Northern Rockies Medical Center

“Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 485.623(d) for Critical Access Hospitals (CAHs), a life safety code (LSC) survey was performed on 2/21/24. 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 39 Business Occupancies. The building construction type was found to be Type II (211) and contains 3 smoke compartments. No new construction had taken place since the last survey in 2016. The facility had two patients/residents at the time of survey. This building is the old LTC building. It contains a main floor and a basement. The main floor is separated from the CAH by a 2-hour barrier. Since 1992, the Physical Therapy office has resided in the basement of the facility. It operates under the same provider number as the CAH, therefore it was surveyed. Since the Physical Therapy area lacked a separation from the rest of the basement, the whole basement area was surveyed. It had not been surveyed previously. These requirements were not met as evidenced by the following deficiencies:”

“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: 32381 Based on observation, the facility failed to ensure 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 and 19.3.2.1.3. Findings include: 1. During an observation on 2/21/24 at 2:33 p.m., the central supply room was inspected. The room is a storage room and thus considered a hazardous room. The corridor door to the room was also inspected. It was found to be lacking an automatic latching system that would latch the door under the power of the self-closer. It was fitted with a manual thumb-latch mechanism that latches the door.”

“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: 32381 Based on interview and record review, the facility failed to ensure smoke detector sensitivities were completed in accordance with NFPA 72 National Fire Alarm and Signaling Code, 2010 Edition, 14.4.5.3.2-14.5.3.3 These deficiencies affect all of the smoke compartments. Findings include: 1. During record review on 2/21/24, records for the fire alarm and smoke detection systems were reviewed. There was no documentation of when smoke detector sensitivities were completed. In an interview on 2/21/24 at 2:30 p.m., staff member B stated the panel is old and it does not monitor the sensitivities, they have to be done manually.”

“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 entire facility in accordance with NFPA 101, Life Safety Code, 2012 Edition, Section 19.3.5.1., and failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2. Findings include: 1. During an observation on 2/21/24 at 1:59 p.m., the ER vestibule was inspected. It was found to be lacking any sprinkler coverage. It contained some combustible items as well. 2. During an observation on 2/21/24 at 2:28 p.m., the back room of central supply was inspected. A sprinkler head within the room was observed, blocked by a ceiling mounted light fixture.”

“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: 32381 Based on record review and observation, the facility failed to: a) maintain the sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 14.2, b) test or replace gauges on the sprinkler system every five years, in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Sections 13.2.7.1 and 13.2.7.2, c) ensure sprinkler heads over 50 years old had been tested or replace in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protections Systems, Table 5.1.1.2, Sections 5.3.1.1.1, 5.3.1.2, and 5.3.1.3, d) document weekly standpipe gauge readings per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 13.2.7.1., e) 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). Findings include: 1. During a review of facility records on 2/21/24, it was found that the 5 year internal pipe inspection for the sprinkler system had not been completed. The last time the internal inspection had been completed was in 2012. 2. Review of the facility’s sprinkler reports and through observation on 2/21/24 at 2:05 p.m., there was no evidence the gauges had been calibrated or replaced in the last five years. 3. During a review of facility sprinkler reports on 2/21/24, it was found the vendor stated the sprinkler heads in the hospital were over 50 years old. This was on a report from December of 2023. The facility had not had any of the heads sampled and tested at the time of the survey. Sampling must include a minimum of 4 heads or 1% of the total in the space, whichever is greater. 4. During a review of facility sprinkler reports on 2/21/24 it was determined the facility is not monitoring or documenting standpipe gauge readings on a monthly basis for a wet system. 5. During an observation on 2/21/24 at 1:45 p.m., the server room was inspected, it was found to be missing a ceiling tile.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to maintain a corridor door resistant to the passage of smoke in accordance with NFPA 101, 2012 Edition, Section 19.3.6.3.1 and 19.3.6.3.2. Findings include: 1. During an observation on 2/21/24 at 1:28 p.m., The dirty side of the laundry corridor door was inspected. The door was found to have a large gap about 1/2” at the top, this is not resistant to the passage of smoke. This door was also found to have a flip latch and a padlock on the outside of the door. It is not accessible from the egress side and could get an occupant locked inside the room. 2. During an observation on 2/21/24 at 1:28 p.m., the clean side of the laundry corridor door was found to be equipped with a two-step locking mechanism.”

