Madison Valley Medical Center

“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 1/17/24 at 11:30 a.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 1/17/24 showed the facility did not include a policy and procedure for the use of volunteers in an emergency.”

“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 1/17/24. Under this regulatory requirement, the facility must meet the applicable provisions of the National Fire Protection Association’s (NFPA) 101 LSC, 2012 Edition, and those mandatory Codes referenced by that edition. The facility was surveyed specifically using Chapter 19 Existing Health Care Occupancies. The building construction type was found to be Type II (111) and contained two main floor and three lower level smoke compartments. There is a 2-hour separated Rural Health Clinic (RHC). New construction occured in 2022, creating a pharmacy. A two hour barrior seperates the pharmacy from the CAH. This space was surveyed under chapter 38 New Business Ocupancy. The facility’s PT area was also expanded in 2022. The facility is licensed for 10 beds and at the time of survey, 3 was the patient census. The facility does not meet the prescriptive requirements of the applicable LSC or its referenced Codes that require vertical openings used for convenience to be at least 1-hour rated construction at one level as written under deficiency K311. The Fire Safety Evaluation System (FSES) based on the National Fire Protection Association (NFPA) 101A, Guide on Alternative Approaches to Life Safety, 2013 Edition, has been utilized to determine whether or not a level of safety is provided which is equivalent to the LSC. The FSES conducted on 1/17/24 indicates that an equivalent level of safety will be provided with the correction of the following deficiencies: K0223, K0321, K0353, K0712, K0761, K0918, and K0919. 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: 40068 Based on observations, 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. This deficiency affects 1 of 3 lower level smoke compartments and 1 of 2 main floor smoke compartments in the facility. Findings include: 1. During an observation on 1/17/24 at 12:44 p.m., the PT room was inspected. The corridor door was observed to have a magnetized hold-open device, which was not connected to the facility’s fire panel, attached to the door. The door was fitted with a self-closure. 2. During an observation on 1/17/24 at 1:26 p.m., the ER soiled utility room had a kick-down door stop. This door was fitted with a self-closure. When the door stop is being used the door would not close under the power of the self-closure.”

“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 interview, the facility failed to ensure all vertical openings containing stairs and a penthouse were properly enclosed with 1 hour rated doors and other rated construction in accordance with NFPA 101, 2012 edition, section 19.3.1.1. This deficiency had the potential to affect 3 of 5 total smoke compartments (including the main level and the lower levels). Findings include: During an observation on 1/17/24 at 1:07 p.m. the stairwell connecting the east zones of the lower and upper levels and, serving the “communicating stairway” between the levels, were made of glass walls and door enclosures with metal framing. The glass structures at the main and the lower level were not of 1-hour fire rating for the vertical separation. During an interview on 1/17/24 at 1:08 p.m. staff member A stated there had not been any changes to the stairwell since the last life safety code survey in 2015.”

“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, the facility failed to assure hazardous rooms 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. This deficiency affects 1 of 3 lower-level smoke compartments in the facility. Findings include: 1. During an observation on 1/17/24 at 10:05 a.m., the mechanical room was inspected. The corridor door to the mechanical room was fitted with self-closing devices and would not close under the power of the self-closure.”

“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 the facility failed to: a) 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, and b) failed to ensure sprinkler piping was fee from external loads in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2 c) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1 (3). This deficiency affects all smoke compartments at the facility. Findings include: 1. During an observation on 1/17/24 at 12:46 p.m., the PT restroom was inspected. The sprinkler head was loaded with dust and debris. 2. During an observation on 1/17/24 at 12:48 p.m., the server room was inspected. Ceiling tiles were observed to be missing in the room. 3. During an observation on 1/17/24 at 1:09 p.m., the south awning was inspected. There were multiple zip ties with spikes attached to the sprinkler piping. 4. During an observation on 1/17/24 at 1:20 p.m., the radiology room was inspected. a ceiling tile was observed with a hole in it. 5. During an observation on 1/17/24 at 1:26 p.m., the ER bay was inspected. A sprinkler head was loaded with dust and debris. 6. During an observation on 1/17/24 at 1:29 p.m., the dea-con bay was inspected. There were cords hanging off the sprinkler piping. 7. During an observation on 1/17/24 at 1:32 p.m., the nursing area was inspected. A sprinkler head was loaded with dust and debris.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 40068 Based on interview, and record review the facility failed to ensure all employees were kept informed with respect to their duties during a fire drill, ensuring competency per NFPA 101. 2012 Edition, section 19.7.1.2., and 19.7.1.6. This deficiency affects all facility occupants. Findings include: During an interview on 1/17/24 at 10:53 a.m. staff member B stated he just started completing sign-in seets for fire drills in November 2023. Review of the facility fire drills on 1/17/24 showed, the following quarters did not have staff sign in sheets of who attended, to ensure competency with the fire drill protocol: January - March 2023 April - June 2023 July - September 2023”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 40068 Based on record review and interview, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12.1 and in accordance with NFPA 80-2010, Section 5.2.4.2 (written report). This deficiency affects all smoke compartments at the facility. Findings include: Review of the fire safety maintenance records on 1/17/24, reflected the lack of the annual fire door assembly testing documentation. The facility must identify the required fire/smoke barriers, as well as electronically controlled doors and doors with special locking arrangement in the building and show inspections of all components of the doors in those barriers. During an interview on 1/17/24 at 11:20 a.m., staff member B stated an outside vendor inspects the facility’s doors annually, however the facility did not have documentation.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 40068 Based on interview and record review, the facility failed to have evidence of the generator weekly visual documentationin accordance with NFPA 110 Standard for Emergency and Standby Power Systems, 2010 Edition, Sections 8.4.1 and 8.4.2.4. This deficiency affects all smoke compartments. Findings include: During an interview on 1/17/24 at 11:24 a.m., staff member B stated he did not have documentation of the weekly visual inspections of the generator. Record review of the generator information on 1/17/24 did not include any weekly visual documentation of the generator in the last year.”

