Carson Valley Health

“Subsistence Needs for Staff and Patients CFR(s): §403.748(b)(1), §418.113(b)(6)(iii), §441.184(b)(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1), §483.475(b)(1), §485.542(b)(1), §485.625(b)(1) [(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal. This Standard is not met as evidenced by: 42420 Based on record review and interview, the facility failed to include sewage and waste disposal in their emergency preparedness plan (EPP). Findings include: On 07/16/2025 at 8:47 AM, the facility’s EPP lacked a process to dispose of waste in the event of a disaster. On 07/16/2025, the Emergency Manager confirmed the EPP lacked a process to dispose of waste.”

“This Statement of Deficiencies was generated as a result of a Medicare Life Safety Code (LSC) recertification survey conducted at your facility on 07/15/2025 through 07/17/2025. Your facility was surveyed using the “EXISTING” Health Care Occupancy chapter of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition and NFPA 99, Health Care Facilities Code, 2012 Edition. The existing building was a two-story building with a NFPA 220 construction Type II (222) and was fully equipped with an automatic fire sprinkler system. The new expansion building was a one-story building with a NFPA 220 construction type Type III (211). The building was protected throughout by an automatic fire sprinkler system. The building was equipped with a Category 1 Medical Gas system including piped in oxygen, instrument air, medical air, medical vacuum that included Waste Anesthetic Gas Disposal (WAGD). The facility was licensed for 11 Medical/Surgical beds, 10 Swing beds, and 4 Intensive Care Unit beds. The facility was equipped with five Type 1 Essential Electrical Systems as defined in NFPA 99, 2012 Edition. Note: The facility was equipped with a piped-in medical gas system. The findings and conclusions of any investigation by the Division if Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigations, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified:”

“Fire Alarm System - Out of Service CFR(s): NFPA 101 Fire Alarm - Out of Service Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.6 This Standard is not met as evidenced by: 42420 Based on document review and interview, the facility failed to ensure a person performing fire watch duties had no other duties. Findings include: On 07/16/2025 at 1:04 PM, the facility’s Fire Watch Policy, revised 07/08/2024, failed to document a person conducting fire watch duties was not responsible for other duties. On 07/16/2025, the Director of Facilities and Security confirmed persons conducting fire watch had no other duties.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 42420 NFPA 25, Standard for the inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). NFPA 13 National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, 2010 Edition 6.2.7 Escutcheons and Cover Plates. 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler. 6.2.7.2* Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly. 6.2.7.3 Cover plates used with concealed sprinklers shall be part of the listed sprinkler assembly. 6.2.8 Guards. Sprinklers subject to mechanical injury shall be protected with listed guards. Based on observation, document review and interview, the facility failed to maintain the automatic fire sprinkler system as required. Findings include: On 07/15/2025 through 07/16/2025, the following automatic fire sprinkler system concerns were present: - On 07/15/2025 at 12:58 PM, the recessed sprinkler in changing room had a gap between the cover and the ceiling, exposing the interstitial space. - On 07/15/2025 at 1:35 PM, two sprinklers in the material supply overflow room lacked escutcheons, exposing the interstitial space. - On 07/16/2025 at 9:50 AM, in the behavioral health storage room, items were stored two inches from the sprinkler. On 07/15/2025 and 07/16/2025, the Director of Facilities and Security and Maintenance Director were present at each discovery.”

“Sprinkler System - Out of Service CFR(s): NFPA 101 Sprinkler System - Out of Service Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service. 18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) This Standard is not met as evidenced by: 42420 Based on document review and interview, the facility failed to ensure a person performing fire watch duties had no other duties. Findings include: On 07/16/2025 at 1:04 PM, the facility’s Fire Watch Policy, revised 07/08/2024, failed to document a person conducting fire watch duties was not responsible for other duties. On 07/16/2025, the Director of Facilities and Security confirmed persons conducting fire watch had no other duties.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 42420 National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition 110.12 Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. (B) Integrity of Electrical Equipment and Connections. Internal parts of equipment, including busbars, wiring terminals insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken, bent, cut, or deteriorated by corrosion, chemical action, or overheating. Article 314 - Outlet, Device, Pull, and Junction Boxes; Conduit bodies; Fittings; and Handhole Enclosures 314.28(c) Pull and Junction Boxes and Conduit Bodies. (c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110. Article 400 - Flexible Cords and Cables 400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: 1) As a substitute for the fixed wiring of a structure 2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors 3) Where run through doorways, windows, or similar openings 4) Where attached to building surfaces Exception to 4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B) 5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings 6) Where installed in raceways, except as otherwise permitted in the Code 7) Where subject to physical damage Based on observation and interview, the facility failed to ensure electrical wiring and equipment complied with the National Electric Code, National Fire Protection Association (NFPA) 70. Findings include: On 07/15/2025 and 07/16/2025, the following electrical concerns were present: - On 07/15/2025 at 9:38 AM, in the Care Coordination room, a UL 1363 rated relocatable power tap (RPT) had an extension cord plugged into it, creating a daisy chain. The RPT had a computer and printer plugged into it. - On 07/15/2025 at 10:00 AM, in the Manager office, a Keurig was plugged into a UL 1363 rated RPT. - On 07/15/2025 at 10:18 AM, in the Equipment room, a C-MAC® for intubation and a vital sign machine were plugged into a non UL 1363A rated RPT. - On 7/15/2025 at 11:10 AM, at the Emergency Room nurses’ station, a coffee pot and a small refrigerator were plugged into a RPT. - On 7/15/2025 at 11:22 AM, at the Emergency Room nurses’ station B, a space heater was plugged into a RPT. - On 7/15/2025 at 11:24 AM, in the Emergency Room manager office, a Keurig and a small refrigerator were plugged into a residential-style RPT. - On 7/15/2025 at 3:00 PM, in the old pre-operative room, GFCI receptacle had a broken ground hole. - On 7/16/2025 at 9:37 AM, in the behavioral health room, a one-plug receptacle was broken. - On 7/16/2025 at 10:00 AM, in the Chief Nursing Officer’s office, a yellow extension cord with a space heater and a computer plugged into it was plugged into a RPT, creating a daisy-chain. - On 7/16/2025 at 10:13 AM, in the infusion manager’s office, the junction box next to the sink was missing its cover. On 07/15/2025 and 07/16/2025, the Director of Facilities and Security and Maintenance Director were present at each discovery.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 42420 Based on observation and interview, the facility failed to conduct fire drills once per shift, per quarter. Findings include: On 07/15/2025 and 07/16/2025, the facility lacked documented evidence of a fire drill conducted during the third quarter night shift (7:00 PM to 7:00 AM) and fourth quarter night shift. On 07/15/2025 and 07/16/2025, the Director of Facilities and Security and Maintenance Director confirmed the missing fire drills.”

“Electrical Systems - Receptacles CFR(s): NFPA 101 Electrical Systems - Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 42420 National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition 210.8 Ground-Fault Circuit-Interrupter Protection for Personnel. Ground-fault circuit-interruption for personnel shall be provided as required in 210.8(A) through (C). The ground-fault circuit-interrupter shall be installed in a readily accessible location. (A)(7) Sinks - located in areas other than kitchens where receptacles are installed within 1.8 m (6 ft) of the outside edge of the sink. Based on observation and interview, the facility failed to install ground fault circuit interrupters (GFCI) in areas less than six feet from a sink edge. Findings include: On 07/15/2025 and 07/16/2025, the following receptacles were not GFCI receptacles as required: - On 07/15/2025 at 2:13 PM, in Exam Room 3, a duplex receptacle was 13.5 inches from the sink edge; however, the receptacle was not the required GFCI. - On 07/15/2025 at 2:16 PM, in Exam Room 5, a duplex receptacle was 14 inches from the sink edge; however, the receptacle was not the required GFCI. - On 07/16/2025 at 9:46 AM, in the Behavioral Health corridor, a duplex receptacle was 11 inches from the sink edge; however, the receptacle was not the required GFCI. - On 07/16/2025 at 10:09 AM, in a vacant office in the old cardiology office, a duplex receptacle was 16 inches from the sink edge; however, the receptacle was not the required GFCI. - On 07/16/2025 at 10:11 AM, in the dietician’s office, a duplex receptacle was 15 inches from the sink edge; however, the receptacle was not the required GFCI. - On 07/16/2025 at 10:12 AM, in the authorization specialist’s office, a duplex receptacle was 15.5 inches from the sink edge; however, the receptacle was not the required GFCI. - On 07/16/2025 at 10:13 AM, in the infusion manager’s office, a duplex receptacle was 17 inches from the sink edge; however, the receptacle was not the required GFCI. - On 07/16/2025 at 10:15 AM, in the project manager’s office, a duplex receptacle was 17 inches from the sink edge; however, the receptacle was not the required GFCI. On 07/15/2025 and 07/16/2025, the Director of Facilities and Security and Maintenance Director were present at each discovery.”