“Rubbish Chutes, Incinerators, and Laundry Chu CFR(s): NFPA 101 Rubbish Chutes, Incinerators, and Laundry Chutes 2012 EXISTING (1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5. (2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7. (3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.) (4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use. 19.5.4, 9.5, 8.4, NFPA 82 This Standard is not met as evidenced by: 32381 Based on observations, the facility failed to assure that a fire-rated door, protecting the linen chute, closed and latched with the efforts of the self-closing device per NFPA 101 2012 Edition, Sections 19.5.4.4. The findings include: 1. During an observation on 2/21/24 at 1:27 p.m., the chute room was inspected. The lower linen chute door was found to be lacking the necessary latches to keep it closed.”

“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: 32381 Based on record review, 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 and in accordance with NFPA 80-2010, Section 5.2 (written report). Findings include: 1. Review of the fire safety maintenance records on 2/21/24., 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.”

“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 2/21/24 at 2:02 p.m., the zone valve box in ER OB was identified. It was found to be partially obstructed from view and instant access by stored items in the room.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 32381 Based on record review, the facility failed to maintain the receptacles in patient areas. Findings include: Record review on 2/21/24 revealed non-hospital grade receptacles located in patient care rooms in the facility did not have annual retention testing as required by sections 6.3.4.1.2 and 6.3.4.1.3 in NFPA 99, Health Care Facilities Code, 2012 Edition. Actual NFPA Standard: NFPA 99 (2012), 6.3.4.1 Maintenance and Testing of Electrical System. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. 6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).”

“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: 32381 Based on observation, the facility failed to ensure a labeled remote manual stop station for the generator was installed in accordance with NFPA 110-2010, Section 5.6.5.6 and 5.6.5.6.1. Findings include: 1. During an observation on 2/21/24 at 2:15 p.m., the generator was inspected. The generator lacked a labeled manual stop station at a remote location on the outside of the prime mover, of a type in order to prevent inadvertent or unintentional operation of the generator in an emergency.”

“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: 35356 Based on interview and record review, the facility failed to develop a process to ensure all inpatients signed a written notice that there was no Doctor of Medicine or Osteopathy onsite, in the CAH 24-hours per day, and may not be present during all hours services are furnished for the patient for 11 (#s 1, 3, 4, 5, 6, 7, 8, 9, 10, 12, and 19) of 22 sampled inpatients and 2 (#s 2 and 18) of 2 observation patients. Findings include: Review of the following admission documents provided to inpatient admissions for patients (#s 1, 3, 4, 5, 6, 7, 8, 9, 10, 12, and 19) and observation patients (#s 2 and 18) failed to show in writing, and signed by the patient, the notification an MD or DO was not present in the CAH 24-hours a day, seven days a week: - Patient Belongings Form, not dated; - Tips to Prevent Fall, not dated; - Patient Rights and Responsibilities, not dated; - Important Message from Medicare, not dated; and - General Consent for Admission or Treatment, not dated. During an interview on 2/14/24 at 11:24 a.m., staff member A stated the notice regarding no MD or DO onsite was posted in the emergency room. Staff member A stated they did not provide a written notice and/or obtain a signed acknowledgement from all inpatient admissions and all patient observation stays. A request was made on 2/13/24 at 3:00 p.m., for the facility policy regarding the written notice and signed acknowledgement, which was required when the CAH did not have an MD or DO onsite at all times. No policy was received prior to the end of the survey.”

“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 written policies and procedures to include strategies to ensure the maintenance of all essential mechanical, electrical, and patient-care equipment utilized by the facility; failed to ensure all essential mechanical, electrical, and patient-care equipment were identified and included in an inventory list which included a record of maintenance activities; and failed to ensure all essential medical equipment was identified and maintained through a facility established maintenance strategy. The accumulative effect of this deficiency had the potential to affect all patients provided care services by the facility. Findings include: 1. Established Equipment Maintenance Policy and Procedures A request was submitted on 2/13/24 at 4:30 p.m., to provide a copy of the facility’s policy and procedure for strategies to ensure the maintenance of all essential mechanical, electrical, and patient-care equipment. No policy or procedure was provided by the end of the survey. During an interview on 2/14/24 at 2:13 p.m., staff member A stated the facility did not have an established policy or procedure which ensured the maintenance of all essential mechanical, electrical, and patient-care equipment. 2. Patient-Care Equipment List During an interview and record review on 2/14/24 at 1:00 p.m., staff member Y and B stated they did not have a complete inventory of equipment required to meet patient needs; which also readily identified critical-care equipment and equipment essential to patient care. A request to review the facility’s complete inventory list was not provided by the end of the survey. 3. Initial Use Evaluation and Periodic Maintenance of Patient-Care Equipment During an observation on 2/13/24 at 1:00 p.m., the following patient-care equipment was observed to not have a periodic maintenance sticker, which identified that 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 for use: - Located at the nurses’ station: Huntleigh doppler, model number FD2, - Located at the nurses’ station: Autocode Prodigy glucometer, serial number: 51850-494036, and - Located in the emergency department: LUCAS chest compression machine. During an interview and record review on 2/14/24 at 1:00 p.m., staff member Y and A stated they did not have a record of the Huntleigh doppler, the Autocode Prodigy glucometer, and the LUCAS chest compression machine having been inspected, tested, and maintained by the facility or by their contracted alternative equipment maintenance (AEM) contractors. During a phone interview on 2/14/24 at 1:30 p.m., NF4 stated they did not have a record of the Huntleigh doppler, the Autocode Prodigy glucometer, and the LUCAS chest compression machine, in their list of equipment to be maintained for the facility.”