“Electrical Equipment - Other CFR(s): NFPA 101 Electrical Equipment - Other List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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 10 (NFPA 99) This Standard is not met as evidenced by: 40068 Based on observation, the facility failed to keep the room housing the Emergency Power Supply System (EPSS) free from any other equipment per NFPA 110 2010 Edition, Section 7.2.1.2. This deficiency affects 1 out of 3 main floor smoke compartments. Findings include: 1. During an observation on 1/17/24 at 1:04 p.m., the generator room was inspected. The room housing the generator was also being used as a storage room for items such as a snow blower and a multiple gas cans. The room housing the generator can only be used to store items for maintaining the generator.”

“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: 35356 Based on observation, interview, and record review, the facility failed to establish, implement, and follow a policy and procedure for ensuring all essential mechanical, electrical, and patient-care equipment were identified and included on an inventory list which included a record of maintenance activities; failed to ensure all equipment was inspected and tested for performance and safety before initial use; and failed to ensure all essential medical equipment was maintained through a facility established maintenance strategy. The accumulative effect of this deficiency had the potential to affect all patients provided care services utilizing the identified equipment. Findings include: A review of the facility’s policy and procedure titled, Maintenance, with a revision date of 4/1/23, failed to include procedures for the initial inspection and testing for performance safety of essential patient care equipment. 1. During an observation and record review on 1/3/24 at 2:00 p.m., the following emergency room based medical equipment was identified as not having a facility established maintenance sticker, did not have an initial safety evaluation, and was not listed on the facility’s established equipment maintenance list: - A McGrath (Covidien) Video Laryngoscope. - A Butterfly Ultrasound Machine. During an interview on 1/3/24 at 4:00 p.m., staff member B stated she had checked with staff member D and they did not have the video laryngoscope or the ultrasound device identified on their facility’s periodic maintenance log. Staff member B stated these two machines had not had an initial evaluation prior to their use in the emergency department. 2. During an observation and record review on 1/3/24 at 2:00 p.m., the following glucose machines were identified as not having a facility established maintenance sticker, did not have an initial safety evaluation, and were not listed on the facility’s established equipment maintenance list: - Xpress glucometer with a label marked: 5/467 - Xpress glucometer with a label marked: 6/468 During an interview on 1/3/24 at 4:00 p.m., staff member B stated she had checked with staff member D and they did not have the two glucometers identified on their facility’s periodic maintenance log. Staff member B stated these two machines had not had an initial evaluation prior to their use in the emergency department. Staff member B stated she did check with staff member E, and the lab did perform an initial glucose control to test the high and low readings prior to them being utilized on the unit; however, the glucometers were not identified in the facility’s periodic maintenance list.”

“RADIOLOGY SERVICES CFR(s): §485.635(b)(3) Radiology services. Radiology services furnished by the CAH are provided by personnel qualified under State law, and do not expose CAH patients or personnel to radiation hazards. This Standard is not met as evidenced by: 41951 Based on interview and record review, the facility failed to follow their established policies and procedures to ensure all radiologic technologists were up to date on their CPR certifications. This deficient practice had the potential to affect any direct-care patients in need of emergent basic life support in the radiology department. Findings include: Review of the facility’s policy and procedure titled, Basic Life Support Certification, last reviewed on 12/27/23, showed: - “Policy: - Improve patient safety by ensuring that personnel are properly trained in the basic techniques of Cardiopulmonary Resuscitation. - Procedure: - All employees involved in direct patient care must be CPR certified ... - It shall be the employee’s responsibility to attend refresher courses so that the BLS certification card does not expire. - Proof of renewed certification must be presented to the department manager. ...” Review of the facility’s job description for a Registered Radiologic Technologist, last revised 3/2/22, showed: - ... “Minimum Requirements - ... CPR Certification. ...” Review of the facility’s personnel files, on 1/4/24, showed staff member R’s BLS certification was expired. During an interview on 1/4/24 at 10:38 a.m., staff member A stated according to the records from the radiology department, staff member R’s BLS certification had expired. He stated staff member R had worked after the expiration of the certification.”

