Miners’ Colfax Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 49835 Based on record review and interview the facility failed to meet the Emergency Medical Treatment and Labor Act (EMTALA) to ensure a medical screening exam was done for all patients that present to the Emergency Department. This deficient practice is likely to lead to poor outcomes related to patients not being evaluated when seeking medical care. The findings are: A. The facility failed to perform a medical screening exam. Refer to tag A-2406.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 49835 Based on record review and interview the facility failed provide a medical screening examination that ensured an emergency medical condition was not present for 3 (P (patient) 9, 10 and 11) out of 20 (P1-P20) patients reviewed. This deficient practice could likely result in patients not receiving medical treatment for an emergency medical condition. The findings are: A. Record review of the facility’s policy titled “Medical Screening Exam EMTALA” dated 09/01/2024, under section 4. It states all patients coming to request emergency services receive an appropriate Medical Screening Examination (MSE). B. Record review of the Emergency Room Activity log dated 03/01/2025 through 09/15/2025 revealed the following: - P9 entered the Emergency Room (ER) on 06/16/2025 at 11:25 am and checked out on 06/16/2026 at 11:26 am. - P10 checked in on 06/16/2025 at 11:27 am and checked out 11:28 am - P11 was checked in on 06/16/2025 at 11:32 am and checked out 06/16/2025 at 11:33 am. -The disposition of P9, P10 and P11 were noted as registration error, the times of the check out did not match the time the patients were in the ER. The ER Activity log also showed there was only one other patient being seen in the ER at the time P9, P10 and P11 were in the ER. -P10 returned to the ER on 06/17/2025. C. Record review of the ER video dated 06/16/2025 of the ER waiting room, it was noted that patients P9, P10 and P11 all came in with their mother and were registered to be seen in the ER. During registration for P9, P10 and P11 had wrist bands applied for identification reasons. P9, P10 and P11 with their mother sat down in the waiting room and was called back to the triage room by the S [staff] 3 (clinical), after 3 minutes the patients left the triage room and walked out of the ER. D. Record review of P9’s, P10’s and P11’s ER medical records revealed the records did not contain any documentation for the ER visit on 06/16/2025 by S3. E. Record review of P10’s, a 2-year-old, ER medical record dated 06/17/25, P10 arrived back at the ER at 10:01 pm. The local police department had sent P10 to hospital #2 so that P10 could be seen by a SANE (Sexual Assault Nurse Examiner) nurse. The SANE nurse contacted the Pediatrician at hospital #3 and the Pediatrician in the pediatric emergency room was concerned because P10 did not have a blood pressure (the force of blood pushing through the walls of the arteries) taken and was concerned about a hypertensive crisis (a sudden increase in blood pressure) and needed emergency evaluation and transfer to hospital #3 pediatric emergency department. P10 presented with development of breast and having monthly vaginal bleeding with pubic hair. P10 was air lifted out on 06/18/2025 at 4:58 am to hospital #3 with admission to the Pediatric Emergency with accepting provider and hospital for a potential medical emergency. E. Record review of the facility’s ED director email to the provider on duty on 06/16/2025 revealed the subject line “72 hour follow up” asking about the EMS and why it was not done. The response from the provider on duty was “I don’t remember this patient”, “I was not aware of this patient” and “patient left and I never knew the patient was here”. F. During an interview with S6 (Clinical) on 09/16/2025 at 9:30 am it was confirmed that P9, P10 and P11 should have had a triage assessment and taken back for a full MSE by the provider. If the patients needed to speak to the local police, S3 should have called the police to the ER and if the patients needed to be transferred for higher level of care the patients could have been transferred safely. G. During an interview with S2 (clinical) on 09/16/2025 at 2:45 pm it was confirmed that P9, P10 and P11 should not have been sent to the local police department and should have been seen in the ER. A triage assessment should have been completed, and the provider should have been notified that the patients needed to be seen. H. During an interview with S5 (clinical) on 09/17/2025 at 9:15 am it was confirmed that P9, P10 and P11 did come into the ER on 06/16/2025 and were seen in the triage room with S3 (clinical), and S3 sent the patients to the Local Police Department to file a report. I. During an interview S3 on 09/17/2025 at 9:22 am it was confirmed P9, P10 and P11 did come into the ER to be seen for possible sexual and physical abuse on 06/16/2025, and was sent to the local police department to file a report. S3 confirmed there was no triage assessment completed for P9, P10 and P11. There was no documentation for this ER visit. J. During an interview with S1 (clinical) on 09/17/2025 at 9:25 am it was confirmed that P10 returned to the ER on 06/17/2025 and it was noted the patient had been in the ER on 06/16/2025 with no triage assessment or Emergency Medical Screening (MES).”

