Fort Defiance Indian Hospital

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop 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: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 39022 Based on record review and staff interview, the facility did not review and update their emergency preparedness plan at least every two years in accordance with the requirements of 42 CFR 482.15(a). Findings include: On 6/4/25 at 10:00am, review of the “Emergency Preparedness Policy” (dated 9/21) revealed the policy was last reviewed and revised on 9/21/21. Interview with the Chief of Quality Services confirmed that the policy was last reviewed in September 2021. This finding was confirmed with the Chief of Quality Services and Safety Manager at the time of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“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: 39022 Based on record review and staff interview, the facility did not develop a policy or procedure to track and document the location of on-duty staff during and after an emergency in accordance with the requirements of 42 CFR 482.15(b)(2). Findings include: On 6/4/25 at 10:05am, review of the “Fort Defiance Indian Hospital Board, Inc Emergency Action Plan 2025 - Adolescent Care Unit (ACU) Roll Call Sheet” revealed the facility did not have a written process in place for documenting the specific name and location of the receiving facility or other location for on-duty staff. This finding was confirmed with the Safety Manager at time of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“A Life Safety Code Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) from 6/2/25 to 6/5/25. At this Recertification Survey, Fort Defiance Indian Hospital was found not to be in substantial compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 482.41(b), Standard: Life safety from fire and 42 CFR 482.41(c), Standard: Building safety. Fort Defiance Indian Hospital is composed of three separate buildings. Building 0103 (Tsehootsooi Medical Center) is a two-story building with partial basement built in 2002 of Type II (111) construction and classified as healthcare occupancy. Building 0203 (“Sanders Clinic”) is a one-story building built in 2014 of Type III (200) construction and classified as business occupancy. Building 0303 (“Wellness Center”) is a one-story building built in 2016 of Type II (000) constructing and classified as business occupancy. All three buildings are fully sprinklered and supplied with emergency power by diesel generators. Fort Defiance Indian Hospital has a total of 56 dually certified beds. At the time of the survey, the average daily census was 23. The requirements at 42 CFR 482.41(b) and 42 CFR 482.41(c) were NOT MET for Building 0303 as evidenced by the following standard-level deficiencies:”

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 39022 Based on observation and staff interview, the facility did not maintain the construction classification for the building as required by NFPA 101 - 2012 edition, Sections 19.1.6.1, 4.5.8 and NFPA 220 - 2012 edition, Section 4.1, 4.1.1 and Table 4.1.1. Findings include: 1. On 6/3/25 at 8:45am, observation in room 1A3-05 electrical room revealed several areas totaling about five square feet in the ceiling where the fire retardant had been removed/damaged exposing the bare steel of the structural I-beams. 2. On 6/4/25 at 7:55am, observation in the lab revealed two holes in the floor approximately one-inch in diameter. These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 39022 Based on observation and staff interview, the facility did not maintain egress doors in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.2.2.2.4 and 7.2.1.6.1. Findings include: 1. On 6/4/25 at 9:00am, observation at the exit doors near the cardio area revealed one leaf did not unlatch when the panic bar was pressed preventing the door from opening. 2. On 6/425 at 9:15am, observation at the exit doors in the physical therapy area revealed one leaf did not unlatch when the panic bar was pressed preventing the door from opening. These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 39022 Based on observation and staff interview, the facility did not maintain doors with self-closing devices in accordance with the requirements of NFPA 101 - 2012 edition, Section 19.2.2.2.7. Findings include: 1. On 6/3/25 at 2:10pm, observation in room 2B2-03 revealed the door had a self-closing device installed and did not latch when tested three times by the surveyor. 2. On 6/4/25 at 8:00am, observation in room 1D3-07 revealed the door had a self-closing device installed, but was being held open by a doorstop. These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This Standard is not met as evidenced by: 39022 Based on observation and staff interview, the facility did not properly install alcohol-based hand rub (ABHR) dispensers in accordance with the requirements of NFPA 101 - 2012 edition, Section 19.3.2.6. Findings include: 1. On 6/3/25 at 4:15pm, observation in the “Fastrak” area revealed an ABHR dispenser installed directly above an outlet. 2. On 6/4/25 at 8:00am, observation in room 1D3-07 revealed an ABHR dispenser installed directly above a light switch. 3. On 6/4/25 at 11:20am, observation outside room 2C3-06 revealed an ABHR dispenser installed directly above a light switch. These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“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: 39022 Based on observation, record review, and staff interview, the facility did not maintain the fire alarm system in accordance with the requirements of NFPA 101 - 2012 edition, Sections 18.3.4 and 9.6 and NFPA 72 - 2010 edition. Findings include: 1. On 6/3/25 at 3:25pm, observation in room 1B1-11 revealed flatten storage boxes were piled up directly in front of a pull station. 2. On 6/3/25 at 3:35pm, observation in the main electrical room revealed the circuit disconnect for the fire alarm did not have red identification. 3. On 6/4/25 at 9:45am, review of the annual fire alarm inspection reports revealed that the facility did not have an annual inspection of the fire alarm in 2024. 4. On 6/4/25 at 9:50am, review of the annual fire alarm inspection reports revealed that a horn (“2B1-47”) failed on the 10/2/23 annual inspection and the 3/20/25 annual inspection and no documentation to show that the horn had been repaired at any point. 