Mizell Memorial Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 41623 Based on Mizell Memorial Hospital (Hospital A) Medical Record (MR) Emergency Department (ED) video recordings, hospital policy and procedures, Medical Staff Rules and Regulations, ED Logs, Diversion Logs, Court Orders, Hospital B, Receiving Hospital MR, police reports, and interviews with staff, it was determined Mizell Memorial Hospital failed to ensure an appropriate Medical Screening Examination (MSE) was provided within the capability of the hospital’s ED to determine whether or not an emergency medical condition exists for all patients who presented to the ED and failed to ensure a patient received an appropriate transfer to Hospital B. These deficient practices affected one of one patients reviewed via recorded video footage, including Patient Identifier (PI) # 1, who presented to the hospital ED for emergency care on 2/3/26, and had the potential to affect all patients presenting to this hospital for emergency care. Findings include: Cross Refer to A2406 and A2409 for findings.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 41623 Based hospital Emergency Department (ED) video footage, medical record (MR) review, hospital policy and procedure, Diversion Log, ED Logs, and interviews with staff, it was determined the hospital failed to ensure a central log was maintained for each individual who presented to the ED for emergent care whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. This deficient practice did affect one of one patient reviewed via video footage, including Patient Identifier (PI) # 1, who presented to the hospital ED seeking assistance on 2/3/26, and had the potential to affect all patients presenting to this ED. Findings include: Hospital Policy: EMTALA (Emergency Medical Treatment and Labor Act)-Emergency Medical Screening, Treatment and Patient Transfer Policy Number: 2001 Revised/Reviewed: 10/9/17 ...Procedure: ...Emergency Room Log. Mizell Memorial Hospital maintains a central log on each individual who comes to the ED seeking assistance and whether the individual refused treatment, was refused treatment, or was transferred, admitted and treated, stabilized and transferred, or discharged... 1. A review of the video recordings from the camera at the ED ambulance entrance was conducted on 2/10/26 at 2:08 PM with Employee Identifier (EI) # 4, Information Technology Director, and EI # 2, Chief Operating Officer. The following is a summary of the video review: On 2/3/26 at 3:45 PM a Sheriff Deputy car stopped under ambulance entrance awning. At 3:47 PM the officer escorted a Caucasian female into the ED entrance. At 4:10 PM the officer and the Caucasian female exited the ED and the female was placed into the Sheriff Deputy’s car. At 4:16 PM the Sheriff Deputy car exited the ED parking lot. No other video recordings were available for review. Review of handwritten MR revealed PI # 1 arrived at the ED seeking psychiatric treatment on 2/3/26 at 3:50 PM. Review of the ED Log dated 2/3/26 from 3:28 PM to 4:54 PM revealed no documentation PI # 1 presented to the ED seeking assistance and whether PI # 1 was refused treatment, refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. An interview was conducted on 2/10/26 at 4:30 PM with EI # 3, ED Manager, who stated the hospital had gone on diversion due to a loss of internet and phones. EI # 3 stated the staff were using paper charting during the downtime. An interview was conducted on 2/12/26 at 11:16 AM with EI # 3 who confirmed the hospital failed to ensure each patient arriving at the ED seeking assistance was entered into the ED Log.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 41623 Based on Emergency Department (ED) video footage, medical record (MR) review, Hospital Medical Staff Rules and Regulations, hospital policy and procedures, Diversion Log, Emergency Department (ED) Logs, Court Order directive, Hospital B Receiving Hospital, MR, Alabama Uniform Incident/Offense Report, and interviews with staff, it was determined the hospital failed to ensure an appropriate Medical Screening Examination (MSE) was provided within the capability of the hospital’s ED to determine whether or not an emergency medical condition existed for all patients who presented to the hospital ED. This deficient practice did affect one of one patient reviewed via video footage, including Patient Identifier (PI) # 1, who presented to the hospital ED on 2/3/26 and had the potential to affect all patients presenting to this ED. Findings include: Mizell Memorial Hospital Medical Staff Rules & Regulations Revised: 1/4/24 ...36. All patients presenting to the Emergency Department shall have an appropriate ... MSE by a physician, according to EMTALA (Emergency Medical Treatment and Labor Act) guidelines. No exceptions apply to this rule. 37. The MSE should include the utilization of all medically necessary ancillary services available to the Emergency Department, including