“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: 42420 S&C: 14-46-LSC Power strips providing power to non- patient-care-related electrical equipment must be Relocatable Power Taps (RPT) listed as UL 1363. Power strips providing power to patient care-related electrical equipment must be Special-purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL 60601-1. National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition Article 400 - Flexible Cords and Cables 400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: 1) As a substitute for the fixed wiring of a structure 2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors 3) Where run through doorways, windows, or similar openings 4) Where attached to building surfaces Exception to 4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B) 5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings 6) Where installed in raceways, except as otherwise permitted in the Code 7) Where subject to physical damage Based on observation and interview, the facility failed to ensure residential-style relocatable power taps (RPT) were not used to power personal electronics and patient care related electrical equipment (PCREE). Findings include: On 07/15/2025 through 07/16/2025, the following PCREE was not plugged into the required UL 1363A rated RPT: - On 07/15/2025 at 10:18 AM, in the Equipment room, a C-MAC® for intubation and a vital signs machine were plugged into a residential-style RPT. - On 07/15/2025 at 2:06 PM, in Exam Room 1, a vital signs machine was plugged into a six-plug UL 1363 rated RPT. - On 07/15/2025 at 2:13 PM, in Exam Room 2, an exam table was plugged into a six-plug UL 1363 rated RPT. On 07/15/2025 and 07/16/2025, the Director of Facilities and Security and Maintenance Director were present at each discovery.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 42420 National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 Edition 4-3.5.2.2 (b) 2, if stored within the same enclosure, empty oxygen cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed quickly. 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Based on observation and interview, the facility failed to include signage on the door to the room containing greater than 300 cubic feet of oxygen. Findings include: On 07/15/2025 at 9:45 AM, the supply room contained 17 e-sized cylinders; however, the door to the supply room lacked the required signage. On 07/15/2025 at 9:45 AM, the Director of Facilities and the Engineering employee confirmed the 17 e-sized cylinders were greater than 300 cubic feet, thus considered in storage. The Director of Facilities and the Engineering employee confirmed the door to the supply room lacked the required signage.”

“PROVISION OF SERVICES CFR(s): §485.635 Condition of Participation: Provision of Services This Condition is not met as evidenced by: 25065 Based on policy reviews, patient electronic medical record (EMR) reviews, observation, injectable manufacturer’s guidelines review, and interviews, the critical access hospital (CAH) failed to meet the condition of participation of Provision of Services. The CAH failed to meet the requirements related to patient care policies and required CAH services. These deficient practices had the potential to affect all patients receiving services in the CAH. Findings include: Cross Reference C1048 - The registered nurse (RN) failed to assess patients in accordance with critical access hospital (CAH) policies and/or physician orders related to neurological (neuro) checks, vital sign assessments, effectiveness of administered medications, pain, and CIWA (Clinical Institute Withdrawal Assessment - Alcohol) score for six (Patient (P) 1, P4, P5, P10, P14, P20) of 20 patient EMRs reviewed for RN assessment from a total sample of 23 patients. Cross Reference C1049 - The CAH failed to ensure: 1. Medications were administered in accordance with physician orders for three (Patient (P) 3, P4, P5) of 20 patient EMRs reviewed for medication administration from a total sample of 23 EMRs and 2. Fluids placed in the warmer observed in the emergency department (ED) on 07/08/25 at 9:43 AM met the manufacturer’s guidelines for storage. Cross Reference C1050 - The CAH failed to ensure a nursing care plan was developed and kept current in accordance with the CAH’s policies for three (Patient (P) 1, P2, P3) of 20 patient EMRs reviewed for a current nursing care plan from a total sample of 23 EMRs. Cross Reference C1052 - The CAH failed to ensure physical therapy (PT) evaluations had documentation of all required content in accordance with the CAH policy for two (Patient (P) 5, P7) of two patient EMRs reviewed with physician orders for Physical Therapy evaluations from a total sample of 23 patients.”

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 25065 Based on review of the Governing Body Bylaws, review of the Medical Staff Bylaws and Rules and Regulations, patient electronic medical record (EMR) review, CAH policy review, and interviews, the critical access hospital (CAH) failed to ensure the governing body or individual that assumed full legal responsibility for determining, implementing and monitoring policies governing the CAH’s total operation and for ensuring that CAH policies were administered so as to provide quality health care in a safe environment had physicians write new orders when a patient was discharged from observation status and admitted as an inpatient for one (Patient (P) 7) of one patient EMR reviewed with a change from observation status to an inpatient admit from a total sample of 23 patients. This deficient practice had the potential to affect all patients who had observation status physician orders and were then admitted to the CAH as an inpatient. Findings include: Review of the CAH’s “Third Amended and restated Bylaws [name of CAH], A Nevada Nonprofit Corporation, approved on 08/31/22, indicated the bylaws included no documentation related to the medical staff and physician orders. Review of the CAH’s “[name on the hospital] Medical Staff Bylaws,” dated 2020 (no documented month and day when approved), indicated “. . . These Bylaws are adopted in recognition of the mutual accountability, interdependence and responsibility of the Medical Staff and the Governing Body of [name of hospital] in protecting the quality of medical care provided in the Hospital and monitoring the competency of the Hospital’s Medical Staff . . . the Medical Staff acknowledges that the Governing Body must act to protect the quality of medical care provided and the competency of the Medical Staff, and to provide for the responsible governance of the Hospital. In adopting these Bylaws, the Medical Staff commits to exercise its responsibilities with diligence and good faith; and in approving these Bylaws, the Governing Body commits to allowing the Medical Staff reasonable independence in conducting the affairs of the Medical Staff. . .” Review of the CAH’s “[name of CAH] Medical Staff Rules,” effective 01/01/20, indicated “. . . All entries in a medical record must be legible, complete, dated, timed, and authenticated by the member who is responsible for ordering, providing or evaluating the services provided. . .” There was no documentation in the CAH;s medical staff rules related to physician orders for patients on observation status who were then admitted as an inpatient. Review of the CAH policy titled “Outpatient Observation,” reviewed/revised May 2025, indicated “. . . Observation status is defined as the use of a bed for short-term monitoring and treatment of a patient outpatient condition to determine possible inpatient admission or discharge . . . 2. Once physician writes the order for observation, the “clock” time observation begins is when the patient is placed into observation which should coincide with the time the physician order is written. If after one midnight, the physician has determined that the patient is not stable or safe enough for discharge, then the UR Nurse/Nursing Supervisor will use the two midnight rule and Interqual (a system of evidence-based clinical guidelines and decision support tools used in healthcare for utilization management, particularly for determining the medical necessity of healthcare services; helps ensure that patients receive the appropriate level of care and that healthcare resources are used efficiently; used by payers (insurance companies) and providers (hospitals, doctors) to guide decisions about admissions, continued stays, and specific treatments to review inpatient criteria to assist the physician with status determination and the patient may become an inpatient, have observation time extended up to 48 hours, or be referred for secondary review). 3. Observation exceeding 48 hours are generally denied. If a particular case appears to have exceptional circumstances to justify approval, then the need is to be documented in the medical record by the physician and Director of Risk/Quality must be notified.” Review of the CAH policy titled “Admission & [and] Level of Care Review,” reviewed/revised February 2025, indicated “. . . Interqual criteria is considered a screening tool and the decision to admit a patient to the hospital or place into observation is ultimately determined by the physician . . . If a patient does not meet an outpatient observation level of care per Interqual, yet is not medically stable enough for discharge from the ED and requires ongoing treatments or monitoring, then the UR representative can approve the observation status as determined by the physician. After 1[one] midnight of observation, the physician should make a decision concerning the patient’s discharge or change the status to an inpatient admission pert the 2 [two] midnight rule . . . If the diagnosis, treatment, stabilization, and discharge can reasonably be expected in two midnights or more, then inpatient status should be considered. . .” Review of P7’s “Event Log” (located under the “Summary” tab, then the “Overview” tab), with P7’s EMR navigated by DON, indicated P7 was admitted as an inpatient on 07/06/25 at 12:09 PM (time is 12:10 PM on the physician orders). Review of P7’s H&P (located under the under the “All Notes” tab, then the “H&P” tab) indicated P7 presented with left knee pain after a fall. Review of P7’s physician orders (located under the “Manage Orders” tab, then under the “Orders” tab) indicated an order on 07/04/25 at 12:50 PM by Medical Doctor 1 (MD1) to admit to “Observation - Outpatient” followed by an order by MD1 on 07/06/25 at 12:10 PM to admit “Inpatient.” Review of the physician orders indicated new physician orders were not documented when P7 was changed from observation status to inpatient. During an interview on 07/09/25 at 3:00 PM, Director of Nurses (DON) confirmed new physician orders were not written when P7 was admitted as an inpatient on 07/06/25 at 12:10 PM. During an interview on 07/10/25 at 8:45 AM, Chief Medical Officer (CMO) stated the physicians were not writing new orders when patients were admitted to inpatient from an observation bed and were using the same physician orders written when the patient was placed on observation status.”

