Rosebud Health Care 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 (LSC) survey was performed on 2/6/24. 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 utilizes two buildings for patient care as follows: Building 01 Critical Access Hospital Building 02 Rural Health Clinic Building 01 was surveyed specifically using Chapter 19, Existing Health Care Occupancies. The building construction type was found to be Type V (111) and contained 3 smoke compartments. There is a two hour separation between the Rural Health Clinic (RHC) and the CAH. This area was surveyed under the Business Occupancy Chapter (39) in NFPA 101 Life Safety Code. The CAH is licensed for 24 beds and at the time of survey, 4 patients was the census. These requirements were not met as evidenced by the following deficiencies.”

“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: 32381 Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7 and section 19.2.2.2.8. Findings include: 1. During an observation on 2/6/24 at 10:26 a.m., the corridor from the kitchen to the back receiving area was inspected. The door separating receiving from the kitchen was being held open by the arm of an electric wheelchair.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 32381 Based on observations, the facility failed to maintain all fire alarm systems in accordance with the standards of NFPA 72-2010, Section 10.5.5.2.1 - 10.5.5.2.4. This deficiency affects all smoke compartments. Findings include: 1. During an observation on 2/6/24 at 10:29 a.m., the fire alarm control panel (FACP) was inspected. The main power circuit panel and breaker was not identified at the FACP. There were two electrical panels which held breakers for the FACP. The correct breaker was also not identified at the panels.”

“Fire Alarm System - Initiation CFR(s): NFPA 101 Fire Alarm System - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse’s stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200’ travel distance is not exceeded. 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5 This Standard is not met as evidenced by: 32381 Based on an observation, the facility failed to ensure accessibility to a manual fire alarm box in accordance with NFPA 101, 2012 Edition, Section 9.6.2.7 Findings include: 1. During an observation on 2/6/24 at 10:20 a.m., the cafeteria was inspected. A fire alarm pull station was blocked by a table with a microwave sitting on it.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to sprinkle the receiving area under the overhead door, in accordance with NFPA 101, Life Safety Code, 2012 Edition, Section 19.3.5.1 and NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.7.5.3.2. Findings include: 1. During an observation on 2/6/24 at 10:27 a.m., the receiving area was inspected. There was no sprinkler coverage under the overhead door when it was in the open position.”

“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: 32381 Based on observation, the facility failed to inspect portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 7.2.1.2. Findings include: 1. During an observation on 2/6/24 at 11:00 a.m., the portable extinguisher in the area of the standpipe was inspected. It was not marked as having been inspected in January.”

“Gas and Vacuum Piped Systems - Other CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum 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 5 (NFPA 99) This Standard is not met as evidenced by: 32381 Based on record review, the facility failed to ensure piped oxygen shutoff valves were accessible in accordance with NFPA 99 Healthcare Facilities Code 2012 Edition, Section 5.1.4.8.4. Findings include: 1. During an observation on 2/6/24 at 11:10 a.m., the zone valve boxes were identified. The zone valve box for rooms 4-10 and the lab was found to have a large desk, a chair, and a computer cart set up for the CNAs, in front of the zone valves. Zone valves must remain clear of obstruction at all times.”

“COMPLIANCE FED, ST, AND LOCAL LAWS AND REGS CFR(s): The CAH is in compliance with applicable Federal laws and regulations related to the health and safety of patients. This Standard is not met as evidenced by: 45448 Based on interview and record review, the facility failed to provide notice of the right to formulate an advance directive for 2 (#s 10 and 12) of 35 sampled patients. This deficient practice had the potential for the facility to provide life-sustaining treatments against the patient’s wishes. Findings include: A review of patient #10’s medical record showed an inpatient admission date of 11/13/23. No notification of advance directives was present in the medical record. A review of patient #12’s medical record showed an inpatient admission date of 6/24/23. No notification of advance directives was present in the medical record. Record review of a facility policy, “Advance Medical Directives,” last revision date of 10/2015, showed: “ ...1. At time of admission assessment, nursing staff will question all patients, or their surrogate decision-maker as to whether they have an Advance Medical Directive document. ...This will be documented on the Advanced Directive Acknowledgement form. ...” During an interview on 1/30/24 at 1:33 p.m., staff member B said the facility would usually provide information on advance directives for inpatients and swing bed patients. Staff member B said advance directive information was not provided for emergency room, respite, observation, or outpatient testing.”