“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 has the potential to affect any patient who received medications from the pharmacy. Findings include: During an observation on 2/12/24 at 2:28 p.m., the pharmacy medication storage room was inspected. Upon inspection, it was noted the temperature of the room felt cold. No thermostat or temperature control was observed in the room. During an interview on 2/12/24 at 2:30 p.m., staff member F stated the medication storage room used to be extremely warm, but the facility now had air conditioning set up for that area. Staff member F stated the facility did not have a thermostat in the room to monitor the temperature. Review of a facility document titled, “Medication Storage and Handling, Pharm,0016,” with a revision date of 07/2023, showed: ... “9. Drug storage requirements are as follows: Refrigeration = 34-45 degrees F, Freezer = -13 to 14 degrees F, Cool Place = 46-59 degrees F, Room Temp. = 59-86 degrees F.””

“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 interview and record review, the facility failed to complete a thorough investigation after theft of medications from the emergency room crash cart were discovered on two separate occasions. This deficient practice has the potential to affect any person in the facility. Findings include: Review of a facility document titled, “Pharmacy and Therapeutics Minutes,” dated February 2023, showed: ... “2.2 Medication occurrences/errors for January: 4 ... 2.2.4 Crash cart tampered, 3 vials of naloxone (Narcan) missing. ...” A review of a facility document titled, “Pharmacy and Therapeutics Minutes,” dated November 2023, showed: ... “3.1 Medication occurrences/errors for October: 2 ... 3.1.2 Crash cart lock broken, nitro tabs missing.” Review of a facility document titled, “Safety Committee Minutes,” dated February 9th, 2023, showed: ...”Safety incident report-A med cart was left unattended and got broken into by a patient.” During an interview on 2/12/24 at 2:20 p.m., staff member F stated, “Any issues that arise with medications, medication errors, drug reactions, and diversions are all addressed through policy and procedures as well as through risk management and medical staff. We look for root causes and educate staff as needed.” During an interview on 2/13/24 at 9:30 a.m., staff member I stated if the plastic lock was broken or the tape that was covering the plastic lock is tampered with, the director of nursing was notified and a complete inventory of the crash cart was completed. Staff member I stated the carts are checked twice a day, at the beginning of each shift. During an interview on 1/13/24 at 10:28 a.m., Staff member J stated, “They had some problems in the past with medications going missing. We do not keep controlled substances in the carts anymore, and there is one cart that we moved to a different area. We are to be checking on the patients frequently to decrease the amount of alone time they have with the crash cart.” During an interview on 2/15/24 at 10:23 a.m., staff member A stated there were no investigation reports for the two incidents of medication theft. Staff member A stated the thefts were discussed with nursing and administration. Staff member A stated, “I checked the cameras after the incidents, but I could not tell who the person was.” Staff member A stated, “Law enforcement was not called, and I am really not sure why we did not notify them.” Staff member A stated the crash carts were to be checked each shift by nursing staff. If the seal was broken, then a full inventory of the cart was to be completed and management and pharmacy was to be notified. Review of a facility policy titled, “Drug Diversion Reporting and Response Pharm.0052,” with a revision date of 10/2023, showed: ... “1. The prevention of drug diversion is essential to the safety of [Facility] patients and is the individual responsibility of every [Facility] employee. ... 3. All suspected incidents of drug diversion will be thoroughly investigated. ... ... 6. The President, CNO, Director of Acute Care Services, Pharmacist and Risk Manager will manage the investigation of all reports of suspected drug diversion. ...””

