HEALTH &WELFARE D E P A R T M E N T 0 F CERTIFIED MAIL: I D A H 0. January 31,2013

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1 C.L "BUTCH" OTTER- Governor RICHARD M. ARMSTRONG -Director I D A H 0 D E P A R T M E N T 0 F HEALTH &WELFARE DEBBY RANSOM, R.N., R.H.I.T- Chief BUREAU OF FACILITY STANDARDS 3232 Elder Street P.O. Box Boise, Idaho PHONE: (208) FAX: (208) fsb@dhw.iclaho.gov CERTIFIED MAIL: January 31,2013 Greg L. Maurer, Administrator Elmore Medical Center- Nursing Home 895 North 6th East, PO Box 1270 Mountain Home, Provider#: Dear Mr. Maurer: On January 22, 2013, a Facility Fire Safety and Construction survey was conducted at Elmore Medical Center- Nursing Home by the Department of Health & Welfare, Bureau of Facility Standards to determine if your facility was in compliance with State Licensure and Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid programs. This survey found that your facility was not in substantial compliance with Medicare and Medicaid program participation requirements. This survey found the most serious deficiency to be a widespread deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy, as documented on the enclosed CMS-2567, whereby significant corrections are required. Enclosed is a Statement of Deficiencies and Plan of Correction, Form CMS-2567, listing Medicare and/or Medicaid deficiencies, and a similar State Form listing licensure health deficiencies. In the spaces provided on the right side of each sheet, answer each deficiency and state the date when each will be completed. Please provide ONLY ONE completion date for each federal and state Tag in column X5 (Completion Date), to signify when you allege that each tag will be back in compliance. NOTE: The alleged compl.jance date must be after the "Date Survey Completed" (located in field X3) and on or before the "Opportunity to Correct" (listed on page 2). After each deficiency has been answered and dated, the administrator should sign both

2 Greg L. Maurer, Administrator January 31,2013 Page 2 of4 Statement of Deficiencies and Plan of Correction, Form CMS-2567 and State Form, in the spaces provided and return the originals to this office. Your Plan of Correction (PoC) for the deficiencies must be submitted by February 13, Failure to submit an acceptable PoC by February 13, 2013, may result in the imposition of civil monetary penalties by March 5, Your PoC must contain the following: What corrective action( s) will be accomplished for those residents found to have been affected by the deficient practice; How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action( s) will be taken; What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and, Include dates when corrective action will be completed. All references to federal regulatory requirements contained in this letter are found in Title 4 2, Code of Federal Regulations. Remedies will be recommended for imposition by the Centers for Medicare and Medicaid Services (CMS), if your facility has failed to achieve substantial compliance by February 26, 2013, (Opportunity to Correct). Informal dispute resolution of the cited deficiencies will not delay the imposition of the enforcement actions recommended (or revised, as appropriate) on February 26,2013. A change in the seriousness of the deficiencies on February 26,2013, may result in a change in the remedy. The remedy, which will be recommended if substantial compliance has not been achieved by February 26, 2013, includes the following: Denial of payment for new admissions effective April22, CPR (a)

3 Greg L. Maurer, Administrator January 31,2013 Page 3 of 4 If you do not achieve substantial compliance within tlrree (3) months after the last day of the survey identifying noncompliance, the CMS Regional Office and/or State Medicaid Agency must deny payments for new admissions. We must recommend to the CMS Regional Office and/or State Medicaid Agency that your provider agreement be terminated on July 22, 2013, if substantial compliance is not achieved by thattime. Please note that this notice does not constitute formal notice of imposition of alternative remedies or termination of your provider agreement. Should the Centers for Medicare & Medicaid Services determine that termination or any other remedy is warranted, it will provide you with a separate formal notification of that determination. If you believe these deficiencies have been corrected, you may contact Mark P. Grimes, Supervisor, Facility Fire Safety and Construction, Bureau of Facility Standards, 3232 Elder Street, PO Box 83720, Boise, ld , Phone#: (208) , Fax#: (208) , with your written credible allegation of compliance. If you choose and so indicate, the PoC may constitute your allegation of compliance. We may accept the written allegation of compliance and presume compliance until substantiated by a revisit or other means. In such a case, neither the CMS Regional Office nor the State Medicaid Agency will impose the previously recommended remedy, if appropriate. If, upon the subsequent revisit, your facility has not achieved substantial compliance, we will recommend that the remedies previously mentioned in this letter be imposed by the CMS Regional Office or the State Medicaid Agency beginning on January 22, 2013, and continue until substantial compliance is achieved. Additionally, the CMS Regional Office or State Medicaid Agency may impose a revised remedy(ies), based on changes in the seriousness of the non-compliance at the time of the revisit, if appropriate. In accordance with 42 CFR , you have one opportunity to question cited deficiencies through an informal dispute resolution process. To be given such an opportunity, you are required to send your written request and all required information as directed in Informational Letter # Informational Letter # can also be found on the Internet at: htto :/ lhealthandwelfare.idaho. gov /Providers/ProvidersF aciliti es/statef ederalprograms/n ursingf a ciliti es/tabidl 4 34/Default.aspx Go to the middle of the page to Information Letters section and click on State and select the following:

4 Greg L. Maurer, Administrator January 31,2013 Page 4 of 4 BFS Letters (06/3 0/11) Long Term Care Informal Dispute Resolution Process R Request Form Tills request must be received by February 13,2013. If your request for informal dispute resolution is received after February 13, 2013, tbe request will not be granted. An incomplete informal dispute resolution process will not delay the effective date of any enforcement action. Thank you for tbe courtesies extended to us during tbe survey. If you have any questions, please contact us at (208) Sincerely, 'ikr -~a-:--- Mark P. Grimes, Supervisor Facility Fire Safety and Construction MPG/dmj

5 (X4) 10 KOOO (X1} PROVERJSUPPLIERICLIA SUMMA.RY (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATOR OR LSC ENTIFYING INFORMATION) INITIAL COMMENTS The facility is a single story Type V(111) wing located within a Critical Access hospital. The facility was built in 1965 with major renovations and additions in , most of which were in the hospital portion of the building. Renovation to the nursing home was completed in The facility is fully sprinklered with a new sprinkler system installed in March 2009 and has a recently updated fire alann system. Currently the facility is licensed for 38 SNF/NF beds. The following deficiencies were cited during the annual life safety code survey conducted on January 22, The facility was surveyed under the LIFE SAFETY CODE, 2000 Edition, Existing Health Care Occupancy, and 42 CFR The survey was conducted by: A. BUILDING 01 -ENTIRE NF WING B':WING -""-==---- 'STREET ADDRESS, CllY, STATE, ZIP CODE 895 NORTH l 6TH EAST MOUNTAIN HOME, 1D KOOO OMB NO !22/2()13 (X5) Tom Mroz, CFI-11 Health Facility Surveyor Facility Fire/Life Safety & Construction Program K 018 NFPA 1 Oi LIFE SAFETY CODE STANDARD SS=F Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1% inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting are permitted K018 Roller latches are prohibited by CMS regulations in all health care facilif!er REPRESEI'JTATIVE'S SIGNATURE TITLE (X6) men nding with n ast risl< (") denotes a deficiency which the instit on may be excused from correcting providing it is determined that other safeguar. provi sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disdosable 90 days fa!lowing the te of s rvey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. DNOQ21 If continuation sheet Page 1 of 17

6 CEI'-JTERS FOR MEDICARE & MEDICA SERVICES AND PlAN OF CORRECTION NAME OF PROVER OR SUPPUER (X4) PREFtx (X1) PROVERISUPPLIERJCLIA SUMMARY (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATOR OR LSC ENTIFYING INFORMATION) A BUILDING 01 - ENTIRE NF WING B. WING 895 NORTH l 6TH EAST PROVlDER'S PLAN OF CORRECTION OMB NO /22/2013 (X5) K 018 Continued From page 1 K 018 This Standard is not met as evidenced by: Based on observation and interview, the facility failed to protect an opening in a corridor wall with a door that was capable of resisting the passage of smoke. This potentially exposed residents to a smoke/fire environment The deficient practice affected one of two smoke compartments, staff and 25 residents. The facility has the capacity for 38 beds and at the time of the survey the census was25. Findings include: Observation on 01/22/13 at 10:48 a.m., revealed that the Activities storage room door had a 12 inch by 14 inch louver at the bottom of door. The door was not smoke resistive. Interview with the facility Maintenance Engineer on 01/22/13 at 10:48 a.m., revealed the facility was not aware the Activities storage room door was not smoke resistive. The finding was acknowledged by the Administrator and verified by the Maintenance Engineer at the exit interview on 01/22/13. K018 The louver in the Activities Storage Room door has been blocked from the back side. All other doors have been inspected for transfer grill deficiencies. Maintenance staff will be educated on the requirements ofnfpa 101, and will monitor the installation of all new doors to ensure this deficiency doesn't occur again. 2/26/13 Actual NFPA Standard: NFPA 101, Transfer Grilles. Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors. DNOQ21 If continuation sheet Page 2 of 17