“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 crash cart were replaced prior to the expiration date. This deficient practice had the potential to affect any pediatric patient requiring the need of these supplies. Findings include: During an observation and interview on 1/30/24 at 11:30 a.m., staff member I pointed to the pediatric crash cart and said outdates would be found in the cart. Staff member I said the items were on backorder and were left on the pediatric cart. The cart was not used often and the emergency room did not see many pediatric patients. The following items were found expired in the pediatric crash cart: Cardiac Pediatric ECG pads: Expiration 9/3/20, 2 packages, Expiration 6/9/22, 5 packages Suction Catheter 8fr: Expiration 1/5/23, 1 each Salem Sump 8fr: Expiration 3/1/23, 1 each Endotracheal Tube 3.5mm uncuffed: Expiration 4/8/23, 1 each Intubating Stylet 6fr: Expiration 5/2023, 1 each Endotracheal Tube 4.0mm cuffed: Expiration 5/28/23, 2 each Pediatric Pulse Oximeter 10-50kg: Expiration 1/1/24, 3 each Endotracheal Tube 4.5mm cuffed: Expiration 7/8/23, 2 each Endotracheal Tube 5.0mm cuffed: Expiration 2/28/23, 1 each Endotracheal Tube 5.5mm cuffed: Expiration 6/28/23, 2 each During an interview on 1/30/24 at 12:10 p.m., staff member E said she was not aware of any items being on backorder at this time. Staff member E said the emergency room staff had not notified central supply of the outdated items. During an interview on 1/30/24 at 1:45 p.m., staff member B said she expected the carts to be checked twice a week and all outdated items to be replaced. Review of a facility policy, “CPR Cart Maintenance and Inspection,” last revision date 4/2019, showed: “ ...3. Monthly a. The CPR cart will be opened, and all drawers will be checked against the inventory list to ensure that all medications, supplies and equipment are present and not outdated. ...c. If supplies are missing or outdated, nursing will request replacement from central supply. The nurse will then replace the item once obtained from Central Supply. The outdated supplies will be returned to Central Supply. ...””

“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 observation and interview, the facility dietary staff failed to label food items when food packages were opened and partially used for meal preparation. This deficient practice had the potential to affect all patients and residents within the facility. Findings include: During an observation and interview on 1/29/24 at 4:05 p.m., staff member K said the items stored in the dry storage room were usually dated when the item was opened but it depended on who was working at the time. The following items were found to be opened and not dated: Bread stuffing- top of package rolled closed and taped, not dated Potato chips- top of package rolled closed and taped, not dated Walnut package- top of package rolled closed and taped, not dated Sliced almonds bag- top of package rolled closed and taped, not dated Orange jello package- corner of package open, not dated Krusteaz pancake mix- box top closed, not dated Worcestershire sauce- ¼ full gallon container, not dated Balsamic Vinegar- ½ full gallon container, not dated During an interview on 1/30/24 at 7:50 a.m., staff member E said items had not been labeled with open dates. Staff member E said the items should have been dated when they were opened.”

“RECORDS SYSTEM CFR(s): The records are legible, complete, accurately documented, readily accessible, and systematically organized. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure the residential rights acknowledgement signatures form was filled out completely and correctly upon admission for 3 (#s 2, 6, and 13) of 14 sampled swing bed patients. This deficient practice has the potential to affect patients admitted to a swing bed within the facility. Findings include: 1. Review of patient #2’s paper medical record showed a form acknowledging resident rights. The form was signed by patient #2’s representative. Underneath the signature line the form stated, “...If a Resident’s Representative Signed, Complete the Following: Printed name and relationship to resident.” This portion of the form was not completed. The form also did not include the patient’s name or identify their attending physician. This area was not completed. 2. Review of patient #6’s paper medical chart showed a form acknowledging resident rights. The form was signed by patient #6’s representative. Underneath the signature line the form stated, “...If a Resident’s Representative Signed, Complete the Following: Printed name and relationship to resident.” This portion of the form was not completed. The form also did not identify thier attending physician. This area was not completed. 3. Review of patient #13’s paper medical record, dated 7/1/21, showed an acknowledgment of resident rights signed by someone other than the patient. However, the form was not completed appropriately. The form did not have the relationship to the patient, the date of the signature, or the signature of a witness. It was not possible to determine when the form was signed and if it was completed at the time of the patient’s admission on 7/1/21. During an interview on 2/1/24 at 9:45 a.m., staff member T stated she was responsible for completing the admission paperwork and getting all of the appropriate signatures. During an interview on 2/1/24 at 9:55 a.m. staff member B stated it was her responsibility to make sure the documentation in the charts was completed correctly and she had not had the time to make sure it was done. Staff member B stated, “It’s my fault things are not done correctly. I have not properly trained staff member T.””