“NURSING SERVICES CFR(s): A registered nurse or, where permitted by State law, a physician assistant, must supervise and evaluate the nursing care for each patient, including patients at a SNF level of care in a swing-bed CAH. This Standard is not met as evidenced by: 17281 25065 Based on policy reviews, patient electronic medical record (EMR) reviews, and interviews, the registered nurse (RN) failed to assess patients in accordance with critical access hospital (CAH) policies and/or physician orders related to neurological (neuro) checks, vital sign assessments, effectiveness of administered medications, pain, and CIWA (Clinical Institute Withdrawal Assessment - Alcohol) score for six (Patient (P) 1, P4, P5, P10, P14, P20) of 20 patient EMRs reviewed for RN assessment from a total sample of 23 patients. This deficient practice had the potential to affect all patients receiving services at the CAH. Findings include: 1. Neuro checks: Review of P1’s “Event Log” (located under the “Summary” tab, then the “Overview” tab), with P1’s EMR navigated by Clinical Analyst Quality 2 (CAQ2), indicated P1 was admitted as an inpatient on 07/05/25 at 1:35 PM with a chief complaint of P1 was getting out of the car the previous night when P1 slipped and fell on gravel resulting in a head strike with no loss of consciousness (located in the “ED Provider Note” documented on 07/05/25 at 10:28 AM (located under the “All Notes” tab, then the “ED” tab, then the “Progress Notes” tab). Review of P1’s physician orders (located under the “Manage Orders” tab, then the “Orders” tab) indicated an order on 07/05/25 at 2:00 PM for neuro checks every four hours. Review of P1’s nursing assessments of neuro status (located under the “Flowsheets” tab, then the “Assessment” tab) indicated P1’s neuro status assessment was documented on 07/08/25 at 3:15 AM and on 07/08/25 at 8:00 AM. The 8:00 AM neuro assessment was more than four hours since the previous assessment at 3:15 AM. During an interview on 07/08/25 at 12:34 PM, CAQ2 confirmed the neuro assessment performed on 07/08/25 at 8:00 AM was greater than four hours from the previous assessment. 2. Vital signs: a. Review of P1’s “Event Log” (located under the “Summary” tab, then the “Overview” tab), with P1’s EMR navigated by Clinical Analyst Quality 2 (CAQ2), indicated P1 was admitted as an inpatient on 07/05/25 at 1:35 PM with a chief complaint of P1 was getting out of the car the previous night when P1 slipped and fell on gravel resulting in a head strike with no loss of consciousness (located in the “ED Provider Note” documented on 07/05/25 at 10:28 AM (located under the “All Notes” tab, then the “ED” tab, then the “Progress Notes” tab). Review of P1’s physician orders (located under the “Manage Orders” tab, then the “Orders” tab) indicated an order on 07/05/25 at 1:18 PM to assess vital signs every six hours. Review of P1’s nursing assessments of vital signs (located under the “Flowsheets” tab, then the “Assessment” tab) indicated P1’s vital signs were assessed on 07/06/25 at 10:50 AM, then at 7:25 PM with no pulse and respiration documented, then a full set of vital signs at 10:34 PM, and then at 8:00 AM on 07/07/25 (not every six hours as ordered). Review indicated P1’s vital signs were assessed on 07/07/25 at 7:11 PM then at 5:07 AM on 07/08/25 (more than six hours between vital sign assessments). Review indicated P1’s vital signs were assessed at 3:30 PM on 07/08/25 then at 11:14 PM (more than six hours between vital sign assessments). During an interview on 07/08/25 at 12:34 PM, CAQ2 confirmed P1’s vital signs were not assessed every six hours as ordered by P1’s physician. b. Review of P4’s “Event Log” (located under the “Summary” tab, then the “Overview” tab), with P4’s EMR navigated by Director of Nurses (DON), indicated P4 was admitted as an inpatient on 07/08/25 at 8:53 AM with a chief complaint of a small bowel obstruction (located in the “General Surgery History & [and] Physical Note” documented on 07/08/25 at 8:24 AM. Review of P4’s physician orders (located under the “Manage Orders” then under the “Orders” tab)) indicated an order on 07/08/25 at 10:09 AM to assess vital signs every two hours times four, then every four hours times 24 hours, and then per unit policy. Review of P4’s nursing assessments of vital signs (located under the “Flowsheets” tab, then the “Assessment” tab) indicated P4’s vital signs were assessed on 07/08/25 at 8:52 AM, 11:28 AM, 3:35 PM (not every two hours as ordered), 6:59 PM, 11:58 PM, and 7:45 AM on 07/09/25 (not every four hours as ordered). During an interview on 0709/25 at 10:26 AM, DON stated P4’s vital signs were not assessed as ordered by the physician. c. Review of P5’s “Event Log” (located under the “Summary” tab, then the “Overview” tab), with P5’s EMR navigated by Director of Nurses (DON), indicated P5 was admitted as an inpatient on 07/01/25 at 5:17 PM. Review of P5’s history and physical (H&P) (located under the under the “All Notes” tab, then the “H&P” tab) indicated P5 presented with alcohol intoxication. Review of P5’s physician orders (located under the “Manage Orders” then under the “Orders” tab) indicated an order 07/01/25 at 6:15 PM as follows: If CIWA (Clinical Institute Withdrawal Assessment - Alcohol) score 5-10, assess VS (vital signs) and CIWA Q 4 hours If CIWA score 11-14, assess VS and CIWA every two hours If CIWA score 15-25, assess VS and CIWA Q one hour and continuous pulse ox If CIWA score greater than 25, assess VS Q 15 minutes and continuous pulse ox Discontinue CIWA assessments when score is less than 5 for 72 hours. Review of P5’s nursing assessments of vital signs (located under the “Flowsheets” tab, then the “Assessment” tab) indicated vital signs were not documented on 07/02/25 at the 12:35 AM assessment (CIWA score was 13) and at the 2:35 AM assessment (CIWA score at 2:30 AM was five) and then not documented again until 3:48 AM. There was no documentation of vital sign assessment at 2:33 PM when P5’s CIWA score was 14. During an interview at 12:21 PM on 07/09/25, DON confirmed P5’s vital signs were not assessed as ordered in accordance with the CIWA assessments. 3. Review of the facility policy titled, “Transfusion Therapy” last revised on 08/09/24 revealed, “ ...Informed consent is obtained according to organizational policy and procedure ...Start the transfusion slowly at approximately 2ml [milliliters] per minute for the first 15 minutes and remain near the patient; increase the transfusion rate, if there are no signs of reaction ...Baseline vital signs documented within one hour prior to start of transfusion. Vital signs 15 minutes after the start of the transfusion. Vital signs every hour during the transfusion. Post transfusion vital signs within one hour post transfusion. ...” Review of P10’s “Face Sheet” located in the electronic medical record (EMR) under the “Demographic” tab revealed P10 was admitted to the hospital on 07/01/25 with diagnoses of periprosthetic fracture around internal prosthetic hip joint (fracture hip). Review of the “Physician Orders” located in the EMR under the “Manage Order” tab revealed an order dated 07/04/25 at 7:32 AM to transfuse one unit Red Blood Cells. Review of the “Informed Consent of Refusal for Blood Transfusion” document dated 07/04/25 located in the EMR under the “Media” tab revealed, “ ...I consent to have a transfusion of the following blood product ...” The area on the document did not identify the blood product the patient was consenting to receive. The area was not filled out and was left blank. Review of the EMR under the “Flowsheets” tab revealed “Blood Transfusion Documentation” that revealed one unit PRBC (packed red blood cells) transfusion was started on 07/04/25 at 11:33 AM and stopped on 07/04/25 at 2:33 PM. Review of the EMR under the “Assessment” tab revealed vital signs were obtained at 11:32 AM prior to the PRBC transfusion. Vital signs were next obtained on 07/04/25 at 11:47 AM (one hour 14 minutes after the start of the transfusion) and on 07/04/25 at 3:27 PM. Review of the EMR did not reveal vital signs were obtained 15 minutes after the start of the blood transfusion or every hour during the blood transfusion. Review of P10’s EMR failed to reveal the rate of administration of the PRBC received on 07/04/25 was documented. During an interview on 07/09/25 at 11:33 AM, the Director of Nursing (DNS) stated the blood transfusion consent form should include the type of blood product the patient is consenting to receive. The DNS confirmed the area on P10’s transfusion consent form did not include what blood product the patient was to receive. The DNS stated per hospital policy the rate the blood transfusion is started at and then progressed to should be documented by the nurse. The DNS stated vital signs should be obtained 15 minutes after the start of the blood transfusion and every hour thereafter until the transfusion is completed. The DNS confirmed the rate of the blood transfusion and vital signs were not obtained per hospital policy. Review of P14’s “Face Sheet” located in the EMR under the “Demographics” tab revealed P14 was admitted to the hospital on 05/26/25 with diagnoses that included hepatic encephalopathy. Review of the “Physician Orders” located in the EMR under the “Manage Order” tab revealed an order dated 06/15/25 at 10:06 AM to transfuse one unit of Red Blood Cells. Review of the “Informed Consent of Refusal for Blood Transfusion” document dated 06/15/25 located in the EMR under the “Media” tab revealed, “ ...I consent to have a transfusion of the following blood product ...” The area on the document did not identify the blood product the patient was consenting to receive. The area was not filled out and was left blank. Review of the EMR under the “Flowsheets” tab revealed “Blood Transfusion Documentation” that revealed one unit PRBC (packed red blood cells) transfusion was started on 06/15/25 at 12:58 PM and stopped on 06/15/25 at 3:15 PM. Review of P14’s EMR failed to reveal the rate of administration of the PRBC received on 06/15/25 was documented. During an interview on 07/09/25 at 11:33 AM, the Director of Nursing (DNS) stated the blood transfusion consent form should include the type of blood product the patient is consenting to receive. The DNS confirmed the area on P14’s transfusion consent form did not include what blood product the patient was to receive. The DNS stated per hospital policy the rate the blood transfusion is started at and then progressed to should be documented by the nurse. The DNS confirmed the rate of the blood transfusion was not documented in the medical record. 4. Review of the facility policy titled, “Medication Distribution and Administration” last revision date 05/11/25 revealed, “ ...The nurse will monitor for effectiveness and adverse drug reactions of the medication administered to a patient.” Review of P20’s “Flow Sheet” located in the EMR under the “Demographic” tab revealed P20 presented to the hospital emergency room on 06/09/25 at 3:29 AM and was discharged home on 06/09/25 at 4:19 AM. Review of the “Triage Note” dated 06/09/25 at 3:34 AM located in the EMR under the “ED (Emergency Department)” tab, revealed, “ ...Pt BIB [brought in by] family from home ...Patient ambulatory with steady gait. AAO x4 upon arrival. Respirations even/unlabored, No apparent distress at this time ...BP [blood pressure] 138/88, pulse (!) 104, temp 26.7 C (98.1 F) (oral), respirations 16 ...SpO2 [oxygen saturation] 98% on room air ... level four (4) acuity.” Review of the “Physician Orders” located in the EMR under the “Manage Order” tab revealed an order dated 06/09/25 at 3:47 AM for Valium 0.5mg (milligram) one dose by mouth. Review of the “Medication Administration Record (MAR)” dated 06/09/25 at 3:50 AM located in the EMR under the “MAR” tab revealed Valium 0.5mg was administered. Review of P20’s EMR did not reveal documentation that the effectiveness of Valium administered on 06/09/25 was assessed. During an interview on 07/10/25 at 10:45 AM, Registered Nurse (RN) 2 stated he/she did not recall P20 but did review P20’s EMR prior to the interview. RN2 stated P20 presented to the emergency room with a chief complaint of anxiety and received Valium per the physician’s order. RN2 stated he/she normally conducts an assessment after administering medication to treat anxiety. RN2 confirmed the EMR did not include documentation that P20 was assessed for the effectiveness of Valium after it was administered. 5 Pain assessment: Review of the CAH policy titled “Pain Management,” reviewed/revised 06/25/25, indicated “. . . Pain Management is the process of promoting the effective assessment, diagnosis and treatment of pain . . . Pain will be assessed in all patients upon admission and a pain goal will be chosen for effective management of pain . . . The pain management process includes pain assessment, planning and intervention, reassessment of patient responses to or outcomes of pain management measures, education of patient and family regarding pain management, and documentation of assessments, reassessments, interventions and education provided. 4. Pain scales will be utilized . . . to assess pain that are consistent with the patients age, condition and ability to understand: numerical pain rating scale 0-10 . . . Non-Verbal Scale . . . Pain will be assessed on a regular and ongoing basis, but every four hours at a minimum by the RN. Pain will be reassessed after one hour of a patient being medicated for pain to establish the effectiveness of the medication. . a. Review of P23’s “Flow Sheet” located in the EMR under the “Demographic” tab revealed P23 presented to the hospital emergency room on 05/16/25 at 2:40 PM. Review of the “Nursing Assessment” located in the EMR under the “ED” tab, revealed possible stroke, history of CVA, and a pain level score of 5 out of 10. The location of the pain was listed as the head. Review of the “Nursing Assessment” revealed the next pain assessment was not conducted until 05/16/25 at 8:00 PM. During an interview on 07/10/25 at 8:42 AM, the DNS stated per hospital policy pain assessments should be completed at a minimum every four hours. The DNS confirmed P23 did not have pain assessment conducted per the hospital policy on 05/16/25. b. Review of P4’s “Event Log” (located under the “Summary” tab, then the “Overview” tab), with P4’s EMR navigated by Director of Nurses (DON), indicated P4 was admitted as an inpatient on 07/08/25 at 8:53 AM with a chief complaint of a small bowel obstruction (located in the “General Surgery History & [and] Physical Note” documented on 07/08/25 at 8:24 AM. Review of P4’s physician orders (located under the “Manage Orders”) indicated an order for Hydromorphone (Dilaudid) (indicated for the management of pain in patients where an opioid analgesic is appropriate) injection 0.5 mg (milligrams) every two hours as needed intravenously (IV) starting on 07/08/25 at 4:41 AM until discontinued for severe pain at level of seven to 10 and ketorolac (Toradol) injection (used for the short-term relief of moderately severe pain) 15 mg every six hours as needed IV for pain level four to six starting on 07/08/25 at 10:03 AM. Review of P4’s MAR (located under the “Manage Orders” tab, then the “MAR” tab) indicated Dilaudid 0.5 mg IV was administered on 07/08/25 at 2:26 PM with no documented assessment of the pain level and at 5:28 PM with a pain level assessment of six at 5:20 PM (dose for Dilaudid was for pain level of seven to 10). Review of P4’s MAR indicated Toradol 15 mg IV was administered at 10:58 AM on 07/08/25 with no pain assessment documented. During an interview on 07/09/25 at 10:26 AM, DON stated the pain medications, Dilaudid and Toradol, were not administered in accordance with the pain assessments as ordered by the physician. 6. CIWA score assessment: Review of P5’s “Event Log” (located under the “Summary” tab, then the “Overview” tab), with P5’s EMR navigated by Director of Nurses (DON), indicated P5 was admitted as an inpatient on 07/01/25 at 5:17 PM. Review of P5’s history and physical (H&P) (located under the under the “All Notes” tab, then the “H&P” tab) indicated P5 presented with alcohol intoxication. Review of P5’s physician orders (located under the “Manage Orders” then under the “Orders” tab) indicated an order 07/01/25 at 6:15 PM as follows: If CIWA (Clinical Institute Withdrawal Assessment - Alcohol) score 5-10, assess VS (vital signs) and CIWA Q 4 hours If CIWA score 11-14, assess VS and CIWA every two hours If CIWA score 15-25, assess VS and CIWA Q one hour and continuous pulse ox If CIWA score greater than 25, assess VS Q 15 minutes and continuous pulse ox Discontinue CIWA assessments when score is less than 5 for 72 hours. Review of P5’s nursing assessments of CIWA score (located under the “Flowsheets” tab, then the “Assessment” tab) indicated on 07/01/25 at 5:30 PM P5’s CIWA score was 8, requiring the score to be reassessed in four hours. Review indicated P5’s CIWA score was not reassessed until 12:00 AM on 07/02/25 (score was 7). Review indicated P5’s CIWA score was assessed on 07/02/25 at 2:33 PM as a score of 14, requiring CIWA to be assessed every two hours. There was no documented assessment at 4:30 PM and 6:30 PM as required by the physician orders. During an interview on 07/09/25 at 12:21 PM, DON stated P5’s CIWA was not assessed in accordance with the physician orders based on the score obtained at the time of the assessment.”