7 (X1) PROVER!SUPPLIERICLIA ENTIFICATION NUMBER A. BUILDING 01 -ENTIRE NF WING OMB NO (X4) B. WING~ l SUMMARY (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATOR OR LSC ENTIFYING INFORMATION) GROSS-REFERENCED TO THE APPROPRIATE 01/22/2013 {X5) K018 Continued From page 2 Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain fiammable or combustible materials shall be permitted to have ventilating louvers or to be undercut. K 018 K 029 NFPA 101 LIFE SAFETY CODE STANDARD SS=F One hour fire rated construction (with % hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with and/or protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted K029 This Standard is not met as evidenced by: Based on observation and interview, the facility failed to provide separation of hazardous areas from other areas in the facility. This potentially exposed residents to a smoke/fire environment The deficient practice affected one of two smoke compartments, staff, and 25 residents. The facility has the capacity for 38 beds with a census of 25 the day of survey. Findings include: 1. Observation on 01/22/13 at 11:28 a.m., revealed that the door to the shower room opposite the laundry storage room was not equipped with a self closing device. The shower room was in excess of 50 square feet and was being used for storage of combustibles, i.e. adult K029 1&2) Self closing device is being installed on the shower room door & the transfer grill blocked off. Maintenance staff and the Director of Nursing Services will be educated on the requirements of NFPA 101, The Director of Nursing will monitor the self closing door for two weeks to ensure it is functioning properly. All other doors have been inspected for self closing device deficiency. To ensure this deficiency doesn't occur again, Maintenance staff will monitor when installing doors and through work orders. 2/26/13 DNDQ21 If continuation sheet Page 3 of 17

8 (X4)1D (X1) PROVER/SUPPLIERJCLlA A BUILDING 01 - ENTIRE NF WING B. WING------~--- l SUMMARY (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATOR OR LSC ENTIFYING INFORMATION) Printed: 01/ {X5) K 029 Continued From page 3 diapers in cardboard boxes. Interview with the Maintenance Engineer on 01/22/13 at 11:28 a.m., revealed that the facility was not aware of the requirement for combustible storage rooms in excess of 50 square feet to be equipped with self closing devices. 2. Observation on 01/22/13 at 11:30 a.m., revealed that the door to the shower room opposite the laundry storage room had a transfer grill The shower room was in excess of 50 square feet and was being used for storage of combustibles, i.e. adult diapers in cardboard boxes. Interview with the Maintenance Engineer on 01/22/13 at 11:28 a.m., revealed that the facility was not aware that the exemption allowing transfer grills in shower rooms was negated when combustible storage was introduced to the shower room. The finding was acknowledged by the Administrator and verified by the Maintenance Engineer at the exit interview on 01/22/13 Item #1 Actual NFPA Standard: NFPA 101, Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system. The doors shall be self-closing or automatic-closing. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. Item #2 Actual NFPAStandard: NFPA 101, Transfer Grilles. Transfer grilles, regardless of whether they are K029 DNOQ21 If continuation sheet Page 4 of 17

9 ELMORE lllled CTR- NURSING HOME {X1) PROVERISUPPLlERJCLlA (X4}!D l SUMMARY (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATOR OR LSC ENTIPfiNG INFORMATION) A. BUILDING 01 -ENTIRE NF WING B. WING STREET ADDRESS, Cf1Y, STATE, ZIP CODE COMPLEfED (XS) K 029 Continued From page 4 protected by fusible link-operated dampers, shall not be used in these walls or doors. Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials shall be permitted to have ventilating louvers or to be undercut K 038 NFPA 101 LIFE SAFETY CODE STANDARD SS=F Exit access is arranged so that exits are readily accessible at all times in accordance with section K029 K038 This Standard is not met as evidenced by: Based on observations and staff interview, the facility failed to assure that exit accesses are readily accessible to evacuate the facility at all times. This potentially prevents residents from leaving a smoke or fire environment This deficient practice affected three of seven smoke comparrments, staff, and 25 residents. The facility has the capacity for 38 beds with a census of 25 the day of survey. Findings include: 1.) Observation on 01122/13 at9:25 a.m., revealed that the north east exit enclosure to the exterior from the Multi-Purpose Room had been utilized for storage. Interview on 01122/13 at 9:25 a.m., with the Maintenance Engineer revealed the facility was aware storage was prohibited in this area. K038 1) Storage has been removed from the northeast exit enclosure to the exterior from the Mnlti-Pui]Jose Room. Staff will be educated about prohibited storage in the exit enclosure. DNS or designee will monitor to ensure compliance. 2/26/13 2.) Observation on 01/22/13 at 10:54 a.m., revealed that the exit by room 20 discharged onto DNOQ21 If continuation sheet Page 5 of 17

