Brodstone Healthcare

“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 interview, the Critical Access Hospital (CAH) failed to ensure a comprehensive assessment, and a discharge summary was completed on 5 (patient 32, 33, 34, 35, 36) of 5 swing bed records. This failed practice has to the potential to affect all swing bed patients of the CAH. The number of swing bed patients at the CAH for fiscal year 2025 was 117. Findings are: - Review of Patient 32’s medical record (7/31/25 at 8:20AM) revealed a swing bed admission of 1/15/25-1/23/25 for altered mental status and weakness. Review of the entire medical record revealed a comprehensive assessment (1/22/25) that lacked documentation of cognitive patterns, mood and behavior patterns, activity pursuits and medications. Review of the discharge summary (1/23/25) lacked documentation of the recapitulation of the patients stay that includes patient diagnoses, course of illness/treatment or therapy, pertinent lab, and radiology and consultation reports. The discharge summary also lacked evidence of a final summary of the patients status and the reconciliation of pre-discharge medications with post discharge medications. - Review of Patient 33’s medical record (7/31/25 at 9:29AM) revealed a swing bed admission of 2/28/25-3/24/25 for a subarachnoid hemorrhage (bleeding around the brain). Review of the entire medical record revealed a comprehensive assessment (2/28/25) that lacked documentation of mood and behavior patterns, dental and nutritional status, activity pursuits and medications. Review of the discharge summary (3/24/25) lacked documentation of the recapitulation of the patients stay that includes diagnoses, course of illness/treatment or therapy, pertinent lab, radiology and consult reports. The discharge summary also lacked evidence of a final summary of the patients status and the reconciliation of pre-discharge medications with post discharge medications. - Review of Patient 34’s medical record (7/31/25 at 10:00AM) revealed a swing bed admission of 3/6/25-3/27/25 for septic arthritis with a partial knee revision (an infection of a joint requiring a procedure to replace part of an artificial joint). Review of the entire medical record revealed a comprehensive assessment (3/6/25) that lacked documentation of mood and behavior patterns, activity pursuits and medications. Review of the discharge summary (3/27/25) lacked a recapitulation of the patients stay that includes diagnoses, course of illness/treatment or therapy, pertinent lab, radiology and consult reports. The discharge summary also lacked evidence of a final summary of the patients status and the reconciliation of pre-discharge medications with post discharge medications. - Review of Patient 35’s medical record (7/31/25 at 10:28AM) revealed a swing bed admission of 4/10/25-5/8/25 for a cerebral vascular accident (CVA or stroke is a blood clot in the brain that causes neurological deficiencies). Review of the entire medical record revealed a comprehensive assessment (4/11/25) that lacked documentation of mood and behavior patterns, activity pursuits and medications. Review of the discharge summary (5/8/25) lacked the recapitulation of the patients stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consult reports. The discharge summary also lacked evidence of a final summary of the patients status and the reconciliation of pre-discharge medications with post discharge medications. - Review of Patient 36’s medical record (7/31/25 at 10:48AM) revealed a swing bed admission of 5/5/25-5/12/25 for cellulitis (infection in the skin). Review of the entire medical record revealed a comprehensive assessment (5/5/25) that lacked documentation of mood and behavior patterns, activity pursuits and medications. Review of the discharge summary (5/12/25) lacked the recapitulation of the patients stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consult reports. The discharge summary also lacked evidence of a final summary of the patients status and reconciliation of pre-discharge medications with post discharge medications. - Review of the facility policy Comprehensive Assessment Form (CAF) Swing Bed: Completion of Form (review date unknown), revealed the comprehensive assessment will describe the patient’s capacity to perform daily life functions and significant impairments describing the patient’s capacity to perform daily life functions and significant impairments in functional and mental ability. - Review of the facility policy Final Summary of Patient’s Swing Bed Stay (review date unknown), revealed the final summary provides the following information: A recapitulation of the patient’s stay, final summary of patient’s previous and current status, post discharge plan which outlines services, follow up, durable medical equipment, referrals to support agencies, how the patient or family will access services, outpatient therapies, and continued education needs. - Interview (8/31/25 at 11:15AM) with RN-A confirmed the comprehensive assessments and discharge summaries for the above medical records lacked required information.”

“42 CFR 485.623 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. Brodstone Healthcare is a 25 bed, 2-story facility of Type II (000) construction, The plan approval was 2008 & 2022. The facility is fully fire sprinkler protected with corridor smoke detection. Smoke barriers run through Stairs 166, Radio Office, Main Lobby, Ante 239, and Corridor 266. Brodstone Healthcare was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 485.623, Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 38543 Based on observation and interview, the facility failed to maintain corridors free of obstructions. The corridor width was 7’11” wide. This deficient practice could delay the evacuation of residents and staff during an emergency. The facility census was 8 patients. Findings are: Observation on 7-29-25 at 1:45 pm revealed carts were being stored in the corridor outside of the materials management room. During an interview on 7-29-25 at 1:45 pm, Facility Staff A confirmed the carts in the corridor were not in use and were being stored.”

“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: 38543 Based on observation and interview, the facility allowed accumulation of foreign matter on fire sprinklers and failed to prevent obstruction to the spray pattern of fire sprinklers. This deficient practice could impact the response and effectiveness of the sprinkler system and a larger fire could spread outside of the room into the exit corridor, The facility census was 8 patients. Findings are: Observations on 7-29-25 between 1:50 pm and 2:20 pm revealed: 1. There was foreign matter on five sprinklers in the laundry room. 2. There was foreign matter on five sprinklers in the Kitchen. 3. Items stored on the top shelf of the walk-in freezer obstructed the sprinkler. During an interview on 7-29-25 between 1:50 pm and 2:20 pm, Facility Staff A confirmed the findings.”

“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: 38543 Based on observation and staff interview, the facility failed to ensure corridor doors sealed within the door frame. This condition would not prevent the spread of smoke and fire into the corridor. The facility census was 8. Findings are: Observation on 7-29-25 at 1:20 pm revealed the 45 min fire rated door (1072A) going to the materials management room had a gap greater than 1/8 of an inch. During an interview on 7-29-25 At 1:20 pm, Facility Staff A confirmed the findings.”