West Holt Memorial Hospital

“EMERGENCY PROCEDURES CFR(s): §485.635(b)(4) Emergency procedures. In accordance with the requirements of §485.618, the CAH provides medical services as a first response to common life-threatening injuries and acute illness. This Standard is not met as evidenced by: 52353 Based on employee training record review, facility policy and procedure review and staff interview the Critical Access Hospital (CAH) failed to ensure 3 of 3 surgical registered nurse staff have the ability to to provide emergent medical first response in the treatment of Malignant Hyperthermia and failed to conduct competency drills. This failed practice had the potential to affect all surgical patients of the CAH. The average number of surgeries performed at the CAH on a monthly basis is 12. A. Review of staff member A’s (hire date 8/2/21) entire HealthStream record (computer based yearly competency training) revealed a lack of documentation on the ability to provide emergent medical first response in the treatment of Malignant Hyperthermia (emergent life threatening reaction to medications used in surgery) and lacked documentation of participation in competency drills. -Review of staff member B’s (hire date 5/21/07) entire HealthStream record revealed a lack of documentation on the ability to provide emergent medical first response in the treatment of Malignant Hyperthermia (MH) and lacked documentation of participation in (MH) competency drills. -Review of staff member C’s (hire date 9/11/78) entire HealthStream record revealed a lack of documentation on the ability to provide emergent medical services in the treatment of (MH) and lacked documentation of participation in (MH) competency drills. B. The facility lacked evidence of a policy and procedure for (MH) drills and staff preparedness. C. Interview with Director of Outpatient and Surgery Services (2/11/26 at 2:45 PM) confirms “correct” the above surgical registered nurse staff lack evidence of documentation in the ability to provide emergent medical first response in the treatment of (MH). Stated “last (MH) drill was in 2022” confirmed “no documentation” of staff participation in (MH) drills.”

“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: 52353 Based on medical record review, review of policy and procedure and staff interview the Critical Access Hospital (CAH) failed to ensure a discharge summary that included a recapitulation of the patients stay was documented for 2 of 5 swing bed patients (Patients 33 and 36). This failed practice had the potential to affect all swing bed patients at the CAH. The average number of swing bed patients on a monthly basis is 1. Findings are: A. Review of Patient 33’s medical record ( 2/11/26 at 4:00PM) revealed a swing bed admission on 11/3/25-11/17/25 for a femur neck fracture (broken hip). Review of the entire medical record revealed a lack of evidence of a discharge summary that included a recapitulation of the patients stay. -Review of Patient 36’s medical record (2/12/26 at 9:15AM) revealed a swing bed admission on 8/20/25-9/2/25 for malaise (general feeling of discomfort). Review of the entire medical record revealed a lack of evidence of a discharge summary that included a recapitulation of the patients stay. B. Review of policy and procedure Swing Bed Recapitulation (Reviewed 11/11/25)...”A recapitulation of the swing bed patient’s stay will be completed on each swing bed discharge.” C. Interview with Director of Inpatient Services and Hospital Nursing ( 2/12/26 at 10:20AM) confirmed “yes” the above medical records lack a discharge summary that included a recapitulation of the patients stay.”

“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. The West Holt Memorial Hospital is Type II (111) construction, one story with a basement, and is fully sprinklered. The facility has smoke detection in corridors and spaces open to corridors. Central supply and a health clinic are adjoining this structure separated with two hour fire rated construction. The facility had a census of 1 on the day of survey. West Holt Memorial Hospital 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.”

“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: 39858 Based on observation and interview, the facility failed to maintain 1-hour fire separation of hazardous/storage rooms. This deficient practice would not prevent the spread of fire and smoke within the smoke zones. The facility has a capacity of 15 beds with a census of 1 on the day of survey. Findings are: Observations on 2-10-26 between 11:14 am and 11:40 am revealed the following: 1. A hole in the east wall of the mechanical room measuring approximately 1 ½ inches by 2 inches. 2. Several openings around conduit penetrations in the oxygen storage room. During interviews on 2-10-26 between 11:14 am and 11:40 am, Maintenance Staff A confirmed the findings.”

“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: 39858 Based on documentation review, observation and interview, the facility failed to provide physical protection of fire alarm wiring. This deficient practice would cause the fire alarm system to fail to activate in a timely manner. The facility has a capacity of 15 with a census of 1 on the day of survey. Findings are: Observation on 2-10-26 at 11:14 am revealed 1. A fire alarm junction box in the mechanical room with no cover installed to protect the wiring 2. No label or red cover to indicate that it is fire alarm wiring. During an interview on 2-10-26 at 11:14 am Maintenance Staff A confirmed the findings.”

“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: 39858 Based on observation and interview, the facility failed to maintain all required equipment and appurtenances for the fire sprinkler system. This deficient practice could impact the response time and effectiveness of the sprinkler system. The facility has the capacity for 15 beds with a census of 1 patient on the day of survey. Findings are: Observation on 2-10-26 at 12:15 pm revealed a missing escutcheon on the sprinkler in the main IT room. During an interview on 2-10-26 at 12:15 pm, Maintenance staff A confirmed the findings.”