10 Feo :25PM Elmore Medical Center DEPARTMENT OF HEALTH N~D HUMAN SERVICES CENTERS FOR MEDICARE & MEDICND SERVICES STATEMENT OF OEFICIENCIES AND PLAN OF CORREC110N NAME OF PROVER or SUPPLIER E(..MORE MED GTR.- NURSING HOME (X4} (X1} PROVEP.JSUPPLIERIGLIA BmFICATION NUMBER; > SUMMARY STATEMENT OF DERCIENCIES (Eil.CH DEFJCIE!\tGY MUST 3E P'R~C~;;DED BY FULL REGlJLATO~Y OR LSC ENTIFYING INFORMATION} K 038 Continued From page 5 an approximate 15 ' walkway that was covered in approximately 2-3 inches of snow with no clear path leading to a public way. The exit was identified as a required emergency ex~ on the facility evacuation plan and was identified by an ernerge11cy illurr inated exit sign. Interview with the Maintenanca Engineer on 01/22113 at i 0:54 a.m., revealed that the facility does not use the.. designated exit, and was not aware that it was requirod to be kept cie8n. of snow Bi1"d piovidb a surface usable for evacuation l)y patients with walkers or wheelchairs during all weather cooditions for travel to the public way. 3.) Observation on 01/22113 at 10:5oa.m. revealed!hal!he exit by room 20 discharged into a concrete patio area for resident use. The exit was identified as a required emergency exit or> the facility evacuation plan and was identified by an emergency illuminated ex~ sign. The exit from the patio to the public way was four>d to be locked With a keyed padlock requiring a key to exil The exit was not locked for exclusively clinical needs. Interview on 01/22/13 at 10;56 a.m. with the Maintenance Engineer revealed the Charge Nurse kept the key locked in the med cart and!he facility was not aware of the requirement to be able to open the exit gate without a key or that all staff carry a key at all times. 4.) Observation on 01/22113 at 11:16 a.m. revealed that the cross corridor doors in the sou\h wing were fo1.1nd to be locked with a magnetic Jock requiring an access control card to exit thereby eliminating the second means of egress from theadminislratiof! wing. The exit was identified as a required emergency exit on!he facility avacuatlon plan and was identified by an emergency illuminated exit sign. Interview on 01/22113 a! 11:16 a.m., with the Maintenance (X2) MULTIPLE CONST'RUCnON A. BIJILDII<G 01 - ENTIRE NF WING B. WING STR.EET ADDRESS. CI1Y, STATE, ZIP CODE MOUNTAIN HOME, & KD3B No PROVER'S PlAN OF CORRECTION (f::ach CORRECTl\IEACTION SHOULD BE CRDSS-REF'!::RENCED TO THEAPPR.OPRlATE DEFICIEr-lcY} P. 2 Printed: Oi/ COMPLEfED 2&5) Snow has boon removed. from exit by Room 20 and west con:;dor exit Those areas have; been added to the snow :removal procedures- 01/22!2013 Maintooance staff will be cducared about l~a!ol, 7.1QJ,~19.2.l OJ;!()_ 7.2.L.?:~~t. _. accoss requirements. 3) The key is availabl the Nuu;es' Station and a memo has sent to staff DNS or designee will omtor through LTC initial,orientation d annuill mandatory education. 4 & 6) lnstalling emergency exit ovtrride button on the ox.it side of South Wing and the two oross oorridor doors in the hospital X-Ray/ Ultrasound wing. Completion of wtirk will bo mouimrcd by Maintenance staff...5) ;!,.,r~ ~(,? Pt/1 tjitt;ll'rr' IXSJ COMPLEflON OATE /GSH -(() ~U-~ 4-.SO~ff ~ tp~&-/ff. /-r-h,h/'t:':ll R/1 ;Zf<I///,R 4 /}I"'r,.,VA t(sj>d df PV,&/.J ~,il/>md.f' p)/cl ~#/:tal - t)y/?fl ~W? v.-?.t'j, q/?lj;//a ptj ';fb'i!h_.& iv# FORM CMS-2867(02-99) Prevlous Versions Obsolete DNOQ21 ()r,.t:: l'r. li continuation sheet Page B of 11