“REHABILITATION THERAPY SERVICES CFR(s): Physical therapy, occupational therapy, and speech-language therapy pathology services furnished at the CAH, if provided, are provided by staff qualified under State law, and consistent with the requirements for therapy services in §409.17 of this subpart. This Standard is not met as evidenced by: 35356 Based on interview and record review, the facility failed to ensure the developed plan of care for therapy services included the frequency and duration of the physical and occupation therapy services for 2 (#s 2 and 18) of 20 sampled patients. This deficient practice had the potential to affect all patients receiving therapy services. Findings include: During an interview on 1/3/24 at 10:30 a.m., staff member N stated the frequency and duration of recommended therapy services should be included in each patient’s therapy plan of care. 1. A review of patient #2’s medical record showed a physician order, dated 12/27/23, for PT evaluate and treat. Review of patient’s #2’s PT Acute Evaluation and PT Care Plan, completed on 12/28/23, failed to include the prescribed frequency and duration of the therapy services to be provided. 2. A review of patient #18’s medical record showed a physician order, dated 10/18/23, for PT/OT evaluate and treat. A review of patient #18’s PT and OT established plan of cares failed to include the prescribed frequency and duration of those therapy services to be provided. During an interview on 1/4/24 at 11:06 a.m., staff member B stated she had spoken with staff member N regarding patient #’s 2 and 18’s therapy plan of cares and the recommended frequency and duration were not included in their plan of cares.”

“RECORDS SYSTEM CFR(s): Reports of physical examinations, diagnostic and laboratory test results, including clinical laboratory services, and consultative findings; This Standard is not met as evidenced by: 41951 Based on interview and record review, the facility failed to ensure a medical doctor co-signed and assumed full responsibility for the H&P, when a patient was admitted by a mid-level practitioner for 2 (#s 4 and 8) of 5 sampled patients. Findings include: 1. Review of patient #4’s medical record showed an admission date and H&P completed on 11/10/23, by staff member W. The H&P was not co-signed for approval and the responsibility of the patient care was not assumed by the MD/DO. 2. Review of patient #8’s medical record showed an admission date and H&P completed on 9/10/23, by staff member Z. The H&P was not co-signed for approval and the responsibility of the patient care was not assumed by the MD/DO. During an interview on 1/4/24 at 8:35 a.m., staff member G stated 100 percent of mid-level providers’ patient charts were reviewed by an MD. During an interview on 1/4/24 at 8:43 a.m., staff member G stated mid-level providers had admitting privileges and were required to notify an MD of an admission. She stated all mid-level providers’ H&P’s were co-signed by the MD.”

“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: 35356 Based on interview and record review, the facility failed to ensure their organ, tissue, and eye donation program (OPO) was integrated into their facility’s Quality Assurance and Performance Improvement Program (QAPI). This deficient practice had the potential to affect all patients with a requested organ donor and imminent death. Findings include: During an interview and record review on 1/3/24 at 1:00 p.m., staff member B stated the facility currently did not include their OPO program into their QAPI. She stated there was currently no documentation from their QAPI meeting minutes which would include the OPO program since it currently was not included in their QAPI.”

“FREEDOM FROM ABUSE, NEGLECT & EXPLOITATION CFR(s): Freedom from abuse, neglect and exploitation (§483.12(a)(1), (a)(2), (a)(3)(i), (a)(3)(ii), (a)(4), (b)(1), (b)(2), (c)(1), (c)(2), (c)(3), and (c)(4) of this chapter). “ §483.12(a)(1) Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms.(a) The facility must-(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; “ §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. “ §483.12(a)(3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. “ §483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. “ §483.12(b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, “ §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This Standard is not met as evidenced by: 41951 Based on interview and record review, the facility failed to follow their established policies and procedures to provide on-going training to their employees on the prohibition and prevention of patient abuse. Findings include: Review of the facility’s policy and procedure titled, Mistreatment, Abuse, and Neglect, last reviewed on 11/1/22, showed: - ... “Annual education will be provided to hospital staff on how to recognize abuse, preventive measures, how to recognize the elements that may lead to abuse, appropriate interventions to deal with alleged abuse situations, reporting, the investigation processes and possible outcomes of alleged abuse situations. ...” Review of the facility’s employee personnel files for staff members B, C, I, J, L, O, R, and Y showed no evidence of annual or additional sessions on abuse training. During an interview on 1/4/24 at 10:51 a.m., staff member A stated the last abuse training was in March of 2022. He stated there had not been additional training since then unless the employee was newly hired.”