior to the end of the survey. 2. Review of patient #3’s Care Plan Conference Summary, dated 10/17/23, showed the patient had an admission date of 2/23/23 with diagnoses of depressive disorder, cognitive impairment, diabetes type II, chronic kidney disease stage III, overactive bladder, anxiety, and falls. Review of patient #3’s care plan, dated 10/17/23, failed to show problems, goals, or interventions addressing the resident’s diet, psychosocial needs, diabetes monitoring, behaviors, bowel or bladder function, ADL function, code status, medications, or any other type of pertinent information essential to provide ongoing care to the patient. Review of patient #4’s Care Plan Conference Summary, dated 10/17/23, showed the patient had an admission date of 6/28/19 with diagnoses of diabetes type II, hypothyroidism, mixed anxiety and depressive disorder, senile dementia, and insomnia. Review of patient #4’s care plan, dated 10/17/23, failed to show problems, goals, or interventions addressing diet, psychosocial needs, any diabetes monitoring, behaviors, ADL function, code status, medications, or any other type of pertinent information essential to provide ongoing care to the patient. Review of patient #5’s Care Plan Conference Summary, dated 1/22/24, showed the patient had an admission date of 9/17/19 and a diagnosis list which included a TBI, hypertension, sexual disorder, prostate cancer, and impaired cognition. Review of patient #5’s care plan, dated 1/22/24, failed to show problems, goals, or interventions addressing diet, psychosocial needs, behavior monitoring, code status, medications, or any other type of pertinent information essential to provide ongoing care to the patient. Review of patient #6’s Care Plan Conference Summary, dated 11/15/23, showed the patient had an admission date of 5/30/23 and a diagnosis list which included gastrointestinal hemorrhage, TBI, hypertension, renal transplant, A-fib, recurrent UTI’s, and failure to thrive. Review of patient #6’s care plan, dated 11/15/23, failed to show problems, goals, or interventions addressing diet, psychosocial needs, behavior monitoring, code status, medications, transplant information, ADL status, or any other type of pertinent information essential to provide ongoing care to the patient. Review of patient #7’s Care Plan Conference Summary, dated 1/22/24, showed the patient had an admission date of 1/20/23 and a diagnosis list which included A-Fib, rheumatoid arthritis, stroke, osteoporosis, and a history of dysphagia. Review of patient #7’s care plan, dated 1/22/24, failed to show problems, goals, or interventions addressing diet, psychosocial needs, behavior monitoring, code status, medications, ADL status, or any other type of pertinent information essential to provide ongoing care to the patient. Review of patient #8’s Care Plan Conference Summary, dated 11/15/23, showed the patient had an admission date of 1/17/22 and a diagnosis list which included Parkinson’s disease, hypertension, hypothyroidism, atherosclerosis, breast cancer, and chronic pain. Review of patient #8’s care plan, dated 11/15/23, failed to show problems, goals, or interventions addressing diet, psychosocial needs, behavior monitoring, code status, medications, ADL status, or any other type of pertinent information essential to provide ongoing care to the patient. 41652 Review of patient #14’s Care Plan Conference Summary, dated 1/15/24, showed the resident was admitted on 1/3/24 and had diagnoses which included a left below the knee amputation with a prosthesis, atrial fibrillation, congestive heart failure, diabetes, and hypertension. Review of patient #14’s care plan, dated 1/15/24, failed to show any problems, goals, or interventions related to the amputation, mobility, diabetes care, psychosocial needs, or medications. During an interview on 2/28/24 at 8:53 a.m. staff member B stated the sheet in front of the care plan was the comprehensive assessment and care plan summary. Staff member B stated she knew there was a lot of work to be done in this area. Staff member B stated there had been a few policies which had been retired and new ones were not approved yet. Review of the facility’s policy titled, “Care Planning,” dated 7/19/21, showed it was the responsibility of the admitting RN to initiate the care plan based on a thorough patient assessment. The policy also showed it was the responsibility of the RN to review and update the care plan as needed.”

