Quincy Valley Medical Center

“PROVISION OF SERVICES CFR(s): §485.635 Condition of Participation: Provision of Services This Condition is not met as evidenced by: 47458 . Based on observation, interview, and document review, the Critical Access Hospital failed to meet the requirements for the Condition of Participation for Provision of Services. Failure to establish and implement policies and procedures for hospital services provided to all patients admitted to the hospital risks substandard and inconsistent care which can lead to negative patient outcomes. Findings included: 1. Failure to ensure that staff follow approved policies and procedures places patients at risk for physical and psychological harm, loss of dignity, and violates the patients’ rights. Cross Reference: C 1006 2. Failure to obtain the correct restraint order for the appropriate restraint type puts patients and staff at risk of harm. Cross Reference: C 1006 3. Failure to perform the required face-to-face evaluation to determine whether the patient meets the specific criteria for physical or chemical restraint or seclusion places patients at risk of harm, injury, or other decline in status. Cross Reference: C 1006 4. Failure to monitor patients in restraints places patients at risk for physical and psychological harm, other decline in status, loss of dignity and violation of patient rights. Cross Reference: C 1006 5. Failure to assess and reassess a patient’s pain risks inconsistent, inadequate, or delayed relief of pain and risks patient harm related to delayed recognition of adverse effects of pain medication. Cross Reference C 1049 6. Failure to reposition impaired mobility patients potentially leads to the risk of pressure injuries, discomfort, loss of dignity, and pain. Cross Reference C 1049 7. Failure to perform specialized assessments for patients created a risk that patients would not receive timely medical treatment appropriate to their care needs and could result in poor patient outcomes or death. Cross Reference C 1049 Due to the cumulative effect of these findings, the Condition of Participation at 42 CFR 485.635 Provision of Services was NOT MET. .”

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 47458 . Based on observation, interview, and review of hospital policies and procedures, the hospital failed to ensure that staff verified emergency supplies and equipment were available and ready for use as directed by hospital policy. Failure to ensure that supplies and equipment are available and ready for use risks poor patient outcomes during medical emergencies. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Supply Procurement and Expiration Procedure,” Policy Reference ID #200.12, effective 11/24, showed the following: a. It is the policy of Quincy Valley Medical Center to provide safe patient care at all times. Ensuring patient care supplies are available for use and are not expired is integral to providing safe quality care. b. The supply expiration procedure is on the 1st day of the month, it is expected that the day shift Charge Nurse pulls a new equipment/expired packet from the log, labels the new month’s form with the current month and year, places each form in its required location, collects all of the prior month’s forms and submits them to the CNO’s inbox and posts the ER & Acute Care Monthly Expired Supply Checks form at the nurse’s station. c. The Employee responsibility includes all patient care staff in the Emergency Department (ED) and Acute Care Unit are expected to have knowledge of this policy and utilize the expired supply procedure on a monthly basis. d. It is the responsibility for any employee working between the 1st - 7th of each month to perform a thorough review of all supplies in that location for expired supplies and to remove expired supplies from circulation 2. On 02/17/26 between 1:35 PM and 3:45 AM, Surveyor #2 and the Employee Health RN (Staff #201) inspected the ED. The inspection showed the following: On the Broselow Cart in ED Trauma Bay: a. Two I-gel supraglottic airway size 2.5 (for 25-35 kilogram), with a manufacturer’s expiration date of 11/25. b. One Broselow/Hinkle purple pediatric emergency system oxygen delivery system, with a manufacturer’s expiration date of 08/25. c. One Broselow/Hinkle white pediatric intubation module, with a manufacturer’s expiration date of 11/25. d. One Coviden Shiley 4 DCT tracheostomy tube size 4.0 cuffed, with a manufacturer’s expiration date of 11/25. 3. At the time of the review, Staff #201 verified the expired emergency supplies and removed from use. .”

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 43911 . Based on observation, interview, and document review, the hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2012 edition. Failure to ensure a fire-safe environment of hospital hazards risks patient, visitor, and staff safety. Findings included: Refer to deficiencies written on Life Safety Code Inspection Report found at shell RPQN21. .”