“AGREEMENTS AND ARRANGEMENTS CFR(s): [The CAH has agreements or arrangements (as appropriate) with one or more providers or suppliers participating under Medicare to furnish other services to its patients, including-] (iii) Food and other services to meet inpatients’ nutritional needs to the extent these services are not provided directly by the CAH. This Standard is not met as evidenced by: 35356 Based on observation, interview, and record review, the facility failed to ensure nutritional services were provided to meet the nutritional needs of inpatients by ensuring a dietitian reviewed and approved dietary menus supplied by the contracted meal service provider prior to the implementation of the menu; failed to ensure textured diets were approved by a dietitian; and failed to ensure the meals were prepared in a sanitary environment by the contracted meal service provider. This deficient practice had the potential to affect all patients receiving meal services provided by the facility. Findings include: 1. Review and Approval of Dietary Menus A review of the facility’s Dietary Contract, signed 10/5/20, showed in Addendum V - Dietitian Coverage Services: - “...Dietitian Services: [Contracted Agency], through its employee or contractors...will provide to [the Facility] dietitian services of a clinical and non-clinical nature as follows: - a. The [Contracted Agency] Dietitian(s) will meet with [Facility] [Staff member B], [Facility staff member D] (the [Facility] Management) to develop a plan and schedule to provide the following services: - ... iii. Acute Care - [Contracted Agency] Dietitian(s) will review and approve dietary menus supplied by contracted meal service provider prior to implementation...” During an interview on 2/12/24 at 11:15 a.m., staff member B stated the contracted dietitians do not come to the facility to provide oversight of patient dietary needs or complete nutritional assessments. She stated they review nutritional needs over the phone or through tele-medicine. Staff member B stated she was not sure if the contracted dietitians reviewed the menus prior to implementation. During an interview on 2/13/24 at 9:20 a.m., staff member L stated they do not always receive the correct therapeutic diets for patients. She stated sometimes they will only receive a regular diet when a specific therapeutic diet was ordered for a patient. She stated when that happened, they would try to modify the meal to the best of their ability to reflect the correct therapeutic diet. During an interview on 2/13/24 at 10:25 a.m., staff member B stated they have had difficulty getting the correct therapeutic diet from the contracted meal service. She said they must look at the provided meal and make sure it was correct and if not, they would try to modify the meal as needed. During an interview on 2/13/24 at 11:00 a.m., staff member K stated she was only the contact dietitian, and she did not provide any direct oversight, review, or approval, of the facility’s dietary and therapeutic menus. Staff member K stated she did not physically come to the facility. She stated none of the dietitians which work for her provide direct dietary oversight or review and approval of the dietary or therapeutic menus provided by the contracted meal service. Staff member K stated she relied on NF1 to review the menus. Staff member K stated she was not sure if NF1 was an employee of the facility. During an interview on 2/13/24 at 11:15 a.m., NF1 stated he was not an employee of the facility and was not aware he was required to review and approve the dietary and therapeutic menus for the facility. Review of the contracted meal service dietary menu for, 2/11/24 through 2/17/24, showed the menu was reviewed and approved by a dietitian, NF5. A review of dietary menus from 12/1/23 through 2/10/24 showed the menu was approved by NF1. During a phone