“NOTICE OF RIGHTS CFR(s): A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under state law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to inform patients and/or their representatives of their rights prior to providing or discontinuing care 12 (#s 2, 13, 15, 16, 17, 18, 21, 22, 23, 24, 25, and 26) of 26 sampled patients. This deficient practice had the potential to affect the exercise of rights for all patients receiving care in the facility. Findings include: Review of patient #2’s medical record showed the patient had come to the emergency department on 2/25/24 and was discharged on 2/26/24. No acknowledgement of patient rights was in the medical record. Review of patient #13’s EMR, showed the patient was admitted to swing bed on 1/10/22. Review failed to show an acknowledgement of patient rights was in the medical record. Review of patient #15’s EMR, showed the patient was admitted to swing bed on 2/8/24. Review failed to show an acknowledgement of patient rights was in the medical record. Review of patient #16’s EMR, showed the patient was admitted to swing bed on 2/13/24. Review failed to show an acknowledgement of patient rights was in the medical record. Review of patient #17’s EMR, showed the patient was admitted to swing bed on 1/24/23. Review failed to show an acknowledgement of patient rights was in the medical record. Review of patient #18’s EMR, showed the patient was admitted to swing bed on 1/19/24. Review failed to show an acknowledgement of patient rights was in the medical record. Review of patient #21’s medical record showed the patient was seen in the emergency department on 2/22/24 and was transferred to another facility on the same date. No acknowledgement of patient rights was found in the medical record. Review of patient #22’s medical record showed the patient had come to the emergency department on 2/12/24 and was transferred to another hospital on the same day. No acknowledgement of patient rights was in the medical record. Review of patient #23’s medical record showed the patient was seen in the emergency department on 2/7/24 and was transferred to another facility on the same date. No acknowledgement of patient rights was found in the medical record. Review of resident #24’s medical record showed the patient had come to the emergency department on 11/14/23 and was admitted into an inpatient bed. No acknowledgment of patient rights was in the medical record. Review of patient #25’s medical record showed the patient was seen in the emergency department on 11/3/23. The patient, who had abdominal pain, was placed in observation and subsequently discharged home on 11/4/23. No acknowledgement of patient rights was found in the medial record. Review of patient #26’s medical record showed the patient had come to the emergency department on 10/26/23 and expired on 10/26/23. No acknowledgement of patient rights was in the medical record. During an interview on 2/28/24 at 2:03 p.m., staff member H stated when she had patients sign the required paperwork in the emergency department, there was not a copy of the patient’s rights in the packet. Staff member H stated she had not been giving the patients copies of the patient rights form. During an interview on 2/28/24 at 2:20 p.m., staff member B stated, “A new form will be added in the packets going forward, and I will be looking at the policy and procedure for this.” During an interview and document review on 2/28/24 at 2:22 p.m., staff member B provided the admission paperwork for swing bed skilled, swing bed intermediate, acute, observation, and emergency department. The paperwork for the swing bed intermediate stays included an admission agreement, dated November of 2023, which specifically referenced a policy on swing bed patient’s rights titled, “C-XXX Swing Bed Patient’s Rights and Responsibilities.” Upon request for this policy, staff member B stated the identified document was not a policy. The form in the facility’s policy management system was the Patient Rights and Responsibilities form which was given to acute and swing bed skilled admissions, not emergency department or swing bed intermediate admissions. Staff member B stated the swing bed intermediate admissions were usually long term admissions and a different rights form was being used. A request for the patient rights form given to emergency department patients was submitted on 2/28/24 and was not received prior to the end of the survey. A request for the patient rights form given to swing bed skilled admissions was submitted on 2/28/24 and was not received prior to the end of the survey. 41652”

“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: 41652 Based on interview and record review, the facility failed to inform all patients whom to contact to file a grievance for 6 (#s 13, 15, 16, 21, 23, and 25) of 26 sampled patients. The deficient practice had the potential to limit a patient’s right to submit a grievance to the facility. Findings include: 1. Review of patient #13’s EMR showed the patient was admitted to an intermediate swing bed on 1/10/22. The review failed to show documentation the resident had not been given the patient rights form which included information regarding the process for submission of a grievance, but not who to contact to submit a grievance. During an interview and document review on 2/28/24 at 2:22 p.m., staff member B provided the admission paperwork for swing bed skilled, swing bed intermediate, acute, observation, and emergency department encounters. The paperwork for the swing bed intermediate stays included an admission agreement, dated November of 2023, which specifically referenced a policy on swing bed patient’s rights titled, “C-XXX Swing Bed Patient’s Rights and Responsibilities.” Upon request for this policy, staff member B stated the identified document was not a policy. The form in the facility’s policy management system was the Patient Rights and Responsibilities form which was given to acute and swing bed skilled admissions, not swing bed intermediate admissions. Staff member B stated the swing bed intermediate admissions were usually long term admissions and a different rights form was being used. The patient rights form being given to swing bed patients did not contain information regarding who was to be contacted in order to submit a grievance. Staff member B stated she could not find any documentation in patient #13’s EMR which showed he or his representative had been informed of the process for submitting a grievance to the facility. 2. a) Review of patient #15’s EMR, with a swing bed skilled admission date of 2/8/24, failed to show documentation the patient was informed of her right to submit a grievance to the facility. The acknowledgement of receipt of patient rights form included information regarding the submission of a grievance. The resident’s EMR did not contain this acknowledgement. b) Review of patient #16’s EMR, with a swing bed skilled admission date of 2/13/24, failed to show documentation the patient was informed of her right to submit a grievance to the facility. During an interview on 2/28/24 at 2:22 p.m., staff member B stated the Consent for Care form had a statement of acknowledgement the patient had received the Notice of Patient Rights which provided information regarding the submission of a grievance. Staff member B stated, “If the Consent for Care form was not in the record, there was no other way to determine if the patient was informed of their rights.” 3. a) Review of patient #21’s EMR, with an emergency department admission date of 2/22/24, failed to show documentation the patient was informed of her right to submit a grievance to the facility. b) Review of patient #23’s EMR, with an emergency department admission date of 2/7/24, failed to show documentation the patient was informed of his right to submit a grievance to the facility. c) Review of patient #25’s EMR, with an emergency department admission date of 11/3/23, failed to show documentation the patient was informed of his right to submit a grievance to the facility. During an interview on 2/28/24 at 2:03 p.m., staff member H stated when she had patients sign the required paperwork in the emergency department, there was not a copy of the patient’s rights in the packet. Staff member H stated she had not been giving the patients copies of the resident rights form. During an interview on 2/28/24 at 2:20 p.m., staff member B stated, “A new form will be added in the packets going forward, and I will be looking at the policy and procedure for this.” During an interview on 2/28/24 at 2:22 p.m., staff member B stated the Consent for Care form had a statement of acknowledgement the patient had received the Notice of Patient Rights which provided information regarding the submission of a grievance. Staff member B stated if emergency department patients were not being given a copy of the patient rights form, they would not have been given the necessary information about how to submit a grievance. A request for the patient rights form given to emergency department patients was requested on 2/28/24 and was not received prior to the end of the survey.”