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 47458 . Item #1 - Restraint Training Based on record review, interview, and review of hospital policy and procedures, the hospital failed to ensure that staff were adequately trained on restraint devices for 1 of 1 medical record reviews (Patient #201). Failure to ensure that staff follow approved policies and procedures places patients at risk for physical and psychological harm, loss of dignity, and violates the patients’ rights. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Restraints: Use, Monitoring, Documentation & Reporting,” Policy Reference ID #230.29, last revised 12/25, showed the following: Training requirements: a. Nursing staff must be trained and able to demonstrate application and release of restraints annually. b. Physicians who would be ordering restraints must have education and awareness of this policy with annual education. 2. On 02/17/26 between 1:35 PM and 3:00 PM, Surveyor #2 and the Employee Health RN (Staff #201) inspected the Emergency Department (ED). Surveyor #2 located a cupboard with posey soft limb restraints and inquired about other types of restraints used at the facility. Staff #201 reported that the hospital only uses posey soft limb restraints. 3. On 02/18/26 between 3:45 PM and 5:20 PM, Surveyor #2 and the Employee Health RN (Staff #201) reviewed the medical records of 2 patients with orders for violent or self-destructive behavior restraints between 11/20/25 and 12/15/25. The review showed that Patient #201 was a 16-year-old male seen in the ED with complaints of suicidal ideation and arrived in the ED at 4:42 PM. a. Patient #201 had a verbal order entered by a RN for violent restraint locked leather 4-point, 4 hours for ages 18 and over on 12/14/25 at 5:21 PM. b. Documentation showed the restraint applied on 12/14/25 at 5:06 PM and discontinued at 5:51 PM was locked leather 4 point restraint. c. Surveyor #2 interviewed Staff #201 regarding the 4-point locking leather restraint. Staff #201 reported ED staff had inquired with the Chief Nursing Officer about obtaining other types of restraints. The Chief Nursing Officer obtained a sample of 4-point locking leather restraints that were to be reviewed by various staff. The restraints were placed in a drawer at the nurse’s station. The 4-point locking leather restraints were placed on Patient #201. 4. At the time of the review, Staff #201 verified no one in the facility has been trained by the facility on the 4-point locking leather restraints as they were not intended to be used on patients. Staff #201 stated since this episode of restraint, the 4-point locking leather restraints have been removed from the facility. Item #2 - Restraint Orders Based on document review and interview, the hospital failed to adopt and implement policy and procedures to ensure provider orders for restraints specified the type of restraints in 2 of 2 patient records reviewed (Patients #201 and #202). Failure to obtain the correct restraint order for the appropriate restraint type puts patients and staff at risk of harm. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Restraints: Use, Monitoring, Documentation & Reporting,” Policy Reference ID #230.29, last revised 12/25, showed the following: a. If the patient’s behavior is causing harm to self or others, the RN may apply restraints in an emergency and obtain an order within a few minutes. The order may be verbal or by telephone, entered by an RN. Reassess the patient immediately post restraint placement. b. The order must include: The reason for restraint, the type, the restraint location (i.e. limb/laterality), and restraint duration. c. A chemical restraint is any drug used to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. 2. On 02/18/26 between 3:45 PM and 5:20 PM, Surveyor #2 and the Employee Health RN (Staff #201) reviewed the medical records of 2 patients with orders for violent or self-destructive behavior restraints between 11/20/25 and 12/15/25. The review showed the following: a. Patient #201 was a 16-year-old male seen in the ED with complaints of suicidal ideation and arrived in the ED at 4:42 PM. b. Patient #201 had a provider order for Haldol (a medication used to treat mental health and severe behavioral problems or agitation) 10 milligrams intramuscularly (IM) that was administered 12/14/25 at 5:18 PM. Surveyor #2 found no evidence of a provider order for chemical restraints. c. Patient #202 was a 42-year-old female seen in the Emergency Department (ED) for complaints of erratic behavior after taking recreational drugs. d. On 11/20/25 at 10:41 PM, on 11/21/25 at 1:57 AM, and on 11/21/25 at 2:18 AM, Patient #202 had a provider order for restraints for violent restraint - bed, side rails, soft limb restraint 4-point. e. Patient #202 had a provider order for Haldol 10 milligrams IM that was administered on 11/20/25 at 10:14 PM. Patient #202 had a provider order for Diphenhydramine (a medication frequently used with Haldol in the ED to treat acute agitation) 50 milligrams intravenously (IV) that was administered on 11/20/25 at 11:02 PM. Patient #202 had a provider order for Olanzapine (a medication sometimes used together with Haldol to manage acute agitation or severe psychosis) 10 milligrams IM that was administered on 11/20/25 at 11:46 PM. Patient #202 had a provider order for Ativan (a benzodiazepine that can be used to treat acute and severe agitation) 4 milligrams IV that was administered on 11/21/25 at 12:30 AM. Patient #202 had a provider order for Ativan 2 milligrams IV that was administered on 11/21/25 at 1:08 AM and at 2:46 AM. Surveyor #2 found no evidence of any provider orders for chemical restraint. 