“RECORDS SYSTEM CFR(s): For each patient receiving health care services, the CAH maintains a record that includes, as applicable-- (i) Identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient; This Standard is not met as evidenced by: 41652 Based on interview and record review, the facility failed to ensure all patient records contained a properly executed informed consent for care for 6 (#s 13, 14, 15, 16, 17, and 18) of 35 sampled patients. This deficient practice has the potential to affect all patient choices when consenting for care in the facility. Findings include: 1. Review of patient #13’s medical record, with an admission date of 7/1/21, failed to show a signed consent for care was executed on the date of admission. During an interview on 2/1/24 at 8:12 a.m., staff member R stated patient #13 was admitted to swing bed status on 7/1/21. A request was made, on 1/30/24, for patient #13’s consent for care for his swing bed admission on 7/1/21. The consent for care provided showed patient #13 signed his first name only and no date for the patient’s signature was shown. The staff member’s signature was dated 11/15/20. No other documentation which showed the correct admission date was provided prior to the end of the survey. 2. Review of patient #14’s medical record, with an initial admission date of 5/2/22, failed to show a signed consent for care was executed on the date of admission. During an interview on 2/1/24 at 8:12 a.m., staff member R stated patient #14 was admitted to the emergency department on 4/22/22 and transfered to another hospital. Staff member R stated patient #14 was initially admitted to a skilled swing bed on 5/2/22. A request was made, on 1/30/24, for patient #14’s consent for care for her skilled swing bed admission on 5/2/22. The consent for care provided was dated 5/17/22. No other documentation was provided prior to the end of the survey. 3. Review of patient #15’s medical record, with an admission date of 11/21/23, failed to show a signed consent for care was executed on the date of admission. During an interview on 2/1/24 at 8:12 a.m., staff member R stated patient #15 was in an observation bed from 11/8/23 to 11/10/23, and in a respite care bed from 11/10/23 to 11/21/23. A request was made, on 1/31/24, for patient #15’s consent for care for his swing bed admission on 11/21/23. The consent for care provided was dated 11/8/23. No other documentation was provided prior to the end of the survey. 4. Review of patient #16’s medical record, with an admission date of 7/1/22, failed to show a signed consent for care was executed for the 7/1/22 swing bed admission. During an interview on 2/1/24 at 8:12 a.m., staff member R stated patient #16 was admitted to swing bed status on 7/1/22. A request was made, on 1/31/24, for patient #16’s consent for care for the 7/1/22 admission. The consent provided was dated 3/25/22. No other documentation was provided prior to the end of the survey. 5. Review of patient #17’s medical record, with an admission date of 11/20/20, failed to show a signed consent for care was executed for the 11/20/20 admission. During an interview on 2/1/24 at 8:12 a.m., staff member R stated patient #17 was admitted to swing bed status on 11/20/20. Staff member R stated the patient was a regular nursing home patient prior to the 11/20/20 admission to swing bed. A request was made, on 1/31/24, for patient #17’s consent for care for the 11/20/20 admission. The consent provided was dated 11/30/19. No other documentation was provided prior to the end of the survey. 6. Review of patient #18’s medical record, with an admission date of 3/25/21, failed to show a signed consent for care was executed for the swing bed admission. During an interview on 2/1/24 at 8:12 a.m., staff member R stated patient #18 was a respite patient from 2/26/21 through 3/25/21 and was admitted as a swing bed patient on 3/25/21. A request was made, on 1/31/24, for patient #18’s consent for care for the 3/25/21 admission. The consent provided was dated 2/26/21. No other documentation was provided prior to the end of the survey. During an interview on 2/1/24 at 9:45 a.m., staff member B stated staff member T was responsible for obtaining signed consent for care forms for patients admitted to a swing bed. Staff member B stated she failed to train staff member T regarding this responsiblility, which had resulted in a number of swing bed patients who did not have properly executed consents for care for their current swing bed stays.”

