Every finding on record at Cody Regional Health Spirit Mountain Hospice

Based on medical record review, and staff interview, the facility failed to ensure the POC included all pertinent information for 5 of 14 sample patients (#1, #2, #4, #5, #6). The findings were: --- 1. Review of the POC for patient #1 showed diagnoses that included dementia, anxiety, radiculopathy and osteoarthritis. The care needs and goals addressed skin integrity, comfort care, spiritual, and pain management. The following concerns were identified.            a. Observation during the home visit on 6/4/25 at 11:30 AM showed the patient was assisted by the spouse and nurse to stand and ambulate. The nurse donned gloves and assessed an open wound to the coccyx area. The nurse duffed gloves and performed hand hygiene.  The spouse revealed they were applying ointment to the coccyx wound.  b. Interview during a home visit on 6/4/25 at 11:30 AM with the spouse revealed the patient fell this morning into a desk. Further, she revealed the patient had more frequent falls in the last couple of weeks.c. The facility failed to ensure falls was addressed on the care plan. The POC showed under DME and supplies: “None at this time.” Under safety measures: it showed “Safety measures, precautions, and/or restrictions are in place.” The facility failed to include in DME’s gloves, and ointment. In the safety measures the facility failed to state what safety measure, precautions, and/or restrictions were in place.2. Review of the POC for patient #2 showed diagnoses that included malignant neoplasm of thyroid gland, atrial fibrillation pneumonia and retention of urine. The care needs and goals addressed skin integrity, comfort care, spiritual care, pain management, fall prevention, medication management. The following concerns were identified:                a. Observation during the home visit on 6/4/25 at 9:30 AM showed the patient had a bedside commode, incontinent briefs, grip bars in shower and by toilet, wheelchair, incontinent pads, cane, gloves and tegaderm dressings. The POC under DME and supplies only showed “Walker”.3. Review of the POC for patient #4 showed diagnoses that included chronic obstructive pulmonary disease, anxiety, chronic respiratory failure with hypoxia, personal history of nicotine dependence and altered mental status. The care needs and goals showed comfort care, spiritual, pain management, skin integrity, and oxygen management. The following concerns were identified:                a.  The DME and supplies showed “as needed at CRH Hospice House". The facility failed to include what supplies were needed.                b. The safety measures showed “Safety measures, precautions, and/or restriction are in place.” The facility failed to state what safety measure, precautions, and/or restrictions were in place.4. Review of the POC for patient #5 showed diagnoses that included secondary malignant neoplasm of brain, lung, bone, and large intestine and rectum, neoplasm related pain. The care needs and goals showed comfort care, spiritual, pain management, skin integrity, urinary catheter management, oxygen management. The following concerns were identified:                a. The DME and supplies showed “DME and supplies as needed.” The facility failed to showed what DME and supplies were needed.                b. The safety measures showed “Safety measures per Hospice House protocol”. The facility failed to showed what the safety measures were.5. Review of the POC for patient #6 showed diagnoses that included acute kidney failure, systemic inflammatory response syndrome of non-infectious origin with acute organ dysfunction, dementia, malignant neoplasm of bladder and benign prostatic hyperplasia without lower urinary tract symptoms.  The care needs and goals showed comfort care, pian management, skin integrity, urinary catheter management. The following concerns were identified:                a. The DME and supplies showed “DME and supplies as needed per the Hospice House.” The facility failed to show what DME and supplies were needed.                b. The safety measures showed “Safety measures, precautions, and/or restrictions are in place.” The facility failed to showed what the safety measures were.6. Interview with RN #2 on 6/4/25 at 12:30 PM revealed if a new staff were to take care of the patient, they would not know what the DMEs and safety measures were, based off the care plan.7. Interview with RN #4 on 6/4/25 at 1:45 PM revealed she did the care plans for the patients. She stated the staff would not know what DMEs were needed and what safety measures were needed.