“NURSING SERVICES CFR(s): §485.635(d)(3) All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. This Standard is not met as evidenced by: 25065 Based on policy reviews, observation, injectable manufacturer’s guidelines review, patient electronic medical records (EMR) review, and interviews, the critical access hospital (CAH) failed to ensure: 1. Medications were administered in accordance with physician orders for three (Patient (P) 3, P4, P5) of 20 patient EMRs reviewed for medication administration from a total sample of 23 EMRs and 2. Fluids placed in the warmer observed in the emergency department (ED) on 07/08/25 at 9:43 AM met the manufacturer’s guidelines for storage. These deficient practices had the potential to affect all patients receiving services at the CAH. Findings include: 1. Review of the CAH policy titled “Medication Distribution and Administration,” reviewed/revised 05/11/25, indicated “. . . All staff members who participate in medication management processes are responsible for maintaining and verifying patient-specific information, using paper-based or electronic charts and records . . . Drugs are administered only with the order of a physician or other individual who has been granted privileges to write such orders . . . All schedule, PRN [as needed] and STAT medications are charted on the MAR [medication administration record] immediately upon administration, including signature and title of person, and site if applicable. . indicated P4 was admitted on .” Review of P3’s “Event Log” (located under the “Summary” tab, then the “Overview” tab), with P3’s EMR navigated by Clinical Analyst Quality 2 (CAQ2), indicated P3 was admitted as an inpatient on 07/07/25 at 1:11 AM with a chief complaint of abdominal pain, upper abdominal pain, and nausea (located in the “ED Provider Note” documented on 07/06/25 at 6:49 PM (located under the “All Notes” tab, then the “ED” tab, then the “Progress Notes” tab). Review of P3’s physician orders (located under the “Manage Orders”) indicated an order on 07/07/25 at 11:45 AM to administer Zarxio (helps protect hematopoietic stem and progenitor cells (HSPCs), the source of blood cell lineages, including neutrophils, red blood cells, and platelets) injection 480 micrograms (mcg) subcutaneously SQ) once. Review of P3’s medication administration record (MAR) (located under the “Manage Orders” tab, then the “MAR” tab) indicated Zarxio was not administered on 07/07/25 at 11:45 AM with documentation by Registered Nurse (RN) 1 that the reason was “missed dose.” Review of the MAR indicated Zarxio was administered on 07/07/25 at 4:50 PM. There was no documentation in P3’s EMR that RN1 notified P3’s physician that Zarxio was not administered as ordered or that RN1 notified the pharmacist to obtain the medication at 11:45 AM. During an interview on 07/08/25 at 3:05 PM, CAQ2 stated the Zarxio was not administered as ordered by P3’s physician, and there was no documentation in P3’s EMR that P3’s physician or the pharmacist were notified of the dose not being available. Review of P4’s “Event Log” (located under the “Summary” tab, then the “Overview” tab), with P4’s EMR navigated by Director of Nurses (DON), indicated P4 was admitted as an inpatient on 07/08/25 at 8:53 AM with a chief complaint of a small bowel obstruction (located in the “General Surgery History & [and] Physical Note” documented on 07/08/25 at 8:24 AM. Review of P4’s physician orders (located under the “Manage Orders”) indicated an order for Hydromorphone (Dilaudid) (indicated for the management of pain in patients where an opioid analgesic is appropriate) injection 0.5 mg (milligrams) every two hours as needed intravenously (IV) starting on 07/08/25 at 4:41 AM until discontinued for severe pain at level of seven to 10 and ketorolac (Toradol) injection (used for the short-term relief of moderately severe pain) 15 mg every six hours as needed IV for pain level four to six starting on 07/08/25 at 10:03 AM. Review of P4’s MAR (located under the “Manage Orders” tab, then the “MAR” tab) indicated Dilaudid 0.5 mg IV was administered on 07/08/25 at 2:26 PM with no documented assessment of the pain level and at 5:28 PM with a pain level assessment of six at 5:20 PM (dose for Dilaudid was for pain level of seven to 10). Review of P4’s MAR indicated Toradol 15 mg IV was administered at 10:58 AM on 07/08/25 with no pain assessment documented. During an interview on 07/09/25 at 10:26 AM, DON stated the pain medications, Dilaudid and Toradol, were not administered in accordance with the pain assessments as ordered by the physician. Review of P5’s “Event Log” (located under the “Summary” tab, then the “Overview” tab), with P5’s EMR navigated by Director of Nurses (DON), indicated P5 was admitted as an inpatient on 07/01/25 at 5:17 PM. Review of P5’s history and physical (H&P) (located under the under the “All Notes” tab, then the “H&P” tab) indicated P5 presented with alcohol intoxication. Review of P5’s physician orders (located under the “Manage Orders”) indicated the following orders on 07/01/25 at 6:15 PM: If CIWA (Clinical Institute Withdrawal Assessment - Alcohol) score 5-10, assess VS (vital signs) and CIWA Q 4 hours If CIWA score 11-14, assess VS and CIWA every two hours If CIWA score 15-25, assess VS and CIWA Q one hour and continuous pulse ox If CIWA score greater than 25, assess VS Q 15 minutes and continuous pulse ox Consider transfer to ICU (intensive care unit) if CIWA score is greater than 20 for more than four hours, patient has received six mg Ativan in one hour, or a total of 15 mg of Ativan in four hours. Discontinue CIWA assessments when score is less than 5 for 72 hours. Ativan (medication that treats anxiety and helps the nervous system to slow down) 0.5 mg tablet every four hours as needed for CIWA 5-7; hold if respirations less than 12 per minute or sedation scale is greater than four Ativan 1 mg tablet every four hours as needed for CIWA 8-10; hold if respirations less than 12 per minute or sedation scale is greater than four Ativan 2 mg tablet every two hours as needed for CIWA 11-14; hold if respirations less than 12 per minute or sedation scale is greater than four Ativan 3 mg tablet every one hour for CIWA 15-25; hold if respirations less than 12 per minute or sedation scale is greater than four Ativan 4 mg tablet every 15 minutes for CIWA greater than 25; ; hold if respirations less than 12 per minute or sedation scale is greater than four. Review of P5’s MAR indicated Ativan was not administered with the CIWA assessment of seven on 07/02/25 at 12:00 AM (should have received Ativan 0.5 mg tablet) and with the CIWA assessment of five on 07/05/25 at 2:30 AM (should have received Ativan 0.5 mg tablet). During an interview on 07/09/25 at 12:21 PM, DON stated P5 did not receive the Ativan 0.5 mg tablet on 07/02/25 at 12:00 AM and 2:30 AM as ordered by the physician. 2. Review of the CAH’s policy titled “Fluid/ Blanket Warmer,” reviewed/revised July 2025, indicated “. . . Intravenous/irrigation fluids and blankets will be stored according to the manufacturer’s recommendation. . . Ensure warmer temperature does not exceed 130 degrees F. [Fahrenheit] The warming oven temperature must be controlled by a calibrated thermometer, and in order to protect from damage, the irrigating fluid containers should not come into direct contact with the heating elements. 2. Solutions will remain in their overwraps until use and will not come into direct contact with any metal components within the oven. 3. IV fluids, in their overwraps, can remain in the oven for up to 30 days unless otherwise specified by the manufacturer’s recommendations. Record the expiration date on the overwrap when solution is initially placed in oven. 4. Once removed from the oven, solutions should be used within 24 hours or discarded, and not returned to stock supply. . .” Review of the manufacturer’s guidelines titled “Sodium Chloride Injection, USP” (United States Pharmacopeia), revised June 2018, indicated “. . . Sodium Chloride Injection, USP is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment in single dose containers for intravenous administration . . . It is recommended the product be stored at room temperature (25 [degrees] C [Centigrade]/77 [degrees]F); brief exposure up to 40 [degrees] C/l104 [degrees] F does not adversely affect the product. . .” There was no documentation of a specific amount of time to determine what would be considered a “brief exposure.” Observation on 07/08/25 at 9:43 AM in the ED revealed two 1000 milliliters plastic bags in the overwraps of 0.9% (per cent) Sodium Chloride in the warmer that had a temperature setting of 105 degrees Fahrenheit. Observation revealed a notation of 07/06/25 written on the bag with no indication whether the date was the date the fluids were placed in the warmer or the date the bags were to be removed from the warmer as required by the CAH policy. Observation revealed documentation on the bag of Sodium Chloride injection read “. . . store at room temperature 77 degrees F. and avoid excessive heat. . .” During an interview on 07/08/25 at 10:30 AM, ED Manager confirmed the tag on the IV fluids did not designate whether the date was the date the bags were placed in the warmer or the date the bags were to be removed from the warmer. ED Manager stated the policy allowed IV bags of solution to remain in the warmer for 30 days. ED Manager stated he/she did not know what the manufacturer guidelines stated regarding the temperature and time at which the solution could be warmed.”

