Three Rivers Hospital

“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 NKB021. .”

“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: 43911 . Based on interview and document review, the Critical Access Hospital’s Governing Body failed to periodically review their bylaws as directed in their bylaws. Failure to periodically review bylaws risks inappropriate oversight and outdated practice. Findings included: 1. Document review of the hospital’s document titled, “Public Hospital District No. 1, Okanogan and Douglas Counties, Washington, d/b/a Three Rivers Hospital, Board of Commissioners Bylaws,” dated 02/27/18, showed that the bylaws shall be periodically reviewed, at least once every two years and revised as appropriate. 2. On 02/05/25 at 3:30 PM, Surveyor #4 reviewed the hospital’s Board of Commissioners (governing body) Bylaws and meeting minutes from 2024 and 2025 to date. The surveyor noted that the bylaws had not been updated since 02/27/18. Surveyor #4 interviewed the Chief Operating Officer (Staff #401) about the bylaws and whether there were any updated versions. Staff #401 confirmed that the 2018 dated bylaws were the most current reviewed version. .”

“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 - Nephrostomy tube care policy Based on record review and interview, the hospital failed to develop and implement policies and procedures to define standards of care for nephrostomy tube patients. Failure to develop and implement policies and procedures risks inappropriate and/or ineffective patient care and poor patient outcomes. Reference: Agency for Clinical Innovation, Management of patients with nephrostomy tubes Nursing toolkit, (2022). Management principles in the acute care setting; all nephrostomy tubes must be checked for patency and abnormal signs or symptoms (e.g. pain, leakage, bleeding, tubing placement) at least once per 8-10-hour shift; at every bedside handover, or as required in the acute care setting. Findings included: 1. On 02/06/25 between 9:15 AM and 12:30 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201) reviewed the medical records of 2 inpatients and 4 Swingbed patients admitted to the medical/surgical unit. The review showed Patient #217 was a 64-year-old female admitted as a Swingbed patient to the medical/surgical unit on 09/27/24 with a diagnosis of strengthening (PT/OT) post pyelonephritis and a history of uterine cancer with a left sided nephrostomy tube. Surveyor #2 found no evidence of documented care for Patient #217’s nephrostomy tube. 2. On 02/06/25 at 10:15 AM, Surveyor #2 interviewed Staff #201 what the policy is for routine nephrostomy tube care. Staff #201 stated the facility does not have a policy for nephrostomy tube care, however the facility refers to Lippincott’s Nursing Procedures for care. Staff #201 reviewed Lippincott’s Nursing Procedures for nephrostomy tube care and could not find specific information pertaining to timeframes for nephrostomy tube care. 3. At the time of the review, Staff #201 verified there was no documentation in the medical record for nephrostomy tube care. Item #2 - Surgical time out Based on observation, interview, and document review, the Critical Access Hospital failed to implement its policy and procedure for completing a surgical time out for 1 surgical time out observed (Patient #203). Failure to systematically perform a time out risks medical errors and patient harm. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Fire Safety in the Operating Room,” Policy Stat ID 15421622, last approved 07/24, showed the patient’s fire risk needs to be communicated during the timeout procedure. 2. On 02/04/25 between 1:30 PM and 2:50 PM, Surveyor #2, the Chief Nursing Officer (Staff #201) and Surgical Services Manager (Staff #202) inspected the Operative Area. Surveyor #2 observed a surgical procedure of an inguinal hernia repair. Surveyor #2 observed that the surgical time out did not include a fire risk assessment or discussion. 3. After the observation, Staff #201 confirmed that there was not a fire risk assessment and discussion completed as part of the surgical time out process for the case observed as per policy. Item #3 - Chemical restraint orders Based on record review, interview, and document review of hospital policy and procedures, the hospital failed to ensure providers orders for restraint contained the appropriate order of restraints to be utilized for 2 of 2 patients placed in restraints reviewed (Patient #222 and #223). Failure to place complete provider orders increases the risk of incorrect restraint application and risks physical and psychological harm, loss of dignity, and violation of patient rights. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Use of Patient Restraints,” Policy Stat ID 17075325, last revised 11/24, showed the following: a. A restraint is defined as any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of the patient to move his/her arms, legs, body, or head freely. Use of measures to involuntarily restrain movement of the whole or a portion of a patient’s body; as a means of modifying a patient’s behavior, in a patient who does not require medical immobilization; adaptive support or those patients not requesting voluntary immobilization. b. A physical restraint is any manual method, or physical or mechanical device, material or equipment attached or adjacent to the patient’s body that he or she cannot easily remove, that restricts freedom of movement or normal access to one’s body. c. A chemical restraint is a drug used as a restraint is a medication used to control behavior or to restrict the patient’s freedom of movement and is not a standard treatment for the patient’s medical or psychiatric condition. d. Restraints will only be used when less restrictive methods are not sufficient to protect the patient or others from injury. The decision to restrain requires adequate and appropriate clinical justification. Restraint is to be applied for no longer than it is clearly needed and any doubts about the need for restraint should be resolved in favor of an alternative to restraint. e. Provider order should be obtained and documented, unless a licensed nurse authorizes its emergent use because the patient poses an immediate danger to self, staff, or others. f. Documentation entries in the patient’s record is relative to each episode of restraint use must be documented on the Restraint E-form, and must include the type of restraint authorized and duration of use. 2. On 02/06/25 between 2:10 PM and 3:15 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201), reviewed the medical records of 2 restraint patients. The review showed the following: a. Patient #222 was a 31-year-old female brought to the Emergency Department (ED) on 10/12/23 at 1:00 PM by her mother stating she is having a psychotic episode. Patient #222 had nursing documentation at 2:30 PM of increased agitation, pacing the room, pulling at clothing, going through drawers in the hospital room, throwing things on the floor, and throwing drawers on the floor. Patient #222 had nursing documentation at 2:45 PM of being at the triage desk, not making sense, provider attempted to talk to patient, and patient throwing items in the hallway. Patient #222 had a provider order to receive Haldol (an antipsychotic medication used to treat mental health conditions) 5 milligrams intramuscularly (IM) and Benadryl (a medication used in combination with antipsychotic medications to treat medical health conditions) at 5:20 PM. Surveyor #2 found no evidence of an order for chemical restraints. Patient #222 had nursing documentation at 4:40 AM that she eloped but had returned to the hospital and police assistance was requested to get her back in the hospital. Patient #222 had a provider order on 10/13/23 and was administered Benadryl 50 milligrams IM at 5:04 AM, Ativan (a medication used to treat anxiety) 2 milligrams IM at 5:05 AM, and Haldol 5 milligrams IM at 5:06 AM. Surveyor #2 found no evidence of an order for chemical restraints. b. Patient #223 was a 38-year-old male brought the ED on 02/24/24 at 8:34 PM by Sheriff for a domestic violence call and being severely agitated. Patient #223 had a provider order on 02/04/24 and was administered Ativan 2 milligrams IM at 8:54 PM, Benadryl 50 milligrams IM and Haldol 5 milligrams IM at 8:55 PM. Surveyor #2 found no evidence of an order for chemical restraints. 3. At the time of the review, Staff #201 verified the missing orders for chemical restraints. Item #4 - Restraint renewal orders Based on record review, interview, and document review of hospital policy and procedures, the hospital failed to ensure providers orders for restraint contained the appropriate order of restraints to be utilized for 1of 2 patients placed in restraints reviewed (Patient #222). Failure to place complete provider orders increases the risk of incorrect restraint application and risks physical and psychological harm, loss of dignity, and violation of patient rights. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Use of Patient Restraints,” Policy Stat ID 17075325, last revised 11/24, showed the following: a. A restraint is defined as any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of the patient to move his/her arms, legs, body, or head freely. Use of measures to involuntarily restrain movement of the whole or a portion of a patient’s body; as a means of modifying a patient’s behavior, in a patient who does not require medical immobilization; adaptive support or those patients not requesting voluntary immobilization. b. A physical restraint is any manual method, or physical or mechanical device, material or equipment attached or adjacent to the patient’s body that he or she cannot easily remove, that restricts freedom of movement or normal access to one’s body. c. Restraint will only be used when less restrictive methods are not sufficient to protect the patient or others from injury. The decision to restraint requires adequate and appropriate clinical justification. Restraint is to be applied for nor longer than it is clearly needed and any doubts about the need for restraint should be resolved in favor of an alternative to restraint. d. Orders for restraint are defined by specific time limits and the continued need for restraint will be reassessed within the time limit. e. The frequency for which a new order is required for behavioral restraints is 4 hours for adults over the age of 17. 