3. At the time of the review, Staff #201 verified the missing orders for the chemical restraints and verified the verbal order for violent restraint locked leather restraints 4-point, 4 hours for ages 18 and over was not the appropriate age related order. Item #3 - Face-to-Face Evaluation within 1 hour Based on record review, interview, and document review of hospital policies and procedures, the hospital failed to ensure that staff performed a face-to-face evaluation for patients with restraint orders for 2 of 2 patients reviewed with violent or self-destructive restraint orders (Patient #201 and #202). Failure to perform the required face-to-face evaluation to determine whether the patient meets the specific criteria for physical or chemical restraint or seclusion places patients at risk of harm, injury, or other decline in status. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Restraints: Use, Monitoring, Documentation & Reporting,” Policy Reference ID #230.29, last revised 12/25, showed that the physician must perform and document an in-person, face-to-face evaluation within 1 hour of restraint application. If the patient’s behavior resolves and the restraint or seclusion is discontinued before the physician arrives to perform the 1-hour face-to-face evaluation, the physician is still required to conduct the evaluation within 1 hour. This evaluation must include: the patient’s immediate situation, the patient’s reaction to the intervention, the patient’s medical and behavioral condition including a complete review of systems, history, medication review, and contributing factors and the need to continue or terminate the restraint. 2. On 02/18/26 between 3:45 PM and 5:20 PM, Surveyor #2 and the Employee Health RN (Staff #201) reviewed the medical records of 2 patients with orders for violent or self-destructive behavior restraints between 11/20/25 and 12/15/25. The review showed the following: a. Patient #201 was a 16-year-old male seen in the ED with complaints of suicidal ideation and arrived in the ED at 4:42 PM. Patient #201 was placed in locked leather 4-point restraint on 12/14/25 at 5:06 PM. Surveyor #2 found no evidence of a face-to-face evaluation by the provider within one hour that includes the 4 elements of the face-to-face evaluation described in the facility’s policy. b. Patient #202 was a 42-year-old female seen in the Emergency Department (ED) for complaints of erratic behavior after taking recreational drugs. Patient #202 was placed in soft 4 point restraint on 11/20/25 at 10:05 PM. Surveyor #2 found no evidence of a face-to-face evaluation by the provider within one hour that includes the 4 elements of the face-to-face evaluation described in the facility’s policy. 3. At the time of the review, Staff #201 verified the missing face-to-face evaluations. Item #4 - Chemical Restraint Monitoring Based on record review, interview, and review of hospital policy and procedures, the hospital failed to ensure that patients placed in restraints were monitored for safety for 2 of 2 medical record reviews (Patient #201 and #202). Failure to monitor patients in restraints places patients at risk for physical and psychological harm, other decline in status, loss of dignity and violation of patient rights. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Restraints: Use, Monitoring, Documentation & Reporting,” Policy Reference ID #230.29, last revised 12/25, showed the following: a. Continuous monitoring of the patient restraint or seclusion is necessary. b. Documentation is every 1-hour (plus or minus 5 minutes) or more frequently as patient condition warrants. Monitor the patient’s condition and document the results in the record. The 1-hour assessment must include (at minimum) the patient’s psychological status, physical comfort, and circulation and respiration. c. Every 2 hours (plus or minus 15 minutes) monitor the patient for physical needs and document the results in the record. The 2-hour assessment should include (at minimum) vital signs (may exceed 2 hours, not to exceed every 4 hours), assessment of hydration needs, assessment of hunger needs, and assessment of elimination needs. d. The Surveyor found no monitoring guidelines for a patient receiving chemical restraint in the hospital’s policy. 2. On 02/18/26 between 3:45 PM and 5:20 PM, Surveyor #2 and the Employee Health RN (Staff #201) reviewed the medical records of 2 patients with orders for violent or self-destructive behavior restraints between 11/20/25 and 12/15/25. The review showed the following: a. Patient #201 had a provider order for Haldol (a medication used to treat mental health and severe behavioral problems or agitation) 10 milligrams intramuscularly (IM) that was administered 12/14/25 at 5:18 PM. Surveyor #2 found no evidence of chemical restraint monitoring documented in the medical record. b. Patient #202 was a 42-year-old female seen in the Emergency Department (ED) for complaints of erratic behavior after taking recreational drugs. Patient #202 had a provider order for Haldol 10 milligrams IM that was administered on 11/20/25 at 10:14 PM. Patient #202 had a provider order for Diphenhydramine (a medication frequently used with Haldol in the ED to treat acute agitation) 50 milligrams intravenously (IV) that was administered on 11/20/25 at 11:02 PM. Patient #202 had a provider order for Olanzapine (a medication sometimes used together with Haldol to manage acute agitation or severe psychosis) 10 milligrams IM that was administered on 11/20/25 at 11:46 PM. Patient #202 had a provider order for Ativan (a benzodiazepine that can be used to treat acute and severe agitation) 4 milligrams IV that was administered on 11/21/25 at 12:30 AM. Patient #202 had a provider order for Ativan 2 milligrams IV that was administered on 11/21/25 at 1:08 AM and at 2:46 AM. Surveyor #2 found no evidence of any provider orders for chemical restraint. Surveyor #2 found no evidence of chemical restraint monitoring documented in the medical record. 3. At the time of the review, Staff #201 stated they were not sure if there were different chemical restraint assessment monitoring needed performed when chemical restraints were used and could not locate where that would be in the medical record. .”