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment This Condition is not met as evidenced by: 45841 Based on observation, interview, document review, and facility policy review, the facility failed to meet the conditions of participation for physical plant and environment. The facility failed to ensure patient care equipment was maintained in a safe operating condition for 1 (portable ultrasound machine #1251051) of 3 portable ultrasound machines observed in the Emergency Department (ED). The facility further failed to ensure proper temperature control in the food preparation area for 10 of 14 temperature logs reviewed. These failure had the likelihood to impact patient health and safety. Findings included: 1. A facility policy titled, “Preventive Maintenance Program,” revised 01/11/2024, revealed, “Policy: A Preventive Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and public. Policy Explanation and Compliance Guidelines: 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer’s recommendations, maintenance requests, grand rounds, life safety requirements, or experience.” During a concurrent interview and observation of the facility on 10/14/2024 at 9:30 AM, the surveyor noted a portable ultrasound machine, #1251051, in the hallway of the ED that had a preventative maintenance (PM) sticker with an expiration date of 12/2023. The Maintenance Supervisor stated the company that provided PM on the equipment had recently been at the facility, and he was not sure how the ultrasound machine was missed.. On 10/16/2024 at 11:30 AM, portable ultrasound machine #125051 was observed in the hallway of the ED. The Long-Term Care Administrator asked Registered Nurse (RN) #16 to remove the portable ultrasound machine from service and RN #16 was noted to roll the machine down the hallway. During an interview on 10/16/2024 at 11:35 AM, RN #16 stated there was a newer ultrasound machine in the ED that would occasionally have a glitch and when it glitched, the older machine, #1251051, would be used. Per RN #16, the older machine was rarely needed and had been used occasionally since December 2023. 2. A facility policy titled, “Dishwashing Temperature,” with an approve date of 07/31/2021, indicated, “a. The wash temperature shall be 150-165 [degrees] F [Fahrenheit].” The policy also indicated, “b. The final rinse temperature shall be 180 [degrees] F or above but not to exceed 194 [degrees] F.” A facility policy titled, “Food Safety Requirements,” with an approved date of 07/31/2021, indicated, “Practices to maintain safe refrigerated storage include: i. Monitoring food temperatures and functioning of the refrigeration equipment daily and routine intervals during all hours of operation.” The “Sandwich Table Temperature Chart” for September 2024, revealed the required temperature was between 36 and 41 degrees F. Per the chart, there were 22 documented times when the temperature was not within range. Per the chart, “If the temperature is out of compliance, notify maintenance and the dietary manager.” There was no evidence to indicate maintenance or the Dietary Manager (DM) were notified. The “Walk-In Refrigerator Temperature Chart” for September 2024, revealed the required temperature was between 36 and 41 degrees F. Per the chart, there were four documented times when the temperature was not within range. Per the chart, “If the temperature is out of compliance, notify maintenance and the dietary manager.” There was no evidence to indicate maintenance or the DM were notified. The “Walk-In Freezer Temperature Chart,” for September 2024, revealed the required temperature was between -10 and 0 degrees F. Per the chart, there was one documented time when the temperature was not within range. Per the chart, “If the temperature is out of compliance, notify maintenance and the dietary manager.” There was no evidence to indicate maintenance or the DM were notified. The “Reach In Cooler #2 Temperature Chart” for September 2024, revealed the required temperature was between 36 and 41 degrees F. Per the chart, there was six documented time when the temperature was not within range. Per the chart, “If the temperature is out of compliance, notify maintenance and the dietary manager.” There was no evidence to indicate maintenance or the DM were notified. The “Reach In Cooler #1 Temperature Chart” for September 2024, revealed the required temperature was between 36 and 41 degrees F. Per the chart, there was 37 documented times when the temperature was not within range. Per the chart, “If the temperature is out of compliance, notify maintenance and the dietary manager.” There was no evidence to indicate maintenance or the DM were notified. The “Dishwasher Temperature Chart,” for September 2024, revealed the required minimum wash temperature was 150 degrees F and the minimum rinse temperature was 180 F. Per the chart, there was four documented times when the temperature was not within range. Per the chart, “If the temperature is out of compliance, notify maintenance and the dietary manager.” There was no evidence to indicate maintenance or the DM were notified. The “OB [obstetrics] Refrigerator [sic]/Freezer Temperature Chart,” for September 2024, revealed the required refrigerator temperature was between 36 and 41 degrees F and the freezer temperature was between -10 and 0 degrees F. Per the chart, there was three documented times when the temperature was not within range. Per the chart, “If the temperature is out of compliance, notify maintenance and the dietary manager.” There was no evidence to indicate maintenance or the DM were notified. The “ER [Emergency Room} Refrigerator [sic]/Freezer Temperature Chart,” for September 2024, revealed the required refrigerator temperature was between 36 and 41 degrees F and the freezer temperature was between -10 and 0 degrees F. Per the chart, there was six documented times when the temperature was not within range. Per the chart, “If the temperature is out of compliance, notify maintenance and the dietary manager.” There was no evidence to indicate maintenance or the DM were notified. The “Med/Surg [medical/surgical] Refrigerator [sic]/Freezer Temperature Chart.” for September 2024, revealed the required refrigerator temperature was between 36 and 41 degrees F and the freezer temperature was between -10 and 0 degrees F. Per the chart, there was seven documented times when the temperature was not within range. Per the chart, “If the temperature is out of compliance, notify maintenance and the dietary manager.” There was no evidence to indicate maintenance or the DM were notified. During an interview on 10/16/2024 at 1:10 PM, the DM acknowledged the out-of-range temperatures on the charts for September 2024. The DM stated when things were too cold in the cold table, he found that staff took the temperature too close to the cooling source and not in the middle. The DM stated he did not document any follow up for the out-of-range temperatures and that he or maintenance were notified.”