interview on 2/20/24 at 11:00 a.m., NF1 stated he was not sure who NF5 was, but assumed the person was a member of the nursing home administration staff. He stated he did not approve the menu for the week of 2/11/24 through 2/17/24. During a phone interview on 2/20/24 at 11:30 a.m., staff member A stated they were not sure who NF5 was, but assumed they were a “nursing home employee likely on the corporate side.” During a phone interview on 2/20/24 at 12:01 p.m., staff member A stated they contacted the corporate department for their contracted dietary meal service, and stated NF5 was a corporate dietitian from the contracted food service provider. 2. Texture Diets not Approved During an interview on 2/12/24 at 11:15 a.m., staff member B stated the expectation would be for the dietitian to approve any altered texture diets for dysphagia diets. Review of the contracted meal service dietary menu for altered texture diets for dysphagia diets showed the following texture diets were not reviewed or approved by the facility’s dietitian: - Pureed Diet, Level 4 Pureed Food for Adults, - Minced and Moist Diet, Level 5 Minced and Moist Food for Adults, - Soft and Bite-Sized, Level 6 Soft and Bite-Sized for Adults, - Regular Easy to Chew. During an interview on 2/13/24 at 11:00 a.m., staff member K stated she was only the contact dietitian, and she did not provide any direct oversight, review, or approval, for the facility’s altered texture diets for dysphagia diets provided by the contracted meal service. Staff member K stated she relied on NF1 to review the different diets and menus. During an interview on 2/13/24 at 11:15 a.m., NF1 stated he was not an employee of the facility and was not aware he was required to review and approve the altered texture diets for dysphagia diets. 3. Ensure Dietary Services were Provided in a Sanitary Environment During an observation on 2/13/24 at 9:20 a.m., the kitchen and meal prep of the contracted dietary meal service location was inspected. Observations reflected the following unsanitary food storage and preparation conditions: - Opened and not sealed, and not dated, 25-pound bags of sugar in the primary food storage, - Opened, not sealed, and not dated, 25-pound bag of confectioners’ sugar, - Raw beef sitting on the food prep counter next to onions being prepared for chopping, - Eight clear bins with blue lids, containing dried food goods such as flour, sugar, powdered sugar; stored in an open cupboard. The blue lids were sticky to touch and littered with white powder and dried food debris. - Food service plates, bowls, and utensils, were stored in an uncovered cabinet and not covered. The cabinet had scattered dried food debris and dust around the plates. - The walk-in cooler had large pieces of food debris on the floor under the food shelves. - Three covered drains recessed into the kitchen floor had a large accumulation of wet food debris. - The floor and wall around the food service area had a large amount of accumulated dried and wet food debris. The wall next to the food service/plate warmer area had large amount of food spatter on the wall. - The ceiling and the air vents in the kitchen had large accumulation of dust and cobwebs. During an interview on 2/13/24 at 9:45 a.m., NF2 stated she had never been provided oversight by the facility. She stated they were supposed to complete the deep cleaning schedule every week. She said she posted the deep cleaning schedule on Sunday, and the kitchen staff had until Saturday to complete the items on the deep cleaning schedule. NF2 stated they have been short staffed, and they have also had their hours cut, so much of the deep cleaning had not been completed for several weeks. A review of the contracted meal service’s Master Deep Clean List, from 1/21/24 through 2/17/24, reflected the items on the list had not been completed for this time period.”