“NURSING SERVICES CFR(s): A nursing care plan must be developed and kept current for each inpatient. This Standard is not met as evidenced by: 25065 Based on policy review, patient electronic medical record (EMR) reviews, and interviews, the critical access hospital (CAH) failed to ensure a nursing care plan was developed and kept current in accordance with the CAH’s policies for three (Patient (P) 1, P2, P3) of 20 patient EMRs reviewed for a current nursing care plan from a total sample of 23 EMRs. This deficient practice had the potential to affect all patients receiving services at the CAH. Findings include: Review of the CAH policy titled “Nursing Care Plans,” reviewed/revised 05/15/25, indicated “. . . Nursing care plans will be individualized and evidence-based and kept current for each hospitalized patient . . . Adding Care Plan Goals: Click the “add care plan” button to incorporate goals tailored to the patient’s needs based on patient status, diagnosis and assessment findings. . . Care Plan goals may be automatically incorporated based on patient documentation; however, it is essential for nursing staff to review and modify these goals to ensure that the Care Plan is customized to meet the unique needs, preferences, and medical conditions of each individual patient . . . During each subsequent shift or change in patient status, the RN [registered nurse] will review the Care Plan and document the care plan progress on ALL active goals, and create a progress note that includes the problem statement, the measurable goal, problem interventions, and the outcome. . .” 1. Review of P1’s “Event Log” (located under the “Summary” tab, then the “Overview” tab), with P1’s EMR navigated by Clinical Analyst Quality 2 (CAQ2), indicated P1 was admitted as an inpatient on 07/05/25 at 1:35 PM with a chief complaint of P1 was getting out of the car the previous night when P1 slipped and fell on gravel resulting in a head strike with no loss of consciousness (located in the “ED Provider Note” documented on 07/05/25 at 10:28 AM (located under the “All Notes” tab, then the “ED” tab, then the “Progress Notes” tab). Review of P1’s nursing care plan (located under the under the “All Notes” tab, then the “Care Plan” tab) developed on 07/05/25 at 6:12 PM indicated the following problems/goals were documented: 1. Fall risk / Patient will remain free from falls 2. Knowledge deficit / Patient and family/care givers will demonstrate understanding of plan of care, disease process/condition, diagnostic tests and medications 3. Pain / Alleviation of pain or a reduction in pain to the patient’s comfort goal 4. Skin integrity / Skin integrity is maintained or improved 5. Wound/incision healing / Patient’s wound,/surgical incision will decrease in size and heals properly. There was no documentation of a means of measurement to determine when the goal was met. During an interview on 07/08/25 at 1:02 PM, Clinical Analyst Quality 2 (CAQ2) stated P1’s nursing care plan goals were not written in measurable terms to be able to determine when the goal was met. 2. Review of P2’s “Event Log” (located under the “Summary” tab, then the “Overview” tab), with P2’s EMR navigated by Clinical Analyst Quality 2 (CAQ2), indicated P2 was admitted as an inpatient on 07/07/25 at 7:56 PM. Review of P2’s history and physical (H&P) (located under the “All Notes” tab, then under the “H&P” tab) documented on 07/07/25 at 6:08 PM indicated P2’s chief complaint was shortness of breath secondary to hypoxia caused by immunotherapy. Review of P2’s nursing care plan (located under the under the “All Notes” tab, then the “Care Plan” tab) developed on 07/08/25 at 4:39 AM indicated the following problems/goals were documented: 1. Knowledge deficit / Patient and family/care givers will demonstrate understanding of plan of care, disease process/condition, diagnostic tests and medications 2. Bowel elimination / Establish and maintain regular bowel function 3. Fluid volume / Fluid volume balance will be maintained 4. Mobility / Patient’s capacity to carry out activities will improve 5. Respiratory / Patient will achieve/maintain optimum respiratory ventilation and gas exchange 6. Self-care / Patient will have the ability to perform ADLs independently or with assistance (bathe, groom, dress, toilet and feed) 7. Urinary elimination / Establish and maintain regular urinary output 8. Discharge planning - pneumonia / Patient will verbalize understanding of lifestyle changes and therapeutic needs post discharge. There was no documentation of a means of measurement to determine when the goal was met. During an interview on 07/08/25 at 2:34 PM, CAQ2 stated P2’s nursing care plan goals were not written in measurable terms to be able to determine when the goal was met. 3. Review of P3’s “Event Log” (located under the “Summary” tab, then the “Overview” tab), with P3’s EMR navigated by CAQ2, indicated P3 was admitted as an inpatient on 07/07/25 at 1:11 AM. Review of P3’s H&P (located under the “All Notes” tab, then under the “H&P” tab) documented on 07/06/25 at 11:04 PM indicated P3’s chief complaint was upper abdominal pain and nausea. Review of P3’s nursing care plan (located under the under the “All Notes” tab, then the “Care Plan” tab) developed on 07/07/25 at 4:01 AM indicated the following problems/goals were documented: 1. Knowledge deficit / Patient and family/care givers will demonstrate understanding of plan of care, disease process/condition, diagnostic tests and medications 2. Skin integrity / Skin integrity is maintained or improved 3. Communication / The ability to communicate needs accurately and effectively will improve 4. Bowel elimination / Establish and maintain regular bowel function 5. Gastrointestinal irritability / Nausea and vomiting will be absent or improve; diarrhea will be absent or improved. There was no documentation of a means of measurement to determine when the goal was met. During an interview on 07/08/25 at 4:36 PM, CAQ2 stated P3’s nursing care plan goals were not written in measurable terms to be able to determine when the goal was met.”

