Osmond General Hospital

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 52353 Based on observations, policy and procedure review and staff interview, the Critical Access Hospital (CAH) failed to follow facility policy and procedure for hand hygiene for 2 of 2 patients (Patient 41 and 42) observed. The CAH also failed to follow policy and procedure for administration of nebulizer breathing treatments. These failed practices had the potential to affect all patients of the CAH. The CAH reported a census of 188 patients and 585 Emergency Room patients for the FY 2025. A. Observation (2/23/26 at 12:50PM) RN (Registered Nurse)-C entered patient 42’s room without performing hand hygiene. -Observation (2/24/26 at 11:00AM) RN-F observed in the Emergency Room (ER) placing on gloves to perform Intravenous (IV) insertion (line placed to give medication) insertion. RN-F attempted IV insertion in patient 41’s right arm, removed gloves with no hand hygiene performed. RN-F observed placing on gloves attempted IV insertion in patient 41’s right upper arm, removed gloves with no hand hygiene performed. RN-F observed placing on gloves to attempt IV insertion on patient 41’s left arm, removed gloves with no hand hygiene performed. -Review of policy and procedure titled Infection Control Prevention Program (Reviewed 6/25) stated...”The use of alcohol-based sanitizer or soap and water...upon entering a patients room...after removing gloves.” -Interview with RN-C (2/23/26 at 1:15PM) confirmed “yes” hand hygiene was not performed prior to entering patient 42’s room. -Interview with RN-F (2/24/26 at 11:45AM) confirmed “yes” hand hygiene was not performed after removing gloves. B. Observation (2/23/26 at 12:50PM) RN-C without wearing gloves or performing hand hygiene opened nebulizer (dispenses fine mist medication) placed albuterol (medication to help you breath) in medication cup and with bare hands placed face mask on patient 42’s face. After nebulizer treatment was completed, RN-C with bare hands removed face mask from patient and rinsed medication cup in sink without wearing gloves and without performing hand hygiene. -Review of Lippincott Nursing Procedures ninth edition states...”Nebulizer therapy...implementation...perform hand hygiene..put on gloves.” -Interview with Director of Nursing (2/26/26 at 10:35AM) confirmed facility uses Lippincott Nursing Procedures as policy and procedure for administration of nebulizer therapy. -Interview with RN-C (2/23/26 at 1:15PM) confirmed “yes” no hand hygiene and no gloves worn during pt 42’s administration of nebulizer treatment. RN-C stated “If they are in isolation then I’d be gloved and gowned up.””

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 52353 Based on observation of skin preparation for Intravenous (IV) insertion, medical record review, review of policies and procedures and staff interviews, the Critical Access Hospital (CAH) failed to follow facility policy and procedure for skin preparation for IV insertion for 1 (Patient 41) of 1 patients observed. The facility also failed to document PICC line assessments for 1 (Patient 33) of 2 records reveiwed of patients with PICC lines and failed to perform weekly PICC line dressing changes for 1 (Patient 40) of 2 medical records reviewed of patients with PICC lines. This failed practice had the potential to affect all patients of the CAH with IV insertions performed or PICC lines in place. The CAH reported a Emergency Room census of 585, swing bed census of 48 and outpatient infusion census of 18 for FY 2025. Findings are: A. Observation (2/24/26 at 11:00AM) in the Emergency Room (ER) of skin preparation for IV insertion for Patient 41. Registered Nurse RN-F opened an IV start kit and obtained a chlorhexidine scrub (used to prevent infection) and performed scrubbing with chlorhexidine scrub to Patient 41’s right lower arm in preparation of inserting an IV. RN-F then reused the same chlorhexidine scrub for a second time scrubbing Patient 41’s right upper arm in preparation for inserting an IV. RN-F continued to reuse the same chlorhexidine scrub a third time scrubbing Patient 41’s left arm in preparation of inserting an IV. -Review of Lippincott Nursing Procedures ninth edition states ...”IV insertion...prepare the insertion site using an antiseptic agent...chlorhexidine preferred.” -Interview with RN-F (2/24/26 at 11:45) confirmed “yes” the same chlorhexidine scrub was used on three different skin sites, the right lower arm, right upper arm and left arm in preparation for IV insertion. -Interview with Director of Nursing (2/26/26 at 10:35AM) confirmed facility uses Lippincott Nursing Procedures as policy and procedure for IV insertions, confirmed chlorhexidine scrub is a “single use product” to prevent contamination. B. Review of Patient 33’s swing bed medical record (2/24/25 at 4:30PM) from (10/14/25-10/27/25) revealed the patient was admitted from an acute care facility on 10/14/25 due to a left toe amputation and need for IV antibiotics. -Review of Patient 33’s medical revealed PICC line lacked documentation of assessments of site on the following: -10/15/25 AM -10/15/25 PM -10/16/25 AM -10/19/25 PM -10/22/25 AM -10/22/25 PM -10/23/25 PM -10/24/25 AM -10/24/25 PM -10/25/25 AM -Review of policy and procedure titled Line Care/Maintenance-Central Venous Access devices (Revised 6/25) states...”Flush every 12 hours...PICC line documentation...refer to Lippincott Nursing Procedures.” -Review of Lippincott Nursing Procedures ninth edition states...”documentation must include site assessment, catheter maintenance, flushing and patency of line.” -Interview with Directory of Nursing (2/26/25 at 1030AM) confirms “yes” the above medical record is lacking PICC line documentation of assessments performed on the above dates and times. C. Review of Patient 40’s outpatient clinic medical record (2/25/26 at 2:00PM) revealed the patient received outpatient IV antibiotic infusions thru PICC line for MSSA Bacteremia (infection in the blood) from (12/25/25-2/4/26). -Review of Patient 40’s medical record revealed PICC line documentation of dressing change on 1/15/26 with next dressing change documented on 2/4/26 documented twenty days later. -Review of the medical record revealed provider placed order ( (12/25/25 at 08:59AM)...”q (every) Wednesday, Dressing change per facility protocol.” -Review of policy and procedure titled Line Care/Maintenance-Central Venous Access Devices (Revised 6/25) stated...”change dressing every 7 days.” -Interview with Directory of Nursing (2/26/26 at 10:30AM) confirmed “yes” the above medical chart lacks documentation from (1/15/26-2/4/26) of a dressing change every 7 days.”

