Thayer County Health Services

“SURGICAL SERVICES CFR(s): If a CAH provides surgical services, surgical procedures must be performed in a safe manner by qualified practitioners who have been granted clinical privileges by the governing body, or responsible individual, of the CAH in accordance with the designation requirements under paragraph (a) of this section. This Condition is not met as evidenced by: 46123 Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure that outdated patient care supplies were removed from the patient care areas in the surgical services department. This failed practice has the potential to affect all patients receiving care in the surgical services department. The CAH reported 713 scopes/surgical procedures during the 2023 fiscal year. Findings are: A. Observations during the surgical services tour (12/4/24 at 2:00PM) revealed outdated supplies at the following 4 locations in the surgical services department: - Procedure room anesthesia cart: Extension set 32inch - 2 expired 4/1/22, 1 expired 5/1/24; - Scrub sink: Povidone-Iodine EZ Scrub (a soap scrub used by staff prior to surgery) 8 expired 11/24; - Operating Room (OR) Room: Remover lotion - 4 expired 9/2/2022, 3 expired 7/21/21 Mastisol liquid adhesive - 1 expired 7/23, 2 expired 11/24; and - Code Cart: Lubricating Jelly Packets 4 expired 6/24 Stylet with Soft Distal Tip 10 french 1 expired 10/17/24. B. Interview (12/4/24 at 2:00PM) with RN-M revealed that each nurse has an area in the OR that they are responsible for checking for outdates. RM-M agreed that items were outdated. Requested a policy for monitoring of outdated supplies for the Surgical Services Department. RN-M stated that they did not have a policy for outdated supplies.”

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 46123 Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure all outdated supplies are removed from the code cart in the Emergency Department (ED). This failed practice has the potential to affect all patients treated in the ED. The CAH reported 1,347 ED patients seen in fiscal year 2023. Findings are: A. ED tour conducted (12/4/24 at 9:28 AM) revealed outdated supplies in ED CODE cart that included the following: - 10 french stylet with soft distal tip expired 10/17/24; - 10 french stylet with soft distal tip expired 10/11/23; and - Angiocath 16-gauge 5.25 inch expired 3/2018. B. Interview (12/4/24 at 9:28 AM) with RN-G during the ED tour revealed that the department did not have a policy to monitor outdates in nursing care areas only a sign off sheet with all areas that nursing is responsible for monitoring. Nurses are responsible for checking for outdates in the ED for items not located in the pyxis. RN-G agreed that items were outdated. Surveyor requested a copy of the sign off sheet that nursing uses for checking areas for outdates prior to exit. The form was not provided before the exit conference.”

“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: 43000 Based on staff observations, medical record review, review of facility policies, staff interview and review of the National Library of Medicine reference, the Critical Access Hospital (CAH) failed to label intravenous (IV) antibiotics with the administration rate directions per facility policy and standards of practice for 1 (Patient 36) of 1 sampled patient. This failed practice had the potential to affect all patients of the CAH receiving IV antibiotics. The CAH reported an inpatient census of 248 patients and 713 surgical patients for the fiscal year ending 2023. Findings are: A. Medication administration observation (12/2/2024 at 1:46 PM) revealed Register Nurse (RN) -L training RN-K to prepare, reconstitute and administer Cefazolin, an IV antibiotic, for Patient 36. RN-K entered the medication room without performing any hand hygiene and reviewed the order for Patient 36 in the Pyxis machine (an automated locked dispensing system to obtain medications). RN-K then obtained 2 vials of the antibiotic Cefazolin 2 grams (g) and 1 twenty milliliter (ml) vial of sterile water from the Pyxis machine. RN-K took the vials to a prep counter and sat them down to the side, applied gloves and took a Sani Wipe (a disinfectant wipe to create an antiseptic surface) and wiped the prep counter. RN-K then removed gloves, obtained a 20 ml syringe out of a multi-use box of syringes and a needle. RN-K applied gloves without completing hand hygeine and opened the 20 ml syringe and needle. RN-K then opened all vials and wiped the tops with alcohol for 5 seconds each. RN-K attached the needle to the 20 ml syringe, placed into the 20 ml vial of sterile water and withdrew “about 10 ml” and then injected the 10 ml of sterile water into one vial of Cefazolin 1 g. RN-K rotated the vial to mix the contents, withdrew the needle and placed the needle into the 20 ml vial of sterile water and withdrew 10 ml of sterile water and placed the needle into the 2nd vial of Cefazolin 1g and injected the water. RN-K rotated the vial to mix contents and withdrew the mixture into the 20 ml syringe. RN-K then placed the needle with syringe into the first vial of Cefazolin and withdrew the contents of the vial. The total amount in the 20 ml syringe was 19 ml. RN-L had written a label that had the patient’s name and Cefazolin 2g written on it. No administration instructions. RN-K removed gloves, obtained a tubing set from the storage unit, gathered the 20 ml syringe of medication and the 2 empty Cefazolin vials. RN-L