“EQUIPMENT, SUPPLIES, AND MEDICATION CFR(s): Equipment, supplies, and medication used in treating emergency cases are kept at the CAH and are readily available for treating emergency cases. The items available must include the following: This Standard is not met as evidenced by: 45841 Based on observation, interview, document review, and facility policy review, the facility failed to ensure supplies used for treating emergency cases were labeled with an opened and expiration date, expired items were discarded, and the crash cart was checked monthly per the facility policy. These failures had the potential to affect all patients who received care at the facility, with the likelihood to delay care of patients in an emergency case. Findings included: 1. A facility policy titled, “Inventory Outdated Supplies/Medication Procedure,” with an approval date of 11/10/2009, indicated, “6. Procedure When supplies are delivered to [facility name] and placed on shelves all supplies with an expiration date excluding high use items will be marked with a colored dot corresponding to the year for that color. They will further write in, using a black sharpie the month of expiration.” A facility policy titled, “Blood Glucose Monitoring,” last revised 07/2023, indicated, “6.17 New bottles of test strips will be dated upon opening (month, day and year), and the discard date will be noted as 6 months after opening (month, day, year).” An undated material insert for “StatStrip Glucose Hospital Meter Test Strips” indicated, “11. Expiration The expiration date is printed on the vial of test strips. Once opened, the StatStrip Glucose Hospital Meter Test Strips are stable when stored as indicated for up to 6 months or until expiration date, whichever comes first.” On 10/14/2024 at 11:31 AM, the surveyor observed an eSwab collection and preservation of aerobic, anaerobic, and fastidious bacteria was observed in the cabinet above the sink in Trauma One, with an expiration date of 06/30/2023. On 10/14/2024 at 11:32 AM, an intubating stylet was observed on top of the respiratory cart in Trauma One, with an expiration date of 07/29/2024. During an interview on 10/14/2024 at 11:38 AM, Registered Nurse (RN) #3 stated the eSwabs were utilized for wound cultures. RN #3 confirmed the expiration date was 06/30/2023. According to RN #3, staff did not obtain the eSwabs from that cabinet, that they obtained them from the medication room, which was why the expiration date could have been missed. During an interview on 10/14/2024 at 11:40 AM, Respiratory Therapist #4 stated the stylets were rarely used, so the expired one was likely pulled out of the cart and placed on top since it was expired. During a concurrent interview and observation of the crash cart in Trauma One of the Emergency Department (ED) on 10/15/2024 at 2:10 PM, the following expired items were noted: - two 20 gauge intravenous (IV) catheters, with an expiration date of 07/31/2024; - one 20 gauge IV catheter, with an expiration date of 09/16/2024; - one 22 gauge IV catheter, with an expiration date of 07/31/2024; - one 18 gauge IV catheter, with an expiration date of 09/30/2024; - four 16 gauge IV catheters, with an expiration date of 01/31/2024; - two 14 gauge IV catheters, with an expiration date of 04/30/2024; - an IV start kit, with an expiration date of 07/31/2024; - one 25 gauge eclipse needle, with an expiration date of 09/30/2024; - one size 7 surgical glove, with an expiration date of 05/2024; - one size 7 surgical glove, with an expiration date of 09/28/2024; and - one pack of gauze sponges, with an expiration date of 08/01/2024. The Emergency Department Nurse Manager (EDNM) confirmed the supplies found were expired. The EDNM stated the expectation was that staff inspected each item once a week for expiration dates. During a concurrent interview and observation of the medication room in the ED on 10/15/2024 at 2:38 PM, the following expired items were noted: - one IV catheter, with an expiration date of 04/15/2024; - one peripheral IV catheter, with an expiration date of 06/30/2024; and - one opened vial of glucose test strips, with no date opened or expiration date listed. The EDNM confirmed the found supplies were expired. The EDNM stated that the nursing staff were expected to check for expiration dates in the medication room weekly as well as the crash carts. The EDNM acknowledged the glucose test strips were not dated, and that staff were expected to mark the container with an opened and expiration date. During an interview on 10/15/2024 at 7:20 PM, RN #7 stated generally expiration dates in the ED were checked every first Saturday of the month and the check included supplies in the patient rooms, medication rooms, trauma rooms, and crash carts. RN #7 stated glucose test strips should be dated. Per RN #7, the technician in the ED was responsible for glucometer checks, and if they opened the vial, they should date the vial when opened. During a concurrent interview and observation of the laboratory on 10/15/2024 at 11:31 AM, the surveyor observed an eSwab collection and preservation of aerobic, anaerobic, and fastidious bacteria, with an expiration date of 07/17/2024, a specimen collection swab, with an expiration date of 09/17/2023, and one prothrombin time test, with an expiration date of 09/30/2024. The Laboratory Manager (LM) stated he did not know the expired swabs were in the drawer. The LM stated they were probably left over from testing during the pandemic. Per the LM, the night shift was responsible for checking the date of supplies in the laboratory. During a concurrent interview and observation of the obstetric unit on 10/16/2024 at 10:09 AM, a container that contained a glucometer and test strips was noted to have two opened vials of test strips that were not labeled with an opened or expiration date. The CNO stated the glucometer test strips usually would be marked with an opened and discard date on the bottles and that the bottles found were not marked. Per the CNO, the nursery nurses were responsible for the supplies in the nursery. During a concurrent interview and observation of the birthing cart in the nursery on 10/16/2024 at 10:22 AM, there were two gauge IV catheters that had an expiration date of 09/30/2024, one IV catheter that had an expiration date of 10/11/2024, and five 23 gauge needles, with an expiration date of 08/31/2024. The CNO acknowledged the supplies were expired. During a concurrent interview and observation of the surgical department on 10/16/2024 at 10:42 AM, the following expired items were found: - a bottle of hydrogen peroxide 3%, with an expiration date of 03/2020; - four boxes of optical implants, with an expiration date of 03/2017; - two boxes of optical implants, with an expiration date of 02/2017; and - nine stainless steel surgical blades, with an expiration date of 09/30/2023. The CNO acknowledged the expired supplies and stated that the exam room used to be utilized for patients when the facility did eye procedures, but they did not perform eye procedures anymore, and now physicians used it to dictate their notes. 2. A facility policy titled, “Crash Cart Preparedness,” with an approval date of 10/19/2023, indicated, “6. Procedure 6.1 Drugs and supplies in the adult crash cart and pediatric bags will be checked monthly for out dates and condition of supplies and after each use.” The facility crash cart checklist for July 2024 indicated the crash cart should be checked every Sunday during the night shift. The checklist revealed documentation to indicate the crash cart was checked twice in July 2024. The facility crash cart checklist for August 2024 indicated the crash cart should be checked every Sunday during the night shift. The checklist revealed no documentation to indicate the crash cart was in August 2024. The facility crash cart checklist for September 2024 indicated the crash cart should be checked every Sunday during the night shift. The checklist revealed documentation to indicate the crash cart was checked once in September 2024. The facility crash cart checklist for October 2024 indicated the crash cart should be checked every Sunday during the day and the night shift. The checklist revealed documentation to indicate the crash cart was checked once in October 2024.”