11 :--.. DEPARTMENT OF HEALTH AND HUMAN SERVICES STATEMEI>ITQ< DEFICIENCIES Al\10 PLA.N OF CORRECTION (X4) K038 (X1) PROVlDERISUPPL!ERJCLlA A. BUILDING 01 -ENTIRE NF WING B. WING &95 NORTH l 6TH EAST SUMMARY (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATOR OR LSC ENTIFYING INFORMATION) Continued From page 6 Engineer revealed the facility was not aware of the requirement to be able to open the exit door without a key, tool, or special knowledge. K038 (EJ\CH CORRECTIVE ACTION SHOULD BE 01122/2013 (X5) 5.) Observation on 01122/13 at 11:4.0 a.m., revealed that the west conidor exit discharged onto an approximate 15' walkway that was covered in approximately 2-3 inches of snow with no clear path leading to a public way. The exit was identified as a required emergency exit on the facility evacuation plan and was identified by an emergency illuminated exit sign. Interview with the Maintenance Engineer on 01/22/13 at 11:40 a.m., revealed that the facility does not use the designated exit, and was not aware that it was required to be l<ept clean of snow and provide a surface usable for evacuation by patients with walkers or wheelchairs during all weather conditions for travel to the public way. 6.) Observation on 01/22/13 at 1:05 p.m., revealed that the two cross corridor doors in the hospital X-Ray/Ultrasound wing were found to be capable of being locked with a magnetic lock requiring a key to exit thereby eliminating the second means of egress from the Surgery and Cat Scan wings. The exits were identified as a required emergency exit on the facility evacuation plan and were identified by emergency illuminated exit signs. Interview on 01/22/13 at 1:05 p.m., with the Maintenance Engineer revealed the facility was not aware that locks, if provided, shall not require the use of a key, The findings were acknowledged by the Administrator and verified by the Maintenance Engineer atthe exit interview on 01/22/13. DNOQ21 li continuation sheet Page 7 of 17

12 (X4) (X1) PROVER/SUPPLIERICLIA A BUILDING 01 - ENTIRE NF WING B. WING l MOUNTAIN HOME, SUMMARY 10 (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATOR OR LSC ENTIFYING INFORMATION) Printed: 01/ /2013 (X5) K038 Continued From page 7 Actual NFPA Standards: I K038 Item #1: NFPA 101, Means of Egress Reliability Furnishings and Decorations in Means of Egress No furnishings, decorations, or other objects shall obstruct exits, access!hereto, egress therefrom, or visibility thereof. Items # 2 and #5: NFPA 101, Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Items #3, #4 and #6 NFPA 101, Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. K043 DNOQ21 lf continuation sheet Page 8 of 17

13 DEPARTMENT OF HEALTH AND HUMAN SERV!C~;~~ AND PLJ\N OF CORRECTION (X1) PROVERISUPPUERICLIA A. BUILDING 01 - ENTIRE NF WING B. WING 01122/2013 (X4) ld SUMMARY [ (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY!! OR LSC ENTIFYING INFORMATION) 10 (X5) K043 Continued From page K043 This Standard is not met as evidenced by: Based on observation and interview, the facility failed to provide resident room doors that opened readily from the egress side. This potentially prevents occupants from leaving a smoke or fire environment. This deficient practice affected one of two smoke compartments, staff, and 2 residents. Findings include: Observation on 01/22/13 at 11:10 a.m. revealed that the exit access door from resident room #19 and #20 had a key lock on both sides of the resident room door. The locking arrangement did not ensure free access to the corridor from the inside of the resident room. Interview on 01/22113 at 11:10 a.m. with the Maintenance Engineer revealed the facility was not aware the use of key locks had the potential to trap residents in their room and prohibit occupants from exiting in an emergency. K043 Key locks on Rooms 19 & 20 have been removed and overlayed with metal. All resident doors have been inspected to ensure facility-wide compliance. Maintenance staff and the Director of Nursing Services will be educated about the requirements ofnfpa Maintenance staff will no longer install key locks on resident doors. 2/26/13 The finding was acknowledged by the Administrator and verified by the Maintenance Engineer at the exit interview on 01/22/13. Actual NFPAStandard: Locks shall not be permitted on patient sleeping room doors. Exception No. 1: Key-locking devices that restrict access to the room from the corridor and that are operable only by staff from the corridor side shall be permitted. Such devices shall not restrict egress from the room.. Exception No. 2: Door-locking arrangements I FORM CMS~2567(02~99} Previous Versions Obsolete DNOQ21 If contlnuation sheet Page 9 of 17