“REHABILITATION THERAPY SERVICES CFR(s): Physical therapy, occupational therapy, and speech-language therapy pathology services furnished at the CAH, if provided, are provided by staff qualified under State law, and consistent with the requirements for therapy services in §409.17 of this subpart. This Standard is not met as evidenced by: 25065 Based on policy review, patient electronic medical records (EMR), and interviews, the critical access hospital (CAH) failed to ensure physical therapy (PT) evaluations had documentation of all required content in accordance with the CAH policy for two (Patient (P) 5, P7) of two patient EMRs reviewed with physician orders for PT evaluations from a total sample of 23 patients. This deficient practice had the potential to affect all inpatients receiving PT services when admitted to the CAH. Findings include: Review of the CAH policy titled “Rehabilitation Evaluations,” reviewed/revised 08/29/23, indicated “. . . Upon receipt of a verbal or written physician’s order for OT [occupational therapy], PT, and/or SLP [speech and language pathology], the licensed therapist will complete an initial evaluation within 24 hours (Mo-Fri) [Monday through Friday] for inpatients . . . Evaluations must contain the following information: a. Rehabilitation potential . . . h. Therapy plan, including frequency and duration . . .” 1. Review of P5’s “Event Log” (located under the “Summary” tab, then the “Overview” tab), with P5’s EMR navigated by Director of Nurses (DON), indicated P5 was admitted as an inpatient on 07/01/25 at 5:17 PM. Review of P5’s history and physical (H&P) (located under the under the “All Notes” tab, then the “H&P” tab) indicated P5 presented with alcohol intoxication. Review of P5’s “Physical Therapy Initial Evaluation” (located under the “All Notes” tab, then under the “Progress Notes” tab) documented on 07/02/25 at 4:45 PM by PT DPT1 (Physical Therapist Doctorate of Physical Therapy) indicated no documentation of the rehab potential and the frequency and duration of PT visits. 2. Review of P7’s “Event Log” (located under the “Summary” tab, then the “Overview” tab), with P7’s EMR navigated by DON, indicated P7 was admitted as an inpatient on 07/06/25 at 12:09 PM. Review of P7’s H&P (located under the under the “All Notes” tab, then the “H&P” tab) indicated P7 presented with left knee pain after a fall. Review of P7’s “Physical Therapy Initial Evaluation” (located under the “All Notes” tab, then under the “Progress Notes” tab) documented on 07/05/25 at 9:12 AM indicated no documentation of the rehab potential and the frequency and duration of PT visits. During an interview on 07/09/25 at 3:32 PM with Rehab Services Manager (RSM) and PT DPT2 present, PT DPT2 confirmed P5’s and P7’s PT evaluations did not include each patient’s rehab potential and frequency and duration of PT visits as required by the CAH policy.”