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 45841 Based on observation, interview, and facility policy review, the facility failed to ensure patient care equipment was maintained in a safe operating condition, for 1 (portable ultrasound machine #1251051) of 3 portable ultrasound machines observed in the Emergency Department (ED). Findings included: A facility policy titled, “Preventive Maintenance Program,” revised 01/11/2024, revealed, “Policy: A Preventive Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and public. Policy Explanation and Compliance Guidelines: 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer’s recommendations, maintenance requests, grand rounds, life safety requirements, or experience.” During a concurrent interview and observation of the facility on 10/14/2024 at 9:30 AM, the surveyor noted a portable ultrasound machine, #1251051, in the hallway of the ED that had a preventative maintenance (PM) sticker with an expiration date of 12/2023. The Maintenance Supervisor stated the company that provided PM on the equipment had recently been at the facility, and he was not sure how the ultrasound machine was missed.. On 10/16/2024 at 11:30 AM, portable ultrasound machine #125051 was observed in the hallway of the ED. The Long-Term Care Administrator asked Registered Nurse (RN) #16 to remove the portable ultrasound machine from service and RN #16 was noted to roll the machine down the hallway. During an interview on 10/16/2024 at 11:35 AM, RN #16 stated there was a newer ultrasound machine in the ED that would occasionally have a glitch and when it glitched, the older machine, #1251051, would be used. Per RN #16, the older machine was rarely needed and had been used occasionally since December 2023.”

“PROPER VENTILATION, LIGHTING, AND TEMPERATURE CFR(s): (5) There is proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas. This Standard is not met as evidenced by: 45841 Based on interview, document review, and facility policy review, the facility failed to ensure proper temperature control in the food preparation area for 10 of 14 temperature logs reviewed. This had the likelihood to place patients at risk for consuming food that was not maintained correctly. Findings included: A facility policy titled, “Dishwashing Temperature,” with an approve date of 07/31/2021, indicated, “a. The wash temperature shall be 150-165 [degrees] F [Fahrenheit].” The policy also indicated, “b. The final rinse temperature shall be 180 [degrees] F or above but not to exceed 194 [degrees] F.” A facility policy titled, “Food Safety Requirements,” with an approved date of 07/31/2021, indicated, “Practices to maintain safe refrigerated storage include: i. Monitoring food temperatures and functioning of the refrigeration equipment daily and routine intervals during all hours of operation.” The “Sandwich Table Temperature Chart” for September 2024, revealed the required temperature was between 36 and 41 degrees F. Per the chart, there were 22 documented times when the temperature was not within range. Per the chart, “If the temperature is out of compliance, notify maintenance and the dietary manager.” There was no evidence to indicate maintenance or the Dietary Manager (DM) were notified. The “Walk-In Refrigerator Temperature Chart” for September 2024, revealed the required temperature was between 36 and 41 degrees F. Per the chart, there were four documented times when the temperature was not within range. Per the chart, “If the temperature is out of compliance, notify maintenance and the dietary manager.” There was no evidence to indicate maintenance or the DM were notified. The “Walk-In Freezer Temperature Chart,” for September 2024, revealed the required temperature was between -10 and 0 degrees F. Per the chart, there was one documented time when the temperature was not within range. Per the chart, “If the temperature is out of compliance, notify maintenance and the dietary manager.” There was no evidence to indicate maintenance or the DM were notified. The “Reach In Cooler #2 Temperature Chart” for September 2024, revealed the required temperature was between 36 and 41 degrees F. Per the chart, there was six documented time when the temperature was not within range. Per the chart, “If the temperature is out of compliance, notify maintenance and the dietary manager.” There was no evidence to indicate maintenance or the DM were notified. The “Reach In Cooler #1 Temperature Chart” for September 2024, revealed the required temperature was between 36 and 41 degrees F. Per the chart, there was 37 documented times when the temperature was not within range. Per the chart, “If the temperature is out of compliance, notify maintenance and the dietary manager.” There was no evidence to indicate maintenance or the DM were notified. The “Dishwasher Temperature Chart,” for September 2024, revealed the required minimum wash temperature was 150 degrees F and the minimum rinse temperature was 180 F. Per the chart, there was four documented times when the temperature was not within range. Per the chart, “If the temperature is out of compliance, notify maintenance and the dietary manager.” There was no evidence to indicate maintenance or