“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: 47458 . Item #1 - Pain Assessment/Reassessment Based on interview, document review, and review of the hospital’s policy and procedure, the hospital failed to ensure staff members completed and documented pain and pain assessment/reassessment for 1 of 2 patients with pain medication orders reviewed (Patient #204). Failure to assess and reassess a patient’s pain risks inconsistent, inadequate, or delayed relief of pain and risks patient harm related to delayed recognition of adverse effects of pain medication. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Pain Management”, no Policy Reference ID, last reviewed 03/25: a. It is the policy of Quincy Valley Medical Center to respect and support the patient’s right to appropriate assessment and management of pain. b. It is the responsibility of all clinical staff to assess and periodically reassess the patient for pain and relief from pain including the intensity and quality (i.e., character, frequency, location and duration of pain), and response to treatment. c. The patient will undergo re-assessment of pain at least once per shift and after every pain control mechanism employed by patient care providers. d. Pain should be assess at least every assessment and should include time interval for re-assessment ex: 15-30 mins after IV meds and within 1 hour after oral meds. 2. On 02/18/26 between 11:30 AM and 12:30 PM, Surveyor #2 and the Medical Records Supervisor/Pharmacy Tech (Staff #202) reviewed the medical records of 1 adult patients admitted to the Acute Care Unit (ACU) between 11/12/25 and 02/16/26 with provider orders for pain medications. The review showed Patient #204 was a 71-year-old male admitted to ACU for acute renal insufficiency, dehydration, asthenia (abnormal physical weakness), hyperkalemia (elevated blood potassium levels) and hyponatremia (decreased sodium levels in the blood). Patient #204 had a provider order for oxycodone (a narcotic medication used to treat pain) 5 milligrams orally every 4 hours as needed. Patient #204 had the following missing pain assessments or reassessments associated with oxycodone pain medication administrations: a. Patient #204 received oxycodone 5 milligrams orally on 02/14/26 at 3:59 AM for a pain score of 7/10. Patient #204 had a pain reassessment of 2/10 at 5:47 AM (missing a period of approximately 105 minutes). b. Patient #204 received oxycodone 5 milligrams orally on 02/14/26 at 1:11 PM for a pain score of 7/10. Patient #204 had a pain reassessment of 8/10 at 3:52 PM (missing a period of approximately 100 minutes). c. Patient #204 received oxycodone 5 milligrams orally on 02/14/26 at 6:58 PM, Surveyor #2 found no evidence of a pain assessment associated with this administration. d. Patient #204 received oxycodone 5 milligrams orally on 02/14/26 at 11:19 PM. Surveyor #2 found no evidence of a pain assessment associated with this administration. e. Patient #204 received oxycodone 5 milligrams orally on 02/15/26 at 3:19 AM for a pain score of 10/10. Patient #204 had a pain reassessment of 5/10 at 5:34 AM (missing a period of approximately 135 minutes). f. Patient #204 received oxycodone 5 milligrams orally on 02/15/26 at 9:40 PM for a pain score of 8/10. Patient #204 had a pain reassessment of 3/10 at 11:55 PM (missing a period of approximately 105 minutes). g. Patient #204 received oxycodone 5 milligrams orally on 02/16/26 at 5:53 AM for a pain score of 8/10. Patient #204 had a pain reassessment of 8/10 at 7:48 AM (missing a period of 115 minutes). 3. At the time of the review, Staff #202 verified the missing pain reassessment within 30 - 60 minutes. Item #2 - Repositioning every 2 hours Based on document review, interview, and review of policies and procedures, the hospital failed to ensure that patients with impaired mobility receive repositioning every 2 hours for 1 of 1 records reviewed (Patients #204). Failure to reposition impaired mobility patients potentially leads to the risk of pressure injuries, discomfort, loss of dignity, and pain. Findings included: 1. Document review of hospital policy and procedure titled, “Acute Care Unit: Nursing Documentation and Patient Assessment,” Policy Reference ID#230.78, effective date 11/24, showed that: a. It is the policy of Quincy Valley Medical Center to outline minimum documentation requirements to meet established standards for clinical documentation and regulatory requirements. Documentation timing/specifics may be more frequent and/or inclusive based on patient needs, nursing judgement, and/or provider orders. b. The complete and required admission assessment/history includes screenings (Braden score, Glasgow Coma Scale, Morse Fall Scale, PHQ-2/PHQ-9), head-to-toe, allergies, lines, vitals, measurements, drains, tubes, and wounds. c. The Flowsheets is a record of the patient’s assessment and data collected throughout the patient’s hospitalization. Items in the Flowsheets include measurements (i.e. blood glucose), screenings (i.e. Morse Fall Scale, Glasgow Coma Scale, Braden Scale, PHQ-2/PHQ-9), ADLs, drains, head-to-toe, intake and output, lines, tubes, vitals and wounds. 