2. On 02/06/25 between 2:10 PM and 3:15 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201), reviewed the medical records of 2 restraint patients. The review showed Patient #222 was a 31-year-old female brought to the Emergency Department (ED) on 10/12/23 at 1:00 PM by her mother stating she is having a psychotic episode. Patient #222 had nursing documentation at 4:40 AM that she eloped but had returned to the hospital and police where assistance was requested to get her back in the hospital. Patient #222 had a provider order for 4-point leather restraints to all 4 extremities on 10/13/23 at 4:45 AM and was placed in 4-point leather restraints at 4:55 AM. The 4-point leather restraints were discontinued at 12:35 PM. Surveyor #2 found no evidence of an order to renew restraints after the initial order at 4:45 AM (missing a period of approximately 3 ½ hours). 3. At the time of the review, Staff #201 verified the missing order to renew the restraints after the first hours. Item #5 - Face-to-Face Evaluation 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 (Patient #222 and #223). 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, “Use of Patient Restraints,” Policy Stat ID 17075325, last revised 11/24, showed when behavioral restraints are used a provider must assess the patient face-to-face within one hour. 2. On 02/06/25 between 2:10 PM and 3:15 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201), reviewed the medical records of 2 restraint patients. The review showed the following: a. Patient #222 was a 31-year-old female brought to the Emergency Department (ED) on 10/12/23 at 1:00 PM by her mother stating she is having a psychotic episode. Patient #222 had a provider order for 4-point leather restraints to all 4 extremities on 10/13/23 at 4:45 AM. Surveyor #2 found no evidence of a face-to-face assessment by a provider within one hour in the medical record. b. Patient #223 was a 38-year-old male brought the ED on 02/24/24 at 8:34 PM by Sheriff for a domestic violence call and being severely agitated. Patient #223 had a provider order for 4-point restraints on 02/24/24 at 8:30 PM. Surveyor #2 found no evidence of a face-to-face assessment by a provider within one hour in the medical record. 3. At the time of the review, Staff #201 verified the missing face-to-face assessments by the provider. .”

“AGREEMENTS AND ARRANGEMENTS CFR(s): §485.635(c)(4) The person principally responsible for the operation of the CAH under §485.627(b)(2) of this chapter is also responsible for the following: (i) Services furnished in the CAH whether or not they are furnished under arrangements or agreements. (ii) Ensuring that a contractor of services (including one for shared services and joint ventures) furnishes services that enable the CAH to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 47458 . Based on interview, document review, and review of the hospital’s quality and performance improvement program, the Critical Access Hospital failed to ensure that performance measures for patient care services furnished under arrangement or agreements (contracted services) were developed and evaluated through the hospital’s quality program as directed by 2 of 3 contracts reviewed. Failure to oversee the performance of all patient care services and departments risks provision of improper or inadequate care and adverse patient outcomes. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Contract Management,” Policy Stat ID 14134073, last approved 10/24, showed the following: a. Contract owners will complete an annual review of their contracts either with a physical Contract/Agreement Review Checklist form or in Intelligent Contract. If completing a physical form, the completed review should be uploaded for storage in Intelligent Contract. b. All contracts will be evaluated by the Compliance Officer on a rolling month-to-month basis as they become due, on or before the date of execution, using the “Contract Quality Review Checklist”. c. Reviewed contracts will be routed to the Chief Executive Officer (CEO) for final review. d. Upon review by the Compliance Committee and CEO, the contract/agreement and checklist will be routed to the Administrative Assistant for scanning, filing, and logging. 2. On 02/05/25 between 1:00 PM and 1:30 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201) reviewed 3 contracts. The review showed the following: a. The facility had a contract with AMN Healthcare for nurse staffing (previously the facility used a company called Medefis) dated 04/23. Surveyor #2 found no evidence of an annual review of the contracted service for AMN Healthcare or Mediefis. b. The facility had a contract for tele-pharmacy services provided by Medication Review that was updated on 02/20. Surveyor #2 found no evidence of an annual review of contracted service. 3. At the time of the review, Staff #201 verified that there was not annual review of the contracted services. .”