“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 complete an AMA (Against Medical Advice) form prior to a patient leaving the facility for 1 (#17) of 22 sampled patients. This deficient practice has the potential to affect all patients in the emergency department who wish to leave the facility against medical advice. Findings include: A review of patient #17’s electronic medical record showed on 1/27/24, patient #17 had come to the emergency department for care. Patient #17 decided he no longer wanted to be in the emergency department and left. No AMA form was signed by patient #17 or emergency department staff. No AMA for was located in the patient’s medical records. During an interview on 2/15/24 at 10:00 a.m., staff member B stated she had held a nurses meeting on 2/14/24, and nursing staff told her they were not good at getting forms or consents signed by patients. Review of a facility policy titled, “Against Medical Advice (AMA), Leaving Without Being Seen (LWBS), Clinical.0056,” with a revision date of 02/2023, showed: ... “A. Patients Leaving Against Medical Advice: ... 5. Take all reasonable steps to have the patient or legally responsible person sign the appropriate section of the Leaving Without Being Seen/Leaving Against Medical Advice Form.””

“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: 47752 Based on interview and record review the facility failed to obtain consent to treat forms for 4 (#s 15, 16, 17, and 19) of 22 sampled residents. This deficient practice has the potential to affect all patients coming into the facility for treatment. Findings include: A review of patient #15’s electronic medical record showed no consent to treat was obtained during an emergency room visit on 2/11/24. A review of patient #16’s electronic medical record showed no consent to treat was obtained during an emergency room visit on 2/14/24. A review of patient #17’s electronic medical record showed no consent to treat was obtained during an emergency room visit on 1/27/24. A review of patient #19’s electronic medical record showed no consent to treat was obtained during an in-patient stay on 2/3/24. During an interview on 2/14/24 at 3:27 p.m., staff member B stated all facility staff knew consents needed to be signed by the patients. During business hours, the business office would get the consents signed when they complete paperwork with the patient. Staff member B stated, “I see a pattern with this, it looks like these patients all came in on night shift. I now know what shift to start educating staff.” Staff member B stated there was not follow through to make sure forms and charts are completed, it had, “fallen by the wayside.” During an interview on 2/15/24 at 10:00 a.m., staff member B stated she had held a nurses meeting on 2/14/24, and nursing staff told her they were not good at getting forms or consents signed by patients. During an interview on 2/15/24 at 10:28 a.m., staff member A stated the facility did not have a policy for the hospital, but used the swing bed criteria and admission process for admissions and consent to treat in the hospital setting. Review of a facility document titled, “[Location] Bed Criteria and Admission Process SWB110C,” with a revision date of 03/2023, did not address patient consent to treat.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 47752 Based on observation, interview, and record review, the facility failed to have clean medical supplies in the emergency room. This deficient practice has the potential to cause infection and affect all patients in the emergency room requiring the use of medical supplies. Findings include: During an observation on 2/13/24 at 9:20 a.m., the facility emergency department was inspected. The emergency department crash cart, located in the emergency department was inspected. One 100 mm oral airway, one 90 mm oral airway, two 80 mm oral airways, two 70 mm oral airways, two 60 mm airways, and two unpackage anal scopes were observed being stored in a plastic container that contained debris and fibers. During an observation on 2/13/24 at 9:25 a.m., a large, discolored, clear plastic bag was observed, hung on a peg board by a hook though the bag. The bag had fibers and debris in the bottom of the bag. The bag contained the following supplies: - two 100 mm oral airways, - four 90mm oral airways, - two 80 mm oral airways, - two 70 mm oral airways, and - twenty 60 mm oral airways. Below the bag containing the oral airways, was a clear bag that hung on the peg board with a hook though it. The bag contained debris and fibers. A Yankauer suction set up was in the bag. This set up was out of the original packaging and placed in the contaminated bag. During an interview on 2/13/24 at 9:45 a.m., staff member I stated, “The airways do not need to be sterile, it’s just a clean procedure.” Staff member I could not verbalize the facilities infection control plan. During an observation and interview on 2/13/24 at 1:20 p.m., staff member AA explained the process for ordering supplies for the different departments. Staff member AA showed the packaging the Yankauer suction set up came in. The packaging was sealed. Staff member AA stated the packaging was sealed to keep the supplies clean until they were ready to be used. During an interview on 2/15/24 at 8:10 a.m., staff member B stated staff have been educated on infection prevention. Staff member B stated all staff are educated upon hire, but also throughout the year by in-services, HealthStream assignments, and audits. A review of a facility policy, untitled, with no revision date, showed: “The purpose of the Infection Prevention and Control Program is to reduce the risk of acquiring and transmitting infections and communicable diseases between patients, employees, medical staff, volunteers, and visitors. ...” ... “I. IPC activities include, but are not limited to the following: a. Monitoring and evaluating key performance aspects of infection control include eight (8) core competency activities: ... vi. Environment of care. vii. Cleaning, sterilization, disinfection, and asepsis ...””

