Cherry County Hospital

“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, facility policy review and staff interview the Critical Access Hospital (CAH) failed to ensure a complete discharge summary for 4 of 4 swing bed patients (Patients 32, 33, 35 and 36) reviewed. This failed practice had the potential to affect all swing bed patients at the CAH. The number of swing bed patients at the CAH for Fiscal Year 24 was 54 swing bed patients. Findings are: A. Review of Patient 32’s medical record (5/21/25 at 5:00 PM) revealed a swing bed admission of 12/31/24 - 2/14/25 for a right distal femur fracture (a broken thigh bone that happens near the knee joint). Review of the entire medical record revealed a lack of evidence of a complete discharge summary of the patients stay that included a final summary of the patient’s status with all comprehensive assessment requirements documented (Customary routine, communication, mood and behavior patterns, disease diagnoses and health conditions, skin condition, and reconciliation of all pre-discharge medications with the post discharge medications). - Review of Patient 33’s medical record (5/22/25) revealed a swing bed admission of 1/22/25 - 1/27/25 for a catheter associated urinary tract infection and clostridioides difficile (c-diff a serious infection leading to diarrhea and inflammation of the colon). Review of the entire medical record revealed a lack of evidence of a complete discharge summary of the patients stay that included a final summary of the patient’s status with all comprehensive assessment requirements documented (customary routine, mood and behavior patterns, skin condition, and reconciliation of all pre-discharge medications with the post discharge medications). - Review of Patient 35’s medical record (5/22/25) revealed a swing bed admission of 4/30/25 - 5/5/25 for pneumonia needing intravenous antibiotics (antibiotics given through a catheter in the vein). Review of the entire medical record revealed a lack of evidence of a complete discharge summary of the patients stay that included a final summary of the patient’s status with all comprehensive assessment requirements documented (customary routine, vision, continence, skin condition, and reconciliation of all pre-discharge medications with the post discharge medications). - Review of Patient 36’s medical record (5/22/25) revealed a swing bed admission of 2/3/25 - 2/27/25 for congestive heart failure exacerbation (CHF - the heart is unable to pump enough blood to meet the body’s needs with a sudden worsening of symptoms such as shortness of breath, fatigue, swelling in extremities and persistent cough). Review of the entire medical record revealed a lack of evidence of a complete discharge summary of the patients stay that included a final summary of the patient’s status with all comprehensive assessment requirements documented (customary routine, mood and behavioral pattern, continence, skin condition, and reconciliation of all pre-discharge medications with the post discharge medications). B. Review of facility policy Discharge Summary Policy (Effective Date: 5/20/2025) revealed, the discharge summary will include a synopsis of the patient’s swing bed stay, disposition, plans for continuity of care and condition at the time of discharge. Additional pages may be attached. C. Interview with Chief Nursing Officer (CNO) (5/22/25 at 11:05AM) revealed, the current swing bed policies provided on request are all the facility has. CNO has started to review policies but was unaware that policies were from outdated regulations. -Interview with RN-A (5/22/25 at 11:20AM) revealed, all printed documents requested for swing bed patients are the complete discharge summary or recapitulation of the patient stay.”

“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: 39858 Based on record review and interview, the facility failed to conduct required specific gravity testing of the electrolyte of the starting batteries for the emergency generator. This deficient practice would not ensure the emergency generator would operate upon loss of normal power. The facility had a census of 6 on the day of survey. Findings are: During record review on 5-21-25 at 2:39 pm, the facility failed to produce documentation to assure the specific testing of the electrolyte of the batteries for the emergency generator was conducted monthly. During an interview on 5-21-25 at 2:39 pm, Maintenance Staff A and B confirmed the lack of testing.”

“42 CFR 482.41. 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 18, New Health Care Occupancies of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code. Cherry County Hospital is a single story building of Type II (111) non-combustible construction. There are two areas that would be considered a second story. These two areas contain HVAC systems only and are only accessible to Maintenance Personnel. These two areas are 100% fire sprinkler protected, and protected by the facility’s smoke detection devices. Cherry County Hospital was constructed in 1975, with building additions in 1994, 1997, 2006. A major remodel of the existing building and a new building addition was completed in 2019. Facility is 100% fire sprinklered protected, all corridors, lobbies, dining, and areas open to the corridor are protected by smoke detection devices interconnected to the buildings fire alarm system. The facility has a Physicians Clinic attached to the hospital. This clinic is separated by a two-hour fire separation wall with 1 1/2 hour fire rated doors located in the corridors. The fire alarm system and fire sprinkler system are interconnected to transmit the alarm throughout the building, and to the local 911 Center for dispatching the local fire department. Cherry County Hospital was found to be not in compliance with the requirements for participation in Medicare / Medicaid at 42 CFR 482.41 Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition”

“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: 39858 Based on observation and interview, the facility failed to provide battery powered emergency lighting in the maintenance / electrical rooms where the controls and switches for the emergency generator are located. This deficient practice would cause confusion and delay repairs to the generator equipment in the event of a generator failure during an emergency. The facility had a census of 6 on the date of survey. Findings are: Observation on 5-21-25 at 5:08 pm revealed there was no emergency light fixture with back-up battery power provided in the rooms containing the controls and switches for the emergency generator. During an interview on 5-21-25 at 5:08 pm, Maintenance Staff A and B confirmed the findings. NFPA 110, 2010 ed. 7.3.1 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access.”

“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: 39858 Based on record review and interview, the facility failed to conduct required specific gravity testing of the electrolyte of the starting batteries for the emergency generator. This deficient practice would not ensure the emergency generator would operate upon loss of normal power. The facility had a census of 6 on the day of survey. Findings are: During record review on 5-21-25 at 2:39 pm, the facility failed to produce documentation to assure the specific testing of the electrolyte of the batteries for the emergency generator was conducted monthly. During an interview on 5-21-25 at 2:39 pm, Maintenance Staff A and B confirmed the lack of testing.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 39858 Based on observation and interview, the facility allowed the use of a light duty multi-plug surge protector as a substitute for permanent electrical wiring. This deficient practice could cause electrical injury and fires. The facility had a census of 6 on the day of survey. Findings are: Observation on 5-21-25 at 3:49 pm revealed the use of a light duty multi-plug surge protector, powering a small fan, a phone charger and a laptop computer in the corridor of the old specialty clinic. During an interview on 5-21-25 at 3:49 pm, Maintenance Staff A and B confirmed the findings.”