Buchanan County Health Center

“42 CFR 485.623(d) Buchanan County Health Center 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. Buchanan County Health Center is a 2 story building that was built in 1967 with additions in 1987, 1992, 1998, 1999, 2001, 2004, 2010, 2018, and 2025. The building is composed of Type II (000) construction. The facility is fully sprinklered and there is supervised smoke detection located in the corridors and the spaces open to the corridors. The facility has 25 certified beds. At the time of the survey, the census was 7. 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: 23031 Based on observation and interview, the facility failed to provide emergency task illumination in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-6.4.2.2.4.2 (3) (b)), 2012 Edition and National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.9.2.7), 2012 Edition. This deficient practice affects all residents who receive medication. This facility has a capacity of 25 and a census of 7. Findings include: 1. Observation and interview on 01/21/26 at 12:04 p.m., revealed the Emergency Room Medication Room did not contain automatic emergency task illumination. The lights in this room was controlled by a switch. In the event of a power outage this room could be left in darkness if the switch were in the off position even if the facility was under emergency generator power. The Maintenance staff verified this observation at the time of the survey process. 2. Observation and interview on 01/21/26 at 12:24 p.m., revealed the Staff Room #1246 Medication Room did not contain automatic emergency task illumination. The lights in this room was controlled by a switch. In the event of a power outage this room could be left in darkness if the switch were in the off position even if the facility was under emergency generator power. The Maintenance staff verified this observation at the time of the survey process.”

“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: 23031 Based on observation and interview, the facility failed to provide unobstructed sprinkler coverage in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.5.11), 2012 Edition and National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems (Section-8.6.5.2.2.1), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 7. Findings include: Observation and interview on 01/21/26 at 12:40 p.m., revealed the dry side air compressor located in the basement “riser room” was not hard-wired directly into the buildings electrical system as required. Electrical power was provided to the air compressor by a standard electrical plug-in cord to an electrical outlet. The Maintenance Staff verified this observation at the time of the survey process.”

“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: 23031 Based on observation and interview, the facility failed to ensure that smoke barriers are free of penetrations which would prevent the passage of smoke to an adjacent smoke compartment in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-8.5.6.2), 2012 Edition. This deficient practice affects approximately 3 patients, staff, and visitors. This facility has a capacity of 25 and a census of 7. Findings include: Observation and interview on 01/21/26 at 12:07 p.m., revealed an approximate 3/4-inch hole and an approximately 3-inch tube penetration in a smoke barrier above the ceiling at the 1 hour rated double doors of ED/Wound wing. The Maintenance staff verified this observation at the time of the survey process.”

“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: 23031 Based on record review and interview, the facility was not properly documenting all elements of testing for the emergency generator in accordance with National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems (Section-8.4.1), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 7. Findings include: 1. Record review and interview on 01/21/26 at 10:32 a.m., revealed that during monthly load testing of the facility’s diesel powered Emergency Generator the facility was not documenting the operation of the Transfer switch. The Maintenance Staff verified this observation at the time of the survey process. 2. Record review and interview on 01/21/26 at 10:34 a.m., revealed that during weekly inspection of the facility’s diesel powered Emergency Generator the facility was not documenting the inspection of the belts/hoses. The Maintenance Staff verified this observation at the time of the survey process.”