“RECORDS SYSTEM CFR(s): For each patient receiving health care services, the CAH maintains a record that includes, as applicable-- (i) Identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient; This Standard is not met as evidenced by: 47458 . Item #1 -Surgical informed consent Based on interview, record review, and review of policy and procedures, the Critical Access Hospital failed to properly obtain surgical informed consent as directed by the hospital’s policy and procedure for 5 of 5 patient consent’s reviewed (Patient #206, #207, #208, #209, and #210). Failure to properly obtain consent for treatment risks patients receiving care that may not be to the patient’s desires. Findings included: 1. Document review of the hospital policy titled “Informed Consent for Treatment” Policy Stat ID #11476877, last approved 11/22, showed informed consent for treatment must consist of a discussion between the patient and provider of: a. All the material facts that a reasonably prudent patient under similar circumstances would need to make an informed choice as to whether to receive the proposed treatment. b. The recognized serious possible risks, complications, and anticipated benefits involved in treatment administered and recognized possible alternative forms of treatment, including non-treatment. c. Alternatives to the proposed treatment include the reasonably possible risks, drawbacks, complications and expected benefits or effects of the proposed treatment. d. The nature and character of the proposed treatment. e. Potential complications or problems related to the treatment and recuperation from the treatment. f. The likelihood of achieving the treatment goals or anticipated outcomes. g. Verification that the patient understands the information and has had an opportunity to ask questions and have those questions answered to their satisfaction. h. The informed consent form is prepared by the attending physician or operating physician and is discussed with the patient by the physician. i. Documentation must clearly indicate that the patient has had the opportunity to ask any and all questions they may have about the proposed procedure. j. The nurse witnessing the signature of the patient signs, dates and times in the appropriate location. 2. On 02/05/25 between 9:55 AM and 11:00 AM, Surveyor #2, the Surgical Services Manager (Staff #202) and Chief Nursing Officer (Staff #201) reviewed the medical records of 5 patients receiving care in the Surgical Department. The review showed the following: a. Patient #206 had a right total knee arthroplasty surgery on 01/02/25. Surveyor #2 found no evidence the full disclosure and witness section on the informed consent form was signed by the patient. b. Patient #207 had a laparoscopic cholecystectomy (a surgical procedure to remove the gallbladder) on 01/21/25. Surveyor #2 found no evidence the witness section on the informed consent form was signed by the patient. c. Patient #208 had an open reduction and internal fixation (ORIF) of the right 5th metacarpal neck (a surgical procedure to fix a right-hand fracture) on 01/23/25. Surveyor #2 found no evidence the witness section on the informed consent form was signed by the patient. d. Patient #209 had an esophagogastroduodenoscopy (a procedure that allows a healthcare professional to examine the lining of the esophagus, stomach, and part of the small intestine) on 09/18/24. Surveyor #2 found no evidence the witness section on the informed consent form was signed by the patient. e. Patient #210 had a colonoscopy (a procedure that allows a healthcare professional to examine the inside of the colon and rectum) on 11/06/24. Surveyor #2 found no evidence the witness section on the informed consent form was signed by the patient. 3. At the time of the observation Staff #202 verified the missing witness signatures on the informed consent form. Item #2 - Consent to treat Based on interview, record review, and document review of hospital policy and procedures, the Critical Access Hospital failed to ensure that hospital staff properly obtained consent to treat for 6 of 16 patients reviewed (Patient #201, #204, #205, #214, #215, and #216). Failure to properly obtain consent for treatment risks patients receiving care that may not be to the patients’ desires. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Admission Forms, Advance Directives or POLST, Bill of Rights, Consent for Treatment Medicare Message,” Policy Stat ID 10813526, last approved 12/21, showed the following: a. All patients admitted to Three Rivers Hospital (inpatient or outpatient) will be given disclosure information and appropriate forms of consent pertaining to their care. b. If the patient has questions regarding the consent forms, these questions will be answered before obtaining signatures. c. Consent will be obtained before care/treatment is given except in an emergency situation. d. It is the Patient Registration Representative or Admitting Clerk responsibilities to provide the patient with proper consent forms and applicable disclosure statements at the time of admission. e. During hours when the Registration Department or Admitting staff is not present, nursing staff will provide these services. 