put on a glove and took the empty vial of sterile water out of the trash where it had been discarded and handed the soiled vial to RN-K. RN-K took all vials and syringe out of the medication room. RN-K and RN-L both used hand sanitizer prior to entering the patient room. RN-K applied gloves, pulled up the order in the computer at the patient bedside and took the scanning device off the wall and scanned the patient wrist band and the vials of solutions, including the soiled vial from the trash can. With the same soiled gloves on, RN-K then placed the 20 ml syringe of Cefazolin, package of tubing set and alcohol wipes on the windowsill that was not wiped off and contained patient personal items. RN-K then opened the package of tubing and primed the tubing with the antibiotic solution from the 20 ml syringe. RN-K placed the 20 ml syringe into the IV pump and wiped the patients Peripherally Inserted Central Catheter (PICC) (a central intravenous catheter that is inserted peripherally through the arm to administer IV medications) for 5 seconds. RN-K then attached a 10 ml syringe with normal saline and flushed the PICC line without aspirating for blood return. RN-K then attached the tubing from the 20 ml syringe with the IV antibiotics and set the pump at 8 minutes to infuse the medication. B. Record review of Patient 36’s admission history and physical revealed that the patient, age 78, admitted on 11/13/20204 for IV antibiotics, physical and occupational therapy after a right total hip arthroplasty clean out, with a wound VAC in place due to infection after the surgery. IV antibiotics to continue to 12/12/2024 per Infectious Disease physician. Review of Patient 36’s physicians order dated 11/13/2024 revealed an order for Cefazolin (Ancef) 2 grams, IV push every 8 hours with a stop date of 12/13/2024 for Bone and/or joint infection, lacking administration directions on the order.Review of Patient 36’s Medication Administration Records (MAR) for the month of November and December revealed under the Cefazolin order, lacked administration directions located on any of the days the medication was administered, no measurement of the external length of the PICC or arm circumference or dressing change documented since 11/22/2024. C. Interview (12/2/24 at 2:10 PM) with RN-L confirmed that the administration instructions were not on the physician’s order, nor was it on the label for the medications. RN-L verbalized that the nursing staff go by the “IV Shortage Administration Guide” that the pharmacy provided that is hanging on the wall in the medication room. RN-L also verbalized that nursing does the handwritten label due to the label printer not printing correctly. RN-L confirmed that the pharmacist enters the orders into the electronic record and that the administration instructions were not on the order or MAR. D. Interview with the Director of Nursing (DON) (12/2/24 at 2:20 PM) confirmed that the administration rate should be on the MAR and/or in the orders, and confirmed it was not on either the MAR or the orders. Interview with the DON (12/5/2024 at 11:20 AM) confirmed that the nursing staff reconstitute all IV antibiotics. E. Interview with the Pharmacist-I (12/4/2024 at 8:35 AM) confirmed that “we don’t typically put the administration rate into Cerner (the electronic charting system) because there is no way to enter that for an IV push medication”. Pharmacist-I went on to state the “library in the system has drugs available in the system and that piggyback medications have administration directions”. Pharmacist-I did say they could put it under comments, and it would show up on the MAR, and confirmed that their workload is not too heavy that they could enter the administration directions under comments. F. Observation (12/4/2024 at 8:40 AM) revealed Pharmacist-J editing the Cefazolin order for Patient 36 and the infusion rate being entered under comments, made an adjustment in Cerner and then Pharmacist-J printed a label. The label was legible, and the infusion rate appeared on the label. Pharmacist-J was unaware of the label printing problem for the nurses. G. Review of pharmacy facility policy titled Labeling Standards (last revision date of 7/2022) stated under procedure: “IV admixture labels shall include at a minimum: ....name and amount of the basic solution, dose, time/date due, and infusion rate ........”. H. Review of the undated IV Shortage Administration Guide posted on the medication room wall revealed the following: “Cefazolin 0.5g, 1g, 1.5g in 10 ml SWFI 3-5 minutes.” All medications on this list were in alphabetically order and single line spacing. There were 7 medications that began with a C all in a row and 3 with similar names together, increasing the risk for medication errors. I. Review of the National Library for Medicine, under Nursing Advanced Skills: Chapter 2, Administer IV push medications: “Additionally, it is important to consider the specific time frame for drug administration. Many IV medications must be infused over a period of time and cannot be pushed into the venous system rapidly due to potential adverse hemodynamic effects. Medications administered by direct IV route are commonly given very slowly per guidelines outlined in a drug reference guide. Nurses must routinely consult drug reference guides when administering IV push medications to check medication and fluid compatibilities and to ensure that medications are given at the correct rate to prevent complications”.”