the DM were notified. The “OB [obstetrics] Refrigerator [sic]/Freezer Temperature Chart,” for September 2024, revealed the required refrigerator temperature was between 36 and 41 degrees F and the freezer temperature was between -10 and 0 degrees F. Per the chart, there was three documented times when the temperature was not within range. Per the chart, “If the temperature is out of compliance, notify maintenance and the dietary manager.” There was no evidence to indicate maintenance or the DM were notified. The “ER [Emergency Room} Refrigerator [sic]/Freezer Temperature Chart,” for September 2024, revealed the required refrigerator temperature was between 36 and 41 degrees F and the freezer temperature was between -10 and 0 degrees F. Per the chart, there was six documented times when the temperature was not within range. Per the chart, “If the temperature is out of compliance, notify maintenance and the dietary manager.” There was no evidence to indicate maintenance or the DM were notified. The “Med/Surg [medical/surgical] Refrigerator [sic]/Freezer Temperature Chart.” for September 2024, revealed the required refrigerator temperature was between 36 and 41 degrees F and the freezer temperature was between -10 and 0 degrees F. Per the chart, there was seven documented times when the temperature was not within range. Per the chart, “If the temperature is out of compliance, notify maintenance and the dietary manager.” There was no evidence to indicate maintenance or the DM were notified. During an interview on 10/16/2024 at 1:10 PM, the DM acknowledged the out-of-range temperatures on the charts for September 2024. The DM stated when things were too cold in the cold table, he found that staff took the temperature too close to the cooling source and not in the middle. The DM stated he did not document any follow up for the out-of-range temperatures and that he or maintenance were notified.”

“PERIODIC REVIEW OF CLINICAL PRIVILEGES CFR(s): §485.631(d) Standard: Periodic review of clinical privileges and performance. The CAH requires that- (1) The quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners, clinical nurse specialist, and physician assistants at the CAH are evaluated by a member of the CAH staff who is a doctor of medicine or osteopathy or by another doctor of medicine or osteopathy under contract with the CAH. (2) The quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH are evaluated by- (i) One hospital that is a member of the network, when applicable; (ii) One Quality Improvement Organization (QIO) or equivalent entity; (iii) One other appropriate and qualified entity identified in the State rural health care plan; (iv) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH’s patient under an agreement between the CAH and a distant-site hospital, the distant-site hospital; or (v) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH’s patients under a written agreement between the CAH and a distant-site telemedicine entity, one of the entities listed in paragraphs (d)(2)(i) through (iii) of this section. (3) The CAH staff consider the findings of the evaluation and make the necessary changes as specified in paragraphs (b) through (d) of this section. This Standard is not met as evidenced by: 45841 Based on interview, document review, and review of the medical staff bylaws, the facility failed to ensure peer reviews were conducted for 1 (Physician Assistant [PA] #18) of 11 credential files reviewed. The failure had the likelihood to have unqualified personnel on staff at the facility. Findings included: A letter addressed to PA #18 signed by the Chief Executive Officer and dated 04/19/2024, revealed at the 04/19/2024 meeting of the Board of Trustees, PA #18’s application for staff privileges was reviewed and a decision was made to grant PA #18 mid-level privileges as a hospitalist under the supervision of Medical Doctor (MD) #20 and MD #17. Per the letter, PA #18’s privileges would expire on 05/14/2026. Per the letter, “The granting and continuation of these privileges are conditioned upon your acceptance and compliance with all of the conditions and responsibilities specified within the Medical Staff Bylaws Rules and Regulations and Medical Center policies.” The facility “Medical Staff Bylaws,” revised 09/20/2024, indicated “Section 3. Initial Appointment Procedure 3.1 Completion of Application 3.1.1 All requests for applications for appointment to the medical staff and request for clinical privileges will be forwarded to the medical staff office. Upon receipt of the request, the medical staff office will provide the applicant an application package which will include a complete set of the medical staff bylaws.” Per the Medical Staff Bylaws, a completed application included, at a minimum: “i. Three current (dated within six months of application) references from peers knowledgeable about the applicant’s experience, ability and current competency to perform the privileges being requested.” A reveal of PA #18’s credential file, revealed no evidence of three peer review performed. During an interview on 10/15/2024 at 9:30 AM, the Administrative Services Coordinator stated there were no peer reviews conducted for PA #18.”

