Jenkins County Medical Center

“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: 51219 During a review of the facilities Emergency Preparedness Program on February 20, 2026, between 8:45 AM and 11:30 AM it was noted that there was no documentation available that the plan includes whole book not updated or signed. These findings were confirmed by Staff M at the time of discovery. Based on review of Jenkins Medical Center Emergency Preparedness Program and interviews with staff it was determined that the facilities plan was not in substantial compliance set forth in Hospital 42 CFR § 482.15”

“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: 51219 During a tour of the facility with Staff M on February 20, 2026, between 8:45 AM and 11:30 AM observation revealed that in the rear of facility near maintnace shop, there was a blocked exit door that was fixed on site. These findings were confirmed by Staff M at the time of discovery. Reference: 2012 NFPA 101, Chapter 19, Section 19.2.1 and Chapter 7, Section 7.1.10.2.1 Based on observation and staff interviews it was determined the facility failed to ensure exit doors are not blocked. This affects 1 of 6 smoke compartments”

“Vertical Openings - Enclosure CFR(s): NFPA 101 Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box. This Standard is not met as evidenced by: 51219 Based on observation and staff interviews it was determined the facility failed to ensure ceiling tiles are in place. This affects throughout the facility During a tour of the facility with Staff M on February 20, 2026, between 8:45 AM and 11:30 AM observation revealed that throughout the facility, there are ceiling tiles missing from grid. These findings were confirmed by Staff M at the time of discovery. Reference: 2012 NFPA 101, Chapter 19, Section 19.3.1”

“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: 51219 Based on observation and staff interviews it was determined the facility failed to ensure closers and door were in place on hazard areas This affects whole facility During a tour of the facility with Staff M on February 20, 2026, between 8:45 AM and 11:30 AM observation revealed that throughout the facility, there are doors and closers missing on hazards rooms These findings were confirmed by Staff M at the time of discovery. Reference: 2012 NFPA 101, Chapter 19, Section 19.3.2.1.3”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 51219 Based on observation and staff interviews it was determined the facility failed to ensure fire alarm breaker has approved lock This affects whole facility During a tour of the facility with Staff M on February 20, 2026, between 8:45 AM and 11:30 AM observation revealed that the fire alarm breaker is missing approved locking device. These findings were confirmed by Staff M at the time of discovery. Reference: 2012 NFPA 101, 19.3.4.1, 9.6.1.3, 2010 NFPA 72, 10.5.5.2.1 thru 10.5.5.2.4 Based on observation and staff interviews it was determined the facility failed to ensure fire alarm panel is labeled This affects whole facility During a tour of the facility with Staff M on February 20, 2026, between 8:45 AM and 11:30 AM observation revealed that the fire alarm panel was not labeled for the fire alarm breaker. These findings were confirmed by Staff M at the time of discovery. Reference: 2012 NFPA 101,19.3.4.1, 9.6, 9.6.1.3 and 2010 NFPA 72, 10.5.5.2”

“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: 51219 Based on observation, and staff interviews it was determined the facility failed to ensure sprinkler rier has hydraulic data plate This affects 1 of 6 smoke compartments. The findings include: During a tour of the facility with Staff M on February 20, 2026, between 08:45 am and 11:30 am observation revealed that in the riser room the riser is missing hydraulic data plate. These findings were confirmed by Staff M at the time of discovery. Reference:2012 NFPA 101, Chapter 19, Section 19.3.5.1, Chapter 9, Section 9.7.1.1 and 2010 NFPA 13, Chapter 24, Section 24.5.1”