“NURSING SERVICES CFR(s): §485.635(d)(3) All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. This Standard is not met as evidenced by: 43000 Based on staff observations, medical record review, review of facility policies and staff interview, the Critical Access Hospital (CAH) failed to assess for patency of a Peripherally Inserted Central Catheter (PICC) (a central intravenous (IV) catheter that is inserted peripherally through the arm to administer IV medications) prior to administration of medications, the facility also failed to complete measurements to ensure proper placement (significant complications could occur if medication were to be administered in the wrong location) and document PICC dressing changes per facility policy for 1 (Patient 36) of 1 sampled patient. This failed practice had the potential to affect all patients of the CAH receiving IV medications per a PICC line. The CAH reported an inpatient census of 248 patients and 713 surgical patients for the fiscal year ending 2023. Findings are: A. Medication administration observation (12/2/2024 at 1:46 PM) revealed Register Nurse (RN) -L training RN-K to prepare, reconstitute and administer Cefazolin, an IV antibiotic, for Patient 36. RN-K entered the medication room without performing any hand hygiene and reviewed the order for Patient 36 in the Pyxis machine (an automated locked dispensing system to obtain medications). RN-K then obtained 2 vials of the antibiotic Cefazolin 2 grams (g) and 1 twenty milliliter (ml) vial of sterile water from the Pyxis machine. RN-K took the vials to a prep counter and sat them down to the side, applied gloves and took a Sani Wipe (a disinfectant wipe to create an antiseptic surface) and wiped the prep counter. RN-K then removed gloves, obtained a 20 ml syringe out of a multi-use box of syringes and a needle. RN-K applied gloves without completing hand hygeine and opened the 20 ml syringe and needle. RN-K then opened all vials and wiped the tops with alcohol for 5 seconds each. RN-K attached the needle to the 20 ml syringe, placed into the 20 ml vial of sterile water and withdrew “about 10 ml” and then injected the 10 ml of sterile water into one vial of Cefazolin 1 g. RN-K rotated the vial to mix the contents, withdrew the needle and placed the needle into the 20 ml vial of sterile water and withdrew 10 ml of sterile water and placed the needle into the 2nd vial of Cefazolin 1g and injected the water. RN-K rotated the vial to mix contents and withdrew the mixture into the 20 ml syringe. RN-K then placed the needle with syringe into the first vial of Cefazolin and withdrew the contents of the vial. The total amount in the 20 ml syringe was 19 ml. RN-L had written a label that had the patient’s name and Cefazolin 2g written on it. No administration instructions. RN-K removed gloves, obtained a tubing set from the storage unit, gathered the 20 ml syringe of medication and the 2 empty Cefazolin vials. RN-L put on a glove and took the empty vial of sterile water out of the trash where it had been discarded and handed the soiled vial to RN-K. RN-K took all vials and syringe out of the medication room. RN-K and RN-L both used hand sanitizer prior to entering the patient room. RN-K applied gloves, pulled up the order in the computer at the patient bedside and took the scanning device off the wall and scanned the patient wrist band and the vials of solutions, including the soiled vial from the trash can. With the same soiled gloves on, RN-K then placed the 20 ml syringe of Cefazolin, package of tubing set and alcohol wipes on the windowsill that was not wiped off and contained patient personal items. RN-K then opened the package of tubing and primed the tubing with the antibiotic solution from the 20 ml syringe. RN-K placed the 20 ml syringe into the IV pump and wiped the patients Peripherally Inserted Central Catheter (PICC) (a central intravenous catheter that is inserted peripherally through the arm to administer IV medications) for 5 seconds. RN-K then attached a 10 ml syringe with normal saline and flushed the PICC line without aspirating for blood return. RN-K then attached the tubing from the 20 ml syringe with the IV antibiotics and set the pump at 8 minutes to infuse the medication. B. Review of Patient 36’s physicians order dated 11/13/2024 revealed an order for Cefazolin (Ancef) 2 grams, IV push every 8 hours with a stop date of 12/13/2024 for Bone and/or joint infection. No administration directions found on the order. Review of Patient 36’s Medication Administration records for the month of November and December revealed under the Cefazolin order, no administration directions located on any of the days the medication was administered. Patient 36’s medical record lacked measurement of the external length of the PICC or arm circumference or dressing change since last documented on 11/22/2024. C. Review of the facility policy titled Intravenous Access (last revised 3/17/2024) revealed the following under the Medication and Solution