Lucas County Health Center

“INITIAL COMMENTS 42 CFR 485.623(d) Lucas County Health Center was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 482.41(b), Life Safety from Fire and the related National Fire Protection Association(NFPA) Standard 101 - 2012 edition. Lucas County Health Center is a one story building with listed dates of construction of 1969, 1979, 1980, and 1991. The building is composed of Type II(111) 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 25 certified beds. At the time of the survey the census was 8. The requirement at 42 CFR 485.623(d) is NOT MET as evidenced by:”

“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: 51442 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 facility has a capacity of 25 and a census of 8. Findings include: Observation and interview on 1/28/2026 at 11:31 a.m., revealed the door closer was disconnected between the kitchen and kitchen storage room. Maintenance staff verified observation during the inspection process.”

“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: 51442 Based on observation, interview, and record review, the facility failed to inspect and test smoke dampers in accordance with National Fire Protection Association (NFPA) 80, Standard for Fire Doors and Other Opening Protectives (Section-19.4.1.1 and Section 19.4.9), 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 8. Findings include: Observation, interview, and record review on 01/28/2026 at 11:05 a.m., revealed that the facility contained smoke dampers in the ductwork of the air-handling units. The facility was unable to provide documentation that the dampers had been exercised and inspected within the last 6 years. The Maintenance Director verified this observation at the time of the survey process.”

“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: 51442 Based on record review and interview, the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-14.2.1), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 8. Findings include: · Record review and interview on 01/28/2026 at 10:14 a.m., revealed the facility failed to have a 5-year internal obstruction inspection performed for the automatic sprinkler system. The Maintenance Director called and verified that the 5 year internal inspection was due and would be completed on 1-28-206. · There were escutcheon rings for a sprinkler that were hanging from the ceiling at the following locations 1. Nursing station in the infusion room 2. Surgery room 1 has 2 escutcheon rings in need of repair. 3. North Clinic hallway 4. SW Clinic hallway · Dirty sprinkler head at the following locations: 1. Accounting hallway 2. Atrium entry way. · 12 Soiled/corroded sprinkler heads in the kitchen area are in need of repair or replacement The Maintenance Director verified this observation at the time of the survey process.”

“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: 51442 Based on observation and interview, the facility failed to maintain corridor doors in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.6.3.10), 2012 Edition. This facility has a capacity of 25 and a census of 8. Findings include: Observation and interview on 01/28/2026 at 11:25 a.m., revealed a door edge was being used to hold the door open between the kitchen and kitchen storage area. Maintenance staff verified observation during the inspection 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: 51442 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 facility has a capacity of 25 and a census of 8. Findings include: Observation and staff interview on 1/28/2026 at 11:49 a.m., revealed that a portion of the smoke barrier in the ceiling was missing. A portion of the ceiling tile was missing in the x-ray hallway electrical closet. Maintenance director verified observation during the survey process.”