5. On 6/4/25 at 11:25am, observation in the Operating Room corridor near room 2C3-02 revealed a horn/strobe was blocked by a supply cart parked in the corridor. These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“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: 39022 Based on observation, record review, and staff interview, the facility did not maintain its automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 19.3.5, 9.7 and NFPA 25 - 2011 edition. Findings include: 1. On 6/3/25 at 3:15pm, observation in room 1E2-08 revealed oxygen supplies were stored on shelves within 18 inches of the sprinkler. 2. On 6/3/25 at 3:20pm, observation in room 1B3-09 revealed chemical supplies were stored on shelves within 18 inches of the sprinkler. 3. On 6/3/25 at 4:10pm, observation in the kitchen revealed a heavy accumulation of dust buildup on the sprinklers in Fridge 1 and Fridge 2. 4. On 6/4/25 at 7:55am, observation in the Laboratory in the main workstation area revealed a sprinkler missing an escutcheon ring. 5. On 6/4/25 at 8:05am, observation in room 1E3-17 revealed a sprinkler missing an escutcheon ring. 6. On 6/4/25 at 9:30am, review of the annual sprinkler reports revealed that a pressure gauge (“D2 Sectional”) failed on the 3/30/23, 4/30/24, and 3/30/25 annual inspections and no documentation to show that the pressure gauge had been repaired/replaced at any point. These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 39022 Based on observation and staff interview, the facility did not ensure fire extinguishers were maintained in accordance with NFPA 101 - 2012 Edition, Sections 19.3.5.12, 9.7.4.1 and NFPA 10 - 2010 Edition, Section 7.3. Findings include: On 6/4/25 at 9:10am, observation in the main lobby area revealed the fire extinguisher tags were missing monthly inspection signoffs. This finding was confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the time of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 39022 Based on observation and staff interview, the facility did not provide corridor doors in accordance with the requirements of NFPA 101-2012 edition, Sections 19.3.6.3, 19.3.6.3.1 and 19.3.6.3.5. Findings include: 1. On 6/4/25 at 7:30am, observation in the corridor near room 1B5-21 revealed an approximate quarter-inch hole in the door above the lock. 2. On 6/4/25 at 7:35am, observation in room 1B5-15 revealed a quarter-inch hole in the oxygen room door. These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“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: 39022 Based on observation and staff interview, the facility did not ensure that smoke barrier walls were maintained in accordance with the requirements of NFPA 101-2012 edition, Sections 19.3.7, 19.3.7.1, 19.3.7.3, 8.5, 8.5.2, 5.5.2.1, 8.5.2.2, 8.5.2.3 and 8.5.6. Findings include: 1. On 6/3/25 at 4:05pm, observation in room 1B3-12 revealed pipe penetrations that were not properly firestopped. 2. On 6/4/25 at 10:40am, observation at the smoke barrier near room 2C3-17 revealed a pipe penetration that was firestopped with greyish material. Interview with the Facility Manager and Director of Facilities at the same time as observation revealed they were not able to confirm if the greyish material had a fire-rating. These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 39022 Based on observation and interview, the facility did not maintain clearances around electrical panels in accordance with NFPA 101 - 2012 edition, Section 9.1.2 and NFPA 70 - 2011 edition, Section 110. Findings include: On 6/3/25 at 2:00pm, observation in room 2B1-38 revealed ladders stored directly in front of emergency electrical panels. This finding was confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the time of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 39022 Based on record review and staff interview, the facility did not perform fire drills once per shift per quarter and did not transmit the fire alarm signal during all fire drills in accordance with the requirements of NFPA 101 - 2012 edition, Section 19.7.1. Findings include: 1. On 6/3/25 at 12:40pm, review of the “Fire Drill Policy” (revised 9/20/24) revealed the policy states “a minimum of one fire drill per shift per quarter”. Interview with the Safety Manager at the same time as record review revealed the facility had reduced the frequency of the fire drills down to four times per year. When requested to provide the policy documentation that allowed for this reduction in fire drills, the facility was unable to provide the policy. 2. On 6/5/25 at 9:20am, review of the fire drill records revealed the facility conducted silent/coded drills (no transmission of the fire alarm) outside of the allowed nocturnal hours of 9:00pm-6:00am on the third shift of the fourth quarter of 2024 (Oct-Dec) and the first and second shift of the first quarter of 2025 (Jan-Mar). These findings were confirmed with the Chief of Quality Services and Safety Manager at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“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: 39022 Based on observation, record review, and staff interview, the facility did not maintain fire door assemblies in accordance with NFPA 101 - 2012 edition, Sections 8.3.3.1 and 19.7.6, and NFPA 80 - 2010 edition, Section 5.2.4. Findings include: 1. On 6/3/25 at 2:05pm, observation in Labor and Delivery near room 2B2-16 revealed holes in the cross-corridor fire doors. 2. On 6/5/25 at 9:25am, review of the annual fire door inspection report performed on 9/12/24 revealed 20 doors failed inspection and had not been corrected/replaced. These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“Electrical Systems - Wet Procedure Locations CFR(s): NFPA 101 Electrical Systems - Wet Procedure Locations Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment conducted by the facility governing body. Operating rooms defined as wet locations are protected by either isolated power or ground-fault circuit interrupters. A written record of the risk assessment is maintained and available for inspection. 