Based on document review and staff interview, the facility failed to test and maintain the fire alarm system in accordance with the 2010 NFPA 72, National Fire Alarm and Signaling Code. Failure to properly test and maintain the fire alarm system could result in a malfunction or failure of the system, resulting in injury or death in the event of a fire. The deficiency affected the fire alarm system, and could affect all residents, staff, and visitors. --- Document review on 06/03/25 starting at 12:10 PM revealed that the facility failed to perform all required testing of the fire alarm system. No documentation was available at the time of the survey to confirm that the annual inspection and testing of the annunciator panels, notification devices, pull stations, heat detectors, smoke dampers, or smoke detectors had been completed in the last twelve (12) months. Documentation was available to confirm the fire alarm batteries had been inspected and tested in June of 2024, but no additional documentation was available to confirm any additional inspections or testing had been conducted in the last twelve (12) months. Interview with facility personnel revealed that the annual inspection and testing of the system was supposed to take place in January, but had not been completed as of the time of the survey. The annunciator panels, notification devices, pull stations, heat detectors, smoke dampers, and smoke detectors shall be inspected and tested annually, and the fire alarm system batteries shall be inspected and tested semi-annually. Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated that they were aware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency.  Ref: 2010 NFPA 72 Table 14.4.5(15)(i), Table 14.4.5(20), Table 14.4.5(15)(f), Table 14.4.5(15)(e), Table 14.4.5(15)(i), NFPA 90A 4.4.1, Table 14.4.5(6)(3), Table 14.3.1(3)(d)

Based on document review and staff interview, the facility failed to test and maintain the fire sprinkler system in accordance with the 2011 NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Failure to properly test and maintain the fire sprinkler system could result in a malfunction or failure of the system, resulting in injury or death in the event of a fire. The deficiency affected the fire sprinkler system, and could potentially affect all residents, staff, and visitors. --- Document review on 06/03/25 starting at 12:10 PM revealed that the facility failed to conduct all required inspections and tests of the fire sprinkler system.  No documentation was available at the time of the survey to confirm that the internal inspection of the fire sprinkler system had been conducted in the last five (5) years. An inspection of piping and branch line conditions shall be conducted every five (5) years for the purpose of inspecting for the presence of foreign organic and inorganic material. Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated that they were aware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency.  Ref: 2011 NFPA 25 14.2.1Document review on 06/03/25 starting at 12:10 PM revealed that the facility failed to correct identified deficiencies regarding the fire sprinkler system.  Documentation review at the time of the survey revealed that the antifreeze branch had been tested for the freezing point within the last twelve (12) months. The test revealed that the antifreeze solution had a freeze point at +20 degrees F. The antifreeze system protects the attic and garage, and both areas have the potential to reach temperatures below 20 degrees F. The annual fire sprinkler testing took place in October of 2024, and it noted the solution needed to be drained and replaced. If test results indicate an incorrect freeze point the system shall be drained, the solution adjusted, and the systems refilled.Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated that they were aware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency.  Ref: 2011 NFPA 25 5.3.4.3.2

Based on observation, document review, and staff interview, the facility failed to maintain the medical gas system in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to properly maintain the medical gas system could result in a malfunction of the system, resulting in injury or death. The deficiency affected the oxygen supply system, and had the potential to affect all residents that use that system. --- Document review on 06/03/25 starting at 12:10 PM revealed the oxygen supply was not being maintained at standard operating pressure. Documentation revealed that the medical gas system had been inspected in the last twelve (12) months. It was noted on the inspection report that the operating pressure for the oxygen supply was typically between 47 and 45 psi. Observation of the medical gas alarm panel revealed the oxygen supply pressure was at 47 psi. Standard operating pressure for oxygen supply shall be between 50 and 55 psi unless intentionally changed due to equipment or use that requires a different operating pressure. Where medical gas pressure is different from the standard operating pressure the gas piping system and shutoff valves shall be labeled with the nonstandard operating pressure used. Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated that they were aware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency. Ref: 2012 NFPA 99 Table 5.1.11; 5.1.11.2.2

Based on document review and staff interview, the facility failed to test and maintain the Essential Electrical System (EES) in accordance with the 2012 NFPA 99, Health Care Facilities Code, and 2010 NFPA 110, Standard for Emergency and Standby Power Systems. Failure to properly test and maintain the EES could result in a failure of the system, resulting in injury or death in the event of an emergency. The deficiencies affected the EES, and could affect all residents, staff, and visitors. --- Document review on 06/03/25 starting at 12:10 PM revealed that the facility failed to conduct all required testing of the emergency electrical generator. No documentation was available at the time of the survey to confirm that the four (4) hour load test had been conducted in the last three (3) years. Emergency electrical generators shall be tested every thirty-six (36) months for four (4) continuous hours under the available load. Interview with the facilities director at the time of the observation acknowledge the deficiency, but indicated that they were aware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency. Ref: 2012 NFPA 99 6.4.4.1.1.4; 2010 NFPA 110 8.4.9

