Audubon County Memorial Hospital

“42 CFR 485.623(d) (Facility name) was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 485.623(d), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 Edition. (Facility name) is a (# of stories) story building that was built in (year built) with an addition in (year). The building is composed of Type (I) construction. The facility is fully sprinklered and there is supervised smoke detection located in the (corridors, resident rooms, and the spaces open to the corridors). The facility has (# of beds) certified beds. At the time of the survey, the census was (). The requirement at 42 CFR 485.623(d) is NOT MET as evidenced by:”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 42934 Based on record review and interview, the facility failed to test, document and maintain the battery backup emergency lights in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.9.3.1.1(1)), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 7 and a census of 1. Findings include: 1. Record review and interview on 02/25/2026 at 10:50 a.m., revealed the facility could not provide domentaion for monthly 30-second emergency light testing for November and December 2025. 2. Record review on 02/25/2026 at 10:50 a.m., revealed documentation for the monthly and annual emergency light testing is required to list the location of each light unit tested. The facility documentation grouped multiple emergency lights in groups of 2-8 units in sections of the facility. 3. Observation on 02/25/2026 at 11:40 a.m., revealed the emergency lights on the combination exit/emergency light unit located on the north wall in the Kitchen did not illuminate when the battery backup source was tested. The Maintenance Representative verified these observations during the survey.”

“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: 42934 Based on observation and interview, the facility failed to provide separation of hazardous areas in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.2.1.3), 2012 Edition. This deficient practice affects approximately staff located in the Kitchen. This facility has a capacity of 7 and a census of 1. Findings include: Observation and interview on 02/25/2026 at 11:30 a.m., revealed the Food Pantry Room of the Kitchen measuring approximately 15 X 5 feet did not have a door seperating these spaces. The door had a wooden door frame where a door had been removed at some unknown period in the past. These areas are required to be seperated by a fire door assembly on closure or magnetic release attached to the fire alarm system. The Maintenance Representative verified this observation during the survey.”

“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: 42934 Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.2.1.1, by ensuring that sprinkler the sprinkler system has an internal inspection performed every five years. This lack of maintenance could affect the operation of the sprinkler system. This deficient practice affects all residents, staff and visitors in the facility. The facility had a capacity of 7 and a census of 1 at the time of the survey. Findings include: Documentation review and interview 02/25/2026 at 10:50 a.m., revealed the facility failed to provide documentation that the sprinkler system had a five year internal inspection conducted in the last five years. The 07/22/2025 annual inspection report by Midwest Automatic Spinkler Company noted a five year inspection was due. During the survey facility walk-through, the sprinkler gauges on the riser system did not have the date of installation for verification they had been replaced in the last five years. The Maintenance Representative verified this observation during the survey.”

“HVAC - Any Heating Device CFR(s): NFPA 101 HVAC - Any Heating Device Any heating device, other than a central heating plant, is designed and installed so combustible materials cannot be ignited by device, and has a safety feature to stop fuel and shut down equipment if there is excessive temperature or ignition failure. If fuel fired, the device also: * is chimney or vent connected. * takes air for combustion from outside. * provides for a combustion system separate from occupied area atmosphere. 19.5.2.2 This Standard is not met as evidenced by: 42934 Based on observation and interview, the facility failed to provide heating devices that are designed and installed so that combustible material cannot be ignited by the device or its appurtenances according to National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.5.2.2, by not sealing vent piping sections for one of the clothing dryers in the Laundry Room. This deficient practice affect staff in the Laundry Room of the facility. The facility had a capacity of 7 and a census of 1 at the time of the survey. Findings include: Observation on 02/25/2026 at 11:43 a.m., revealed the clothes dryer located in the Laundry Room had a section of exhaust vent tubing secured by gray duct tape. Clothes dryer vent tubing is to be secured with approved dryer tape only. The Maintenance Representative confirmed this observation at the time of discovery.”

“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: 42934 Based on record review and interview, the facility is not properly conduct/documenting fire drills in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.1.4), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 7 and a census of 1. Findings include: 1. Record review and interview on 02/25/2026 at 9:10 a.m., revealed that the facility did not conduct/document a fire drill during the third shift (11:00 p.m.-7:00 a.m.), fourth quarter of 2025. 2. Record review and interview on 02/25/2026 at 9:10 a.m., revealed the third shift fire drills documentation did not include documentation of the time the fire alarm system was tested the next day shift, or verification and documenting that the transmission of the fire alarm signal is being received by the facility ’ s monitoring company. Fire drill documentation only noted “will test alarm during the next day shift”. The Maintenance Representative verified these observations at the time of the survey process.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 42934 Based on record review and interview, the facility failed to document testing of hospital-grade electrical receptacles in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-6.3.4.1.1), 2012 Edition. This deficient practice affects all patients, visitors and staff who may be in the affected areas of the facility. This facility has a capacity of 7 and a census of 1. Findings include: Record review and interview on 02/25/2026 at 10:40 a.m., revealed the facility was unable to provide documentation for testing of hospital-grade electrical receptacles upon initial installation, replacement or servicing. This documentation must be maintained and updated as necessary. The Maintenance Representative verified this observation at the time of the survey process.”