Administration section: “#1.Verify provider order for solution, volume, medication, route, rate, dose, frequency, and duration. #10. Aspirate for appositive blood return from vascular access device (VAD) to confirm patency.” -Under Table 1 that determines dressing changes, type and frequency, and cap change stated; “The dressing should be changed weekly with cap change and should be flushed with 10 ml normal saline before each use.” D. Interview with the Director of Nursing (DON) (12/2/24 at 2:20 PM) confirmed that the administration rate should be on the Medication Administration Record (MAR) and it was not. The DON also confirmed that the medical record for Patient 36 did not show a dressing change or assessment since 11/22/2024. The DON confirmed that the IV Administration policy indicated weekly dressing change and measurement, and to aspirate blood to check for patency prior to each use. E. Interview with the Director of Nursing (DON) (12/4/2024 at 8:20 AM) revealed that the facility did not have a medication management policy but that the DON typed one up the previous day to take to the Policy Review Committee, but it was not active yet. F. Interview with RN-K (12/4/2024 at 8:47 AM) confirmed that hand hygiene was not completed during the IV medication reconstitution and that the nursing staff “typically only aspirate for blood return on the PICC lines once a day, it was done earlier that day”.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 43000 Based on staff observations, medical record review, review of facility policies, staff interview, review of the United States Pharmacopeia 797 reference, and Emergency Department tour, the Critical Access Hospital (CAH) nursing staff failed to reconstitute intravenous (IV) antibiotics in an aseptic manner to prevent cross contamination and the spread of health care associated illness for 1 patient (Patient 36) of 1 sampled patient. The CAH also failed to ensre that patient care supplies and facility cleaning supplies are stored seperately. This failed practice had the potential to affect all patients of the CAH receiving IV antibiotics and emergency services. The CAH reported an inpatient census of 248 patients and 713 surgical patients and 1,347 ED patients for the fiscal year ending 2023. Findings are: A. Medication administration observation (12/2/2024 at 1:46 PM) revealed Register Nurse (RN) -L training RN-K to prepare, reconstitute and administer Cefazolin, an IV antibiotic, for Patient 36. RN-K entered the medication room without performing any hand hygiene and reviewed the order for Patient 36 in the Pyxis machine (an automated locked dispensing system to obtain medications). RN-K then obtained 2 vials of the antibiotic Cefazolin 2 grams (g) and 1 twenty milliliter (ml) vial of sterile water from the Pyxis machine. RN-K took the vials to a prep counter and sat them down to the side, applied gloves and took a Sani Wipe (a disinfectant wipe to create an antiseptic surface) and wiped the prep counter. RN-K then removed gloves, obtained a 20 ml syringe out of a multi-use box of syringes and a needle. RN-K applied gloves without completing hand hygeine and opened the 20 ml syringe and needle. RN-K then opened all vials and wiped the tops with alcohol for 5 seconds each. RN-K attached the needle to the 20 ml syringe, placed into the 20 ml vial of sterile water and withdrew “about 10 ml” and then injected the 10 ml of sterile water into one vial of Cefazolin 1 g. RN-K rotated the vial to mix the contents, withdrew the needle and placed the needle into the 20 ml vial of sterile water and withdrew 10 ml of sterile water and placed the needle into the 2nd vial of Cefazolin 1g and injected the water. RN-K rotated the vial to mix contents and withdrew the mixture into the 20 ml syringe. RN-K then placed the needle with syringe into the first vial of Cefazolin and withdrew the contents of the vial. The total amount in the 20 ml syringe was 19 ml. RN-L had written a label that had the patient’s name and Cefazolin 2g written on it. No administration instructions. RN-K removed gloves, obtained a tubing set from the storage unit, gathered the 20 ml syringe of medication and the 2 empty Cefazolin vials. RN-L put on a glove and took the empty vial of sterile water out of the trash where it had been discarded and handed the soiled vial to RN-K. RN-K took all vials and syringe out of the medication room. RN-K and RN-L both used hand sanitizer prior to entering the patient room. RN-K applied gloves, pulled up the order in the computer at the patient bedside and took the scanning device off the wall and scanned the patient wrist band and the vials of solutions, including the soiled vial from the trash can. With the same soiled gloves on, RN-K then placed the 20 ml syringe of Cefazolin, package of tubing set and alcohol wipes on the windowsill that was not wiped off and contained patient personal items. RN-K then opened the package of tubing and primed the tubing with the antibiotic solution from the 20 ml