Elmore Community Hospital

“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: 49797 Based on observations and interviews with staff during a tour of the hospital by Life Safety Code, it was determined the hospital was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served by this hospital. Findings include: Refer to tags: K-0211, K-0321, K-0324, K-0345, K-0351, K-0353, K-0741, and K-0923.”

“Establishment of the Emergency Program (EP) CFR(s): §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: 49603 Based on review of the emergency preparedness program, and staff interview, it was determined the agency failed to ensure the emergency preparedness program described a comprehensive approach to meeting the health, safety and security needs of staff and patients during an emergency or disaster situation. This had the potential to negatively affect all patients, staff and visitors served by the hospital. Findings include: Refer to: E004, E006, E007, E009, E018, E036 and E037”

“MEDICAL STAFF - BYLAWS AND RULES CFR(s): 482.12(a)(4) [The governing body must] approve medical staff bylaws and other medical staff rules and regulations. This Standard is not met as evidenced by: 49797 Based on a review of the Bylaws, Rules and Regulations, it was determined the Governing Body failed to ensure the Rules and Regulations were updated to include a Nurse Practioner (NP) being listed among the medical professionals allowed to perform the Medical Screening Exam (MSE) in the Emergency Department (ED). This had the potential to affect all patients served by the hospital’s ED. Findings Include: Elmore Community Hospital’s Medical Staff Rules and Regulations... F. Emergency Services.. 7. If any individual, regardless of the ability to pay, comes by him/herself or with another person to the Emergency Department and a request is made on the individual’s behalf for examination or treatment of a medical condition by qualified medical medical personnel... ...The examination will be conducted by the Emergency Room Physician with the assistance of the Emergency Room Nurse... An interview was conducted on 6/19/25 at 1:02 PM with Employee Identifier # 14, Chief Operating Officer, who confirmed the hospital failed to update the Rules and Regulations to include allowing the NP to perform the medical screening exam in the ED.”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 49797 Based on policy review and interviews with staff it was determined the Governing Body failed to assure that all hospital policy and procedures were approved every three years. This had the potential to affect all patients served by the facility. Findings include: A review of the policy and procedures revealed there were policies not reviewed and approved in five years or more. An interview was conducted on 6/19/25 at 1:02 PM with Employee Indentifer # 1, Director of Nursing, who confirmed the policies had not been reviewed, and all policies should be reviewed at least every three years.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 41624 Based on medical record (MR) review, hospital policy and procedure, and interview, it was determined the hospital failed to ensure a physician order was obtained prior to administration of blood products. This deficient practice affected Patient Identifier (PI) # 9, one of two MRs reviewed for administration of blood products and had the potential to affect all patients receiving blood at this hospital. Findings include: Hospital Policy: Blood and Blood Product Administration Policy Number: None listed Review date: 6/1/25 Purpose: The purpose pf this policy is to outline nursing responsibilities for the administration of blood and blood products... ...Policy: Only physicians and mid-level providers may order transfusion of blood or blood products... Procedure: Pre-transfusion A... Access physicians orders in CPSI (electronic medical record) review and print it... 1. PI # 9 was admitted to the hospital on 4/16/25 with a diagnosis of Urinary Tract Infection and Clostridium Difficile. Review of the MR revealed Employee Identifier (EI) # 13, RN, administered a unit of packed red blood cells intravenously to PI # 9 on 4/18/25 at 3:30 PM. Further review of the MR revealed there was no physician order for the unit of blood administered. The RN failed to obtain and document a physician’s order prior to administration of the packed red blood cells. An interview was conducted on 6/19/25 at 12:55 PM with EI # 12, medical scribe, who confirmed there was no physician order within the MR for the unit of packed red blood cells administered to PI # 9.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 49797 Based on medical record (MR) review, hospital policy and procedure, and interviews with staff it was determined the hospital failed to ensure the staff documented the wound care provided per the policy and procedure. This did affect PI # 10, one of two wound care medical records reviewed, and had the potential to affect all wound care patients served by this facility. Findings include: Hospital Policy and Procedure: Dressing changes: Wet, Dry or Sterile. Policy number: None listed Revision date: 4/2013 ...Guidelines:... 25. Document time, amount and character of drainage, condition of wound and surrounding area, presence of odor, type of dressing applied, any type of solution used and the patient’s response to the procedure... 1. PI # 10 was admitted to the facility on 5/2/25 with a diagnosis of Wound Dehiscence. A review of the physician order dated 5/2/25, revealed the following, Wound Vac (vacuum-assisted closure) Orders: Apply the Wound Vac to ulcer on left leg lateral to knee, use foam dressing, Pressure 125 millimeters of mercury continuous. Change Monday, Wednesday and Friday. Replace canister only when full. A review of the wound assessment document dated 5/5/25, 5/7/25, 5/9/25, 5/12/25, 5/15/25, 5/19/25, 5/21/25 and 5/23/25 revealed no documentation of the wound care provided. An interview was conducted on 6/19/25 at 12:52 PM with Employee Indentifer # 1, Director of Nursing, who confirmed the staff failed to complete documentation of the wound care provided.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 47295 Based on observation, hospital policy review, and interviews, it was determined the hospital failed to ensure expired medications and biologicals were not available for patient use. This deficient practice had the potential to negatively affect all patients served by this hospital. Findings include: Hospital Policy: Checking for Expired Supplies Policy Number: None Effective Date: 3/14 Purpose: To prevent the use of expired supplies Policy: 1. All departments that have supply rooms, supply closets, refrigerators...will maintain a monthly check of inventory to make sure supplies are in date and properly stored. 2. All departments that have supplies will maintain a running log to monitor inventory. A tour of the operating rooms (ORs) was conducted on 6/18/25 at 8:45 AM. During the tour of OR 1, OR 2, and the Endoscopy room, multiple medications and supplies were found to be expired in the anesthesia carts, including but not limited to: OR 1 Succinylcholine chloride 10 milliliter (ml) multidose vial (MDV) x1 expired 02/2025 Dexmedetomidine 2 ml single dose vial (SDV) x 8 expired 9/2024 Isoflurane liquid for inhalation 250 ml bottle x2 expired 5/31/23 Hypodermic needle 25 gauge (g) 1.5 inch x 3 with an expired 3/2019 Laryngeal mask airways (LMA) size 1.5 x1 expired 1/28/22, size 2.5 x1 expired 12/28/21 OR 2 LMA size 1.5 x 9 expired 1/28/22 Intranasal mucosal atomization device (MAD Nasal) x1 expired 8/2017 LMA size 5 x1 expired 10/28/19 Flexicare Brite Blade Pro fiberoptic metal disposable laryngoscope blade x1 expired 11/1/23 and x1 expired 7/1/24 Covidien Mallinckrodt intubating stylet 14 french x1 expired 11/24/21 Endoscopy Succinylcholine chloride 10 ml MDV x1 expired 9/2021 Braun safety intravenous catheter 22 g x1 expired 5/1/22, x1 expired 5/1/23, and 20 g x2 expired 8/31/23 During an interview conducted on 6/18/25 at 8:10 AM with Employee Identifier (EI) # 8, Certified Registered Nurse Anesthetist (CRNA), EI # 8 stated he/she is responsible for stocking and maintaining the anesthesia carts in the ORs. An interview conducted on 6/18/25 at 11:00 AM with EI # 15, OR Director, confirmed the CRNA is responsible for maintaining the anesthesia carts and ensuring expired medications and supplies are not available for patient use.”