6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2 This Standard is not met as evidenced by: 39022 Based on observation and staff interview, the facility did not protect wet procedure locations in accordance with NFPA 99 - 2012 edition, Sections 6.3.2.2.8.4, 6.3.2.2.8.7, and 6.4.4.2. Findings include: On 6/4/25 at 11:30am, observation in the Operating Room department revealed none of the operating rooms had ground-fault circuit interrupters installed on the outlets. Interview with the Facility Manager and Director of Facilities at the same time as observation revealed the operating rooms were not protected by an isolated power circuit interrupter nor did the facility have a risk assessment that classified the operating rooms as a non-wet procedure location. This finding was confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the time of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99) This Standard is not met as evidenced by: 39022 Based on observation and staff interview, the facility did not provide functional remote annunciator panels for the essential electric system (EES) in accordance with NFPA 99 - 2012 edition, Section 6.4.1.1.17. Findings include: On 6/4/25 at 2:50pm, observation revealed neither of the two remote annunciators for the emergency generator in the building were functioning when the lamp test button was pressed. This finding was confirmed with the Chief of Quality Services and Nahata Dzil Health Center Maintenance Mechanical Leader at the time of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“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: 39022 Based on record review and staff interview, the facility did not maintain the emergency electrical system in accordance with the requirements of NFPA 101 -2012 edition, Section 19.5.1, 9.1, 9.1.3.1 and NFPA 110 - 2010 edition, Section 8.4.9. Findings include: On 6/5/25 at 9:10am, review of the annual generator preventative maintenance reports revealed that the two-hour loadbank test for Gen 3 on 12/7/24 ended after 1 hour 10 mins. The facility was able to provide documentation that repairs were made to Gen 3, but no loadbank retest was performed. This finding was confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the time of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“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: 39022 Based on observation and staff interview, the facility did not properly utilize power strips in accordance with the requirements of NFPA 101 - 2012 edition, Sections 9.1.2 and NFPA 70, 2011 Edition, Sections 400.7(B) and 400.8(1). Findings include: On 6/4/25 at 7:35am, observation in the corridor outside room 1B5-15 revealed a crash card plugged into a powerstrip that was plugged into an outdoor extension cord (“daisy chained”) This finding was confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the time of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“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: 39022 Based on observation and staff interview, the facility did not store gas cylinders in accordance with the requirements of NFPA 101 - 2012 edition, Section 19.3.2.4, 8.7 and NFPA 99 - 2012 edition, Section 11.3. Findings include: 1. On 6/3/25 at 3:15pm, observation in room 1E2-08 revealed four oxygen cylinders that were mixed and not separated into full any empty cylinders. 2. On 6/3/25 at 4:00pm, observation in room 1B3-13 revealed three nitrous oxide tanks stored upright on the floor and not secured. 3. On 6/4/25 at 7:35am, observation in room 1B5-15 revealed an empty oxygen cylinder with a vendor tag indicating the cylinder was still full. These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“Features of Fire Protection - Fire Loss Preve CFR(s): NFPA 101 Features of Fire Protection - Fire Loss Prevention in Operating Rooms Periodic evaluations are made of hazards that could be encountered during surgical procedures, and fire prevention procedures are established. When flammable germicides or antiseptics are employed during surgeries utilizing electrosurgery, cautery or lasers: * packaging is non-flammable * applicators are in unit doses * Preoperative “time-out” is conducted prior the initiation of any surgical procedure to verify: o application site is dry prior to draping and use of surgical equipment o pooling of solution has not occurred or has been corrected o solution-soaked materials have been removed from the OR prior to draping and use of surgical devices o policies and procedures are established outlining safety precautions related to the use of flammable germicide or antiseptic use Procedures are established for operating room emergencies including alarm activation, evacuation, equipment shutdown, and control operations. Emergency procedures include the control of chemical spills, and extinguishment of drapery, clothing and equipment fires. Training is provided to new OR personnel (including surgeons), continuing education is provided, incidents are reviewed monthly, and procedures are reviewed annually. 15.13 (NFPA 99) This Standard is not met as evidenced by: 39022 Based on record review and staff interview, the facility did not establish emergency procedures for operating room emergencies in accordance with the requirements of NFPA 99 - 2012 edition, Section 15.13. Findings include: 1. On 6/4/25 at 11:38am, review of the “Safety practices in the OR” policy (dated 11/20) revealed the policy did not include procedures outlining safety precautions related to the use of flammable liquids, germicides or antiseptics when there is use of electrosurgery or cautery. Interview with the Interim Nurse Executive Officer confirmed that the operating room staff do complete electrosurgery and utilize cautery equipment routinely. 2. On 6/4/25 at 11:40am, interview with the Interim Nurse Executive Officer revealed that prior to surgeries, a time-out is completed as part of the operating room safety practices. The Interim Nurse Executive Officer confirmed that the “Safety practices in the OR” is the only policy for the operating room that addresses fire safety but the policy does not outline time-out safety checks for flammable liquid use or specific emergency procedures for the operating room including alarm actuation, evacuation, chemical spills, and equipment shutdown procedures. 3. On 6/4/25 at 11:45am, interview with the Interim Nurse Executive Officer revealed that staff in the operating room utilize saline or a fire extinguisher in the event of a fire. The Interim Nurse Executive Officer confirmed that the current “Safety practices in the OR” policy does not include emergency procedures for extinguishing drapery, clothing or equipment fires. 4. On 6/3/25 at 9:00am, review of fire drill records provided by the Safety Manager revealed that the operating room has not had an annual exit drill. Interview with the Interim Nurse Executive Officer on 6/4/25 at 11:40am confirmed annual exit drills were not conducted. These findings were confirmed with the Chief of Quality Services and Acting Chief Nursing Officer at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.”