syringe. RN-K placed the 20 ml syringe into the IV pump and wiped the patients Peripherally Inserted Central Catheter (PICC) (a central intravenous catheter that is inserted peripherally through the arm to administer IV medications) for 5 seconds. RN-K then attached a 10 ml syringe with normal saline and flushed the PICC line without aspirating for blood return. RN-K then attached the tubing from the 20 ml syringe with the IV antibiotics and set the pump at 8 minutes to infuse the medication. B. Review of Patient 36’s admission history and physical revealed that the patient, age 78, admitted on 11/13/2024 for IV antibiotics, physical and occupational therapy after a right total hip arthroplasty clean out, with a wound VAC in place due to infection after the surgery. IV antibiotics to continue through 12/12/2024 per the Infectious Disease physician. C. Interview with RN-K (12/4/2024 at 8:47 AM) confirmed that hand hygiene was not completed during the IV medication reconstitution and that the nursing staff “typically only aspirate for blood return on the PICC lines once a day, it was done earlier this morning”. D. Interview with the Director of Nursing (DON) (12/4/2024 at 8:20 AM) revealed that the facility did not have a medication management policy but that the DON typed one up the previous day to take to the Policy Review Committee, but it was not active yet. The DON confirmed that RN-K and RN-L should have completed hand hygiene per IV administration policy for medication reconstitution. E. Interview with Pharmacist-J (12/4/2024 at 8:45 AM) revealed that the pharmacy did complete training last summer with the nurses on aseptic techniques for reconstituting medications but might have missed the new RN. Pharmacist-J then presented a copy of the Immediate-Use Compounding Competency Assessment form utilized for the training. F. Review of the Immediate-Use Compounding Competency Assessment form (undated) received from the pharmacy on 12/4/2024 revealed the following: “*Hand Hygiene: removed all jewelry on hands and wrists to prevent contamination. Perform hand washing with soap and water and dry with clean, dry paper towel. Appy alcohol-based hand sanitizer to hands and allow to air dry. *Garbing: Apply gloves and disinfect by applying alcohol or disinfecting agent onto gloves and allow to air dry.” G. Review of United States Pharmacopeia (USP) (which is a set of standards for the quality of medicines and medical devices) 797, 1.3 Immediate -Use Compound Sterile Preparation (CSP) stated “#1. Aseptic techniques, processes, and procedures are followed, and written standards of practice are in place to minimize the potential for contact with nonsterile surfaces, introduction of particulate matter or biological fluids, and mix-ups with other conventionally manufactured products for CSPs.” F. ED tour (12/4/24 at 9:28 AM) RN-G opened a locked cupboard in the clean area. Cupboard contained a bottle of instrument pre cleanser, a bottle of enzymatic cleaner on the same shelf as patient care supplies of hydrogen peroxide and hibiclens (a solution used to prevent skin infections). RN-G stated that they didn’t think they could store cleaning products under the sink and that they needed to be in a lock cupboard.”

“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: 46123 Based on policy and procedure review, review of facility Live on Nebraska agreement/dashboard and staff interview, the Critical Access Hospital CAH failed to ensure a defiinition of imminent death and criteria to determine imminent death was included in their Organ and Tissue Donation Policy. This failed practice had the potential to miss a potential donor while organs are still viable. The CAH reported 248 inpatient admissions and 1,347 ED patients for the fiscal year 2023. Findings are: A. Review of the facility policy titled Organ and Tissue Donation (Last Revision 3/25/2022), revealed the policy lacked a definition of imminent death and criteria to determine imminent death to include specific triggers for notification of Live on Nebraska. B. Review of the Live on Nebraska Donor Institution Agreement revealed that the agreement was signed by the CAH on 12/24/2019. The agreement incudes a “Summary of Donor Institution Agreement Proposed Changes” which includes clarified language to better define when a patient would be considered an imminent death and when that patient should be called in for an organ evaluation. The agreement also includes definitions required for facility policy in Article I. -Review of facility Live on Nebraska provided dashboards (1/1/24 -9/30/24) revealed that the facility has had 0 organ donors. D. Interview (12/4/24 at 10:56 AM) with RN-G stated that the CAH does not keep patients on a ventilator so the CAH would not need to worry about imminent death. Clarified with RN-G that CAH does have a ventilator in the ED. RN-G agreed that they do have a ventilator in the ED. RN-G also stated that they “only use the ventilator if they are waiting an extended time for transport.””