14 (X4) (X1) PROVERISUPPLJERICLIA A BUILDING 01 -ENTIRE NF WING B. WING 895 NORTH l 6TH EAST SUMMARY (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATOR OR LSC ENTIFYING INFORMATION) 01/22/2013 (XS) K043 Continued From page 9 shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that keys are carried by staff at all times. K043 K 050 NFPA 101 LIFE SAFETY CODE STANDARD SS=F Fire drills are held at 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. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9 PM and 6 AM a coded announcement may oe used instead of audible alarms K050 This Standard is not met as evidenced by: Based on observation, record review and interview, the facility failed to provide documented fire drills for third shift of the second and fourth quarter in the year This potentially hampers a rapid response that would expose residents to smoke and fire in the facility. The deficient practice affected two smoke compartments in the facility, staff, and all residents. The facility has the capacity for 38 beds and at the time of the survey the census was 25. Findings include: Observation during record review of the facility's fire drill reports for the 12 month period preceding the survey on 01/22113 at 9:15a.m., revealed that the facility was unable to provide a documented fire drill for the third shift of the second and fourth KOSO Fire drills on the 3'd shift will be conducted the second week in Feb Mailltenance staff will be educated about the requirements ofnfpa 101, and flre drills will be conducted one per shif~ per quarter. Maintenance Manager, or designee, will schedule necessary drills quarterly and monitor to ensure compliance. 2/26/13 DNOQ21 If continuation sheet Page 1 a of 17

15 DEPARTMENT OF HEAlfH AND HUMAN SERVICES PJ\10 PlAN OF CORRECTION (X4) (X1} PROVER!SUPPLIERICL!A A. BUILDING 01 - ENTIRE NF WING B. WING 895 NORTH l 6TH EAST MOUNTAIN HOME, 1D SUMMARY (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGUl..C..TOR OR LSG ENTIFYING INFORMATION) PROVER'S PLAN OF CORREC!ION {Ef\.CH CORRECTIVE ACTION SHOULD BE 01/ (X5) COMPLEfiON K 050 Continued From page 10 quarter of Interview with the Maintenance Engineer on 01/22/13 at 9:15a.m. revealed the. facility was unaware of the missing fire drili documentation. K050 The finding was acknowledged by the Administrator and verified by the Maintenance Engineer at the exit interview on 01/22/13. Actual NFPAStandard: NFPA 101, Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nursas, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.. K 062 NFPA 101 LIFE SAFETY CODE STANDARD SS=F Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically , , NFPA 13, NFPA25, K062 This Standard is not met as evidenced by: Based on observation, record review and interview, the facility failed to ensure annual inspection, testing and maintenance of the automatic fire sprinkler system. This has the potential to expose residents to a fire or smoke environment. The deficient practice affected two of two smoke compartments, staff, and 25 K062 Fire Sprinkler System inspection completed January 28,2013 (see attached). Maintenance staff will be educated onnfpa 25, , 2-1, and and schedule inspection annually. Maintenance Manager, or designee, will monitor to ensure compliance. 2/26/13 DNOQ21 If continuation sheet Page 11 of 17

16 (X4)1D (X1) PROVlDER/SUPPLIERJCUA SUMMARY (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATOR OR LSC ENTIFYING INFORMATION) A. BUILDING 01 -ENTIRE NF WING B. WING 895 NORTH l 6TH EAST 01/22/2013 (XS) K062 Continued From page 11 residents. The facility. has the capacity for 38 beds with a census of 25 the day of survey. Findings include: Observation during record review of the facility's automatic fire sprinkler system's inspection and testing reports for the 12 month period prior to the day of survey on 01/22/13 at 9:25 a.m., the facility was unable to provide a documented annual inspection, testing and maintenance report for the automatic fire sprinkler system. Interview with the Maintenance Engineer on 01/22/13 at 9:25a.m., revealed that the facility was late scheduling the inspection. The finding was acknowledged by the Administrator and verified by the Maintenance Engineer at the exit interview on 01/22/13. Actual NFPAStandard: NFPA25, Every required sprinkler system shall be continuously maintained in proper operating condition. Actual NFPA Standard: NFPA 25, 2-1. The minimum requirements for annual routine inspection, testing, and maintenance of sprinkler systems shall conform to Table 2-1 that shall be used to determine the system components to be tested and the minimum required frequencies for inspection, testing, and maintenance. Actual NFPA Standard: NFPA 25, Annually, prior to the onset of freezing weather, buildings with wet pipe systems shall be inspected to verify that windows, skylights, doors, ventilators, other openings and closures, blind spaces, unused attics, stair towers, roof houses, and low spaces under buildings do not expose water-filled sprinkler piping to freezing and to verify that adequate heat [minimum 40 F (4.4oC)] K062 DNOQ21 If continuation sheet Page 12 of 17