2. Document review of the hospital provided document “Nursing Order,” showed that patients with a Braden Score of 18 or less will be turned and positioned ongoing every 2 hours on the even hour and as needed. 3. On 02/18/26 between 11:30 AM and 12:30 PM, Surveyor #2 and the Medical Records Supervisor/Pharmacy Tech (Staff #202) reviewed the medical record of 1 patient admitted to the Acute Care Unit (ACU) between 11/12/25 and 02/16/26 with a nursing order for turning and repositioning every 2 hours for a Braden Score less than 18. Patient #204 was a 71-year-old male admitted to ACU for acute renal insufficiency, dehydration, asthenia (abnormal physical weakness), hyperkalemia (elevated blood potassium levels) and hyponatremia (decreased sodium levels in the blood). Patient #204 had documentation of having active bed sores and was seen by wound care. Patient #204 had a provider order to be admitted as an observation patient in ACU on 02/13/26 at 4:47 PM, and changed to inpatient status ACU on 02/14/26 at 6:01 PM. Patient #204 had a nursing order to be turned and repositioned every 2 hours as needed for a Braden Score less than 18 on 02/14/26 at 12:55 AM. Patient #204 had a documented Braden Score of 15 on 02/13/26 at 8:23 PM and a score of 13 on 02/14/26 at 7:49 AM. Patient #204’s Braden Score remained below 18 through discharge on 02/16/26. Patient #204 had the following documentations of being turned and repositioned every 2 hours: a. Patient #204 had documentation of repositioning on 02/14/26 at 12:06 AM that indicated repositioning assistance required (extensive). b. Patient #204’s next repositioning documentation was on 02/14/26 at 7:09 AM indicating repositioning was offered, patient declined (missing a period of approximately 7 hours). c. Patient #204 had documentation of repositioning on 02/14/26 at 4:20 PM indicating repositioning, other (patient able to shift in bed, offered repositioning, patient refused). d. Patient #204’s next repositioning documentation was on 02/14/26 at 9:00 PM indicating repositioning, assistance required, other (HOB elevated for dinner) (missing a period of approximately 4 ½ hours). e. Patient #204 had documentation of repositioning on 02/15/26 at 4:20 AM indicating assistance required (limited) patient is supine in bed, HOB elevated, pillows removed. f. Patient #204’s next repositioning documentation was on 02/15/26 at 8:10 AM indicating repositioning assistance required, other (offered reposition, patient repositioned to the right side, pillows used to reposition) (missing a period of approximately 3 ½ hours). g. Patient #204 had documentation of repositioning on 02/16/26 at 2:31 AM indicating repositioning assistance required (extensive), repositioned to the right side. h. Patient #204’s next repositioning documentation was on 02/16/26 at 6:03 AM indicating repositioning assistance required (extensive), patient moved to his back and positioned upward (missing a period of approximately 3 ½ hours). i. Patient #204 had documentation of repositioning on 02/16/26 at 8:45 AM indicating repositioning assistance required (total). j. Surveyor #2 found no other evidence of repositioning documentation and Patient # 204 was transferred to a higher level of care on 02/16/26 at 2:32 PM (missing a period of approximately 5 hours). 4. At the time of the review, Staff #202 verified the missing repositioning documentation. Item #3 - Emergency Department Vital Signs Based on document review and interview, the hospital failed to ensure that staff performed and documented timely and appropriate vital signs assessments according to accepted standards of care for 1 of 3 Emergency Department (ED) patients reviewed (Patient #203). Failure to perform specialized assessments for patients created a risk that patients would not receive timely medical treatment appropriate to their care needs and could result in poor patient outcomes or death. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Emergency Department - Nurse Documentation and Patient Assessment Guidelines,” Policy Reference ID #230.79, effective date 11/24, showed the following: a. It is the policy of Quincy Valley Medical Center that nursing documentation will conform to established standards for clinical documentation and regulatory requirements. b. Vital signs will be documented in flowsheets and a full set of vital signs (including temperature) will be documented every 1 hour and within 20 minutes of discharge at minimum, more frequently for higher acuity patients. 2. On 02/18/26 between 10:15 AM and 11:30 AM, Surveyor #2 and the Medical Records Supervisor/Pharmacy Tech (Staff #202) reviewed the medical records of 3 adult patients seen in the ED between 02/09/26 and 02/17/26. The review showed Patient #203 was seen in the ED with a chief complaint of a cat bite on the right hand. Patient #203 arrived to the ED at 4:09 PM and was discharged at 6:55 PM. Patient #203 had a heart rate of 57 beats per minute documented at 4:21 PM. Surveyor #2 found no other evidence of any vital signs documented for this visit. 3. At the time of the review, Staff #202 verified the missing vital sign assessments. .”