on-call physicians, to determine if an emergency medical condition (EMC) exists... Hospital Policy: EMTALA-Emergency Medical Screening, Treatment and Patient Transfer Policy Number: 2001 Reviewed/Revised: 10/9/17 Policy: It is the policy of Mizell Memorial Hospital to provide an appropriate (MSE to any individual who presents to the dedicated emergency department... Procedure: Medical Screening Examination ...When an individual comes to the Emergency Department of Mizell Memorial Hospital ... and a request is made on the individual’s behalf for a medical examination or treatment of a medical condition an appropriate medical screening examination, within the capabilities of the Emergency Department (including ancillary services routinely available to the emergency department) shall be provided to determine whether an emergency medical condition exists... Hospital Policy: Emergency Department Diversion Policy Number: Not Listed Effective: 2/14/25 Policy: The purpose of this policy is to establish a standardized approach for emergency room (ER) diversion when capacity is exceeded, or patient safety is at risk... Procedure: 1. Criteria for ER Diversion: ...Infrastructure Failure: Loss of critical utilities, such as power or water, that impact patient care... The ER must continue to provide (MSE) and stabilizing treatment as required by EMTALA, even during diversion. 1. A review of the video recordings from the camera at the ED ambulance entrance was conducted on 2/10/26 at 2:08 PM with Employee Identifier (EI) # 4, Information Technology Director, and EI # 2, Chief Operating Officer. The following is a summary of the video review: On 2/3/26 at 3:45 PM a Sheriff Deputy car stopped under ambulance entrance awning. At 3:47 PM the officer escorted a Caucasian female into the ED entrance. At 4:10 PM the officer and the Caucasian female exited the ED and the female was placed into the Sheriff Deputy’s car. At 4:16 PM the Sheriff Deputy’s car exited the ED parking lot. No other video recordings were available for review. Review of the ED Log revealed at 3:47 PM the ED had one of seven ED beds available for patient use. No patients had registered and awaited an ED bed. The hospital’s ED had the capacity to provide an appropriate MSE to PI # 1 on 2/3/26. An interview was conducted on 2/10/26 at 4:30 PM with EI # 3, ED Manager, who stated the hospital had gone on diversion due to a loss of internet and phones. EI # 3 stated the staff were using paper charting during the downtime. Review of PI # 1’s handwritten MR revealed the patient presented to the ED seeking psychiatric assistance on 2/3/26 at 3:50 PM. Review of the Diversion Log revealed Mizell Memorial Hospital was on diversion on 2/3/26 from 3:59 PM until 5:55 PM, one hour and 56 minutes. The hospital was not on diversion at 3:50 PM when PI # 1 arrived at the ED seeking psychiatric assistance. Review of the Court Order, dated 2/3/26, attached to the medical record revealed PI # 1 “...is suffering from acute symptoms of a mental disorder and is an immediate danger to herself and others... be detained and confined on an emergency basis at Mizell Memorial Hospital...” Review of the nursing documentation revealed the nurse documented PI # 1 “...appears disheveled, is yelling out, bruising noted to right under eye area. Swelling noted to face and nose with bruising and abrasions...” Review of EI # 9, ED Physician, documentation dated 2/3/26 at 4:00 PM revealed “...The entire Mizell Hospital had been placed on diversion secondary to a complete computer and phone malfunction. As this patient would require medications, labs, and transfer of this data to another hospital that provides psychiatric care, it was realized a long and unacceptable delay would be encountered in trying to treat this patient... I was informed that the location of the order was to be amended and the patient was being taken to (Hospital B).” There was no documentation an appropriate MSE, including an ED Provider examination, laboratory testing, and/or diagnostic testing was performed, within the capability of the hospital’s ED. Review of the Alabama Uniform Incident/Offense Report dated 2/3/26 revealed the Deputy Sheriff documented the ED Physician stated the ER (Emergency Room) “was on lockdown, I am unable to send reports, I am unable to access the system, I am unable to get (PI # 1) a sedative to calm (him/her) down. Can you take (him/her) somewhere else?” An interview was conducted on 2/10/26 at 3:58 PM with EI # 11, Covington County Deputy, who stated (he/she) called the Judge and got the court order changed to take the patient to (Hospital B). EI # 11 also verbalized the ED physician and nurse were aware the patient was leaving the ED. An interview was conducted on 2/11/26 at 1:30 PM with EI # 13, Director of Radiology, who stated the radiology department performed five to six outpatient procedures including one Computed Tomography (CT) scan during the time of the downtime. EI # 13 further