1. On 02/04/25 between 3:10 PM and 4:15 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201) reviewed the medical records of patients receiving care in the hospital’s Emergency Department (ED) and transferred to a higher level of care. The review showed the following: a. Patient #204 was an 85-year-old seen in the ED and transferred to a higher level of care for a nosebleed on 01/16/25. Surveyor #2 found no evidence of a consent to treat form for this ED visit. b. Patient #205 was a 49-year-old seen in the ED and transferred to a higher level of care for saddle pulmonary embolism (a large blood clot in the artery of the lung) on 09/11/24. Surveyor #2 found no evidence of a consent to treat form for this ED visit. 2. Surveyor #2 interviewed Staff #201 regarding the process of obtaining consent to treat from patients. Staff #201 stated if the Registration Staff is not here, the Nursing Staff obtains signatures and later the forms get scanned into the patient’s medical record. At the time of the review, Staff #201 verified the missing consent to treat forms in the medical record. 3. On 02/05/25 between 1:30 PM and 4:00 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201) reviewed the medical records of 6 patients seen in ED. The review showed Patient #202 was a 7-year-old male seen in the ED on 02/02/25 with a chief complaint listed as nausea, vomiting, and chills. Surveyor #2 found no evidence of a consent to treat form for this ED visit. 4. At the time of the review, Staff #201 verified the missing consent to treat form in the medical record. 5. On 02/05/25 between 4:05 PM and 4:40 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201) reviewed the medical records of 3 patients who expired at the facility. The review showed the following: a. Patient #214 was a 72-year-old female seen in the ED on 12/29/24 for nausea, vomiting, and abdominal pain and expired on 12/30/24. Surveyor #2 found no evidence of a consent to treat form in the medical record for this visit. b. Patient #215 was an 84-year-old male admitted to the hospital on 10/02/24 for chronic non-healing extremity ulcer and expired on 10/07/24. Surveyor #2 found no evidence of a consent to treat form in the medical record for this visit. 6. At the time of the review, Staff #201 verified the missing consent to treat form in the medical record. 7. On 02/06/25 between 1:35 PM and 2:10 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201) reviewed the medical records of three patients receiving blood transfusions. The review showed Patient #216 was seen in the ED on 01/16/25 and had an order to transfuse two units of packed red blood cells for anemia. Surveyor #2 found no evidence of a consent to treat form in the medical record for this visit. 8. At the time of the review, Staff #201 verified the missing consent to treat form in the medical record. Item #3 - Blood transfusion consent Based on interview, record review, and document review of the hospital’s policy and procedure, the Critical Access Hospital staff failed to follow its policy and procedure for blood product transfusions for 1 of 3 patients (Patient #211). Failure to follow blood transfusion procedures according to acceptable standards of practice places patients at risk for transfusion reactions and complications. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Blood and Blood Components, Administration of,” Policy Stat ID 15750348, last approved 06/24, showed a consent form will be signed prior to blood transfusion, anyone refusing to accept blood must sign a “Refusal of Blood or Blood Products” form. 2. On 02/06/25 between 1:35 PM and 2:10 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201) reviewed the medical records of 3 patients receiving blood. The review showed Patient #211 had a provider order to receive three units of packed red blood cells on 11/26/24. Surveyor #2 found no evidence of a blood consent form in the medical record. 3. At the time of the review, Staff #201 verified the missing blood consent form. .”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 47458 . Based on observation, interview, and document review of the hospital’s policy, the Critical Access Hospital failed to implement its policy for surgical attire in the restricted areas of the surgical environment. Failure to ensure that staff members follow hospital policy for surgical attire places patients at risk for developing infections. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Surgery Department: Standards of Practice for Surgical Attire,” Policy Stat ID 14320700, last approved 10/23, showed that a beard is to be covered when entering the restricted areas and while preparing and packaging items in the clean assembly section of the sterile processing department. 2. On 02/04/25 between 1:30 PM and 2:50 PM, Surveyor #2, the Chief Nursing Officer (Staff #201) and Surgical Services Manager (Staff #202) inspected the Operative Area. Surveyor #2 observed a surgical procedure of an inguinal hernia repair. Surveyor #2 observed the Surgeon (Staff #203), two surgical technicians (Staff #204 and #205), and a certified registered nurse anesthetist (CRNA) (Staff #206) with exposed facial hair not completely covered by the facial mask. 3. At the time of the observations, Staff #201 verified the observation and stated that beards should be covered. .”

“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: 43911 . Based on observation, interview and document review, the Critical Access Hospital failed to maintain surfaces in a condition that is cleanable and sanitary. Failure to maintain cleanable surfaces in patient care areas puts patients at increased risk of infection. Findings included: 1. Document review of the hospital’s checklist titled, “Monthly Inspection Requirements,” no policy number or approval date, showed the maintenance department checklist for items to inspect during environment of care rounding. The checklist included general life safety items, including checking for wall penetrations, but did not include checking furnishings or surfaces for damages. 2. On 02/05/25 at 11:00 AM Surveyor #4 observed a discharge cleaning of patient room 21 with the Chief Operations Officer (Staff #401). During the observation, the surveyor noticed a large wood wall cabinet near the patient sink. The cabinet had several areas where the wood varnish was worn away. 3. During the observation, Surveyor #4 discussed the worn areas as being a non-cleanable surface with Staff #401. Staff #401 confirmed the damage. 4. On 02/06/25 at 2:30 PM Surveyor #4 toured the physical therapy/rehabilitation gym with Staff #401. During the tour, the surveyor observed a set of wood steps (used for physical therapy) with areas of worn varnish/seal on the hand railing. Staff #401 confirmed the wood was losing its varnish/seal and was no longer a cleanable surface in those areas. .”

“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: 47458 . Based on interview, record review, and review of policies and procedures, the Critical Access Hospital failed to develop and keep current an interdisciplinary comprehensive plan of care that provided measurable objectives and timeframes, included specialized services, and in consultation with the resident and the resident’s representative included the goals for admission and desired outcomes, resident’s preference and potential for future discharge, and discharge plans for 2 of 4 patients admitted to the hospital’s Swingbed program (Patient #220 and #221). Failure to develop an interdisciplinary comprehensive plan of care can result in the inappropriate, inconsistent, or delayed treatment of patient’s needs and may lead to patient harm and lack of appropriate treatment for a medical condition. Findings included: 1. On 02/06/25 between 9:15 AM and 12:30 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201) reviewed the medical records of 4 Swingbed patients admitted to the medical/surgical unit. The review showed the following. a. Patient #220 was an 84-year-old male who was admitted as an inpatient to the medical/surgical unit on 01/11/25 for right hip pain and difficulty ambulation, and on 01/15/25 Patient #220 was transferred to a Swingbed patient for strengthening. Patient #220 was discharged from the facility on 01/25/25. Surveyor #2 found no evidence of an interdisciplinary comprehensive care plan in the medical record. b. Patient #221 was a 79-year-old male who was admitted as a Swingbed patient for strengthening status post hip fracture on 07/29/24 and discharged on 08/15/24. Surveyor #2 found no evidence of an interdisciplinary comprehensive care plan in the medical record. 2. Surveyor #2 interviewed Staff #201 regarding the interdisciplinary comprehensive care plan process. Staff #201 asked the discharge planning nurse (Staff #207) regarding the interdisciplinary care plan process and Staff #207 stated the facility does not have a policy currently regarding interdisciplinary care plans but will work on creating one. Staff #207 stated the facility usually holds an interdisciplinary comprehensive care plan (care conference) with the patient’s provider, therapy, and nursing around every six days and documents the meeting in the discharge planning notes. 3. At the time of the review, Staff #201 verified the missing interdisciplinary comprehensive care plans in the medical records. .”