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 45841 Based on interview, medical staff bylaws, and facility policy review, the facility failed to ensure policies were reviewed biennially (something that occurred every two years) for 6 of 11 sampled policies reviewed. The failure had the likelihood to cause the facility to not maintain best and most current practices. Findings included: The facility “Medical Staff Bylaws,” revised 09/20/2024, indicated, “Section 9. Review, Revision, Adoption, and Amendment 9.1 Medical Staff Responsibility 9.1.1 The medical staff shall have the responsibility to formulate, review at least biennially, and recommend to the Board any medical staff bylaws, rules, regulations, policies, procedures, and amendments as needed.” A facility policy titled, “Discharge from PACU [post-anesthesia care unit]” revealed the policy was last revised 06/10/2009. A facility policy titled, “Inventory Outdated Supplies/Medication Procedure,” revealed the policy had a last revised date of 10/2009 and an adopted by date of 11/10/2009. A facility policy titled, “Dishwashing Temperature” revealed the policy had an origination date of 07/26/2021 and an approved date of 07/31/2021. A facility policy titled, “Food Safety Requirements” revealed the policy had an origination date of 07/26/2021 and an approved date of 07/31/2021. A facility policy titled, “Monitoring of Cooler/Freezer Temperature,” revealed the policy had an origination date of 07/28/2021 and an approved date of 07/31/2021. A facility policy titled, “Record of Food Temperature,” revealed the policy had an approved date of 07/31/2021 and an origination date of 08/02/2021. During an interview on 10/17/2024 at 4:56 PM, the Chief Nursing Officer (CNO) stated the facility was currently working to update the Inventory Outdated Supplies/Medication Procedure policy and since it was a multidisciplinary policy, it took a while to get everyone to review it. The CNO confirmed the most recent approved version of the policy was in 2009. The CNO stated the most current date for the dietary policies was in 2021 and the Discharge from PACU policy was most current as of 2009. The CNO stated she did not believe policy review frequency was outlined in the bylaws.”

“RECORDS SYSTEM CFR(s): (1) The CAH maintains a clinical records system in accordance with written policies and procedures. This Standard is not met as evidenced by: 42305 Based on interview, record review, and facility policy review, the facility failed to ensure there was documentation of a patient’s discharge criteria in the patient’s medical record for 5 (Patients #51, #55, #57, #58, and #60) of 10 surgical records reviewed. The facility further failed to ensure staff documented in a patient’s medical record that advance directive notice was given and if the patient had executed an advance directive for 10 of 10 outpatient medical records reviewed. These failures had the likelihood to result in patients not being properly discharged from the post-anesthesia care unit (PACU) and not having their advanced directives respected. Findings included: 1. A facility policy titled, “Discharge from PACU [post-anesthesia care unit],” with a last revised date of 06/10/2009, indicated, “1. Purpose: To ensure that patients are appropriately and adequately recovered from effects of anesthesia prior to discharge.” Per the policy, “6. Procedure: 6.1 Patients are discharged from the PACU by order of the anesthesia provider or surgeon. The order may be written in the Physician’s Order sheet or on the Post Anesthesia Evaluation where TIME for discharge is indicated and signature of anesthesia provider is present. 6.2 Patients are discharged from the PACU when they have achieved a score of eight (8) or greater on the Aldrete Post Anesthesia Recovery Score for Discharge Criteria.” A patient demographic record revealed the facility admitted Patient #51 on 04/16/2024, for an examination under anesthesia for a possible anorectal advanced flap fistulotomy. The “Discharge Documentation,” revealed the patient discharged on 04/16/2024; however, there was no evidence to indicate Patient #51’s Aldrete Post Anesthesia Recovery Score for Discharge Criteria. A patient demographic record revealed the facility admitted Patient #55 on 07/08/2024 for a laparoscopy cholecystectomy. Per the patient demographic record, Patient #55 discharged on 07/08/2024. Patient #55’s “Surgical Documentation,” dated 07/08/2024, indicated the procedure was performed under general anesthesia. Patient #55’s medical record revealed no evidence to indicate the patient’s Aldrete Post Anesthesia Recovery Score for Discharge Criteria. A patient demographic record revealed the facility admitted Patient #57 on 07/08/2024 for a umbilical hernia repair. Per the patient demographic record, Patient #57 discharged on 07/08/2024. Patient #57’s “Surgical Documentation,” dated 07/08/2024, indicated the procedure was performed under general anesthesia. Patient #57’s medical record revealed no evidence to indicate the patient’s Aldrete Post Anesthesia Recovery Score for Discharge Criteria. A patient demographic record revealed the facility admitted Patient #58 on 04/18/2024 for a dilation and curettage, hysteroscopy, ablation. Per the patient demographic record, Patient #58 discharged on 04/18/2024. Patient #58’s “Surgical Documentation,” dated 04/18/2024, indicated the procedure was performed under general anesthesia. Patient #58’s medical record revealed no evidence to indicate the patient’s Aldrete Post Anesthesia Recovery Score for Discharge Criteria. A patient demographic record revealed the facility admitted Patient #60 on 06/12/2024 for an inguinal hernia repair. Per the patient demographic record, Patient #60 discharged on 06/12/2024. Patient #60’s “Surgical Documentation,” dated 06/12/2024, indicated the procedure was performed under general anesthesia. Patient #60’s medical record revealed no evidence to indicate the patient’s Aldrete Post Anesthesia Recovery Score for Discharge Criteria. During an interview on 10/17/2024 at 5:07 PM, Registered Nurse (RN) #21 stated she did not see the documented discharge criteria for Patients #51, #55, #57, #58, and #60. Per RN #21, staff were expected to document the discharge criteria. 2. A facility policy titled, “Advanced Directive Policy,” revised 07/15/2016, revealed, “4. Every in-patient, and out-patient, as defined in this policy, will receive a notice describing their rights under applicable Federal and State laws to make decisions about their medical care, including their right to accept or refuse treatment and the right to formulate advance directives.” The policy specified, “6. Procedures 6.1 During the admission process, [facility name] staff will inquire if the patient has executed advance directives and will provide the Advanced Directive notice to in-patients and applicable out-patients, or their representatives, describing their rights to make medical care decisions. 