stated the x-rays were sent to be read by the radiologist after the internet came back up. An interview was conducted on 2/12/26 at 12:07 PM with EI # 9, ED Physician, who stated “...I noticed a lot of swelling under each eye and (PI # 1’s) nose looked broken, I was thinking of possible head injury or a bleed...I’m thinking I’m going to have to transfer (PI # 1) because it is a huge mistake to keep (him/her) with a possible head injury...I have an order from the Judge saying (he/she) has to be treated here. I can’t handle this patient...I asked the officer if the Judge could change the order...When I come back, I find they are leaving...” EI # 9 was asked if an MSE was completed, EI # 9 responded “(He/She) would not let us near (him/her) to do vital signs or anything else...I felt the best option for (him/her) was to get (him/her) out of here. It would have been a delay to get the ambulance...” The medical record from Hospital B was reviewed. The section of the MR titled ED- Physician Note dated 2/3/26 20:36 (8:36 PM) the ED physician documented in part, “37 yrs (years) old ...presents to the ED ...with complaints of Psych (psychiatric) Problem ...The patient presents to the emergency department with Apparent altered mental status ...brought in by police ... under a court order ... due to some usual behavior ...this started a couple hours prior to arrival ... difficult to arouse but arousable ... unable to give a story to tell us whether ...consumed any usual substances medications ...street drugs ...unable to tell us ...suicidal homicidal depressed ...psych history is unknown ...02/04 15:55 (3:55 PM) ED Course: CASE DISCUSSED WITH PSYCHIATRIST. PATIENT HAS BEEN MEDICALLY CLEARED. AWAITING PSYCHIATRIC PLACEMENT. SHE/HE IS HEMODYNAMICALLY STABLE ...This is a Certified Medical Emergency: yes ...02/05 07:48 (7:48 AM) ED course: ... Patient’s UDS (Urine drug screen) does have evidence of substances on board and phentermine (medication used temporary aid for weight loss), methamphetamines (a synthetic drug that increases alertness, energy, and concentration) and benzodiazepines (medication used for anxiety and panic disorders) and marijuana (mind altering drug) ...have reviewed ...labs and medical record and ...is medically cleared to a psych facility. Patient did have evidence of urinary tract infection ...currently going to get a dose of Bactrim (medication used most commonly to treat urinary tract infection) ...09:14 (9:14 AM) ED Course: have discussed the case with tele psych physician and after his evaluation he does not see any signs of suicidal or homicidal ideation therefore patient can be discharged for follow up on an outpatient basis. Laboratory testing, a portable chest x-ray, and a Psychiatric consult were obtained. The patient was discharged home on 2/5/26. An interview was conducted on 2/12/26 at 11:16 AM with EI # 3 who confirmed there was no documentation an appropriate MSE was completed. The facility failed to ensure the hospital policy and procedure was followed as evidenced by failing to ensure on 2/3/2026 PI # 1, who was court ordered to be evaluated at Mizell Memorial Hospital, receive an appropriate medical screening examination to include utilization of all medically necessary ancillary services available to the ED to determine if an EMC existed as stated in the policy.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 41623 Based on medical record (MR) review, hospital policy and procedure, Court Order directive, Hospital B, Receiving Hospital MR, and interviews with staff, it was determined the hospital failed to ensure an appropriate transfer was arranged and completed for a patient who presented to the Emergency Department (ED) for a court ordered psychiatric evaluation and treatment. This deficient practice did affect one of one patient reviewed via video footage, including Patient Identifier (PI) # 1, who presented to the hospital ED for emergency care on 2/3/26, and had the potential to affect all patients presenting to this ED. Findings include: Hospital Policy: Transfer from Emergency Department Policy Number: Not Listed Revised: 5/21/25 Purpose: To ensure safe, timely, and appropriate transfer of (ED) patients to another facility when services required exceed the hospital’s capabilities. ...Procedure: ...3. Need for Transfer If the patient requires services not available at Mizell Memorial Hospital or at the request of the patient/legal representative: The ED provider documents the medical necessity for transfer. Patient or legal representative must be informed of the benefits and risks of the transfer. 4. Acceptance by Receiving Facility The receiving facility must have the capability and capacity to treat the patient. The receiving facility and a physician at that facility must accept the patient before the transfer... 5. Consent for Transfer Obtain written consent from the patient or legal representative... Responsibilities ED Physician/Provider: Assess, stabilize, determine need for transfer, contact receiving provider, and complete documentation... 