“MEDICAL STAFF - APPOINTMENTS CFR(s): 482.12(a)(2) [The governing body must] appoint members of the medical staff after considering the recommendations of the existing members of the medical staff. This Standard is not met as evidenced by: 25065 Based on review of the Governing Body Bylaws and Medical Staff Bylaws, physician credentialing files, and interview, the hospital failed to ensure the Governing Body appointed members of the medical staff after considering the recommendations of the existing members of the medical staff for four (Nurse Practitioner (NP) 1, Physician (Phys) 1, Phys2, Chief Medical Officer (CMO)) of six medical staff credentialing files reviewed for governing body appointment. This deficient practice had the potential to affect all patients receiving medical services at the hospital. Findings include: Review of the “Bylaws of [name of hospital board],” approved 01/31/24, indicated “. . . Responsibilities Of The Board - The activities, affairs, and property of the Corporation shall be managed, directed and controlled by the Board, except as otherwise provided in these By-Laws. The duties of the Board of Directors shall be to oversee the work and finances of the Corporation; to ensure that the work and finances of the Corporation are conducted in accordance with the Articles of Incorporation and the By-Laws; to appoint the officers; to approve an annual budget for the Corporation; and auditor’s statements and to generally guide and direct the work of the Corporation in the performance of its purpose and mission. In exercising these responsibilities and managing the affairs of the Corporation, the Board, and the individual Directors thereof, are required to discharge their duties in good faith and with that degree of diligence, care, skill, and accountability which ordinarily prudent people would exercise under similar circumstances in like positions. Review of the “Medical Staff Bylaws,” dated 09/27/24, indicated “. . . The Chief of Staff reviews the application [for appointment or reappointment] for completeness and verifies the application materials. No action shall be taken on an application until all information required by these Bylaws is available and verified. The Chief of Staff then forwards the completed, reviewed application to the appropriate Department Chief, who reviews the application and makes a recommendation to the Medical Executive Committee The Medical Executive Committee reviews the application, and makes a recommendation, which is forwarded to the Board of Directors for final approval. . .” Review of NP1’s credentialing file indicated reappointment and privileges were approved by the MEC (Medical Executive Committee) on 12/12/24 and signed by the Governing Board President or Chair of the Board Credentialing Subcommittee on 12/17/24 without designation whether the reappointment was approved or denied (the line for “Approved” or “Denied” was not checked). Review of Phys1’s credentialing file indicated reappointment and privileges were approved by the MEC on 12/12/24 and signed by the Governing Board President or Chair of the Board Credentialing Subcommittee on 12/17/24 without designation whether approved or denied (the line for “Approved” or “Denied” was not checked). Review of Phys2’s credentialing file indicated reappointment and privileges were approved by the MEC (Medical Executive Committee) on 12/12/24 and signed by the Governing Board President or Chair of the Board Credentialing Subcommittee on 12/17/24 without designation whether the reappointment was approved or denied (the line for “Approved” or “Denied” was not checked). Review of CMO’s credentialing file indicated reappointment and privileges were approved by the MEC on 03/13/25 and signed by the Governing Board President or Chair of the Board Credentialing Subcommittee on 03/27/25 without designation whether approved or denied (the line for “Approved” or “Denied” was not checked). During an interview on 05/09/25 at 1:30 PM, Chief Executive Officer (CEO) reviewed the above credentialing files and confirmed the designation of whether each was approved or denied was not documented. CEO stated the Chief of Staff or the Executive Medical Committee should check to see that all required documentation was complete.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 25065 Based on policy review, “Medical Staff Rules and Regulations” review, observation, patient medical record review, and interviews, the hospital failed to ensure the registered nurse (RN): 1. assured the telemetry monitor was set by the telemetry monitor technician to alert the physician to abnormal vital signs in accordance with physician orders for two (Patient (P) 10 and P13) of two patients with telemetry orders reviewed; 2. informed the physician when a diabetes teaching consult was not performed as ordered for one (P1) of one patient record reviewed with orders for a diabetic consult; 3. performed a CIWA (Clinical Institute Withdrawal Assessment of Alcohol Scale) assessment as ordered by the physician for one (P9) of one patient record reviewed with orders for a CIWA assessment from a sample of 30 patient and three supplemental patients; and 4. monitored the expiration dates of lab tubes on the nursing units so expired lab tubes were not available for use. These deficient practices had the potential to affect all patients receiving services at the hospital. Findings include: 1.Review of the hospital policy titled “Centralized Telemetry Monitoring of MSU [Medical/Surgical Unit] Patients,” last revised 04/08/24, indicated “. . . Certified Telemetry Technicians (CTT) responsibilities: . . . 3. Continuously monitor the heart rates and rhythms of all patient on telemetry. 4. lnterpret and print rhythm strips at the beginning of each shift, every 4 hours (0800, 1200, 1600, 2000, 0000, and 0400 [8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM, 12:00 AM, and 4:00 AM]), and with any rhythm changes. 5. Secure all printed strips to an EKG Rhythm Strip Sheet and placed in the telemetry binder. The EKG Rhythm Strip sheet must be completely filled out and signed. 6. Set default heart rate parameter settings: lower limit is 50 beats per minute and upper limit setting is 120 beats per minute. . . 