“RECORDS SYSTEM CFR(s): The records are legible, complete, accurately documented, readily accessible, and systematically organized. This Standard is not met as evidenced by: 52353 Based on medical record review, policy and procedure review, review of Emergency Flow Sheet record and staff interview the Critical Access Hospital (CAH) failed complete a cardiac arrest on the Emergency Flow Sheet for 1 of 1 (Patient 17) patients. This failed practice had the potential to to affect all patients of the CAH. The CAH had 13 deaths and 188 patients for the FY 2025. Findings are: A. Review of Patient 17’s medical record ( 2/25/26 at 2:00PM) revealed the patient was admitted on 4/8/25 with a diagnosis of Osteomylitis (infection in bone). The medical record revealed the patient had a cardiac arrest (4/26/25 at 7:13AM). Review of entire medical record lacked a completed Emergency Flow Sheet. -Review of nursing progress notes revealed Registered Nurse (RN)-G documented the cardiac arrest as follows: -“Epi [Epinephrine-an emergecny medication] given at 0737, 0740, 0748, 0752 and 0756.” (7:37AM-7:56AM) entries missing drug dosages and route of administration. -“Bicarb [Sodium bicarbonate-an emergency medication]pushed at 0755 (7:55 AM).” Entry missing drug dosage and route of administration. -“Pulse checks read asystole [the total cessation of heart activity resulting in no pulse, blood flow, or breathing].” Entry missing heart rhythm strips. B. Review of policy and procedure titled Cardiac Arrest Responsibilities (Reviewed 6/25) stated...”completion of the cardiac documentation will be done by the on-duty RN.” C. Interview with Director or Nursing (2/26/26 at 10:25AM) confirmed “yes” the above medical record is lacking evidence of “Emergency Flow Sheet the code documentation record”and confirmed the nursing progress note docuemtned by RN-G “lacks” medication dosages, medication routes and lacked generated heart rhythm strips.”

“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 load bank testing of the emergency generator. This deficient practice would not ensure the emergency generator would operate upon loss of normal power. The facility has the capacity for 20 beds with a census of 2 on the day of survey. Findings are: During record review on 2-25-26 at 10:02 am, the facility failed to produce documentation to ensure a load bank test was conducted for the emergency generator within the last 36 months. During an interview on 2-25-26 at 10:02 am, Maintenance Staff A confirmed the lack of testing.”

“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 Osmond General Hospital is a Type II (111) construction single story building that is sprinkled with smoke detection in the corridors and spaces open to the corridors. It was built in 1967 with an addition added in 2005 and has an attached clinic that is separated by a 2-hour firewall. The Osmond General 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.”

“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 load bank testing of the emergency generator. This deficient practice would not ensure the emergency generator would operate upon loss of normal power. The facility has the capacity for 20 beds with a census of 2 on the day of survey. Findings are: During record review on 2-25-26 at 10:02 am, the facility failed to produce documentation to ensure a load bank test was conducted for the emergency generator within the last 36 months. During an interview on 2-25-26 at 10:02 am, Maintenance Staff A confirmed the lack of testing.”