1. An interview was conducted on 2/10/26 at 4:30 PM with EI # 3, ED Manager, who stated the hospital had gone on diversion due to a loss of internet and phones. EI # 3 stated the staff were using paper charting during the downtime. Review of Court Order attached to the medical record revealed PI # 1 was to be “...detained and confined on an emergency basis at Mizell Memorial Hospital...” Review of EI # 9, ED Physician, documentation revealed “... I was informed that the location of the order was to be amended and the patient was being taken to (Hospital B).” Review of Hospital B, receiving hospital, which is located approximately 17 miles away, ED physician documentation, revealed PI # 1 was brought to the ED by police under a court order and was assessed at 4:55 PM for complaints of altered mental status. There was no documentation of Mizell Memorial Hospital sending Hospital B medical records or copies therefore related to the identified EMC for PI # 1 on 2/3/26. An interview was conducted on 2/12/26 at 11:16 AM with EI # 3 who confirmed there was no documentation an appropriate transfer was completed. There was no documentation an appropriate transfer was completed including informing the patient or the person acting on behalf of the patient of the risks and benefits of transfer, the receiving facility and physician acceptance of the patient, patient consent for transfer, physician certification of the risks and benefits of the transfer, or transfer by qualified personnel for PI # 1 on 2/3/26.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 50417 Based on observations and interviews with staff during a tour of the hospital by Life Safety Code and Health surveyors, it was determined the hospital was not constructed, arranged, and maintained to ensure patient safety. This had the potential to negatively affect all patients served by this hospital. Findings include: Refer to tags: K-0133, K-0324, K-0362, K-0372, K-0521, K-0761, K-0918, K-0920, and health survey citation A-701, and A-724.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 50417 Based on medical record (MR) review and staff interview, it was determined the facility failed to ensure twenty-six of thirty patients were informed of the patient’s rights prior to receiving care at the facility. This had the potential to negatively affect all patient’s served by this facility. Review of the MR’s of Patient Identifier (PI) # 1, PI # 2, PI # 3, PI # 4, PI # 5, PI # 6, PI # 7, PI # 8, PI #9, PI # 14, PI # 15, PI # 16, PI # 17, PI # 18, PI #19, PI # 20, PI # 21, PI # 22, PI # 23, PI # 24, PI # 25, PI # 26, PI # 27, PI # 28, PI # 29, and PI # 30 revealed there were no verbal or signed patient rights completed. An interview was conducted on 12/12/24 at 11:17 AM with Employee Identifier (EI) # 4, Interim Chief Executive Officer who confirmed there were no verbal or signed patient rights completed.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 41623 Based on observations, facility policy, and interviews, it was determined the facility failed to ensure the Senior Behavioral Care Unit (SBCU) was free of ligature risks. This deficient practice had the potential to negatively affect all patients admitted to this unit. Findings include: Facility Policy: Suicide Assessment and Preventions Policy Number: Not Listed Revised: 9/14/2017 Purpose: To outline the process for the timely assessment and reassessment of patient’s suicide risk and to provide guidelines for safety interventions. Policy: It is the policy of Mizell Memorial Hospital Senior Behavioral Care Unit to create an environment of care...and successful management of patients who are at an increased risk of suicide or self destructive behaviors... Procedure: 7. Staff are to maintain a safe and therapeutic environment for all patients. Additional safety interventions are implemented for patients on suicide precautions... Remove all potential ligatures...from the environment... Safety and Environment Rounds: 1. It is the responsibility of all staff to maintain a safe and therapeutic milieu for all patients at all times. 2. Safety and Environment Rounds are to be conducted at regular intervals... 3. ... all staff are to be continually aware of the environment and immediately correct or report any identified risks, damage, ... to their supervisor or Plant Operations personnel for immediate mitigation. 1. A tour of the SBCU unit was conducted on 12/10/24 at 9:45 AM with EI # 3, SBCU Manager. The following patient safety concerns were identified: a. Each of the 14 beds on the 12 bed unit had side rails on the upper half of the beds that could be raised and used as ligature attachment. b. The faucet in the Shower Room was constructed in a manner that could allow for a ligature to be attached. Review of the daily SBCU Environmental Safety Rounds for December 2024 revealed no documentation of these safety risks being identified. An interview was conducted on 12/12/24 at 11:00 AM with EI # 3, who confirmed the side rails and the shower faucet could be used as a ligature attachment.