9. Complete a narrative note in the EHR for rhythm changes and RN notifications. . .” The policy did not address the monitoring of blood pressure and the nurse’s responsibility to review the rhythm strips every four hours when the strips were placed in the telemetry monitor’s binder. Observation on 05/06/25 at 2:20 PM in the room where the telemetry monitor technician monitors the rhythm of all patients ordered to be on telemetry revealed Telemetry Technician (Tele) 1 had P10 and P13 being monitored. a.Review of P10’s physician orders (shown to the surveyor by Tele1) on 05/06/25 at 2:20 PM revealed an order to call the physician for a blood pressure less than 100 diastolic, pulse less than 60, and pulse greater than 120. During the observation and interview, Tele1 stated the nurse was supposed to set the blood pressure and pulse parameters. Tele1 confirmed the telemetry monitor was not set to monitor the diastolic blood pressure. Review of P10’s electronic medical record (EMR) indicated an order located under the “Orders” tab by Physician (Phys) 1 on 05/06/25 at 8:03 AM for telemetry and continuous pulse oximetry and to call for systolic blood pressure less than 100, diastolic blood pressure greater than 120, pulse less than 60, and pulse greater than 120. Further review indicated an order by Phys1 on 05/06/25 at 11:32 AM to decrease the low heart rate alarm on the telemetry monitor to 40 beats per minute. Observation on 05/06/25 at 2:20 PM revealed the telemetry monitor was not set at these parameters. b.Review of P13’s physician orders (shown to the surveyor by Tele1) on 05/06/25 at 2:20 PM revealed physician orders for telemetry and continuous pulse oximetry and diastolic blood pressure less than 100, pulse less than 60 and greater than 120 with no parameters for the oxygen saturation. Observation revealed the telemetry monitor was set at systolic blood pressure high rate of 100 and low rate of 95. During an interview on 05/06/25 at 2:40 PM, Tele1 stated he/she only notified the nurse if the oxygen and heart rate were not set according to the physician orders. Review of P13’s EMR under the “Orders” tab, indicated an order by Phys2 on 05/05/25 at 5:22 PM for temperature, pulse, respiration, and blood pressure check every eight hours and to call for systolic blood pressure less than 100, diastolic blood pressure greater than 120, pulse less than 60, and pulse greater than 120. Observation on 05/06/25 at 2:20 PM revealed the telemetry monitor was not set at these parameters. During an interview on 05/09/25 at 12:37 PM with Tele1 and Acting Director of Nursing (ADON) present, Tele1 presented the manual kept by the telemetry technicians with the patient’s monitor strips that were run at times according to hospital policy. Review indicated each strip was interpreted, signed by the telemetry technician, and the RN on the unit. The ADON stated the telemetry monitors were not set up to monitor patients’ blood pressures. The ADON stated the monitors allow for blood pressure monitoring, but they had not begun to set it up as such, because they had not developed the policy for doing so yet. 2. Review of the “Medical Staff Rules and Regulations” dated 09/27/24 indicated “. . . Each consultation report should contain a written clinical assessment and recommendations by the consultant that reflects an examination of the patient and the patient’s medical record. This report shall be made a part of the patient’s record. . . Inpatient consultation reports shall be completed on same day as the consultation requested. . .” Review of P1’s EMR physician order located under the “Orders” tab by Phys2 on 05/04/25 at 8:54 AM indicated an order for a consult on diabetic management teaching due to insulin noncompliance. Review of P1’s medical record indicated no documentation that a diabetic management teaching consult was performed. During an interview on 05/08/25 at 11:17 AM, RN6 confirmed there was no documentation in P1’s medical record that a diabetic management teaching consult was performed. 3. Review of P9’s EMR “Orders” tab indicated an order by Phys3 on 05/05/25 at 5:05 AM for “CIWA PROTOCOL / MSU [medical/surgical unit] 1. Do vitals 2. Determine Flowchart . . . CIWA Assessment using Clinical Indicator Withdrawal Assessment . . . CIWA score < [less than] 8 a. Continue Ciwa [sic] scoring and vital signs q4h x 48hr, then q6h x 24hr b. No alcohol-related medication treatments required CIWA score 8-15 a. Continue Ciwa [sic] scoring and vital signs q1h [every one hour] b. If score is 8 or greater after 4 hr x 48 hr [four hours times 48 hours] then q6h x 24hr [every six hours times 24 hours] b. No alcohol related medication treatments required CIWA score 8-15 a. Continue Ciwa [sic] scoring and vital signs q1h [every one hour] b. If score is 8 or greater after 4 hrs [hours] with medications given per orders, call MD [medical doctor] to discuss patient transfer to ICU [intensive care unit] c. For alcohol related medication treatments - see med [medication] orders” Review of P9’s EMR located under the “Notes” tab indicated P9’s CIWA assessment on 05/05/25 at 3:10 AM had a score of 6. Further review indicated P9’s assessment and vital signs were not documented in accordance with Phys3’s orders. During an interview on 05/08/25 at 2:45 PM, RN6 confirmed P9’s CIWA assessment and vital signs were not documented as ordered by Phys3. 4. Observation on 05/06/25 at 11:00 AM on the pediatric unit revealed a lab cart with 14 lavender pediatric micro containers that expired on 04/30/23, two green vacuettes that expired on 03/06/25, and four orange vacutainers that expired on 04/30/25. Further observation on 05/06/25 at 11:15 AM on the pediatric unit revealed the third drawer of the crash cart had two green microtainers that expired 11/30/24 and two lavender microtainers that expired 04/30/25. These lab supplies were available to be used by the nursing staff. During an interview on 05/06/25 at 11:15 AM, RN1 stated the supply technician was responsible for checking expiration dates of lab supplies in the supply room. RN1 stated once the lab supplies were placed on the nursing unit, it was the responsibility of the nurses and certified nursing assistants to check for expiration dates.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 25065 Based on policy review, patient medical record review, and interview, the hospital failed to ensure the patient’s nursing care plan reflected the patient’s goals and the nursing care to be provided to meet the patient’s needs for five (Patient (P) 1, P7, P16, P17, and P18) of 16 patient records reviewed for the nursing care plan from a sample of 30 patients and three supplemental patients. This deficient practice had the potential for unidentified and unmet care needs and goals important to the patients. Findings include: Review of the hospital policy titled “Patient Care Plans for Inpatient Units,” effective 09/09/22, indicated “. . . B. Each patient’s nursing care is individualized based on identified patient care needs and patient care standards and is consistent with the therapies of other disciplines. C. Evaluation shall include assessing the patient’s individualized care needs, patient’s health status/ conditioning and patient’s response to interventions. . .” The policy did not address goals in relation to the nursing care to be provided to meet the patient’s needs. Review of the hospital policy titled “ACU [Adolescent Care Unit] Nursing Care Plan,” effective 04/08/25, indicated “. . . The individualized nursing care plan includes: a. Nursing assessment to identify patient’s needs by collecting subjective and objective data from the patient, family/legal guardian, and/or from the ACU clinical team when necessary. b. Patient’s individualized existing and/or potential nursing diagnoses. c. Short-term and long-term (when necessary) nursing goals with measurable outcome through planning. D. Implementation of nursing interventions to meet planned goals. . .” 