“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: 51219 Based on observation, and staff interviews it was determined the facility failed to ensure sprinkler heads are dust dust covered or painted. This affects throughout the facility The findings include: During a tour of the facility with Staff M on February 20, 2026, between 08:45 am and 11:30 am observation revealed that the sprinkler heads throughout the facility are painted and dust covered. These findings were confirmed by Staff M at the time of discovery. Reference:2012 NFPA 101, Chapter 19, Section 19.3.5.1, 19.1.1.1.3, 4.6.12.1, 9.7.5 and 2011 NFPA 25, Chapter 5, Section 5.2.1.1.2, 5.2.1.1.4 Based on observation, and staff interviews it was determined the facility failed to ensure storage height are within the requirements. This affects whole facility storage rooms. The findings include: During a tour of the facility with Staff M on February 20, 2026, between 08:45 am and 11:30 am observation revealed that throughout the facility in storage rooms, storage height is not within the height limits. These findings were confirmed by Staff M at the time of discovery. Reference:2012 NFPA 101, Chapter 19, Section 19.3.5.1, Chapter 9, Section 9.7.1.1.(1) and 2010 NFPA 13, Chapter 8, Sections 8.5.6, 8.5.6.1”

“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: 51219 Based on observation, and staff interviews it was determined the facility failed to ensure ceiling for separation is in place. This affects 1 of 6 smoke compartments The findings include: During a tour of the facility with Staff M on February 20, 2026, between 08:45 am and 11:30 am observation revealed that in the riser room the entire ceiling is missing. These findings were confirmed by Staff M at the time of discovery. Reference:2012 NFPA 101 , Chapter 19, Sections 19.3.7.1, 19.3.7.3, Chapter 8 Sections 8.3.5, 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.1, 8.5.6.2, 8.5.6.3, Chapter 4, Section 4.6.12.1”

“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: 51219 Based on observation, and staff interviews it was determined the facility failed to ensure multi taps are not on the floor and mounted properly. This affects throughout the facility The findings include: During a tour of the facility with Staff M on February 20, 2026, between 08:45 am and 11:30 am observation revealed that throughout the facility there are muli taps on the floor not protected from damage. These findings were confirmed by Staff M at the time of discovery. Reference:2012 NFPA 101, 19.5.1.1, 9.1.2 and 2011 NFPA 70, 380.12 (2) Based on observation, and staff interviews it was determined the facility failed to ensure there are not exposed wiring. This affects 1 of 6 smoke compartments The findings include: During a tour of the facility with Staff M on February 20, 2026, between 08:45 am and 11:30 am observation revealed that in the riser room and a office there are exposed wires. These findings were confirmed by Staff M at the time of discovery. Reference:2012 NFPA 101, Chapter 19, Section 19.5.1.1, Chapter 9, Section 9.1 .2 and 2011 NFPA 70, Articles 334.10 (3), 610.12(A), 398.15 Based on observation, and staff interviews it was determined the facility failed to ensure no electrical panels are blocked. This affects 1 of 6 smoke compartments The findings include: During a tour of the facility with Staff M on February 20, 2026, between 08:45 am and 11:30 am observation revealed that near the maintenance shope there is a electrical blocked by equipment. These findings were confirmed by Staff M at the time of discovery. Reference:2012 NFPA 101, Chapter 19, Section 19.5.1.1, Chapter 9, Section 9.1.2 and 2011 NFPA 70 Article 110.26 Based on observation, and staff interviews it was determined the facility failed to ensure faceplate covers on installed This affects throughout the facility The findings include: During a tour of the facility with Staff M on February 20, 2026, between 08:45 am and 11:30 am observation revealed that throughout the facility there are faceplates missing from outlets. These findings were confirmed by Staff M at the time of discovery. Reference:2012 NFPA 101, Chapter 19, Section 19.5.1.1, Chapter 9, Section 9.1.2 and 2011 NFPA 70, Article 406.6”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 51219 Based on observation, and staff interviews it was determined the facility failed to ensure no space heater are in the facility This affects 1 of 6 smoke compartments The findings include: During a tour of the facility with Staff M on February 20, 2026, between 08:45 am and 11:30 am observation revealed that in the admin office there is a space heater with no thermostaic documentation. These findings were confirmed by Staff M at the time of discovery. Reference:2012 NFPA 101 Chapter 19, Section 19.7.8”