“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: 53163 . Based on observation, interview and document review, the Critical Access Hospital failed to maintain its hydrocollator according to the manufacturer’s scheduled cleaning frequency and their policy. Failure to keep the hydrocollator clean and maintained puts patients at risk of infection. Findings included: 1. Document review of the hospital’s policy, “Care/Maintenance of Hot Pack Machine,” Reference #7200.26, effective 01/04/99, showed that the hot pack machine will be cleaned twice monthly. Document review of the facility’s ‘Hydrocollator & Paraffin Cleaning/ Temperature Logbook’ showed that the hydrocollator had been cleaned on the following dates: 01/20/25, 05/21/25, 07/11/25, 10/03/25, 12/24/25, 01/16/26. 2. On 02/18/26 at 10:10 AM, Surveyor #4 and Surveyor #8 observed the facility’s hydrocollator located in the Physical Therapy Gym. The surveyor asked the Physical Therapy/Rehab Director (Staff #402) about the hydrocollator’s cleaning and temperature checking schedule. Staff #402 indicated this is done monthly by Physical Therapy Aides. The surveyor then asked the Lead Physical Therapy Aide (Staff #403) about the process, and she stated that the hydrocollator temperature and cleaning was done monthly and provided the cleaning logbook. Staff #403 stated she was not aware that the unit needed draining and cleaning every two weeks, but this would be started. .”

“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: 53163 . Based on document review and interview, the Critical Access Hospital (CAH) failed to implement emergency preparedness policies and procedures based on a current community or facility risk assessment that fully addresses subsistence needs for staff and patients who evacuate or shelter in place. Failure to fully develop policies and procedures for the subsistence needs of the CAH’s staff and patients risks unsafe conditions during an emergency. Findings included: 1. Document review of the CAH’s emergency preparedness program and policies, reviewed 02/17/26, showed there are specific procedures outlined for the provisions of water, food, medical and pharmaceutical supplies but not for sewage and waste disposal. 2. On 02/18/26 at 8:30 AM, Surveyor #4 and Surveyor #8 discussed the emergency preparedness policies for subsistence needs with the General Services Director (Staff #401). Staff #401 confirmed the current ‘Shelter in Place’ and ‘Emergency Food and Water’ policies had procedures for the provisions of water, food, medical and pharmaceutical supplies but did not include sewage and waste disposal provisions. Staff #401 later provided a draft Addendum Policy for the Emergency Food and Water policy that included provisions for sewage and waste disposal. .”

“This report is the result of an unannounced fire and life safety re-certification survey conducted at Quincy Valley Hospital in Quincy, Washington on February 18, 2026 by representatives of the Washington State Patrol, Fire Protection Bureau (WSP/FPB). The survey was conducted in concert with the Washington State Department of Health Services health survey team. The facility’s Director of Engineering Service accompanied the WSP/FPB surveyor during the physical tour of the facility. The facility is licensed for 8 beds and at the time of this survey the census was 0. The new section of the 2012 Life Safety Code was used in accordance with 42 CFR 482.41- Hospitals, Condition of Participation: Physical environment for the main hospital. The critical access hospital is an 49,232 square foot new construction two story structure of Type II-A construction with exits to grade and have all-weather surface discharges to the public way. The facility is protected throughout by a Type 13 fire sprinkler system and an automatic fire alarm system with corridor smoke detection. The facility is not in compliance with the 2012 Life Safety Code as adopted by the Centers for Medicare & Medicaid Services. Any citation that requires inspection, testing, or maintenance (ITM) is required to have the testing completed, paper results delivered, and any deficiencies found during the ITM corrected before the citation is cleared.”