“RECORDS SYSTEM CFR(s): Dated signatures of the doctor of medicine or osteopathy or other health care professional. This Standard is not met as evidenced by: 41652 Based on interview and record review, the facility failed to ensure all medical provider signatures were dated for 8 (#s 1, 2, 3, 4, 13, 17, 18, and 19) of 35 sampled patients; and the facility failed to ensure the signature authentication document was current and contained all medical practitioners authorized to provide health care services to patients of the CAH. This deficient practice has the potential to affect all documents requiring provider signatures within the patient medical records. Findings include: 47752 1. A review of patient #1’s physician’s orders, dated 12/19/23, 1/2/24, 1/15/24, and 1/22/24, showed a provider signature, but no date indicating when the order was signed. A review of patient #2’s physician’s order, dated 12/19/23, showed a provider signature but no date indicating when the order was signed. A review of patient #3’s physician’s order, dated 11/7/23, showed a provider signature but no date indicating when the order was signed. A review of patient #4’s physician’s orders, dated 8/24/23, 8/25/23, 9/26/23, 10/6/23, 10/30/23, 12/30/23, and 1/2/24, showed a provider signature but no date indicating when the order was signed. Review of patient #13’s provider orders, dated 6/18/22, 7/19/22, 8/31/22, and 12/14/23, showed the handwritten provider orders contained a provider signature without the date the signature was entered into the record. Review of patient #17’s provider orders, dated 12/21/23 and 1/25/24, showed the handwritten provider orders contained a provider signature without the date the signature was entered into the record. Review of patient #18’s provider order, dated 1/24/24, showed the handwritten provider order contained a provider signature without the date the signature was entered into the record. Review of patient #19’s provider order, dated 9/24/23, showed the handwritten provider order contained a provider signature without the date the signature was entered into the record. During an interview on 1/30/24 at 10:22 a.m., staff member B stated, “Ultimately it is my responsibility to make sure the chart documentation is complete, and I just haven’t had time to make sure it was completed.” During an interview on 2/1/24 at 8:12 a.m., staff member R stated it was not part of her process to check provider orders for completeness regarding the date the provider signed a verbal or telephone order written by someone else. 2. Review of the active provider list, dated 1/29/24, showed the facility had six onsite providers. Review of the signature authentication log, last dated 10/20/16, failed to show the signature for four (staff members W, X, Y, and Z) of the six medical providers who provided services onsite at the facility. Review of the facility’s policy titled, “Medical Record Content,” dated June of 2012, showed all reports of procedures and test results were to be documented and authenticated in the patient medical record. The policy also showed handwritten provider orders and verbal (or telephone) orders written by someone other than the provider must be authenticated by the provider giving the order. During an interview on 2/1/24 at 8:12 a.m., staff member R stated the facility had a signature authentication log for medical practitioners. Staff member R stated the log was not current as she had gotten “lax” because of the computer. Staff member R stated she should have been keeping it updated because swing bed patient charts are still paper.”

“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 ensure their organ, tissue, and eye donation program (OPO) was integrated into their swing bed program. This deficient practice had the potential to affect all patients with a requested organ donor or imminent death. Findings include: During an interview on 1/30/24 at 12:30 p.m., staff member B stated the facility’s OPO program did not currently include swing-bed patients. Staff member B stated, “Since most of the swing-bed patients are private pay, they are not included in the OPO.” Review of a facility document titled, “Organ and Tissue Donation,” not dated, showed: “ ...the Donor Referral Line must be contacted of ALL deaths and imminent deaths, regardless of age, or medical/social history, to determine medical suitability for donation.””