1.Review of P1’s electronic medical record (EMR) under the “Notes” tab indicated P1 was admitted on 05/04/25 at 9:23 AM with diagnoses of diabetic ketoacidosis, type II diabetes mellitus, and personality disorder. Review of P1’s nursing care plan located under the “Notes” tab developed on 05/04/25 at 10:40 AM indicated the problems identified included electrolyte imbalance risk, hyperglycemia risk, anxiety, and pain. Review indicated goals for electrolyte imbalance was “The patient will maintain electrolyte levels within normal parameters.” The goal for hyperglycemia risk was “The patient will maintain appropriate glucose levels.” The goal for pain was “The patient will identify factors that relieve pain. The patient will verbalize or demonstrate relief from pain.” There was no documentation that the nursing care plan goals were written as measurable goals that reflected the nursing care to be provided to meet the patient’s needs. 2.Review of P7’s EMR under the “Notes” tab indicated P7 was admitted on 05/01/25 at 11:07 PM with diagnoses of urinary retention and urinary tract infection. Review of P7’s nursing care plan developed on 05/01/25 at 11:16 PM indicated the problems identified were acute pain, infection risk, and knowledge deficiency. Review indicated goals for acute pain were “The patient and family (as appropriate) will identify factors that relieve pain. The patient will verbalize or demonstrate relief from pain.” The goals for infection risk were “The patient will remain afebrile. The patient will have no sign of erythema or purulent drainage. The patient and family (as appropriate) will verbalize understanding the signs and symptoms of infection.” The goal for knowledge deficiency was “The patient and family (as appropriate) will demonstrate knowledge retention related to lower urinary tract infection. The patient will demonstrate behaviors congruent with expressed knowledge.” There was no documentation that the nursing care plan goals were written as measurable goals that reflected the nursing care to be provided to meet the patient’s needs. 3.Review of P16’s EMR under the “Notes” tab indicated P16 was admitted on 05/05/25 at 12:34 PM with diagnoses of major depressive disorder (MDD), generalized anxiety disorder, and alcohol use disorder. Review of P16’s nursing care plan developed on 05/05/25 at 4:28 PM indicated the identified problems were altered social interaction, anxiety, coping impairment, impaired family dynamics, social isolation, and knowledge deficiency. Goals for altered social interaction indicated “The child will demonstrate positive changes in social interactions.” The goal for coping impairment indicated “The child and family or caregiver (as appropriate) will identify appropriate coping behaviors. The child will develop appropriate coping behaviors. The child wi1l use appropriate coping behaviors.” The goal for impaired family dynamics indicated “The child and family or caregiver (as appropriate) will verbalize problems and feelings. The child and family or caregiver (as appropriate) will demonstrate appropriate coping strategies.” The goal for social isolation indicated “The chi1d will increase social interactions.” The goal for knowledge deficiency indicated “The child and family or caregiver (as appropriate) will demonstrate knowledge retention related to depression. The child and family or caregiver (as appropriate) will demonstrate behaviors congruent with expressed knowledge. Review of the nursing goals indicated they were not written with measurable outcome in accordance with the ACU policy. 4.Review of P17’s EMR under the “Notes” tab indicated P17 was admitted on 05/06/25 at 11:22 AM with diagnoses of ADHD (attention deficit hyperactive disorder), cannabis use disorder, and rule out MDD, generalized anxiety disorder, and PTSD (post-traumatic stress disorder). Review of P17’s nursing care plan developed on 05/06/25 at 4:00 PM indicated identified problems included impulsivity, coping impairment, anxiety, and altered social interaction. Review of the goals for coping impairment indicated “The child and family or caregiver (as appropriate) will identify appropriate coping behaviors. The child will develop appropriate coping behaviors. The child wi1l use appropriate coping behaviors.” The goal for altered social interaction indicated “The patient will demonstrate positive changes in social interactions.” Review of the nursing goals indicated they were not written with measurable outcomes in accordance with the ACU policy. 5.Review of P18’s EMR under the “Notes” tab indicated P18 was admitted on 05/06/25 at 10:53 AM with diagnoses of MDD and ADHD. Review of P18’s nursing care plan developed on 05/06/25 at 8:21 PM indicated the identified problems included coping impairment, social isolation, suicide attempt risk, altered social interaction, impulsivity, anxiety. Review of the goal for coping impairment indicated “The child and family or caregiver (as appropriate) will identify appropriate coping behaviors. The child will develop appropriate coping behaviors. The child wi1l use appropriate coping behaviors.” The goal for social isolation indicated “The chi1d will increase social interactions.” The goal for altered social interaction indicated “The patient will demonstrate positive changes in social interactions.” Review of the nursing goals indicated they were not written with measurable outcomes in accordance with the ACU policy. During an interview on 05/08/25 at 9:53 AM with Chief Executive Officer (CEO), Chief Medical Officer (CMO), and Nurse Practitioner (NP) 1, NP1 stated he/she had reviewed the nursing care plans of the patients on the ACU. NP1 stated the nursing goals were not individualized and were not measurable. During an interview on 05/09/25 at 12:37 PM, Acting Director of Nursing (ADON) offered no explanation for the nursing goals on the nursing care plans, not being measurable and not being reflective of the nursing care to be provided to meet the patient’s needs.”