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 NEW Building construction type and stories meets Table 18.1.6.1, unless otherwise permitted by 18.1.6.2 through 18.1.6.7. 18.1.6.4, 18.1.6.5 Construction Type 1 I (442), I (332), II (222) Not allowed non-sprinklered Any number of stories 2 II (111) Not allowed non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 1 story sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 18.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 31000 Based upon observations and staff interviews on February 18, 2026 between approximately 0815 and 1445 hours the facility has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the patients, staff and/or visitors within the facility. Findings include: Level 2 Stairwell 1 - separation in gypsum board above ceiling tiles was observed. Level 2 above cross corridor doors to Acute Care - approximate 12” x 6” penetration with IT cage running through it was observed. The above was discussed and acknowledged by the facility staff.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 31000 Based upon observations and staff interviews on February 18, 2026 between approximately 0815 and 1445 hours the facility has failed to maintain all means of egress continuously free of obstructions. This could inhibit the orderly exit of patients, staff, and visitors out of the building during an emergency and may prevent emergency responders from entering. Findings include: Stairwell 2 Level 1 in the means of egress has combustible materials stored in the stairwell. The above was discussed and acknowledged by the facility staff.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: *Required manual fire alarm system; and *Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and *Automatic sprinkler system, if installed; and *Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 31000 Based upon observations and staff interviews on February 18, 2026 between approximately 0815 and 1445 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close upon activation of the fire alarm. This could result in the passage of smoke or fire from one compartment into another compartment thereby exposing patients, staff, and/or visitors to the toxic products of combustion. Findings include: Wound care center - main entrance door was blocked open. The above was discussed and acknowledged by the facility staff.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 31000 Based upon documentation review, observation and staff interviews on February 18, 2026 between approximately 0815 and 1445 hours the facility has failed to maintain emergency backup lighting. This could render the means of egress dark and delay egress or fall injuries to patients, staff, and/or visitors. Findings include: Facility was unable to provide documentation of annual 90 minute power test on emergency battery backup lighting. Facility was unable to provide documentation of monthly 30 second test of the on emergency battery backup lighting prior to January 2026. The above was discussed and acknowledged by the facility staff.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 NEW Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 18.2.10.1 This Standard is not met as evidenced by: 31000 Based upon documentation review, observations and staff interviews on February 18, 2026 between approximately 0815 and 1445 hours the facility has failed to maintain proper exit signage. This could potentially misdirect patients, staff, and/or visitors during an emergency. Findings include: Facility was unable to provide documentation of annual 90 minute power test on emergency battery exit signs. Facility was unable to provide documentation of monthly 30 second test of the on emergency battery exit signs prior to January 2026. The above was discussed and acknowledged by the facility staff.”

“Laboratories CFR(s): NFPA 101 Laboratories Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered a severe hazard are protected by 1-hour fire resistance-rated separation, automatic sprinkler system, and are in accordance with 8.7 and with NFPA 99. Laboratories not considered a severe hazard are protected as hazardous areas (see K321). Laboratories using chemicals are in accordance with NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals. Gas appliances are of appropriate design and installed in accordance with NFPA 54. Shutoff valves are marked to identify material they control. Devices requiring medical grade oxygen from the piped distribution system meet the requirements under 11.4.2.2 (NFPA 99). 18.3.2.2, 8.7, 8.7.4.1 (LSC) 9.3.1.2, 11.4.3.2, 15.4 (NFPA 99) This Standard is not met as evidenced by: 31000 Based on observation and staff interview of February 18, 2026 between 0815 and 1445 hours the facility failed to maintain their laboratories in a safe and fire resistant manner in accordance with the referenced NFPAs. This could lead to the inability of staff or machinery to function as they should in the event of an emergency or exposed chemicals to magnify the effects of a fire and expose patients, staff, and visitors to these fire dangers. Findings include: Facility was unable to provide laboratory hood inspection report. Documentation on hood indicates the service was performed on June 26, 2025. The above was discussed and acknowledged by the facility staff.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: *residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2. *cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or *cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 31000 Based upon record review and staff interviews on February 18, 2026 between approximately 0815 and 1445 hours the facility has failed to conduct testing/maintenance of the hood and duct fire suppression equipment protecting the commercial cooking equipment. This could result in the failure of the system to operate properly which would endanger the patients, staff, and/or visitors within the facility. Findings include: Facility was unable to provide documentation of 2025 second semi-annual commercial hood ventilation system inspection and cleaning if inspection dictates. Report provided was dated March 18, 2025. The above was discussed and acknowledged by the facility staff.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 31000 Based on observation and staff interviews on February 18, 2026 between approximately 0815 and 1445 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure to notify staff of a problem with the fire alarm system. This could lead to the system not functioning as intended and lead patients, staff, and visitors within the building not being notified of a fire. Findings include: Electrical Panel 1LE1 in main electrical room did not have signage indicating the breaker for fire alarm control panel was in the panel as required by NFPA 70 2011 edition, section 760.121 The above was discussed and acknowledged by the facility staff.”