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 41623 Based on observations, review of Maintenance Work Orders, facility policy and procedures, and interviews, it was determined the facility failed to ensure required maintenance of the physical plant was completed. This deficient practice affected patient care areas on the Medical Surgical Unit and in the Dietary Department. Findings include: Facility Policy: Routine Work Request Department: Plant Operations Policy Number: 1001 Revised/Reviewed: 1/4/24 Purpose: To provide guidelines for submitting, receiving and scheduling routine work requests. Policy: A work order request should be emailed/called in for any repair or maintenance needed. a. Those that fall under Urgent/High priority will be handled as “Emergency Maintenance.” b. All others will be scheduled for accomplishment by Plant Operations by priority level as: 1. Low 2. Normal 3. Medium Procedure: ...The employee entering the work order will be notified by email when the work order is received, assigned to a mechanic, in progress, placed on hold, and upon completion... 1. A tour of the Medical Surgical Unit was conducted with Employee Identifier (EI) # 9 on 12/11/24 at 9:03 AM. The unit had 31 patient rooms with 36 available beds. Out of the 31 patient rooms, eight patient rooms had signs on the doors indicating the rooms were out of service. This impacted 16 beds. The following patient rooms had signs on the door stating they were out of service due to maintenance issues including rooms 321 and 323. An interview was conducted with EI # 6, Registered Nurse, who stated the rooms listed had been out of service for at least a year. Review of the Maintenance Work Orders revealed: Review of Work Order # 3795 revealed the work order was placed on 3/18/24 for repair of room 321 wall flange. The status was listed on the work order as resolved on 3/18/24. Review of Work Order # 4129 revealed the work order was placed on 5/3/24 due to room 323 being hot. The due date was listed as 5/6/24 with comments, resolved. An interview was conducted on 12/11/24 at 2:15 PM with EI # 9, Maintenance Supervisor, who stated Room 321 remained out of service due to a broken drill auger and Room 323 remained out of service due to coils in the air conditioner being clogged. 2. A tour of the Dietary Department, dishwashing area, was conducted on 12/11/24 at 11:45 AM with EI # 1, Chief Operating Officer. The following items were observed in need of repair: Observation of the dishwashing area revealed the right side of the wall at the entry way were missing 33 four inch square tile pieces exposing the subwall. On the left side of the room, the lower section of the wall extending under the dish machine had peeling paint and broken drywall. Additionally, the three foot light casing on the ceiling had peeling paint and was rusted half way the length of the light casing. The surveyor requested work orders for the dishwashing area repairs with none provided. An interview was conducted with EI # 1, who confirmed the facility failed to ensure the required maintenance of the dietary area was completed.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 46293 Based on observations, and staff interviews, it was determined the facility failed to ensure expired supplies were not available for patient use. This had the potential to negatively affect all patients served by the hospital. Findings include: 1. A tour of the surgical suite was conducted on 12/10/24 at 10:05 AM with Employee Identifier (EI) # 8, Surgical Services Manager. The following supplies were found to be expired and available for patient use: Operating Room (OR) # 1 anesthesia cart: One Melker Emergency Cricothyrotomy Catheter Set with an expiration date of 7/2015. OR # 2 anesthesia cart: Two Becton Dickinson (BD) Insyte Autoguard Shielded Intravenous (IV) Catheters with an expiration date of 8/31/23 One Rusch Endotracheal Tube Oral/Nasal 6.5 millimeter (mm) with an expiration date of 2/28/21. OR # 2: Eight Culturettes with an expiration date of 11/29/24. The “Issue” (medical supply room ) Room: Twelve Cautery Tip Polishers with an expiration date of 8/31/24 and four with an expiration date of 4/30/24. OR Hallway: Nine BD 20 gauge (g) x (by) 3.5 mm Spinal Needles with an expiration date of 8/31/24. Six BD 25 g x 3.50 mm Spinal Needles with an expiration date of 9/30/24. Crash Cart # 2: Two green top laboratory tubes with an expiration date of 10/30/24. Block Cart: Two ICUmedical Extension Sets with an expiration date of 1/1/24. Malignant Hyperthermia Cart: One Bard Latex Free Foley Catheter Tray with an expiration date of 7/31/24. An interview was conducted on 12/10/24 with EI # 8, Surgical Services Manager, who confirmed at the time of the tour, the above items were expired and available for patient use.”