Based on document review and staff interview, the facility failed to test and maintain the Patient Care Related Electrical Equipment (PCREE) in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to properly test and maintain PCREE could result in a failure in the equipment, resulting in injury or death. The deficiency affected PCREE in the facility, and could potentially affect any patients that utilize the equipment. --- Document review on 06/03/25 starting at 12:10 PM revealed that the facility failed to test all PCREE for electrical safety . Documentation was available at the time of the survey to demonstrate that the facility was conducting the required electrical safety testing on most PCREE in the facility including patient lifts and patient monitors. Documentation revealed that the electrical safety test was not being conducted for patient beds. Interview with facility staff confirmed the electrical safety test was not being conducted on patient beds. The physical integrity, resistance, leakage current, and touch current tests shall be conducted for all PCREE including patient beds. Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated that they were unaware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency.  Ref: 2012 NFPA 99 10.3

Based on observation and staff interview, the facility failed to properly store oxygen cylinders in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to properly store oxygen cylinders could result in damage to the cylinders and a release of oxygen gas, which could propagate the spread of smoke and fire, resulting in injury or death in the event of a fire. The deficiency affected the garage, and has the potential to affect all residents, staff, and visitors. --- Observation on 06/03/25 at 11:31 AM revealed an oxygen storage tank that was being improperly stored. Observation of the garage revealed a large liquid oxygen dewar tank being stored. The liquid oxygen dewar tank was labeled as having a capacity of 5,250 cubic feet of oxygen gas. Oxygen storage containers exceeding 3,000 cubic feet shall be secured with lockable doors or gates, shall be stored in a 1-hour fire resistance-rated room, shall be heated by indirect means, and shall be provided with a means to secure from falling. Observation of the room revealed the liquid oxygen dewar tank was not secured, and was being stored alongside combustible materials. Interview with facility staff revealed the tank is typically empty when stored, but is at times partially full. Interview with the maintenance personnel at the time of the observation acknowledge the deficiency, and indicated that they were unaware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency. Ref: 2012 NFPA 99 5.1.3.3.2

Based on document review and staff interview, the facility failed to conduct all required emergency preparedness testing. Failure to conduct all required emergency preparedness testing could result in improper execution of the emergency preparedness program in the event of an emergency. The deficiency affect the entire emergency preparedness plan. The findings were: Document review of the emergency preparedness plan on 05/26/22 starting at 11:30 AM revealed that the facility had activated the plan for the COVID emergency this year, but no information was available to confirm that a full-scale test or table top exercise had been completed in the last twelve months. A full-scale test or a table top exercise shall be conducted in a year where a facility has activated their emergency preparedness plan. Interview with the facility Administrator at the time of the exit acknowledged the deficiency. .

Based on document review and staff interview, the facility failed to test and maintain the fire alarm system in accordance with the 2012 NFPA 101, Life Safety Code, and 2010 NFPA 72, National Fire Alarm and Signaling Code. Failure to properly test and maintain the fire alarm system could result in inadequate operation of the system during an emergency, which could result in injury or death. The deficiencies affected one (1) of one (1) fire alarm system. The findings were: Document review on 05/26/22 starting at 10:15 AM revealed that the batteries for the fire alarm system had not been inspected as required. Document review revealed that the fire alarm system batteries had been tested and inspected during the annual inspection of the system, but at no other time during the last 12 months. The batteries for the fire alarm system must be inspected and have the load voltage tested every six months. Interview with maintenance staff at the time of the observation acknowledge the deficiency, and indicated that they were aware of the requirement. Interview with the Administrator at the time of the exit acknowledge the deficiency. Ref: 2012 NFPA 101 19.3.4.1, 9.6.1.3; 2010 NFPA 72 Table 14.3.1(3)(d) and Table 14.4.5(6)(3) Document review on 05/26/22 starting at 10:15 AM revealed that the smoke detector sensitivity test had not been conducted during the previous 24 month. The smoke detector sensitivity test shall be conducted once every 24 months. Interview with maintenance staff at the time of the observation acknowledge the deficiency, and indicated that they were aware of the requirement. Interview with the Administrator at the time of the exit acknowledge the deficiency. Ref: 2012 NFPA 101 19.3.4.1, 9.6.1.3; 2010 NFPA 72 Table 14.5(15)(i) .