“SNF SERVICES CFR(s): The CAH is substantially in compliance with the following SNF requirements contained in subpart B of part 483 of this chapter: §485.645(d)(1) Resident Rights (§483.10(b)(7), (c)(1), (c)(2)(iii), (c)(6), (d), (e)(2) and (4), (f)(4)(ii) and (iii), (g)(8) and (17), (g)(18) introductory text, (h) of this chapter). “ §483.10(b)(7) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident devolve to and are exercised by the resident representative appointed under State law to act on the resident’s behalf. The court-appointed resident representative exercises the resident’s rights to the extent judged necessary by a court of competent jurisdiction, in accordance with State law. “ §483.10(c) Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including: (1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. “ §483.10(c)(2)(iii) The right to be informed, in advance, of changes to the plan of care. “ §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. “ §483.10(d) Choice of attending physician. The resident has the right to choose his or her attending physician. (1) The physician must be licensed to practice, and (2) If the physician chosen by the resident refuses to or does not meet requirements specified in this part, the facility may seek alternate physician participation as specified in paragraphs (d)(4) and (5) of this section to assure provision of appropriate and adequate care and treatment. (3) The facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his or her care. (4) The facility must inform the resident if the facility determines that the physician chosen by the resident is unable or unwilling to meet requirements specified in this part and the facility seeks alternate physician participation to assure provision of appropriate and adequate care and treatment. The facility must discuss the alternative physician participation with the resident and honor the resident’s preferences, if any, among options. (5) If the resident subsequently selects another attending physician who meets the requirements specified in this part, the facility must honor that choice. “ §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. “ §483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement. “ §483.10(f)(4)(ii) The facility must provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident’s right to deny or withdraw consent at any time; “ §483.10(f)(4)(iii) The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident’s right to deny or withdraw consent at any time; “ §483.10(g)(8) The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to: (i) Privacy of such communications consistent with this section; and (ii) Access to stationery, postage, and writing implements at the resident’s own expense. “ §483.10(g)(17) The facility must- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section. “ §483.10(g)(18)[introductory text only] The facility must inform each resident before, or at the time of admission, and periodically during the resident’s stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility’s per diem rate. “ §483.10(h) Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. (1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. (2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. (3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident’s medical, social, and administrative records in accordance with State law. This Standard is not met as evidenced by: 41652 Based on interview and record review, the facility failed to ensure patients admitted to swing bed status were made aware of their rights upon admission for 3 (#s 15, 16, and 17) of 35 sampled patients. This deficient practice has the potential to affect the patient’s ability to exercise their rights. Findings include: 1. Review of patient #15’s medical record, dated 11/21/23, failed to show a signed and dated acknowledgment of the receipt of the facility’s patient rights form. A request was made, on 1/31/24, for the signed acknowledgment of rights for the admission which started on 11/21/23, The form provided was dated 11/11/23, which was during the patient’s respite care stay. No acknowledgment, dated 11/21/23, was provided prior to the end of the survey. 2. Review of patient #16’s medical record, dated 7/1/22, failed to show a signed and dated acknowledgment of receipt of the facility’s patient rights form. A request was made, on 1/31/24, for the signed acknowledgment of rights for the admission which started on 7/1/22, The form provided was dated 3/25/22, which was four months prior to the patient’s swing bed stay. No acknowledgment, dated 7/1/22, was provided prior to the end of the survey. 3. Review of patient #17’s medical record, dated 11/20/20, failed to show a signed and dated acknowledgment of receipt of the facility’s patient rights form. A request was made, on 1/31/24, for the signed acknowledgment of rights for the admission which started on 11/20/20, The form provided was dated 12/4/19, which was a nursing home stay which occurred almost one year prior to the swing bed stay. No acknowledgment, dated 11/20/20, was provided prior to the end of the survey. During an interview on 2/1/24 at 8:12 a.m., staff member R stated the resident was given a new chart when they became a swing bed patient. Staff member R stated there should have been a signed acknowledgment in each medical record. During an interview on 2/1/24 at 9:45 a.m.,, staff member B stated it was staff member T’s responsibility to complete the paperwork for swing bed admissions. Staff member B stated she did not ensure staff member T understood what her responsibilities were when completing admission paperwork for swing bed patients.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 45448 Based on observation and interview, the facility failed to post signs in a public area, specifying the rights of individuals to receive examination and treatment for emergency medical conditions and women in labor. This deficient practice had the potential to affect patients entering the emergency department for services. Findings include: During an observation on 1/31/24 at 7:40 a.m., the entrances to the emergency department were inspected. No EMTALA signs were present at either entrance of the emergency department, or the main entrance to the facility’s admission desk. During an interview on 1/31/24 at 7:52 a.m., staff member B said the facility had signs posted at the entrance of the emergency room. Staff member B said the signs were removed for painting and were not replaced. Staff member B was unable to locate the postings within the facility.”