“EP Training Program CFR(s): §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: 46293 Based on review of the personnel files, and staff interviews, it was determined the hospital failed to ensure all staff completed Emergency Preparedness (EP) training initially upon hire and every two years. This deficient practice did affect seven out of eight personnel files reviewed and had the potential to negatively affect all staff and patients served by the hospital. Findings include: A review of seven out of eight personnel files revealed no documentation of initial EP training upon hire in two out of eight files. Further review of the personnel files revealed, no documentation of EP training every two years in five out of the eight files reviewed for the years 2019 through 2024, respectively. An interview was conducted on 12/12/2024 with Employee Identifier (EI) # 5, Administrative Assistant, who confirmed there was no documentation the staff received EP training initially upon hire and every two years.”

“. K3 Building: 0103 K6 Plan Approval: 1986 K7 Survey Under: 2012 Existing K8 HOSP Generator: One Diesel, Marathon, 180 kW (installed 02/2021) FACP: Simplex 4005 (installed 1998) Locking Devices: Full time magnetic on 2nd floor Geri-Psych Unit Smoke Detection: Corridor Beds: 99 Census: 19 Type of Structure: 1986 Three story protected noncombustible, Type II(222) with a basement. The building has a partial automatic sprinkler system. During a routine recertification survey conducted on this date, the requirements of 42 CFR, Subpart 482.41 were not met as evidenced by the following deficiencies of the 2012 NFPA 101 Life Safety Code (LSC), the 2012 NFPA 99 Health Care Facilities Code and the standards referenced by these codes, as observed by the LS Surveyor while accompanied by the facility maintenance personnel. .”

“Multiple Occupancies - Construction Type CFR(s): NFPA 101 Multiple Occupancies - Construction Type Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows: * The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1 * The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters. 18.1.3.5, 19.1.3.5, 8.2.1.3 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the separation between construction types per the requirements of: 2012 NFPA 101, 19.1.3.5, and 8.2.1.3 (1) This deficiency affects the only 2-hour fire barrier in this building. Findings include: During a tour of the facility, the surveyor observed the door between the Kitchen and Dining Room, in the 2-hour fire barrier separating Building 0103 and Building 0203, had a self-closing device but was propped open with a wood wedge and would not self-close in and emergency. A member of the maintenance staff was present when this deficiency was identified. .”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 42853 . Based on observation, the facility failed to provide an approved method to ensure appliances that are protected under the hood, if they are moved, they are returned to the approved design location per the requirements of: 2012 NFPA 101, 19.3.2.5.1, and 9.2.3 2011 NFPA 96, 12.1.2.2, 12.1.2.3, and 12.1.2.3.1 This deficiency affects the kitchen only. Findings include: During a tour of the facility, the surveyor observed that the facility failed to provide an approved method to ensure appliances that are protected under the hood, if they are moved, they are returned to the approved design location. A member of maintenance staff was present when this deficiency was identified. .”

“Corridors - Construction of Walls CFR(s): NFPA 101 Corridors - Construction of Walls 2012 EXISTING Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area. 19.3.6.2, 19.3.6.2.7 This Standard is not met as evidenced by: 42853 . Based on observation, the facility failed to provide ceilings required for the pendant sprinklers in the facility per the requirements of: 2012 NFPA 101, 19.3.6.2.4 This deficiency affects Laundry Room only . Findings include: During a tour of the facility, the surveyor observed four, 2’ x 4’ ceiling tiles missing in the folding area of Laundry Room. A member of the maintenance staff was present when this deficiency was identified. .”