“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: 46123 Based on medical record review, review of policy and procedure and staff interviews, the Critical Access Hospital (CAH) failed to ensure that 3 of 3 swing bed patients (Parients 32, 34, and 35) reviewed had a comprehensive assessment completed after 14 days and 5 of 5 swing bed patients (Patients 32, 33, 34, 35, and 36) reviewed lacked a recapitulation of stay completed at discharge. This failed practice has the potential to affect all swing bed patients at the CAH. The CAH reported 44 swing bed patients for the fiscal year 2023. Findings are: A. Review of Patient 32’s medical record (12/5/24 at 9:45 AM) revealed patient was admitted to swing bed care on 8/23/24 at 9:09 AM for weakness, fracture of right fibula and Parkinson’s. Discharged on 9/7/24 at 1:45PM. The patient had a 15 day stay. The medical record lacked a comprehensive assessment and a recapitulation of stay. - Review of Patient 33’s medical record (12/5/24 at 10:00 AM) revealed patient was admitted to swing be on 9/18/24 at 12:01 PM for Chronic Obstructive Pulmonary Disease (COPD) (a disease that causes difficulty breathing because lungs do not work correctly) exacerbation. Discharged on 9/24/24 at 3:34PM. The patient had a 6 day stay. The medical record lacked a recapitulation of stay. - Review of Patient 34’s medical record (12/5/24 at 10:15 AM) revealed patient was admitted to swing bed on 8/22/224 at 1:11 PM for anemia and hypotension (low blood pressure). Discharged on 9/6/24 at 3:20PM. The patient had a 15 day stay. The medical record lacked a comprehensive assessment and a recapitulation of stay. - Review of Patient 35’s medical record (12/5/24 at 10:30 AM) revealed patient was admitted to swing bed on 10/8/24 at 12:35 PM for congestive heart failure (CHF) exacerbation and declining status. Discharged on 10/24/24 at 10:45AM. The patient had a 16 day stay. The medical record lacked a comprehensive assessment and a recapitulation of stay. - Review of Patient 36’s medical record (12/5/24 at 10:50 AM) revealed patient was admitted to swing bed on 10/25/24 at 7:25 PM for right hip pain. Transferred to Acute Care Facility on 10/30/24 at 9:10AM. The patient had a 5 day stay. The medical record lacked a recapitulation of stay. B. Review of facility policy titled Comprehensive Swing Bed Assessment ( Last revision 8/24/21) revealed “The comprehensive assessment will be completed within 14 days of admission to swing bed, utilizing the initial interview for the swing bed patient type.” -Review of facility policy titled Swing Bed Program (Last revision 8/24/21) revealed “A Recapitulation of the Patients Stay - This form is to be completed by the Social Worker and the RN on duty.” and “Swing Bed Summary of Patients Stay - This form is to be completed and signed only by the RN on duty. These forms are to be completed within five (5) working days after dismissal of patient.” C. Interview (12/5/24 at 9:45AM) with RN-G and Social Work-N (SW-N) revealed while conducting record reviews during the mock survey, the facility had completed a couple of months ago, that there was difficulty locating the comprehensive assessments and the recapitulations on the swing bed records reviewed. RN-G was able to locate the comprehensive assessment form in the electronic medical record for staff to complete as well as the recapitulation form. RN-G and SW-N both confirmed that for the above (Patients 32, 34 and 35) medical records were lacking the comprehensive assessment after day 14 of swing bed stay. RN-G and SW-N also confirmed that for the above (Patients 32, 33, 34, 35, and 36) medical records were lacking the recapitulation of stay after discharged.”

“Hospital CAH and LTC Emergency Power CFR(s): §482.15(e) Condition for Participation: (e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section. §483.73(e), §485.625(e), §485.542(e) (e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section. §482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1) Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated. 482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2) Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code. 482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2) Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates. *[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):] The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes. (1) National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169, www.nfpa.org, 1.617.770.3000. (i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011. (ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011. (iii) TIA 12-3 to NFPA 99, issued August 9, 2012. (iv) TIA 12-4 to NFPA 99, issued March 7, 2013. (v) TIA 12-5 to NFPA 99, issued August 1, 2013. (vi) TIA 12-6 to NFPA 99, issued March 3, 2014. (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011. (viii) TIA 12-1 to NFPA 101, issued August 11, 2011. (ix) TIA 12-2 to NFPA 101, issued October 30, 2012. (x) TIA 12-3 to NFPA 101, issued October 22, 2013. (xi) TIA 12-4 to NFPA 101, issued October 22, 2013. (xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.. This Standard is not met as evidenced by: 13879 Based on observation, documentation review and interview, the facility failed to have a program for exercising main and feeder circuit breakers connected to the Essential Electrical System, and failed to conduct all required inspections of the emergency generator. These deficient practices increase the probability that the generator would fail to run during an emergency loss of power and the emergency systems in the facility. The facility has the capacity for 17 beds with census of 5 on the day of survey. Findings are: Documentation review on 12-3-24 at 2:14 pm, of the emergency generator maintenance log revealed: 1. No current exercising the emergency breakers or main breaker was provided. 2. No time to transfer was provided on the monthly generator inspection report. 3. Not all parts/components of generator were listed for inspection on monthly generator inspection report. During an interview on 12-3-24 at 2:14 pm, Staff A confirmed that the circuit breaker testing failed to be conducted and the lack of all components were listed on inspection report or the transfer time. NFPA Standard: 2012 NFPA 99, 6.4.4.1.2.1 Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer’s recommendations. A.6.4.4.1.2.1 Main and feeder circuit breakers should be periodically tested under simulated overload trip conditions to ensure reliability.”