17 STATEMENT OF DEFICIENCJES (X1) PROVIOER!SUPPUERICLIA (X4) 1 SUMMARY (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATOR OR LSC ENTIFYING INFORMATION} {X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - ENTIRE NF WING B. WING K062 PROVER'S P!.AN OF CORRECTION 01/22/2013 (XS} K069 This Standard is not met as evidenced by: Based on observation, record review and interview, the facility failed to provide semiannual inspection and maintenance of the kitchen suppression and exhaust system at a minimum interval of at least every six months. This has the potential to expose staff to a fire or smoke environment. The deficient practice affected one of two smoke compartments, staff and no residents. The facility has the capacity for 38 beds with a census of 25 the day of the survey. Findings include: 1.) Observation during record review on 01/22/13 at 10:06 a.m., revealed that the kitchen suppression system's last inspection and K069 1) Kitchen suppression system was inspected 9/17/12 and 1/28/13 (see attached). Maintenance staff will schedule inspections on a six month basis with the next inspection July Maintenance Manager, or designee, will monitor inspection schedule to ensure compliance. 2/26/13 DNOQ21 If continuation sheet Page 13 of 17

18 (X1) PROV!DERISUPPLIERJCUA (X4} 10 I SUMMARY l I(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATOR OR LSC ENTIFYING INFORMATION} A. BUILDING 01 - ENTIRE NF WING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 10 {EACH CORRECTIVE ACTION SHOULD BE 01/22/2013 (X5) K 069 Continued From page 13 maintenance was accomplished on 12/19/11. The facility was unable to provide a documented inspection and maintenance for the twelve month interval between the 12/19/11 and the date of the survey on 01/22/13. Interview on 01/22/13 at 10:06 a.m. with the Maintenance Engineer revealed that the facility was aware of the requirement for the inspection and servicing of the kitchen suppression system within a minimum of at least every six. 2.) Observation during record review on 01/22/13 at 10:15 a.m. revealed that the kitchen exhaust system's last inspection and maintenance was accomplished in 07/12. The facility was unable to provide a documented inspection and maintenance for the six month interval prior or after the 07/12 inspection and the date of the survey on 01/22/13. Interview on 01/22/13 at 10:15 a.m. with the Maintenance Engineer revealed that the facility was not aware it was to be inspected on a semi-annual basis. K069 K069 2) Kitchen exhaust system was inspected on 9/17/13 and 1/28/13 (see attached). Maintenance staff will schedule inspections on a six month basis with the next inspection in July Maintenance Manager, or designee, will monitor inspection schedule to ensure compliance. The finding was acknowledged by the Administrator and verified by the Maintenance Engineer at the exit interview on 01/22/13. Item 1.) Actual NFPAStandard: NFPA 17A, At least semiannually, maintenance shall be conducted in accordance with the manufacturer's listed installation and maintenance manual. Actual NFPA Standard: NFPA 17 A, (g). The maintenance report, with recommendations, if any, shall be filed with the owner or with the designated party responsible for the system. Actual NFPAStandard: NFPA 17A, (h). Each wet chemical system shall have a tag or label securely attached, indicating the month and DNOQ21 If contmuatlon sheet Page 14 of 17

19 (X4)1D (X1) PROV!DER!SUPPLIERICL!A A. BUILDING 01 - ENTIRE NF WING B. WING l MOUNTAIN HOME, SUMMARY 1D (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATOR OR LSC ENTIFYING INFORMATION) 01122/2013 (XS} DA1E K 069 Continued From page 14 year the maintenance is performed and identifying the person performing the service. Only the current tag or label shall remain in place. KD69 K 147 This Standard is not met as evidenced by: Based on observation and interview, the facility failed to ensure electrical wiring was in accordance with the National Electrical Code. This potentially exposed staff to an electrical shock hazard. The deficient practice affected one of two smoke compartments, staff, and no residents. The facility has the capacity for 38 beds with a census of 25 the day of survey. Findings include: Kl47 Soup tureen is plugged directly into the wall. Visual check has occurred by Maintenance to ensure relocateable power taps are not used inappropriately. All items plugged in the kitchen will be approved by Maintenance. Dietary Manager trained staff on kitchen item that can't be plugged into power strips and include in new employee orientation. 2/26/13 Observation on 01/22/13 at 10:28 a.m., revealed FORM CMS-2567{02-99) Previous Versions Obsolete DNOQ21 If continuation sheet Page 15 of 17