“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: 25065 Based on observations, policy reviews, and interviews, the critical access hospital (CAH) failed to ensure a clean and sanitary environment was maintained to avoid the potential transmission of infection by having expired lab tubes available for use in the emergency department (ED) and having a trampoline cover in the rehab gym with multiple tears that prevented surface disinfection. These deficient practices had the potential to affect all patients receiving services in the ED and the rehab gym. Findings include: Review of the CAH policy titled “General Infection Control Practices,” reviewed/revised July 2023, indicated “. . . Work surfaces should be kept clean and uncluttered, and should be cleaned periodically with surface disinfectant wipes. Staff may not have food in clinical areas or their workspace . . . Clean and sterile supplies are to be stored in such a manner as to protect them from contamination. Stock supplies must be rotated and expired supplies are to be pulled from stock on a monthly basis. . .” Observation in the clean supply room of the ED on 07/08/25 at 9:43 AM revealed 27 BD vacutainer yellow top 5.0 milliliter (ml) lab tubes had expired 06/30/25, and two BD vacutainer 6.0 ml pink top lab tubes had expired 01/31/25. During an interview on 07/08/25 at 9:43 AM, ED Manager confirmed the lab tubes had expired. ED Manager stated the staff who stocks the lab tubes should check for expiration dates. ED Manager stated each nurse was supposed to check the lab tube before use for expiration date. He/She stated one ED nurse was assigned to check all supplies in the ED clean supply room twice a month. Observation on 07/10/25 at 9:00 AM in the rehab gym revealed a small trampoline cover had multiple tears that would prevent it from being disinfected thoroughly. During an interview on 07/10/15 at 9:00 AM, Rehab Services Manager (RSM) stated the trampoline cover with multiple tears would prevent the cover from being thoroughly disinfected after use.”

“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: 17281 Based on medical record review, policy review, and interview, the Critical Access Hospital (CAH) failed to ensure the baseline care plans were developed to provide person-centered care for three of six sampled Swing bed (Patients (P) 11, P12, and P13 from a total sample of 23 patients. This failure had the potential to affect any patient admitted to the CAH Swing bed program for care and services. Findings include: Review of the facility policy titled, “Interdisciplinary Comprehensive Person-Centered Care Plan” last revision 05/23/25 revealed, “ ...The IDT [Interdisciplinary Team] will develop and implement a baseline care plan that includes interventions needed to provide effective and person-centered care of the resident. The baseline care plan will be developed within 48 hours of admission to the SWING bed program. ...” 1. Review of P11’s “Face Sheet” located in the electronic medical record (EMR) under the “Demographic” tab revealed P11 was admitted to the hospital Swing bed on 06/04/25. Review of the History and Physical dated 06/04/25 located in the EMR under the “All Notes” tab revealed, “ ...Assessment/Plan: Patient will need a bed on Rehabilitation service ...recurrent Major depressive disorder, in partial remission ...pressure ulcer (present on admission) chronic pressure wounds to bilateral heels. IP [Infection Prevention] wound care consultation ...deaf (present on admission) since early childhood speaks sign language, reads lips ...urinary incontinence (present on admission) ...seizure disorder (present on admission) ....other specified anemias (present on admission) continue to trend closely, transfuse 1 unit PRBC’s [packed red blood cells] for hemoglobin less than 7. ...” Review of P11’s “Baseline Care Plan” dated 06/05/25 located in the EMR under the “All Notes” tab revealed, “ ...Initial goals based on admission order: Improve strength and endurance prior to discharge. Short term: Patient to participate in IV [intravenous] antibiotic therapy and initial weekly reassessment on 06/11/25. Long term: Patient to meet goals set by therapy and nursing prior to discharge anticipated on or before 06/14/25. Patient goals: Patient would like to return home, upon discharge from SWING program, with home health services. ...” Review of the “Baseline Care Plan” did not include interventions to provide effective person-centered care. 2. Review of P12’s “Face Sheet” located in the EMR under the “Demographic” tab revealed P12 was admitted to the hospital Swing bed on 07/03/25. Review of the History and Physical dated 07/03/25 located in the EMR under the “All Notes” tab revealed, “ ...Assessment/Plan: ...Neck abscess (present on admission) MRSA [group of bacteria difficult to treat] infection and bacteremia -wound care ...alcohol use disorder (present on admission) multivitamins ...Marijuana use ...depression ...seizure disorder. ...” Review of P12’s “Baseline Care Plan” dated 0704/25 located in the EMR under the “All Notes” tab revealed, “ ... Initial goals based on admission order. Complete the course of IV antibiotics prior to discharge. Short Term: Patient to participate with daily IV antibiotic infusion, with initial weekly assessment on 07/09/25. Long term: Patient to meet goals set by pharmacy and nursing prior to discharge anticipated on or before 07/22/25. Patient goals: Patient would like to return home, upon discharge from the SWING program, with outpatient wound care services. ...” Review of the “Baseline Care Plan” did not include interventions to provide effective person-centered care. 3. Review of P13’s “Face Sheet” located in the EMR under the “Demographic” tab revealed P13 was admitted to the hospital Swing bed on 07/03/25. Review of the History and Physical dated 07/03/25 located in the EMR under the “All Notes” tab revealed, “ ...Assessment/Plan: ...Postoperative pain- (present on admission) hip x-ray does not show any acute fracture/dislocation- Multimodal pain control-scheduled Percocet [pain medication], as needed Tylenol and Dilaudid [pain medication] ...Chronic hypoxic [not sufficient oxygen] respiratory failure - patient uses O2 intermittently at home, resume Chronic diastolic congestive heart failure ...paroxysmal atrial fibrillation [irregular heart beat] ....BPH (benign prostatic hyperplasia) - watch for retention. ...” Review of P13’s “Baseline Care Plan” dated 0704/25 located in the EMR under the “All Notes” tab revealed, “ ... Initial goals based on admission order. Improve strength and endurance prior to discharge. Short Term: Patient to participate with therapies, and to improve strength and endurance, with initial weekly reassessment on 07/09/25. Long term: Patient to meet goals set by therapies prior to discharge anticipated on or before 07/16/25. Patient goals: Patient would like to return home, upon discharge from the SWING program, with home health services.” Review of the “Baseline Care Plan” did not include interventions to provide effective person-centered care. During an interview on 07/09/10 at 9:25 AM, Clinical Quality Analyst (CQA) 1 stated the patients baseline care plans should be person-centered and include interventions to provide the necessary care to patients. CQA 1 confirmed P11’s, P12’s, and P13’s baseline care plans did not include person-centered interventions.”