6.2 [Facility name] staff will document in the patient’s medical record that the notice was given and if the patient has executed advance directive documents.” Review of the medical records for Patients (#71, #72, #73, #74, #75, #76, #77, #78, #79, and #80) did not reveal evidence to indicate staff documented in the patient’s medical record that the advance directive notice was given or if the patient had executed an advance directive. During an interview on 10/17/2024 at 3:50 PM, Outpatient Registrar #14 stated advance directives were only given to patients who asked it. During an interview on 10/17/2024 at 3:59 PM, the Outpatient Registration Manager stated advance directives were given to outpatients only when they requested it. During an interview on 10/17/2024 at 4:03 PM, Outpatient Registrar #15 stated advance directives were only given to patients who asked it. 45841”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 45841 Based on observation, interview, and facility policy review, the facility failed to ensure suction cannisters in Trauma One were clean and linen was not stored uncovered in the surgical department. These failure had to potential all patients who received services at the facility as there was a likelihood to result in the transmission of infection. Findings included: 1. A facility policy titled, “Emergency Room Cleaning,” with a last revised date of 04/2023, indicated, “1. Purpose: To assure a clean, safe, and sanitary environment for patients and staff members. 2. Applicability: Housekeeping.” On 10/14/2024 at 11:35 AM, a suction canister, attached to the suction regulator labeled “ICU [intensive care unit] 4” in Trauma One, was observed to have a small amount of a pink-orange tinged fluid. During an interview on 10/14/2024 at 11:38 AM, Registered Nurse (RN) #3 stated there was something in the bottom of the suction cannister. According to RN #3, when housekeeping cleaned, they were supposed to change the suction cannisters as well, but anyone could change it out if they saw it was dirty. During an interview on 10/17/2024 at 10:38 AM, the Housekeeping and Laundry Manager (HLM) stated housekeeping was not responsible for the suction cannisters in the patient rooms in the Emergency Department. Per the HLM, the housekeeping staff would notify the nurses or technicians at the nurses’ station as they were responsible for changing the canisters out. 2. A facility policy titled, “Handling of Clean Linen,” with a last revised date of 05/2023, indicated, “6.2 Linen carts will be covered with cart covers which have been disinfected and laundered daily.” During a concurrent interview and observation of the surgical department n 10/16/2024 at 11:11 AM, with Surgical Technician #8. a gurney was noted in the hallway across from the endoscopy room that contained eight piles of clean linens on it, uncovered. Surgical Technician #8 acknowledged the clean linen was uncovered and stated it stemmed from the surgical department being busy. During an interview on 10/17/2024 at 10:38 AM, the Housekeeping and Laundry Manager stated that all linens were to be stored covered, and that included in the surgical area. During an interview on 10/17/2024 at 11:32 AM, Registered Nurse #11 stated clean linen should not be left uncovered, that is should be stored in covered in a cabinet in the supply room.”

“DISCHARGE PLANNING CFR(s): (8) The CAH must assist patients, their families, or the patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but is not limited to, HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The CAH must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences. This Standard is not met as evidenced by: 45841 Based on interview and record review, the facility failed to ensure patients were provided data for post-acute providers that included quality measures and data on resource measures for 1 (Patient #5) of 85 sampled patients. This failure had the likelihood to not allow patients to make a fully informed decision on their post-acute provider options. Findings included: Patient #5’s “History and Physical Reports,” revealed the patient admitted to the facility on 06/03/2024, with a chief complaint of shortness of breath and fluid retention. Patient #5’s “CM [care management] Narrative Note,” entered on 06/11/2024, revealed the patient discharged to a facility and was expected to spend 25 to 30 days in a long-term acute care facility. Patient #5’s medical cord revealed no evidence to indicate that the patient was given data for post-acute providers that included quality measures and data on resource measures. During an interview on 10/17/2024 at 12:07 PM, the Care Management Registered Nurse (CMRN) stated the facility did not provide quality data to patients for post-acute care providers. The CMRN stated the facility did not have a policy to address this and did not provide data to patients for placement options.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 45714 Based on interview and facility document and policy review, the facility failed to provide evidence it conducted two exercises to test the emergency plan at least twice per year during the year of 2023. This deficient practice had the potential to affect all facility occupants Findings included: The facility’s policy titled, “All Hazard Medical Surge Emergency Response Plan,” last revised in 06/2011, specified, “7.8. All [Miners’ Colfax Medical Center] staff will be trained in the All Hazard Emergency Response Plan and related policies and procedures. Staff will participate in a minimum of one “table top” exercise annually and participate in community/county drills as scheduled” and “13.1 Management Team members and available staff members will participate in at least one table-top exercise per year.” The facility’s life safety code and emergency preparedness disaster books for the year of 2023 through October 2024 revealed there were no disaster drills available for review. During an interview on 10/15/2024 at 2:40 PM, the Maintenance Supervisor revealed the Chief Executive Officer (CEO) and the Long-Term Care Administrator and Support Services (LTCA/SS) were responsible for conducting two drills annually to test the emergency plan. He stated he was not aware that the facility must conduct two disaster drills annually to test the emergency plan. He acknowledged he could not find any documentation where the facility had conducted two disaster drills to test the emergency plan for 2023 or 2024. He stated he expected the facility to conduct and document two disaster drills per year to test the emergency plan. During an interview on 10/15/2024 at 3:33 PM, the Chief Nursing Officer (CNO) stated she was unsure if two disaster drills to test the emergency plan were completed for 2023. However, she noted she expected the facility to conduct and document two disaster drills per year to test the emergency plan. During an interview on 10/15/2024 at 3:42 PM, the CEO revealed he was aware the facility must conduct two disaster drills annually to test the emergency plan. He acknowledged the facility lacked documentation to show disaster drills were completed for 2023, noting the drills to test the emergency plan were simply not done in 2023, but identifying they had been planning to complete the drills. He stated the LTCA/SS was responsible for conducting the drills, but noted the LTCA/SS just started in the role in June 2024, so it was the CEO’s responsibility to conduct the drills in 2023. He stated he expected the facility to conduct and document two disaster drills per year to test the emergency plan. During a telephone interview on 10/15/2024 at 4:22 PM, the LTCA/SS revealed he had just started in the role in June 2024 and did not know if the facility had conducted disaster drills to test the emergency plan in 2023. He stated he expected the facility to conduct and document two disaster drills per year to test the emergency plan.”