“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: 51442 Based on record review and interview, the facility is not conducting fire drills at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.1.6), 2012 Edition. This deficient practice affects all residents, staff, and visitors as the lack of drills can affect the abilities of staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 8. Findings include: Based on observation and staff interview on 01/28/2026 at 11:00 a.m., revealed the facility failed to hold fire drills for the evening shift during the 2nd quarter and the night shift during the 3rd quarter of 2025. Maintenance staff verified record review during the survey process.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Categories *Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES. *General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES. *Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours. 3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3 This Standard is not met as evidenced by: 51442 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 8 patients throughout the facility. This facility has a capacity of 25 and a census of 8. Findings include: Record review and interview on 01/28/2026 at 10:29 a.m., revealed the facility was unable to provide documentation for testing of hospital-grade electrical receptacles upon initial installation, replacement or servicing. The Maintenance Director verified this observation at the time of the survey process.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 51283 Based on review of hospital policies and procedures, patient medical records, and staff interviews, the Critical Access Hospital (CAH) failed to provide an appropriate medical screening examination (MSE) within the hospital’s capacity and capabilities, to determine if an emergency medical condition existed for 1(Patient 21, P21) of 21 sampled patients who presented to the emergency department requesting emergency medical services and failed to ensure all patients who presented to the ED for emergency care were registered on the hospital’s ED log for purposes of tracking care provided to patients for 1 (Patient 21, P21) of 21sampled patients. 1. Failure to provide appropriate ED services within the hospital’s capabilities resulted in P21 not receiving an appropriate MSE to determine whether the patient had an emergency medical condition (EMC) [see C-2406]. 2. Hospital staff failed to register P21 on the hospitals ED log, which resulted in staff being unable to maintain a record of the patient’s status, emergency services rendered by staff, and final disposition of the patient (e.g., admitted, discharged) [see C-2405]. The hospital’s combined failures placed all patients who presented to the ED seeking emergency services at risk for a worsening EMC. Findings include: Obstetrical Department. A central log shall be maintained in the Emergency department and the Obstetrical department on each individual who comes to the Emergency Department seeking assistance, recording whether he/she refused treatment, was admitted and treated, was stabilized and transferred, or was discharged ...” c. Medical Screening Exam: “... An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ... When an individual comes to the hospital for emergency care, the hospital must provide the individual with an appropriate medical screening examination (MSE) within the capability of the ED (including ancillary services routinely available to the emergency department) ...” 2. Review of the hospital’s medical records revealed hospital staff failed to provide P21 with an appropriate MSE on 4/12/25 to determine whether the patient had an EMC and required stabilizing treatment or transfer to another medical facility. 3. Review of the hospital’s ED log revealed hospital staff failed to register P21’s request for emergency services on 4/12/25. 4. During an interview on 4/16/25 at 4:30 PM, Staff B (Paramedic) acknowledged P21 did not receive an MSE, nor did staff provide instructions for the patient to enter the hospital to allow for the provision of an MSE. Staff B noted they did not inquire about the patient’s location at the time of the call. 5. During an interview on 4/21/25 at 9:30 AM, Staff I (ED Medical Director) reported the ED had various obstetric/gynecologic (OB/GYN) capabilities to perform assessments of a pregnant patient and fetus. Staff I acknowledged they expected staff to utilize available staff, equipment, and resources to provide an MSE to all patients who presented to the ED requesting emergency services. 6. During an interview on 4/21/25 at 1:12 PM, Staff L (Director of Inpatient Services) acknowledged ED staff failed to register P21 on the ED log dated 4/12/25. Staff L reported the Emergency Medical Treatment and Labor Act (EMTALA) required hospital staff to evaluate all patients who presented to the hospital requesting ED services, including patients who presented to the hospital parking lot.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 51283 Based on staff and patient interviews, hospital polices and procedures and ED logs, the Critical Access Hospital (CAH) failed to maintain a central ED log of all patients who presented to the Emergency Department requesting emergency care and services for 1 (Patient #21, P21) of 21 sampled patients. Failure to maintain a complete ED log resulted in the inability of hospital staff to track the care provided to each individual who presented to the ED seeking care for a potential emergency medical condition (EMC). Findings include: 1. Review of the 12/2024 policy “Emergency Medical Treatment and Labor Act (EMTALA)” revealed in part: a. Purpose: “To ensure compliance with Emergency Medical Treatment and Labor Act (EMTALA) and related laws and requirements ...” b. Central logs ... “The hospital logs reflect all patients who present seeking Emergency Medical Services, including those maintained by the Emergency Department and the Obstetrical Department. A central log shall be maintained in the Emergency department and the Obstetrical department on each individual who comes to the Emergency Department seeking assistance, recording whether he/she refused treatment, was admitted and treated, was stabilized and transferred, or was discharged.” 2. Review of the hospital’s ED log showed no documentation of P21 presenting to the ED and requesting emergency services on 4/12/25. 3. During an interview on 4/16/25 at 11:40 AM, P21 reported presenting to the ED on 4/12/25 at 24 weeks of pregnancy with complaints of decreased fetal movement. The patient requested to be seen by a provider via phone call while in a parking lot on hospital premises, but staff reportedly advised the patient to go to another medical facility due to the hospital only having ultrasound capabilities on weekdays. 