“SPECIALIZED REHABILITATIVE SERVICES CFR(s): Specialized Rehabilitative Services (§483.65 of this chapter). “ §483.65 (a) Provision of services. If specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for a mental disorder and intellectual disability or services of a lesser intensity as set forth at §483.120(c), are required in the resident’s comprehensive plan of care, the facility must- (1) Provide the required services; or (2) In accordance with §483.70(g), obtain the required services from an outside resource that is a provider of specialized rehabilitative services and is not excluded from participating in any federal or state health care programs pursuant to section 1128 and 1156 of the Act. (b) Qualifications. Specialized rehabilitative services must be provided under the written order of a physician by qualified personnel. This Standard is not met as evidenced by: 17281 Based on medical record review, policy review, and interview, the Critical Access Hospital (CAH) failed to provide an Occupation Therapy (OT) evaluation for one of six sampled Swing (Patient (P)11 from a total sample of 23 patients. This failure had the potential to affect any patient admitted to the CAH Swing bed who requires occupational therapy services. Findings include: Review of the facility policy titled, “Rehabilitation Evaluations” last revision date 08/29/23 revealed, “ ... Evaluations are completed in a timely fashion (24 hours) and will contain all the necessary information as outlined in the procedure section ...Upon receipt of a verbal or written physician’s order for OT, PT [physical therapy], and/or SLP [speech language therapy], the licensed therapist will complete an initial evaluation within 24 hours (Mon-Fri) for inpatients. On the weekends occupational and speech therapy are on call, but PT work 7 days/week. ...” Review of the facility policy titled, “Staffing and Assignments” last revision date 12/29/24 revealed, “ ...Swing Bed therapy coverage is available six days a week for PT and five days a week for SLP and OT ...The Rehab Services Manager is ultimately responsible for supervising the therapy treatments. ...” Review of the facility policy titled, “Rehabilitation Services Staffing” last revision date 12/29/24 revealed, “ ... An appropriate staffing of therapists and supportive personnel will be scheduled to provide quality rehabilitation services. ...” Review of P11’s “Face Sheet” located in the electronic medical record (EMR) under the “Demographic” tab revealed P11 was admitted to the hospital Swing bed on 06/04/25 with diagnoses that included weakness and multiple sclerosis (MS). Review of the History and Physical dated 06/04/25 located in the EMR under the “All Notes” tab revealed, “ ...Justification for Admission Status- Patient will need a bed on the Rehabilitation service. ...” Review of the “Physician Orders” dated 06/06/25 located in the EMR under the “Manage Orders” tab revealed an order for “OT Eval [evaluation] and Treat.” Review of the “Occupational Therapy Contact Note” dated 06/12/25 located in the EMR under the “Assessment” tab revealed an OT evaluation was attempted but the patient was outside at 11:45 AM and with the dietitian at 4:40 PM. Review of the “Occupational Therapy Contact Note” dated 06/13/25 located in the EMR under the “Assessment” tab revealed an OT evaluation was attempted but the patient at 2:40 PM but the patient was not feeling well so the evaluation was not completed. Review of P11’s EMR failed to reveal that an OT evaluation was attempted prior to 06/12/15. Review of the “Occupational Therapy Initial Evaluation” dated 06/16/25 located in the EMR under the “Assessment” tab revealed, “ ...admitted to SWING bed program for antibiotics and therapy ...Plan OT 3-5x/week. ...” During an interview on 07/09/25 at 1:00 PM, Occupational Therapist Registered Licensed (OTRL) 1 stated P11 had an order written on 06/06/25 for an OT evaluation. OTRL stated he/she was not working from 06/03/25 through 06/10/25. When he/she returned to work, attempts were made to complete the OT evaluation on 06/12/25 and 06/13/25 but the patient was not available. OTRL 1 stated the evaluation was not completed by the other hospital OT staff member because that staff was out sick. During an interview on 07/09/25 at 1:15 PM, the Rehabilitation Services Manager (RSM) stated there are only two OT staff in house to complete OT evaluations. RSM stated one OT staff was out sick and the other OT staff was on vacation when the OT evaluation was ordered. RSM state he/she was aware there was no OT coverage from 06/05/25 to 06/10/25. RSM stated the Chief Operating Officer (COO) was made aware of the need for additional OT staff during their one on one every other week meetings. RSM confirmed P11’s OT evaluation was not completed per facility policy. During an interview on 07/09/25 at 3:30 PM, COO stated he/she was not aware the hospital did not have OT coverage between 06/05/25 and 06/10/25.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 25065 Based on observation, policy review, and interview, the critical access hospital (CAH) failed to ensure EMTALA (Emergency Medical Treatment and Labor Act) signage was posted in areas where patients waited for treatment. This deficient practice had the potential to affect all patients presenting for examination of an emergency medical condition. Findings include: Review of the CAH policy titled “EMTALA,” effective 08/01/24, indicated “. . . The hospital will post conspicuously signs explaining individuals’ rights to the Emergency Department and other areas where individuals are likely to wait for examination or treatment . . . The hospital will post conspicuously information indicating whether the hospital participates in Medicaid. . .” Observation on 07/08/25 at 9:43 AM in the waiting area (lobby) of the emergency department (ED) revealed the required EMTALA signage posted in English and Spanish on the wall adjacent to the reception window where patients presented to register. Observation revealed the sign was printed on a standard sheet of paper (8.5 x 11 inches) with the required wording of “This hospital participates in Medicaid” in fine print, making it difficult to be seen by the surveyor. Observation revealed EMTALA signage was not posted in the ambulance bay, within the ED where the nursing station and examination rooms were located, and within the examination rooms. There was no posting of the EMTALA signage that could be seen by patients who were brought to the CAH by ambulance and placed in an examination room. During an interview on 07/08/25 at 9:43 AM, ED Manager confirmed the EMTALA signage was not posted in a conspicuous place that could be seen by patients who were brought to the CAH by ambulance and placed in an examination room.”