“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: 45714 Based on observation, interview, and facility policy review, the facility failed to provide and maintain a self-closing or automatic closing device on corridor doors to 1 of 13 hazardous storage room doors in accordance with National Fire Protection Association 19.3.2.1. Findings included: The facility’s policy titled, “Door Closure Policy,” dated 09/02/2009, revealed, “The purpose of this policy is to provide practical safeguards for persons and property from arising hazards.” The policy contained no information regarding maintaining a self-closing device on corridor doors with combustible contents. An observation on 10/15/2024 at 1:15 PM revealed a door to a storage room located across from the radiology department that contained combustible storage of Christmas decorations, cardboard boxes, office supplies, office chairs, medical records, and medical supplies. The storage room measured approximately 450 square feet and was not equipped with a self-closing device. During an interview on 10/15/2024 at 2:43 PM, the Maintenance Supervisor revealed he was aware the radiology department had storage in the storage room in question, but was unaware of the contents in the room. He stated the room was appropriately 450 square feet and needed a self-closing device. He stated he made rounds of the facility daily but had missed inspecting the room in question. He stated he expected a storage room with combustible materials to contain a self-closing device installed on the corridor door. He stated the facility had no policy regarding maintaining a self-closing device on corridor doors with combustible contents. During an interview on 10/15/2024 at 3:47 PM, the Chief Executive Officer revealed the Maintenance Supervisor was responsible for ensuring corridors that required self-closing devices were installed on the doors. He stated he was unaware the storage room across from radiology department had combustible contents. He stated he expected that storage rooms with combustible materials to have a self-closing device installed on the door. During a telephone interview on 10/15/2024 at 4:24 PM, the Long-Term Care Administrator and Support Services revealed the Maintenance Supervisor had just called and told him about the storage room that contained combustible contents but lacked a self-closing device. He stated the Maintenance Supervisor was responsible for ensuring corridor doors with combustible contents contained a self-closing device and expected self-closing devices to be installed on corridor doors with combustible contents.”

“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: 45714 Based on interview and facility document and policy review, the facility failed to provide documentation of monthly load tests of the emergency power generator during 22 of 33 months reviewed. This deficient practice could result in a failure of the emergency power system, leaving the facility without egress and task lighting in the event of a power failure. This deficient practice had the potential to affect all facility occupants. Findings included: The facility’s policy titled, “Emergency Generator,” dated 08/26/2009, revealed, “6.2. The generator testing and maintenance shall occur daily, weekly, monthly, and on an annual basis.” The “Monthly Generator Load Test” for 01/2022 to 09/2024 indicated the generator was only tested under load on 01/2022, 02/2022, 03/2022, 04/2022, 03/2024, 04/2024, 05/2024, 06/2024, 07/2024, 08/2024, and 09/2024. There was no other documentation available for review for the timeframe in question. During an interview on 10/15/2024 at 2:43 PM, the Maintenance Supervisor revealed he was not employed by the facility from May 2022 until August 2023. He stated when returned in August 2023, the generator would transfer and run under load for an hour and then cool down, but would never disengage from running under load. He stated they had to manually turn the transfer switch and breaker off to stop it from continuing to run under load. He stated the maintenance supervisor at the time told him to stop running it under load until the generator could be fixed. He stated it took the facility months to get the problem finally fixed in February 2024. He stated he was aware they had not tested the generator under load monthly as required. He stated he expected the generator to be tested under load monthly. During an interview on 10/15/2024 at 3:46 PM, the Chief Executive Officer revealed he was aware the generator must be tested under load monthly. He stated he did not recall the actual concern with the generator and why it had not been tested under load monthly. He stated the individual in the maintenance supervisor role was responsible for ensuring the generator was tested under load monthly, noting they had some staff turnover during the past couple of years. He stated he expected the facility to conduct monthly generator load tests. During a telephone interview on 10/15/2024 at 4:23 PM, the Long Term Care Administrator and Support Services revealed he started in his role in June 2024 and was just told the generator was not tested monthly under load during some months. He stated he was now responsible for ensuring the monthly load tests were completed and he expected the facility to monthly load test the generator.”