4. During an interview on 4/16/25 at 4:30 PM, Staff B (Paramedic) reported receiving a phone call from P21, in which the patient reported concerns about decreased fetal movement at 24 weeks of pregnancy and requested a medical evaluation. Staff B acknowledged they did not provide instructions for the patient to enter the hospital to be seen by a provider, and thus, staff did not document the patient’s arrival on the ED log. Staff B noted they did not inquire about the patient’s location at the time of the call. 5. During an interview on 4/21/25 at 1:12 PM, Staff L (Director of Inpatient Services) acknowledged ED staff failed to include P21 on the ED log dated 4/12/25. Staff L reported the hospital’s Emergency Medical Treatment and Labor Act (EMTALA) obligations for seeing a person began when they entered hospital property, including the parking lot of the hospital.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 51283 Based on staff and patient interviews and review of hospital documents and policies and procedures, the Critical Access Hospital (CAH) failed to provide an appropriate medical screening examination (MSE) within the hospital’s capabilities for 1 (Patient #21, P21) of 21 sampled patients who presented to the emergency department (ED) requesting evaluation and treatment related to symptoms of decreased fetal movements at 24 weeks gestation. Failure to provide all patients with an appropriate MSE could result in an increased risk of adverse health outcomes, up to and including disability or death. Findings include: 1. Review of the 12/2024 policy “Emergency Medical Treatment and Labor Act (EMTALA)” revealed in part: a. Purpose: “To ensure compliance with Emergency Medical Treatment and Labor Act (EMTALA) and related laws and requirements. To meet the hospital’s obligations under EMTALA to treat all patients presenting to the Emergency Room. The hospital will provide an appropriate medical screening examination, and if the individual has an emergency medical condition, either: a. provide any necessary stabilizing treatment, b. transfer the individual in compliance with the requirements of EMTALA or; c. admit the individual as an inpatient.” b. Medical Screening Exam: “... An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ... When an individual comes to the hospital for emergency care, the hospital must provide the individual with an appropriate medical screening examination (MSE) within the capability of the ED (including ancillary services routinely available to the emergency department) to determine whether an emergency medical condition exists ... individual requests examination or treatment for a medical condition ... The MSE must be the same MSE that the hospital would perform on any individual coming to the hospital with the same signs and symptoms, regardless of diagnosis (labor, AIDS), financial status (uninsured, Medicaid), race, color, national origin, or disability. If the MSE indicates that the patient does not have an emergency medical condition, then appropriate staff must determine the level of care appropriately and manage as indicated, or refer the patient to the patient’s primary care provider for further care ...Hospital staff may not take any action to suggest that the patient leave the hospital prior to an MSE ...” c. When an MSE is required: ... A hospital must provide an appropriate MSE within the capability of the hospital’s emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC (emergency medical condition) exists ... The MSE and other emergency services need not be provided in a location specifically identified as a DED [dedicated emergency department]. The hospital may use areas to deliver emergency services. MSEs or stabilization may require ancillary services available only in areas or facilities of the hospital outside of the DED ...” 2. Review of requested, sampled patient records revealed no medical record and/or documentation of assessments, tests, history and physical, or physician evaluation on 4/12/25 when P21 presented and requested an evaluation related to symptoms of decreased fetal movements. 3. During an interview on 4/16/25 at 11:40 AM, P21 reported presenting to the ED on 4/12/25 at 24 weeks of pregnancy with complaints of decreased fetal movement. The patient requested to be seen by a provider via phone call while in the parking lot on the hospital’s premises, but staff reportedly advised the patient to go to another medical facility due to the hospital only having ultrasound capabilities on weekdays, resulting in the patient commuting approximately 19 miles to Hospital B to obtain an appropriate MSE. 4. During an interview on 4/16/25 at 4:30 PM, Staff B (Paramedic) reported receiving a phone call from P21, in which the patient reported concerns about decreased fetal movement at 24 weeks of pregnancy and requested a medical evaluation. Staff B acknowledged the patient did not receive an MSE, nor did staff provide instructions for the patient to enter the hospital to allow for the provision of an MSE. Staff B noted they did not inquire about the patient’s location at the time of the call. 5. During an interview on 4/17/25 at 9:30 AM, Staff E (ED Advanced Registered Nurse Practitioner (ARNP)) reported awareness of P21’s request for a medical evaluation via phone on 4/12/25 but denied knowledge of the patient’s location at the time of the call. Staff E reported the ED had the capability to perform a number of assessments of the patient and fetus, including the collection and monitoring of vital signs and various laboratory assessments. 6. During an interview on 4/21/25 at 9:30 AM, Staff I (ED Medical Director) acknowledged they expected staff to provide an MSE to all patients who presented to the ED requesting emergency services. Staff I reported the ED had a number of obstetric/gynecologic (OB/GYN) capabilities available at the time of P21’s ED encounter, which included a fetal doppler to assess fetal heart tones, a tocodynamometer (TOCO) to evaluate for contractions, nonstress test (NST) capabilities to evaluate fetal responsiveness, laboratory capabilities to perform a urinalysis (UA), and nitrazine test strips to detect the presence of amniotic fluid, which may indicate whether the patient’s amniotic membrane had ruptured (colloquially known as “water breaking”). 7. During an interview on 4/21/25 at 1:12 PM, Staff L (Director of Inpatient Services) acknowledged the Emergency Medical Treatment and Labor Act (EMTALA) required hospital staff to evaluate all patients who presented to the hospital requesting ED services, including patients who presented to the hospital parking lot.”