“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: 18750 Based on policy review, medical record review, review of controlled substance logs, and interviews, the hospital failed to ensure controlled substances were monitored in accordance with hospital policy. This deficient practice had the potential to affect all patients receiving services of the hospital. Findings include: During a tour of the surgical department on 05/06/25 at 10:00 AM, The binder labeled “Controlled Drugs” set on a cart. During review of the binder, the forms inside were titled “Controlled Drug Inventory Log” and read “All controls must be counted Q24H [every 24 hours].” The forms were dated, and the following was observed: January 2025 was not signed off for Tuesday 01/07/25, Thursday 01/09/25, and Friday 01/10/25. March 2025 was not signed off for Friday 02/14/25 and Tuesday 03/04/25. April 2025 was not signed off for Friday 04/04/25, Thursday 04/10/25, Friday 04/11/25, Thursday 04/24/25, Friday 04/25/25, Monday 04/28/25, and Wednesday 04/30/25. During an interview on 05/06/25 at 10:10 AM, Interim Nurse Executive (INE)1 was asked about the blanks on the forms. INE1 stated there should not be any blanks except on the weekends when no one is here. There should be two nurses that sign off on the count. INE1 stated there was an in service in January 2025 to remind staff to sign off on the forms. Review of the hospital’s policy titled, “OR Surgical Staff Scope of Responsibility” last revised on 05/05/25 revealed, “Purpose: Delineate the responsibilities of the staff. Policy: The provision of nursing services for all types of elective and emergency surgeries. Procedure: Lead Clinical /Charge Nurse: A professional nurse who plans, directs, coordinates, controls, administers, and evaluates care given to patients. The Charge nurse directly supervises and teaches members of the nursing team. Duries include. . .3. Ensure the daily narcotic count is completed and documented. . .””

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 25065 Based on observation, interview, and policy review, the hospital failed to ensure medical records were stored in secure locations where they were protected from potential water damage if the sprinkler system became activated. This deficient practice had the potential to affect all stored paper records kept on shelving in the medical record department that were protected from fire by a sprinkler system. Findings include: Review of the hospital policy titled “Water Damage Policy,” revised 07/28/09, indicated “. . . It is the policy of [name of hospital] to provide a contingency plan in the event records are damaged due to flood. Any type of damage is destructive. Water damage from flood or fire can be the most devastating. PURPOSE: To establish a written standard procedure for medical records department in the event records are damaged due to flood and/or fire sprinkler. Procedures: I. Determine what documentation should be rescued by using the retention requirements. II. Prioritize which records should be removed first in order to keep the hospital functioning. III. Records are to be removed within 48 hours of damage to prevent mold, mildew, and bacterial growth. IV. Depending on the degree of damage, the records can be restored by: A. Air drying the records by placing absorbent material between each document and then fans are used for increased air circulation. B. Freezing the records and keeping them in cold storage. This process stops the deterioration of handwritten data on paper records. C. Freeze drying is the quickest and most expensive method. Only for optimal preservation of original records that are totally irreplaceable. . .” Review of the policy indicated there was no method developed to keep the medical records from being exposed to the sprinkler system. Observation on 05/09/25 at 9:10 AM revealed there was a five-inch stack of medical records that had not been scanned before being reviewed by the quality analysts. Further observation revealed 29 columns of a rolling shelving unit filled with medical records waiting to be purged and sent to the off-site storage facility. Observation revealed there was no protection between each column when rolled shut to protect the records if the sprinkler was activated. During an interview on 05/09/25 at 9:30 AM with Director of Risk management (DRM), Chief Financial Officer (CFO), and Health Information Management Supervisor (HIMS) present, all in attendance confirmed more than 1000 patient records were not protected from potential water damage if the sprinkler system was activated.”

“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: 18750 Based on observations, policy review, and interviews, the food service director failed to ensure 1. kitchen equipment was maintained to ensure an acceptable level of safety and quality related to the three-compartment sink and documentation of the dishwasher temperature logs and 2. implementation of safe practices for food handling by having expired food items available for use in refrigerators on the patient care units. These deficient practices had the potential to affect all patients receiving services in the hospital. Findings include: 1. Review of the hospital’s policy titled, “Guideline for Kitchen Sanitation” last revised 12/20/14, revealed, “Purpose: To prevent cross-contamination of all food preparation areas, serving line, dining areas and appliances shall be cleaned or sanitized after each use. Policy: The Hospital Food Services will make every effort to meet the safety and sanitation compliance of federal, state, and local laws and regulations. Procedures. . . t. Dish Machine Temperatures must be recorded at 7:00 a.m., 12:00 p.m., and 6:00 p.m. 12. Three-Compartment Sink. . .b. Temperatures shall be recorde on three- compartment sink temperatures record sheet during each refill. . .” During a tour on 05/06/25 at 11:30 AM, review of the dishwasher indicated it was a high temperature dishwasher. Review of the “Dish Machine Temperature Chart” revealed temperatures were not recorded on 05/02/25 for 7:00 AM, and there were no recorded temperatures for 05/0125- 05/04/25 for 6:00 PM. Also, during the tour, review of the “Three Compartment Sink Temperature Record was completed. There was a blank for an early check on 05/02/25. During an interview on 05/06/25 at 11:45 AM, the Director of Nutritive Services (DNS) was asked about the blanks on the chart for the dish machine and the record for the three compartment sink. The DNS stated there should be no blanks on the two forms. They should be filled in completely. 