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(b) Policies and procedures. The [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 at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 43911 . Based on document review and interview, the Critical Access Hospital (CAH) failed to develop a policy for the CAH’s role during an 1135 waiver for providing care at an alternate care site. Failure to develop a policy for providing care at an alternate care site during an 1135 waiver risks the inability of the CAH to provide adequate care should they need to relocate patients during the activation of the emergency preparedness plan. Findings included: 1. Record review of the CAH’s emergency preparedness program and policies, reviewed 02/06/25, showed that no policy specifying the CAH’s role for providing care at alternate care sites under an 1135 waiver was present. 2. On 02/06/25 between 11:30 AM and 1:15 PM, Surveyor #4 interviewed the Facilities Director (Staff #402), the Director of Ancillary Services (Staff #403) and the Chief Medical Officer (Staff #404) about the elements of the emergency preparedness program. Staff #403 confirmed the current plan did not include a specific policy for providing care at alternate care sites under an 1135 waiver. .”

“This report is the result of an unannounced fire and life safety re-certification survey conducted at Three Rivers Hospital in Brewster, Washington on February 5 and 6, 2025 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. The facility’s Facilities Engineer/Maintenance Manager accompanied the WSP/FPB surveyor during the physical tour of the facility. The facility is licensed for 48 beds and at the time of this survey the census was 7. 42 CFR 485.623 - Critical Access Hospitals, Condition of Participation: physical plant and environment. The hospital licensed facility consists of two buildings. The 48 building is a two story structure with exits to grade and have all-weather surface discharges to the public way. The facility is not protected by a fire sprinkler system but has an automatic fire alarm system and single station smoke alarms. The building current has administrative functions and traveling staff sleeping quarters. The main hospital building is a one-story building with a partial basement and exits to grade and have all-weather surface discharges to the public way. The building is protected by a Type 13 fire sprinkler system throughout and an automatic fire alarm system with smoke detection. The facility is not in compliance with the 2012 Life Safety Code as adopted by the Centers for Medicare & Medicaid Services.”