“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: 31000 Based on observation and staff interview on February 18, 2026 between approximately 0815 and 1445 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the patients, staff, and/or visitors within the facility. Findings include: Facility was unable to provide documentation of second and fourth quarter 2025 fire sprinkler inspection and service reports. Administration DAS closet - missing fire sprinkler head escutcheon ring. The above was discussed and acknowledged by the facility staff.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 31000 Based on observation and staff interviews on February 18, 2025 between approximately 0815 and 1445 hours the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This potentially delays a quick response to contain a fire from spreading which could expose and endanger patients, staff, and/or visitors within the facility. Findings include: Access to fire extinguishers exceeded 75’ travel distance requirement in the following locations: Roof top AHU Helipad NFPA 10 2010 edition, Table 6.2.1.1 The above was discussed and acknowledged by the facility staff.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 NEW Doors in smoke barriers have at least a 20 minute fire protection rating or are at least 1-3/4 inch thick solid bonded core wood. Required clear widths are provided per 18.3.7.6(4) and (5). Nonrated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Horizontal-sliding doors comply with 7.2.1.14. Swinging doors shall be arranged so that each door swings in an opposite direction. Doors shall be self-closing and rabbets, bevels, or astragals are required at the meeting edges. Positive latching is not required. 18.3.7.6, 18.3.7.7, 18.3.7.8 This Standard is not met as evidenced by: 31000 Based on observation and staff interviews on February 18, 2026 between approximately 0815 and 1445 hours the facility has failed to properly maintain fire/smoke barriers doors within the facility as capable of resisting the passage of smoke. This could result in the products of combustion traveling from one smoke compartment to another which would endanger the patients, staff, and/or visitors within the facility. Findings include: Cross corridor doors by Office 1-101 failed to latch when closed. The above was discussed and acknowledged by the facility staff.”

“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. 18.7.1.4 through 18.7.1.7 This Standard is not met as evidenced by: 31000 Based on documentation review and staff interview on February 18, 2026 between approximately 0815 and 1445 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for each quarter for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering patients, staff, and/or visitors. Findings include: June 2025 day time fire drill did not include time of drill. The above was discussed and acknowledged by the facility staff.”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This Standard is not met as evidenced by: 31000 Based on observation and staff interview on February 18, 2026 between approximately 0815 and 1445 hours the facility failed to maintain their medical gas equipment through testing and inspection possible leading to a problem not being detected, and thus place patients, staff, and visitors to the threat of an accelerated fire. The findings include: Medical gas and vacuum system report dated March 4, 2025 noted the following deficiencies without documentation of correct: Surgical vacuum - manual drain from receiver needs to be pipes to floor drain. Master alarm panel #2: Dew point high - compressor malfunction Carbon monoxide high - compressor malfunction lag pump in use - compressor malfunction Master alarm panel located in mechanical room does not meet code requirements. Emergency oxygen supply connection (ESOC) - fencing around ESOC has plastic (combustible) privacy panels in chain links. The above was discussed and acknowledged by the facility staff.”

“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: 31000 Based on documentation review, observation and staff interviews on February 18, 2026 between approximately 0815 and 1445 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the patients, staff, and/or visitors within the facility. Findings include: Facility was unable to provide documentation of generator acceptance testing after installation. NFPA 110 2010 edition, Section 7.13 Facility was unable to provide documentation of weekly inspections of the emergency generator. Facility was unable to provide documentation of monthly testing of the emergency generator, including testing and recording of electrolyte specific gravity on batteries. The above was discussed and acknowledged by the facility staff.”

“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: 31000 Based on observation and staff interviews on February 18, 2026 between approximately 0815 and 1445 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger patients, staff, and visitors in the facility due to the increased fire risk. Findings include: Laboratory - a non-medical grade multi-plug adapter was in use behind the Atellica Solution analyzer Physical Therapy Hydrotherapy - non-medical grade multi-plug adapter was in use The above was discussed and acknowledged by the facility staff.”