“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: 41792 . Based on observation, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of: 2012 NFPA 101, 19.3.7.3, 8.5.1, 8.5.6.2, 8.5.6.3, and 8.5.4.4 This deficiency affects 2 of 3 smoke barriers. Findings include: During a tour of the facility, the surveyor observed the following: 1. On the 2nd floor, an unsealed 1/2” conduit being used as a cable chase for a gray cable above the ceiling over the cross-corridor doors (at room 230) of the smoke barrier between the Specialty Clinic Nursing Station and the Geri-psych Unit. 2. On the 3rd floor, an unsealed penetration of a 2” copper pipe above the ceiling over the cross-corridor doors (at the stairwell) of the smoke barrier between the ICU and MedSurg Units. A member of the maintenance staff was present when this deficiency was identified. .”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 41792 . Based on review of documentation, the facility failed to maintain the smoke dampers, combination smoke/fire dampers, and ceiling dampers per the requirements of: 2012 NFPA 101, 19.5.2.1, and 9.2.1 2012 NFPA 90A, 5.4.8.1, and 5.4.8.2 2010 NFPA 80, 19.4, and 19.5 2010 NFPA 105, 6.5.2 This deficiency affects the complete building. Findings include: During a tour of the facility, the facility failed to provide documentation of testing the smoke dampers, combination smoke/fire dampers, and ceiling dampers within the past 6 years. A member of the maintenance staff was present when this deficiency was identified. .”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 42853 . Based on the review of documentation and interview, the facility failed to maintain the required fire doors in the two hour fire rated barrier separating the three story construction type II (222) from the one story construction type II (000) (not allowed in a three story building) per the requirements of: 2012 NFPA 101, 19.7.6, and 8.3.3.1 2010 NFPA 80, 5.2, and 5.2.3 This deficiency affects the Kitchen and Dining Room areas. Findings include: During a tour of the facility, the facility failed to provide documentation of its annual fire door inspection and testing within the past 12 months for the kitchen roll down fire assembly doors located in the two hour fire rated barrier separating the Kitchen from the Dining Room at the following locations: 1. At the dish collection window 2. In front of the Victory Warmer equipment A member of the maintenance staff was present when this deficiency was identified. .”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 42853 . Based on observation, the facility failed to maintain the Level 1 EES diesel emergency generator per the requirements of: 2012 NFPA 101, 19.2.9.1, and 7.9.2.4 2010 NFPA 110, 5.6.5.6, and 5.6.5.6.1 2012 NFPA 99, 6.5.4.1.1.2, and 6.4.4.1.1.3 2010 NFPA 110, 8.3.7.1, 8.4.2, 8.4.2.3, 8.3.8, and 8.3.4 This deficiency affects the only Level 1 EES diesel emergency generator . Findings include: During a tour of the facility, the facility failed to provide the following for the Level 1 EES diesel emergency generator : 1. A remote manual stop station of a type to prevent inadvertent or unintentional operation 2. A label for the remote manual stop station 3. The facility failed to provide the following documentation on the Level 1 EES diesel emergency generator: a. Performing monthly testing on the battery for the past 12 months b. The monthly 30 minute exercise failed to meet the requirements per 8.4.2 and the facility failed to provide documentation on an annual supplemental 1.5-hour load test per 8.4.2.3 c. Annual fuel quality test approved by ASTM standards A member of the maintenance staff was present when this deficiency was identified. .”

“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: 41792 . Based on observation, the facility failed to maintain the electrical equipment per the requirements of: 2012 NFPA 99, 10.2.3.6, and 10.2.4 2011 NFPA 70, 400.8 (1), (2), and (5) This deficiency affects the first floor of this building. Findings include: During a tour of the facility, the surveyor observed an artificial Christmas tree with Christmas tree lights plugged in to an electrical extension cord that was installed above the ceiling and dropped down through the ceiling tile above the tree in the Main Lobby. A member of the maintenance staff was present when this deficiency was identified.”