“PERIODIC EQUIPMENT MAINTENANCE CFR(s): 482.26(b)(2) Periodic inspection of equipment must be made and hazards identified must be promptly corrected. This Standard is not met as evidenced by: 49797 Based on preventative maintenance record review and interviews with staff it was determined the hospital failed to perform preventative maintenance (PM) or maintain contracted services for PM of the radiology equipment. This had the potential to affect all patients served by the radiology department. Findings include: During a tour of the radiology department with Employee Identifier (EI) # 6, Radiology Director, the surveyor requested to review the preventative maintance records for the radiology equipment. None were given. An interview was conducted on 6/18/25 at 9:25 AM, with EI # 6, who confirmed the radiology department did not have any PM records. The hospital did not have contracted services to perform PMs of the equipment, nor did the hospital perform the PM checks. The department only had corrective maintenance performed when equipment needed repair.”

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 49603 Based on observations, manufacturer’s directions for use (DFU) for Ecolab Trupower Ultra San dishwasher rinse solution, and interviews with staff it was determined the facility failed to test the dishwasher rinse solution for proper concentration of chlorine. This had the potential to affect all patients admitted to this hospital. Findings include: Ecolab Trupower Ultra San 5-gallon bucket Liquid Sanitizer/Multi-Use Chorine Sanitizer/Sodium Hypochlorite Directions For Use (DFU) ... ...Sanitation Tableware sanitizer and destainer for mechanical spray warewashing machines For sanitizing tableware in low temperature warewashing machines, inject Ultra San into the final rinse water at concentration of 100 parts per million (ppm) available chlorine. Do not exceed 200 ppm. To ensure that available chlorine concentration does not fall below 50 ppm, periodically test the rinse solution with a suitable test kit and adjust the dispensing rate accordingly. A tour of the dietary department was conducted on 6/18/25 at 12:30 PM with Employee Identifier (EI) # 9, Dietary Manager, which included observing the Ecolab dishwashing machine. When asked what is used to test the sanitizer, EI # 9 stated she did not have testing strips to test the rinse solution. The dietary manager failed to ensure staff were testing for correct chlorine concentration of the rinse solution. An interview was conducted on 6/17/25 at 12:30 PM with EI # 9 who confirmed there was no testing of the rinse solution for appropriate concentration per manufacturer’s DFU.”