“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: 35356 Based on interview, and record review, the facility failed to develop a patient-centered comprehensive care plan that included measurable objectives, interventions, and timeframes to meet the patients’ medical, nursing, therapy, nutritional, psychosocial and discharge needs for 7 (#s 1, 4, 5, 6, 7, 8, and 9) of 10 sampled swing bed patients. Findings include: 1. Patient #1 was admitted to acute care services on 2/6/24, and then to swing bed services on 2/9/24. The patient was an active patient during the course of the survey. A review of patient #1’s History and Physical, dated 2/6/24, showed, “Assessment: Left upper extremity weakness suspect CVA, elevated liver enzymes, generalized weakness...” Review of patient #1’s orders showed orders for PT and OT services. Review of patient #1’s Care Plan dated 2/9/24, showed: - Fall Risk related to weakness Patient #1’s care plan failed to include measurable objectives, interventions, and timeframes to meet the patients’ medical, nursing, therapy, nutritional, psychosocial and discharge needs. 2. Patient #4 was admitted to swing bed services on 7/28/23. Review of patient #4’s History and Physical, dated 7/28/23, showed, “...Admitted to swing bed for continued physical therapy. She sustained a sacral fracture and bilateral transverse process fractures of L5... Assessment: Generalized disability and debility, sacral fracture, bilateral L5 spinous process fractures, new onset hypertension, COPD oxygen dependent, obesity... Plan: She’ll receive physical therapy twice a day. We’ll continue with strengthening exercises to improve her mobility and endurance. When she is safe to go home, she will be discharged back to her home residence... Review of patient #4’s Care Plan, dated 7/28/23, showed: - Activity Intolerance related to pain. Patient #4’s care plan failed to include measurable objectives, interventions, and timeframes to meet the patients’ medical, nursing, therapy, nutritional, psychosocial and discharge needs. 3. Patient #5 was admitted to swing bed services on 5/18/23. Review of patient #5’s History and Physical, dated 5/15/23, showed, “Assessment: Comfort Care and Chronic Liver Failure... Plan: Will initiate further comfort care measures at this time. Will increase morphine dosing... She has on board PRN Ativan, Benedryl and Phenergan as needed.” Review of patient #5’s Care Plan, dated 5/18/23, showed: - Fall Risk related to [blank] - Acute Pain related [blank] Patient #5’s care plan failed to include measurable objectives, interventions, and timeframes to meet the patients’ medical, nursing, therapy, nutritional, psychosocial and discharge needs including comfort care needs. 4. Patient #6 was admitted to swing bed services on 6/6/23. Review of patient #6’s History and Physical dated 6/6/23, showed, Plan: She’ll be admitted to our swing bed program where she will receive physical therapy. Also made a consultation for occupational therapy. Her foley catheter was recently discontinued prior to her transfer today. We’ll monitor for urinary retention and do bladder scan if indicated...Would like to avoid a long-term indwelling Foley catheter... Anticipated she will be here with us for approximate 2 weeks, receiving therapy.” Review of patient #6’s Care Plan dated, 6/6/23, showed: - Altered Thought Process related to dementia, expressive aphasia. - Fall Risk related to ORIF. Patient #6’s care plan failed to include measurable objectives, interventions, and timeframes to meet the patients’ medical, nursing, therapy, nutritional, psychosocial and discharge needs. 5. Patient #7 was admitted to swing bed services on 10/18/23. Review of patient #7’s History and Physical, dated 10/18/23, showed, “Plan: we will have physical and occupational therapy see her. She’ll be on Lantus twice daily plus a sliding scale of NovoLog insulin. She is also on Victoza... We’ll continue her on oxycodone as needed. She is a patient of [Provider’s Name] in Conrad. She will follow up there at the time of discharge.” Review of patient #7’s Care Plan dated, 10/18/23, showed: - Acute Pain related to bilateral femur fracture. - Urinary Tract Infection - Actual or Potential. Patient #7’s care plan failed to include measurable objectives, interventions, and timeframes to meet the patients’ medical, nursing, therapy, nutritional, psychosocial and discharge needs. 6. Patient #8 was admitted to swing bed services on 10/13/23. Review of patient #8’s History and Physical, dated 10/13/23, showed, “...admitted to our swing bed program after a 4 day stay in acute acre for UTI and generalized weakness and acute kidney injury... Plan: we will continue physical and occupational therapy. We’ll have her on Cipro... We’ll continue to watch her kidney function. We’ll plan to remove her Foley catheter on 10/17/23. Hopefully, she’ll get stronger and is able to return home in1-2 weeks. Review of patient #8’s Care Plan dated, 10/13/23, showed: - Activity Intolerance related [blank]. - Urinary Tract Infection - Actual or Potential. Patient #8’s care plan failed to include measurable objectives, interventions, and timeframes to meet the patients’ medical, nursing, therapy, nutritional, psychosocial and discharge needs. 7. Patient #9 was admitted to swing bed services on 9/24/23. Review of patient #9’s History and Physical, dated 9/24/23, showed, “Assessment: Congestive heart failure with respiratory distress, hypoxia, type 2 diabetes, hypertension, atrial fibrillation. Plan: We will admit her for care and comfort measures to swing bed. She does seem to responding and hopefully will be able to return to her colony soon. Family is okay with continued use of oral Lasix and oral antibiotics. We also have morphine and Ativan ordered if needed. We’ll hold off on physical therapy at this point as she is too weak to participate.” Review of patient #9’s Care Plan dated, 9/24/23, showed: - Fall Risk related to [blank]. - Skin Integrity - Potential Impairment. - Urinary Tract Infection - Actual or Potential. Patient #9’s care plan failed to include measurable objectives, interventions, and timeframes to meet the patients’ medical, nursing, therapy, nutritional, psychosocial, discharge needs and comfort care. During an interview on 2/15/24 at 10:00 a.m., staff member B stated it was the expectation that a comprehensive care plan was developed for all in-patient and swing bed patients.”