20 ! AND PlAN OF CORRECTION {X1} PROVERISUPPLlERICLlA (X4) 10 -I SUMMARY 1 f(each DEFICIENCY MUST BE PRECEDED BY FULL REGUlATOR OR LSC ENTIFYING INFORMATION) A BUILDING 01 - ENTIRE NF WING B. WING B95 NORTH 6TH EAST 01/22/2013 (X5) K 147 Continued From page 15 a soup tureen plugged into a relocateable power tap that was plugged into a wall outlet in the kitchen. Interview with the Maintenance Engineer on 01/22/13 at 10:28 a.m., revealed that the facility was not aware the relocateable power tap was not listed for kitchen appliances. K 147 The finding was acknowledged by the Administrator and verified by the Maintenance Engineer at the exit interview on 01/22/13. Actual NFPAStandards: NFPA 70, NFPA 101 the Life Safety Code Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. NFPA 70, National Electrical Code, 1999 Edition NFPA Examination, Identification, Installation, and Use of Equipment. (A) Examination. In judging equipment, considerations such as the following shall be evaluated: (1) Suitability for installation and use in conformity with the provisions of this Code FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environ men~ or application. Suitability of equipment may be evidenced by listing or labeling. (2) Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided (3) Wire-bending and connection space (4) Electrical insulation FORM CMS--4ll67(02-99) Previous Versions Obsolete DNOQ21 lf continuation sheet Page 16 of 17

21 (X1) PROVJDERJSUPPUERICLlA A BUILDING 01 - ENTIRE NF WING B. WING 01/ (X4) ld SUMMARY {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC ENTIFYING INFORMATION) (X5) K 147 Continued From page 16 (5) Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service (6) Arcing effects (7) Classification by type, size, voltage, current capacity, and specific use (8) Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment (B) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling. K 147 I See UL listing 1363 and UL XBYS.Guidelnfo Relocatable Power Taps \ DNOQ21 If continuahon sheet Page 17 of 17

22 PRINTED: 01/30/2013 (X1) PROV!DERISUPPLIER/CL!A A BUILDING 01 - ENTIRE NF WING B. WING 01/22/2013 (X4) SUMMARY {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC ENTIFYING INFORMATION) CROSS~REFERENCED TO THE APPROPRIATE (X5) COMPLETE C ooo INITIAL COMMENTS c 000 The Administrative Rules of the Idaho Department of Health and Welfare, Skilled Nursing and Intermediate Care Facilities are found in APA 16, Title 03, Chapter 2. The facility is a single story Type V(111) wing located within a Critical Access hospital. The facility was built in 1965 with major renovations and additions in , most of which were in the hospital portion of the building. Renovation to the nursing home was completed in The facility is fully sprinklered with a new sprinkler system installed in March 2009 and has a recently updated fire alarm system. Currently the facility is licensed for 38 SNF/NF beds. The following deficiencies were cited during the annual life safety code survey conducted on January 22, The facility was surveyed unde the LIFE SAFETY CODE, 2000 Edition, Existing Health Care Occupancy, and APA Rules and Minimum Standards for Skilled Nursing and Intermediate Care Facilities. The survey was conducted by: Tom Mroz, CFI-11 Health Facility Surveyor Facility Fire/Life Safety & Construction Program C FIRE AND LIFE SAFETY 106. FIRE AND LIFE SAFETY. Buildings on the premises used as facilities shall meet all the requirements of local, state and national codes concerning fire and life safety standards that are applicable to health care facilities. This RULE: is not met as evidenced by: Refer to Federal CMS form 2567: c 226 See K018, K029, K038, K043, KOSO, K062, K069, 1<.147 2/26/1 r. ection is requisite to continued program participation. laboratory DIRECTO LIER RESENTATIVE'S SIGNATURE TITLE (X6) STATE FORM

23 PRINTED: 01/30/2013 (X1) PROVER/SUPPLIERICLIA (X2) MULT1PLE CONSTRUCTION A BUILDING 01 - ENTIRE NF WING B. WING ~ 01/22/2013 (X4) SUMMARY (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC ENTIFYING INFORMATION} (XS) COMPLETE c 226 Continued From Page 1 C226 1.) K018 -Transfer Grill 2.) K029 - Hazardous Area 3.) K038 - Exits 4.) KD43- Resident Room Key Lock 5.) K050- Fire Drills. 6.) KD62- Fire Sprinkler 7.) K069 - Kitchen Hood 8.) K147- Relocateable Power Tap lf deficiencies are c1ted, an approved plan of correction IS requjsrte to contmued program part1c1pat1on. STATE FORM DNOQ21 If continuation sheet 2 of 2