“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: 50790 Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 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. The findings include: In the 48 Building on the second floor, the emergency exit door at the Provider Room in the mid-level has a slide lock preventing the door to be used as an exit. 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: 50790 Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 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. The findings include: 1. In the Basement ATS Room (EVS Storage) there was no battery operated emergency light in the generator equipment room. 2. In the Hospital Building in the mechanical room in the upstairs loft area that is housing the ATS equipment, there was no battery operated emergency light installed. The above was discussed and acknowledged by the facility staff.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 50790 Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 hours, the facility has failed to maintain doors and walls to hazardous areas. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger patients, staff and/or visitors. The findings include: 1. In the 48 Building on the first floor, the door to the corridor from the storage room labeled “Keep Out” over 50 square feet was not equipped with a self-closing device. 2. In the basement in the Hospital Building, the rated fire door that opens from the electrical room (EVS Supply Storage) was not equipped with a self-closing device. 3. In the 48 Building on the first floor, the rated fire door that opens from the PPE Room was not equipped with a self-closing device. 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: 50790 Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 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. The findings include: 1. The facility was unable to provide documentation showing the Fire Alarm system has been tested and maintained for the semi-annual inspection, testing, and maintenance within the past 12 months. 2. The facility has not maintained a nuisance log, which is required for a zoned fire alarm system, to allow sensitivity testing to be completed on five-year intervals. Sensitivity testing documentation states last testing was completed on 12-06-2021. Facility shall complete smoke detector sensitivity testing. 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: 50790 Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 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 hospital. The findings include: 1. The facility could not provide documentation indicating their automatic sprinkler system has received the annual forward flow test within the last twelve months for the 48 Building. 2. In the Hospital Building there were sprinkler heads in the basement electrical room that were obstructed by combustible material stored within 18 inches from the bottom of the sprinkler heads. 3. In the 48 Building on the first floor, in the utility room there was an escutcheon cap that was sliding off the fire sprinkler piping. 4. In the 48 Building on the first floor, in the fire riser room there was a broken escutcheon cap near the riser. 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: 50790 Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 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 hospital. The findings include: 1. In the 48 Building on the first floor, in the Kitchen the portable fire extinguisher was blocked by a garbage bin. 2. In the 48 Building on the first floor, in the generator room there were two unsecured fire extinguishers located on the shelves. The above was discussed and acknowledged by the facility staff.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 50790 Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 hours, the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment. The findings include: 1. In the 48 Building on the first floor, the door to the Pharmaceutical waste room did not fully close and latch. 2. In the 48 Building on the first floor, the fire door to the ER Intake desk there was a payment device cord that was blocking the fire drop door preventing it from fully closing and latching. 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 Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 50790 Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 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. The findings include: 1. In the 48 Building on the first floor, the Nurses breaker has a small penetration behind the fridge. 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 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 50790 Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 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. The findings include: In the 48 Building on the first floor, the rated fire door that opens from the Generator Room failed to fully close and latch when tested. The above was discussed and acknowledged by the facility staff.”

“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: 50790 Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730-1100 hours, the facility has failed to maintain electric equipment in a safe manner and in accordance with NFPA 70. This could endanger patients, staff, and visitors in the building by risk of fire, electrocution, or other harm. The findings include: In the 48 Building on the second floor, in the corridor near the Women’s Sleep room there was a broken and missing electrical outlet cover. 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. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 50790 Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 hours, the hospital 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. The findings include: The facility failed to note in several of the fire drill records the type of initiation device and location of the simulated emergency. The above was discussed and acknowledged by the facility staff.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 50790 Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 hours, the hospital has failed to prohibit the use of all space heaters in resident areas and non-approved heaters in staff areas. This could result in a fire due to the ignition of combustible materials that would place patients, staff, and/or visitors in danger. The findings include: 1. In the 48 Building on the second floor, there was a portable heater in the Credentialing Office with no automatic shut-off switch when tipped over. 2. In the 48 Building on the first floor, there was a portable heater in the Supply Storage with combustible storage within 3 feet of the heating element. 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: 50790 Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 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: The facility could not provide documentation showing periodic testing of the medical gas equipment. 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: 50790 Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 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. The findings include: 1. In the 48 Building on the first floor in the Maintenance Office there was an extension cord plugged into a power strip used in place of permanent wiring under the desk. 2. In the 48 Building on the first floor in the Maintenance Office there was an unfused multiplug adapter in use. 3. In the 48 Building on the first floor in the Maintenance Office there was a power strip (desk unit) with two power strips daisy-chained and in use. 4. In the Hospital Building on the first floor in the Kitchen Office there was an unfused power strip plugged into an unfused power strip. 5. In the Hospital Building on the first floor in the IT Office (Room 16) there was a power strip plugged into a power strip. 6. In the Hospital Building on the first floor in the Lab there was a fridge used for patient care plugged into a medical grade power strip, and not into a direct outlet. The above was discussed and acknowledged by the facility staff.”