“FACILITY-WIDE ABT STEWARDSHIP PROGRAM CFR(s): The facility-wide antibiotic stewardship program: (i) Demonstrates coordination among all components of the CAH responsible or antibiotic use and resistance, including, but not limited to, the infection prevention and control program, the QAPI program, the medical staff, nursing services, and pharmacy services; This Standard is not met as evidenced by: 42305 Based on review of facility policy titled “Antimicrobial Stewardship,” review of facility documents, and staff interviews, it was determined that the facility failed to develop and implement a facility-wide antibiotic stewardship program. Findings included: Review of the undated facility policy titled “Antimicrobial Stewardship,” 200, revealed that the hospital antimicrobial stewardship program included the following elements: a. Policy and Procedure b. A multi-disciplinary antimicrobial stewardship committee meeting at least quarterly. Information was reported to the Quality Council, Medical Staff, and Governing Board including strategies and data analysis. The facility chose focus projects based on results from the Infection Control Risk Assessment, considering trends in ordering practices, review of cultures, days of therapy, and vulnerable diagnoses. The policy stated that the procedure included identifying a person with accountability and expertise in antibiotic stewardship. The facility would develop a system to assess antibiotic utilization and antimicrobial resistance. Antimicrobial Stewardship was an ongoing practice and collaborative approach with a multidisciplinary team including pharmacy, physicians, infection control, microbiology, and nursing. Elements and events would be added to the Infection Prevention and Control Risk Assessment. Review of the Infection Control Plan failed to reveal a collaborative approach to antibiotic stewardship to include antibiotic stewardship strategies and data analysis. Review of Executive Committee minutes and Quality Improvement minutes from September 2025 to January 2026 failed to reveal discussions regarding antimicrobial stewardship. An interview took place with Chief Quality Officer (CQO) KK on 2/18/26 at 2:25 p.m. in the Conference Room. CQO KK said there was not an Antibiotic Stewardship Committee. Antibiotic stewardship was discussed in the Pharmacy and Therapeutic Committee. Antibiotic Stewardship was not included in the Infection Prevention Risk Assessment. The facility was still in the policy stages. There was no access to data. The facility had been trying to get interfaced for almost two years to have access to antibiotic data. An interview took place with the Director of Pharmacy (DOP EE) on 2/18/26 at 2:40 p.m. in the pharmacy. DOP EE did not have access to a report of antibiotic trends and tracking. The Electronic Medical Record (eMAR) was not interfacing to trend because the documents were scanned images.”

“NOTICE OF RIGHTS CFR(s): A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under state law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible This Standard is not met as evidenced by: 42305 Based on medical record review, policy titled “Notifying Medicare Beneficiaries of Their Discharge Appeal Rights,” and staff interviews, it was determined that the facility failed to provide the required Important Messages from Medicare (IMMs) to inform patients of their discharge rights for seven patients (P) (P#2, P#3, P#4, P#5, P#6, P#7, and P#10) Medicare beneficiaries who were inpatients. Findings included: A record review revealed that seven (P#2, P#3, P#4, P#5, P#6, P#7, and P#10) of ten inpatient records failed to include signed copies of the initial or follow-up IMMs. Review of the facility policy titled “Notifying Medicare Beneficiaries of Their Discharge Appeal Rights,” REG.834, effective 1/2010, revealed that the facility would provide all Medicare beneficiaries who were hospital inpatients of their rights to appeal a premature discharge. Every Medicare beneficiary would be provided with the IMM within two calendar days of an inpatient admission, or not more than seven days prior to admission. A signed copy of the IMM would be placed in the medical record. A follow-up copy of the IMM would be provided to every beneficiary to ensure the beneficiary was aware of appeal rights at the time needed. The follow-up IMM would be delivered as far in advance as possible, but not more than two days prior to the discharge date. On 2/18/26 at 2:25 p.m. in the Conference Room, the Chief Quality Officer (CQO) said the facility could not find the Important Message for Medicare (IMM) for any of the patients reviewed. An interview took place with the Revenue Cycle Manager (RCM) on 2/19/26 at 11:44 a.m. in the Conference Room. RCM said the IMM was in the packet where patients gave consent. Patients were asked to sign the form at registration. Paper copies would be scanned into the electronic health record. RCM was not sure where the paper copies were located for the patients reviewed.”