“42 CFR 483.90(a)(b) The facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code of the National Fire Protection Association. This facility is governed by Chapter 19, Existing Health Care Occupancies of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code. Thayer County Health Services is a two story building of Type II (000) construction that was built in 1967, 98, 2005, 2015, and is fully fire sprinkler protected. There is supervised smoke detection located in the corridors. Smoke barriers are located between each addition, and through the middle of the original 1967 building. The facility has a capacity of 17 beds with a census of 5 on the day of survey. Thayer County Health Services was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 483.90(a)(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition.”

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to provide an approved construction type for a building attached to the hospital. This deficient practice failed to ensure building integrity during fire conditions which would affect all occupants. The facility has the capacity for 17 beds with a census of 5 on the day of survey. Findings are: Observations on 12-3-24 at 11:50 am revealed, a non-sprinkled wooden garage/shed attached to the hospital. During an interview on 12-3-24 at 11:50 am, Staff A confirmed the attached garage was constructed with wood.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to assure emergency lighting was not switchable. This deficient practice would cause confusion during an emergency. The facility has the capacity for 17 beds with a census of 5 on the day of survey. Findings are: Observations on 12-3-24 at 1:32 pm revealed, the Procedure room provided emergency lights that were switchable. During an interview on 12-3-24 at 1:32 pm, Staff A confirmed the lights in the Procedure room were on emergency power but were switchable. NFPA Standard: 2012 NFPA 99, 6.3.2.2.11.1 One or more battery-powered lighting units shall be provided within locations where deep sedation and general anesthesia is administered.”

“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: 13879 Based on observation and interview, the facility failed to assure doors to hazardous areas provided self-closing device, were not held open, would close and latch within the doorframe. These deficient practices would allow fire, smoke and gasses to migrate into the exit corridor. The facility has the capacity for 17 beds with a census of 5 on the day of survey. Findings are: Observation on 12-3-24 between 11:00 am and 1:28 pm revealed: 1. Pool mechanical room located in the basement failed to provide a self-closing device on the door. 2. Chiller door in the basement was held open with a rubber door chock. 3. Unsealed penetrations in ceiling of the IT room. 4. Transfer switch room door was held open with a wooden block. 5. Fire rated door to the Director of Nutrition was held open with a rubber pig “Ron Jon”. 6. The door to the positive pressure room in the Pharmacy, equipped with a self-closing device failed to close and latch within the doorframe. 7. OR was room door, equipped with a self-closing device was held open with a rubber door chock. During an interview on 12-3-24 between 11:00 am and 1:28 pm, Staff A confirmed the findings.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to provide a cleaning schedule for the kitchen exhaust hood. This deficient practice would increase the potential for a fire, as a fire under the hood could possibly not be extinguished effectively. Findings are: Observation on 12-3-24 at 1:40 pm revealed: 1. No cleaning schedule was provided for the kitchen exhaust hood. During an interview on 12-3-24 at 1:40 pm, Kitchen Staff A stated no written cleaning schedule was provided.”

“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: 13879 Based on observation and interview, the facility failed to assure a box containing spare fire sprinklers was provided, that sprinkler components were installed as designed, and that sprinklers were free of foreign matter. These deficient practices would not allow rapid replacement of a damaged sprinkler and a delay in sprinkler system response. The facility has the capacity for 17 beds with a census of 5 on the day of survey. Findings are: Observations on 12-3-24 between 11:16 am and 1:37 pm, revealed, 1. Facility did not provide a spare sprinkler box in the riser room. 2. Missing sprinkler escutcheon in the Pyxis Room. 3. Two of two sprinkler in the dish room in the kitchen were green with corrosion. During an interview on 12-3-24 between 11:16 am and 1:37 pm, Staff A confirmed no spare sprinkler box was provided, missing escutcheon and corrosion. NFPA Standard: 2010 NFPA 13 6.2.9.1* A supply of at least six spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. 6.2.9.2 The sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property. 6.2.9.3 The sprinklers shall be kept in a cabinet located where the temperature to which they are subjected will at no time exceed 100°F (38°C). 6.2.9.4 Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to assure fire extinguishers were inspected monthly. This deficient practice would delay access to the extinguisher during a fire. The facility has the capacity for 17 beds with census of 5 on the day of survey. Findings are: Observation on 12-3-24 at 11:23 am and 1:08 pm revealed: 1. The fire extinguisher in the elevator equipment room had not been inspected. 2. The inspection tag for the fire extinguisher in the Lab was out of date. During an interview on, 12-3-24 at 11:23 am and 1:08 pm Staff A confirmed extinguisher had not been inspected and needed to be replaced.”