“THERAPEUTIC DIET MANUAL CFR(s): 482.28(b)(3) A current therapeutic diet manual approved by the dietitian and medical staff must be readily available to all medical, nursing, and food service personnel. This Standard is not met as evidenced by: 49603 Based on review of facility policies and procedures, observation, and interviews, it was determined the staff failed to provide a current dietary manual readily available for staff use in day-to-day practice. This had the potential to affect all consumers served by the dietary department. Findings include: During a tour of the Dietary Department on 6/17/25 at 8:45 AM, the surveyor requested the therapeutic diet manual. Employee Identifier (EI) # 8, Dietary Manager, provided a manual with policies and procedures and explained that was the only manual available. The manual did not include current therapeutic diets approved by the dietician and medical staff. An interview On 6/19/25 at 11:18 AM, EI #10, Registered Dietician, confirmed there was no current dietary manual readily available.”

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 49603 Based on review of the Emergency Preparedness (EP) program and interview, it was determined the facility failed to perform and document a facility-based and community-based risk assessment, utilizing an all-hazards approach, to identify all risks or emergencies that the facility would reasonably expect to encounter. This has the potential to affect all persons served by the hospital, staff and visitors. Findings include: A review of the facilities EP program revealed no documentation: a. An all hazards risk assessment including facility based and community based risk. b. The plan was review/revised every two years. c. Strategies for addressing emergency events in the plan were identified. An interview conducted 6/19/25 at 12:35 PM with Employee Identifier # 1, Director of Nursing, confirmed the agency had no documentation an all-hazards risk assessment had been performed, strategies for EP events were identified, and no documentation the plan was reviewed every two years.”

“EP Program Patient Population CFR(s): §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: 49603 Based on review of the Emergency Preparedness (EP) documentation, and staff interview, it was determined the staff failed to ensure the facility developed and maintained an emergency preparedness plan to include patient population, including persons at risk, the type of services provided in an emergency and continuity of operations. This had the potential to negatively affect all patients served by the facility, visitors, and staff. Findings include: EP plan was requested, none provided. An interview was conducted on 6/19/25 at 12:35 PM, with Employee Identifier # 1, Director of Nursing, who confirmed there was no documentation a emergency preparedness plan was developed.”

“Local, State, Tribal Collaboration Process CFR(s): §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: 49603 Based on review of the Emergency Preparedness (EP) documentation, and staff interview, it was determined the staff failed to ensure the facility developed and maintained an emergency preparedness plan to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. This had the potential to negatively affect all patients served by the facility, visitors, and staff. An interview was conducted on 6/19/25 at 12:35 PM, with Employee Identifier # 1, Director of Nursing, who confirmed there was no documentation a emergency preparedness plan was developed which included collaboration with local, tribal, regional, State, and Federal emergency preparedness officials.”

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 49603 Based on review of the Emergency Preparedness (EP) documentation, and staff interview, it was determined the staff failed to ensure the facility developed and maintained an emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. This had the potential to negatively affect all patients served by the facility, visitors, and staff. An interview was conducted on 6/19/25 at 12:35 PM, with Employee Identifier # 1, Director of Nursing, who confirmed there was no documentation of an EP plan which included a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency.”

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 49603 Based on review of Emergency Preparedness (EP) documentation and interview it was determined the facility failed to develop and maintain an emergency preparedness training and testing program. An interview was conducted on 6/19/25 at 12:35 PM, with Employee Identifier # 1, Director of Nursing, who confirmed there was no documentation an emergency preparedness training and testing program was developed.”

“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: 49603 Based on review of the personnel files, and interview with staff, it was determined the hospital failed to ensure the staff received initial training on Emergency Preparedness (EP) and at a minimum of every two years. This affected eight of eight hospital employee’s personnel files reviewed and had the potential to affect all persons served by the hospital. Findings include: Review of the personnel files provided revealed no documentation the hospital employees completed initial EP training and every two years. An interview was conducted on 6/19/25 at 11:35 AM with EI # 11, Human Resources Director, who confirmed the hospital failed to ensure the staff received initial EP training and at a minimum every two years.”