Based on observation and staff interview, the facility failed to install the fire sprinkler system in accordance with the 2012 NFPA 101, Life Safety Code, and 2010 NFPA 13, Standard for the Installation of Sprinkler Systems. Failure to properly install the fire sprinkler system could result in injury or death in the event of a fire. The deficiency affected three (3) of three (3) exterior pergulas. The findings were: Observation on 05/26/22 at 9:05 AM revealed three pergulas attached to the exterior of the building that were over four (4) feet in width. Observation of the pergulas revealed that they were made of wood, with no indication that they were fire treated, and that they were not protected by sprinklers. Canopys and overhangs that are constructed of combustible materials and are over four (4) feet in width shall be protected by sprinklers. Interview with maintenance staff at the time of the observation acknowledge the deficiency, but indicated that they were unaware of the requirement. Interview with the Administrator at the time of the exit acknowledge the deficiency. Ref: 2012 NFPA 101 19.3.5.1, 9.7.1.1; 2010 NFPA 13 8.15.7.1 .

Based on document review and staff interview, the facility failed to inspect and test fire doors in accordance with the 2012 NFPA 101, Life Safety Code, and 2010 NFPA 80, Standard for Fire Doors and Other Opening Protectives. Failure to properly inspect and test fire doors could result in the doors not working properly which could result in injury or death in the event of a fire. The deficiency affected multiple fire doors in the facility. The findings were: Document review on 05/26/22 at starting at 10:15 AM revealed that the facility failed to conduct the annual inspection and testing of fire doors in accordance with the NFPA 80. Document review revealed that no information was available to indicate that the annual inspection and testing of fire doors was completed. All fire doors shall be inspected and tested once every 12 months. Interview with maintenance staff at the time of the observation acknowledge the deficiency, and indicated that they were aware of the requirement. Interview with the Administrator at the time of the exit acknowledge the deficiency. Ref: 2012 NFPA 101 19.7.6, 4.6.12.1; 2010 NFPA 80 5.2.1 .

Based on document review and staff interview, the facility failed to provide a letter of reliability in accordance with the 2010 NFPA 110, Standard for Emergency and Standby Power System. Failure to have a reliable source of natural gas for the essential electrical generator could result in failure of the essential electrical system (EES) which could result in injury or death in the event of a power outage. The deficiency affected one (1) of one (1) EES. The findings were: Document review on 05/26/22 at starting at 10:15 AM revealed that the facility failed to provide a reliable source of natural gas for the essential electrical generator. Document review revealed that no information was available to indicate that the provided source of natural gas for the generator was reliable, and had a low probability of interruption. Proof of reliability from the natural gas provider shall be provided. Interview with the Administrator at the time of the observation acknowledge the deficiency, and indicated that they were unaware of the requirement. Interview with the Administrator at the time of the exit acknowledge the deficiency. Ref: 2010 NFPA 110 5.1.4 .

Based on document review and staff interview, the facility failed to inspect and test the essential electrical system (EES) in accordance with the 2010 NFPA 110, Standard for Emergency and Standby Power System. Failure to properly inspect and test the EES could result in a failure of system, which could result in injury or death in the event of a power outage. The deficiency affected one (1) of one (1) EES. The findings were: Document review on 05/26/22 at starting at 10:15 AM revealed that the facility failed to conduct weekly inspections of the essential electrical generator. Document review revealed that no information was available to indicate that the weekly inspection of the generator was being completed. Essential electrical generators shall be inspected weekly. Interview with maintenance staff at the time of the observation acknowledge the deficiency, and indicated that they were aware of the requirement. Interview with the Administrator at the time of the exit acknowledge the deficiency. Ref: 2010 NFPA 110 8.4 Document review on 05/26/22 at starting at 10:15 AM revealed that the facility failed to conduct all monthly tests of the essential electrical generator batteries. Document review revealed that no information was available to indicate testing of the batteries was conducted during the months of August, July, or June of 2021. The batteries for the essential electrical generator shall be tested monthly. Interview with maintenance staff at the time of the observation acknowledge the deficiency, and indicated that they were aware of the requirement. Interview with the Administrator at the time of the exit acknowledge the deficiency. Ref: 2010 NFPA 110 8.3.7.1