2. Review of the hospital policy titled “Patient Meal Services, Diet Orders, and Tray Delivery,” last revised 07/08/15, indicated “. . . Foods shall be rotated so that the oldest items are the first used. Date all opened items. If canned, put into a clean contained cover and date. Opened cartons shall be used before another is opened. . . Food Supplies a. Each morning the bulk nourishment forms will be inventoried by the FSW [food service worker] on MSU/PEDS [Medical Surgical Unit/Pediatrics], OB [Obstetrics] and ICU [Intensive Care Unit] inpatient wards and the outpatient clinic areas. The Food Service Worker will determine what supplies are below the par level and replenish these items. The bulk nourishment’s [sic] are delivered [sic] 2:30 p.m. b. The FSW will check and rotate perishable items following the first-in/first-out system so that spoilage does not occur. All perishables must be discarded every three days. The foods items must be label [sic] & [and] dated. c. The perishable food items are discarded according to the expiration date or color codes. . .” Observation on 05/06/25 at 10:30 AM revealed the inpatient refrigerator in the kitchen on the Medical/Surgical Unit had the following outdated food items available for use: one slice of bread with a use by date of 05/06/25 at 9:07 AM; a turkey sandwich with no cheese with a use by date of 05/06/25 at 8:17 AM; seven individual containers of Jello with a use by date of 05/06/25 at 8:03 AM. During an interview on 05/06/25 at 10:40 AM with Inpatient Supervisor (InSup) and Dietary Technician (DT) 1 present, DT1 stated the dietary technician checks the par level between 7:00 AM and 7:30 AM and checks the refrigerator temperature. DT1 stated the scheduled time to replace the needed food items in the refrigerator is usually after lunch. InSup stated the dietary technician should have discarded the expired food items at the time the par level check was done. Observation on 05/06/25 at 1:20 PM on the Adolescent Care Unit revealed the refrigerator used to keep patient nourishments had the following food items that were expired and available for use: five containers of Jello with a beyond use date of 05/06/25 at 8:07 AM; four cups labeled as 1% milk with a beyond use date of 05/05/25 at “end of day.” Observation on 05/06/25 at 1:25 AM in the “ACU [Adolescent Care Unit] Healthy Cooking Class Activities Only” room revealed the refrigerator had an opened, undated bag of blue cornmeal and an undated and opened bag of chocolate chips available for use. During an interview on 05/26/25 at 1:25 PM with Chief Executive Officer (CEO) and Acting Director of Nursing (ADON) present, CEO stated the expired food items should have been discarded, and the undated, opened bags of corn meal and chocolate chips should have been labeled with the dates each bag was opened. 25065”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 25065 Based on observation, interviews, and policy review, the hospital failed to ensure appropriate hand hygiene/glove use, hand sanitizer units were maintained, and containers of Sani-Cloth (disinfectant wipes) were available for use. These deficient practices had the potential to increase transmission of bacteria and viruses. Findings include: 1.Review of the hospital policy titled “Hand Hygiene,” last revised 06/14/23, indicated “. . . A. According to the CDC [Centers for Medicare and Medicaid Services] hand hygiene guidelines, employees should perform hand hygiene as follows: 1. When hands are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water 2. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical settings 3. Decontaminate hands before: a. Having direct contact with patients b. Before donning sterile gloves with any procedure c. After contact with a patient’s intact skin (e.g., [for example] when taking a pulse or blood pressure and lifting a patient) d. After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled e. If moving from a contaminated body site to a clean-body site during patient care f. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient g. After removing gloves h. Before eating and after using a restroom . . .” Observation on 05/07/25 at 11:00 AM on the Medical/Surgical Unit with Chief Executive Officer (CEO) and Acting Director of Nurses (ADON) present revealed Registered Nurse (RN) 5 performed a glucose check for Patient (P) 11. Continuous observation revealed RN5 completed the fingerstick to obtain a blood sample. Observation revealed after performing the fingerstick, RN5 documented the results on note paper and used his/her pen without removing contaminated gloves and performing hand hygiene. Observation revealed RN5 donned a new set of gloves after performing hygiene to clean the glucometer (machine used to perform the glucose test). While wearing the same gloves, RN5 wiped the counter with a Sani-Cloth disinfectant wipe and placed the disinfected glucometer on the wiped counter. Observation revealed RN5, while wearing contaminated gloves (from disinfecting the glucometer), opened the drawer under the counter to place the container of test strips. RN5 then removed his/her gloves and performed hand hygiene. During an interview on 05/07/25 at 11:15 AM, RN5 confirmed he/she did not remove his/her gloves after performing the glucose check before documenting the results. RN5 denied placing the container of strips in the drawer with contaminated gloves. RN5 stated he/she removed his/her gloves before placing the container of strips in the drawer. Observation revealed RN5 did not disinfect the container of strips before placing the container in the drawer. During an interview on 05/07/25 at 11:30 AM with Chief Executive Officer (CEO) and Acting Director of Nurses (ADON), when the surveyor explained that observation revealed RN5 did not disinfect the container of test strips before placing the container in the drawer, both CEO and ADON agreed with the observation. 2.Review of the hospital policy titled “Patient Rooms (Terminal),” last revised 08/01/17, indicated “. . . After discharge or transfer, a patient room will be cleaned in the following manner: . . . Inspect and replenish all dispensers (soap, paper towels, and toilet tissue). . .” Review of the hospital policy titled “Installation and Maintenance of Dispensers for Alcohol-based Hand Rub (ABHR),” last revised 03/21/25, indicated “. . . The dispensers should be maintained in accordance with manufacturer guidelines. . .” Review of the hospital policy titled “Cleaning Nurses’ Station,” last revised 11/30/21, indicated “. . . The Environmental Services Department personnel will clean the Nurses’ Stations on a daily basis . . . Damp dust counters, office furniture, cabinets, telephones, and receivers, etc., with a hospital-approved germicidal solution. . . Refill dispensers and supplies as necessary. . .” Observation on 05/06/25 at 10:00 AM on the Medical/Surgical Unit revealed the hand sanitizer unit mounted on the wall outside Room 9 had no bag of sanitizer in the unit. During an interview on 05/06/25 at 10:00 AM during the above observation, Registered Nurse (RN) 1, Charge Nurse, stated the sanitizer bag was removed, because the patient who was in Room 9 had a history of alcohol withdrawal. RN1 stated the patient had been discharged at 5:00 PM on 05/05/25. RN1 stated environmental services should have refilled the sanitizer unit when they cleaned the patient’s room after discharge the previous day. Observation on 05/06/25 at 11:08 AM on the Pediatric Unit revealed a container of Sani-Cloth wipes with an expiration of January 2025 was available for use on the counter of the nurse’s station. During an interview on 05/06/25 at 11:10 AM, RN4 stated staff is supposed to check the expiration date of the Sani-Cloth “when we bring it out” from the supply closet. When the surveyor asked if the expiration date was supposed to be checked before use after the container was brought out, RN4 stated “not that I’m aware of unfortunately.””