“. K3 Building: 0202 K6 Plan Approval: 1993 K7 Survey Under: 2012 Existing K8 Hosp Generator: One Diesel, Catapiilar 500 kW (installed 2013 with remote manual stop station) FACP: Silent Knight (installed 2012) Locking Devices: None Smoke Detection: Corridor Bed: 69 Census: 7 Type of Structure: 1993 one story with a basement protected noncombustible, Type I(332). The facility has a partial automatic sprinkler system. The patient room floor is not sprinklered. During a routine recertification survey conducted on this date, the requirements of 42 CFR, Subpart 482.41 - HOSP 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. .”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the means of egress per the requirements of: 2012 NFPA 101, 19.2.1, and 7.2.1.9.1.3 This deficiency affects 1 of 1 pair of power doors. Findings include: During a tour of the facility, the surveyor observed the pair of cross-corridor power doors between the Emergency Department Hall and the Operating Department Hall did not have a sign on the egress side that reads: “IN EMERGENCY, PUSH TO OPEN”. A member of the maintenance staff was present when this deficiency was identified. .”

“Discharge from Exits CFR(s): NFPA 101 Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the exit discharges per the requirements of: 2012 NFPA 101, 19.2.7, and 7.7 This deficiency affects 1 of 1 exits. Findings include: During a tour of the facility, the surveyor observed that the path from the South Med/Surge exit door to the public way was paved most of the distance from the building but stopped approximately 25’ from the public way, therefore not providing a hard-packed all-weather travel surface the entire distance to the public way. A member of the maintenance staff was present when this deficiency was identified. .”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 42853 . Based on observation, the facility failed to maintain the hazardous rooms per the requirements of: 2012 NFPA 101, 19.3.2.1.2, and 19.3.2.1.3 This deficiency affects one storage room. Findings include: During a tour of the facility, the Medical Record’s Storage Room’s door did not have a self-closing device; this room was over 50 sq. ft. with storage of excessive amounts of paper stored in card board boxes (combustibles). Room located across from Physical Therapy of Bldg. 0202. 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 appliances under the kitchen hood. 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. .”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 41792 . Based on review of documentation, the facility failed to maintain the fire alarm system per the requirements of: 2012 NFPA 101, 19.3.4.1, and 9.6.1.3 2010 NFPA 72, Table 14.3.1(9)(h) This deficiency affects all of the smoke detectors. Findings include: During a tour of the facility, the facility failed to provide documentation of conducting semi-annual visual inspections on the smoke detectors within the past 12 months. A member of the maintenance staff was present when this deficiency was identified. .”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 42853 . Based on observation, the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet per the requirements of: 2012 NFPA 101, 19.3.5.1, 9.7.1.1, and 9.7.7 2010 NFPA 13, 6.2.9.7, and 6.2.9.7.1 This deficiency affects the complete sprinkler system. Findings include: During a tour of the facility, the surveyor observed the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet. The list shall include the following: (1) Sprinkler identification number; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating (2) General description (3) Quantity of each type to be contained in the cabinet (4) Issue or revision date of the list A member of the maintenance staff was present when this deficiency was identified. .”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 42853 . Based on review of documentation, the facility failed to maintain the automatic sprinkler system per the requirements of: 2012 NFPA 101, 19.3.5.1, 9.7.5, and 9.7.8 2011 NFPA 25, 5.3.2.1, 14.2.1,and13.6.2.1 This deficiency affects the automatic sprinkler system. Findings include: During the review of the documentation, the facility failed to provide the following documentation: 1. Of conducting the automatic sprinkler internal pipe inspection within the past 5 years. 2. The riser gauges being replaced or calibrated within the past 5 years. 3. The backflow preventer being tested within the past 12 months. A member of the maintenance staff and the administrator were present when this deficiency was identified. .”

“Smoking Regulations CFR(s): NFPA 101 Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the permitted smoking area per the requirements of: 2012 NFPA 101, 19.7.4 (5), (6) This deficiency affects 1 of 2 buildings. Findings include: During a tour of the facility, the surveyor observed the permitted smoking area for the Chemical Dependency Unit had the following deficiencies: 1. The facility failed to provide an ashtray of noncombustible material 2. The metal container with self-closing cover device was full of combustibles, such as cigarette boxes and styrofoam cups A member of the maintenance staff was present when this deficiency was identified. .”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the oxygen cylinders per the requirements of: 2012 NFPA 99, 11.6.5.4, 11.6.2.3 (11), 11.6.5.1, 11.6.5.2, and 11.6.5.3 This deficiency affects all the Med Gas Room cylinders and back-up oxygen cylinders. Findings include: During a tour of the facility, the surveyor observed the following: 1. The facility failed to protect the outside cylinders against continuous exposure to direct rays of the sun where extreme temperatures prevail and from the ground beneath to prevent rusting at the following locations: A. The back-up “K” oxygen cylinders B. The empty “K” oxygen cylinders at the back of the Medical Gas Room 2. In the Medical Gas Storage Room the facility failed to: A. Properly chain or support seven (7) - 24 cu. ft. oxygen cylinders and twelve (12) - “K” cylinders B. Segregate full and empty cylinders stored together C. Mark empty cylinders to avoid confusion A member of the maintenance staff was present when this deficiency was identified.”