“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: 13879 Based on observation and interview, the facility failed to ensure corridor doors would resist the passage of smoke. This deficient practice would not prevent the spread of fire, smoke and gasses within the exit corridors. The facility has the capacity for 17 beds with census of 5 on the day of survey. Findings are: Observation on 12-3-24 at 11:46 am revealed, room 106 door failed to latch within the doorframe. During an interview on 12-3-24 at 11:46 am, Staff A confirmed the door failed to close and latch within the doorframe.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to assure smoke barrier doors in the facility would be smoke tight. This deficient practice would increase the potential for fire, smoke and gases to spread. The facility has the capacity for 17 beds with census of 5 on the day of survey. Findings are: Observations on 12-3-24 between 12:12 pm and 1:20 pm revealed: 1. Excessive gap between the double smoke doors leading into Surgery from the Ambulance corridor. 2. Excessive gap between the double smoke doors next to Lab/Radiology check-in. 3. Excessive gap between the double smoke doors in Radiology next to DVA. 4. Smoke doors next to Hospitality failed to close and latch within the doorframe. During an interview on 12-3-24 between 12:12 pm and 1:20 pm, Staff A confirmed the excessive gap and that the door failed to latch within the doorframe.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to provide unobstructed access to electrical panels. These deficient practices would cause a delay and injury when turning off the power during an electrical emergency. The facility has the capacity for 17 beds with census of 5 on the day of survey. Findings are: Observations on 12-3-24 at 11:38 am and 1:13 pm revealed: 1. Numerous bags of 40-pound salt in front of panel box ESA in the Mechanical Room next to the soft water equipment. 2. Chair in front of panel boxes in the electrical closet next to the DON office. During an interview on 12-3-24 at 11:38 am and 1:13 pm, Staff A confirmed the items front of the panel boxes. NFPA Standard: 2011 NFPA 70, 65.26 Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. 2011 NFPA 70, 65.32 Sufficient space shall be provided and maintained about electrical equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed, the minimum clear work space shall be not less than 2.0 m (6 1/2 ft) high (measured vertically from the floor or platform) or not less than 914 mm (3 ft) wide (measured parallel to the equipment). The depth shall be as required in 65.34(A). In all cases, the work space shall permit at least a 90 degree opening of doors or hinged panels.”

“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: 13879 Based on observation, documentation review and interview, the facility failed to have a program for exercising main and feeder circuit breakers connected to the Essential Electrical System, and failed to conduct all required inspections of the emergency generator. These deficient practices increase the probability that the generator would fail to run during an emergency loss of power and the emergency systems in the facility. The facility has the capacity for 17 beds with census of 5 on the day of survey. Findings are: Documentation review on 12-3-24 at 2:14 pm, of the emergency generator maintenance log revealed: 1. No current exercising the emergency breakers or main breaker was provided. 2. No time to transfer was provided on the monthly generator inspection report. 3. Not all parts/components of generator were listed for inspection on monthly generator inspection report. During an interview on 12-3-24 at 2:14 pm, Staff A confirmed that the circuit breaker testing failed to be conducted and the lack of all components were listed on inspection report or the transfer time. NFPA Standard: 2012 NFPA 99, 6.4.4.1.2.1 Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer’s recommendations. A.6.4.4.1.2.1 Main and feeder circuit breakers should be periodically tested under simulated overload trip conditions to ensure reliability.”

“Electrical Equipment - Testing and Maintenanc CFR(s): NFPA 101 Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility’s policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8 This Standard is not met as evidenced by: 13879 Based on documentation review and interview, the facility failed to implement the following: testing and inspection as well as written procedures and policies for audits, testing and inspection of power strips throughout the facility. This deficient practice increased the potential of electrical equipment throughout the facility causing injury or a fire. The facility has the capacity for 17 beds with census of 5 on the day of survey. Findings are: Record review on 12-3-24 at 1:36 pm revealed: 1. Documentation of testing for power strips was not provided for review. During an interview on 12-3-24 at 1:36 pm, Staff A confirmed the testing was not conducted.”