“NUTRITION CFR(s): Nutrition (§483.25(g)(1) and (g)(2) of this chapter). “ §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident’s comprehensive assessment, the facility must ensure that a resident- (1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident’s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (2) Is offered sufficient fluid intake to maintain proper hydration and health. This Standard is not met as evidenced by: 35356 Based on interview and record review, the facility failed to ensure a nutritional assessment was completed for a swing bed patient for 1 (#1) of 10 sampled swing bed patients. This deficient practice had the potential to affect swing bed patients with a need for nutritional assessment. Findings include: Patient #1 was admitted to acute care services on 2/6/24 and then to swing bed services on 2/9/24. The patient was an active patient during the course of the survey. A review of patient #1’s History and Physical, dated 2/6/24, showed, “...Plan: ...CT of her abdomen shows some gallbladder sludge and possible gallbladder disease... We will make her NPO until then...” Review of patient #1’s Nursing Nutritional Assessment, dated 2/6/24, showed the patient scored a total of four on her assessment and did not meet the facility’s guideline of eight or higher for a dietary consult. Review of patient #1’s EMR, showed a Nursing Nutritional Assessment by the nurse and/or a nutritional assessment by a dietitian was not completed for the patient when admitted to swing bed services on 2/9/24. Review of patient #1’s diet orders showed a regular diet was ordered by the physician. Review of patient #1’s dietary intake from, 2/9/24 through 2/14/24, showed: - On 2/09/24 at 7:48 p.m., 50% dinner consumed regular diet with 20 ml fluid. - On 2/10/24 at 10:42 a.m., “005% consumed”, and at 6:45 p.m.,75% dinner consumed regular diet. - On 2/11/24 at 7:34 p.m., 75% dinner consumed regular diet. - On 2/12/24 at 9:23 a.m., 10% breakfast consumed regular diet, and at 8:00 p.m., 0% dinner consumed regular diet, patient refused dinner. - On 2/13/24 at 8:30 a.m., 0% breakfast consumed regular diet, refused breakfast. At 12:00 p.m., 0% lunch consumed regular diet, patient refused lunch. At 1:53 p.m., 20% lunch consumed regular diet. At 8:05 p.m., 25% dinner consumed regular diet. - On 2/14/24 at 09:13a.m., 0% breakfast consumed regular diet; patient refused breakfast. At 7:30 p.m., 100% dinner consumed regular diet. - On 2/15/24 at 9:20 a.m., 15% breakfast consumed regular diet. Review of patient #1’s Nursing Assessment dated 2/14/24, showed, ...”Notes: Patient requesting pain medication, PRN Norco given along with scheduled medications. Patient had difficulty swallowing pills due to pocketed in left cheek. Patient attempted to swallow pills with water multiple times, pills remained on tongue or in cheek. Applesauce provided, pt able to swallow pills without difficulty with applesauce.” During an interview on 2/13/24 at 9:15 a.m., staff member J stated patient #1 was experiencing a decrease in her appetite and was not eating much of her provided meals. She stated they had been providing the patient with a Glucerna drink supplement because of her diminished appetite. Staff member J stated they did not have a dietitian that came to the facility for patient consults. She stated they were to complete the Nursing Nutritional Assessment for each patient and if the patient scored an eight or higher, they were to contact the dietitian via phone and they would review the patient’s medical information and make a diet recommendation. Staff member J stated they had not notified the dietitian of the change in patient #1’s appetite. Review of patient #1’s EMR on 2/15/24, failed to show the dietitian was notified of the patient pocketing pills and unable to swallow the pills with water and only with applesauce.”

“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 patient rights prior to providing or discontinuing care for 6 (#s 11, 15, 16, 17, 21, and 22) of 22 sampled residents. 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 #11’s electronic medical record showed an admission date of 7/20/23. No acknowledgement of patient rights was in the medical record. A review of patient #15’s electronic medical record showed an admission date of 2/11/24. No acknowledgement of patient rights was in the medical record. A review of patient #16’s electronic medical record showed an admission date of 2/14/24. No acknowledgement of patient rights was in the medical record. A review of patient #17’s electronic medical record showed an admission date of 1/27/24. No acknowledgement of patient rights was in the medical record. A review of patient #21’s electronic medical record showed an admission date of 10/19/23. No acknowledgement of patient rights was in the medical record. A review of patient #22’s electronic medical record showed an admission date of 2/9/24. No acknowledgement of patient rights was in the medical record. During an interview on 2/14/24 at 10:32 a.m., staff members A and B stated they followed the policy for swing bed patient rights. Staff members A and B stated they were not aware that outpatient procedures/testing or emergency room visits required an acknowledgement of patient rights. Review of a facility document titled, “[Location] Swing Bed: Swing Bed Patient Rights SWB190,” with a revision date of 1/2023, showed: no information about patient rights for the facility.”