“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: 45448 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 for 10 (#s 9, 10, 12, 29, 30, 31, 32, 33, 34, and 35) of 35 sampled patients. This deficient practice has the potential to affect all patients receiving care in the facility the ability to acknowledge their patient rights. Findings include: A review of patient #9’s medical record showed an admission date of 1/19/23. No acknowledgement of patient rights was in the medical record. A review of patient #10’s medical record showed an admission date of 11/13/23. No acknowledgement of patient rights was in the medical record. A review of patient #12’s medical record showed an admission date of 6/24/23. No acknowledgement of patient rights was in the medical record. A review of patient #29’s medical record showed an admission date of 9/26/23. No acknowledgement of patient rights was in the medical record. A review of patient #30’s medical record showed an admission date of 1/15/24. No acknowledgement of patient rights was in the medical record. A review of patient #31’s medical record showed an admission date of 1/2/24. No acknowledgement of patient rights was in the medical record. A review of patient #32’s medical record showed an admission date of 10/11/23. No acknowledgement of patient rights was in the medical record. A review of patient #33’s medical record showed an admission date of 8/27/23. No acknowledgement of patient rights was in the medical record. A review of patient #34’s medical record showed an admission date of 8/17/23. No acknowledgement of patient rights was in the medical record. A review of patient #35’s medical record showed an admission date of 1/3/24. No acknowledgement of patient rights was in the medical record. During an interview on 1/30/24 at 1:33 p.m., staff member B said the facility did not provide a written form for acknowledgement of patient rights for inpatient stays, emergency room visits, or outpatient testing. Record review of a facility policy, “Patient Rights,” dated 9/2008, showed: “Policy: It is the policy of [facility name] that all hospital patients be informed of their rights and responsibilities. ...1. Upon admission to the hospital, the facility will inform the patient and/or representative both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing patient conduct and responsibilities during the stay at the facility. 2. Receipt of this information will be acknowledged in writing and placed in the patient’s medical record. “”

“PRIVACY AND SAFETY CFR(s): The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to provide a safe enviornment for 1 (#8) of 2 sampled patients. This deficient practice resulted in an elopement from the facility. Findings include: Review of a Facility Reported Incident, reported to the State Survey Agency, dated 9/1/23 at 2:00 a.m., showed patient #8 was a respite patient. Staff on the floor confirmed patient #8 was in her room at 1:00 a.m. During the freshwater pass at 2:00 a.m., the patient was not in her room or bathroom. Staff searched room to room in the nursing home, attached critical access hospital, and clinic without success. The immediate grounds were searched by two staff members without success. Law enforcement was contacted, and a staff member used a vehicle to search the local streets and fairgrounds. At 5:00 a.m., patient #8 was still missing and law enforcement was contacted again. Patient #8 was found after sunrise, two blocks from the facility, laying in a yard. Emergency Medical Services were notified and patient #8 was taken to the Emergency Room via ambulance. Review of patient #8’s medical records showed patient #8 was admitted as a respite patient on 8/8/23. Nursing notes dated, 8/9/23 at 5:42 p.m., showed patient #8 stated, “I just want to go home.” Review of patient #8’s Resident Kardex, undated, showed the box marked elopement risk was checked. “Special instructions: * elopement risk*, *wander-guard ordered, -Confused oriented to son.” [sic] Review of patient #8’s medical record showed no further interventions were placed to prevent an elopement at the time of admission. A review of patient #8’s Emergency Room visit, dated 9/1/23 showed: “... 1. Environmental exposure 1. Cool lower extremities, core temperature from initial presentation. With warm IVF and bear-hugger cool extremities warmed. ...7. Skin laceration to LLE, right elbow 1. ABD to the left leg, reported copious clear drainage. ...Patient ultimately discharged from the ED to the NH as a respite patient.” During an interview on 1/31/24 at 11:10 a.m., staff member E stated she was head of emergency preparedness and had initiated the code yellow with the disaster plan as soon as she was notified of the incident. Staff member E stated she had not been notified of the incident until after 6:00 a.m., but when she was notified and “activated the call tree, people were here within four minutes.” Staff member E stated she was unsure why she was not notified right away, but had been educating staff on the importance of timely notification to the appropriate administrative personnel. Staff member E stated she did not think there had been any documentation of the education that she had provided during the staff meeting. During an interview on 1/31/24 at 1:12 p.m., staff members A and B both stated there should have been some other type of interventions started upon patient #8’s admission since a wander-guard was not readily available. During an interview on 1/31/24 at 4:50 p.m., staff member A stated, “There was no difference in policies between the long-term care residents and the swing bed patients. We use the same policies and procedures for everyone.” A request was made on 1/31/24 at 1:50 p.m., for patient #8’s wandering and elopement admission assessment. No assessment was provided prior to the end of the survey. During an interview on 2/1/24 at 7:40 a.m., staff member B stated there was not an elopement assessment completed for patient #8. A review of a facility document titled, “Risk of Wandering and Elopement,” with an effective date of 8/27/19, showed: “Policy: It is the policy of [Facility Name] to assess all Long Term Care residents for risk of wandering and elopement on admission, quarterly, and as needed to ensure the safety of the resident ...” [sic]”