Floyd County Medical Center

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (v) Procedures for reporting adverse drug reactions and errors in the administration of drugs. This Standard is not met as evidenced by: 50440 Based on a review of hospital policies, documents, and interviews with staff, the Critical Access Hospital (CAH) ’ s administrative staff failed to ensure hospital staff documented and reported medication errors for 2 of 10 sampled patients. Failure to document and report medication errors, in accordance with hospital policies and procedures, could result in the administration of incorrect medications, incorrect medication dosage, or incorrect dosing frequency, thereby increasing patients’ risk of experiencing a serious adverse health outcome. Findings include: 1. Review of the 06/2025 policy “Medication Errors” revealed in part: “Policy: Medication dispensing and administration errors will be reported immediately in accordance with the following procedure. The provider who ordered the medication shall be notified by nursing staff if an error reaches the patient. An entry into the Meditech Incident Management must be made by someone directly involved in the error, a supervisor, or a pharmacist. Procedures: 1. The nurse involved, supervisor, or pharmacist shall complete a Patient Report in the Incident Management Desktop. The report should include the time and date the event occurred, when it was discovered, and when the provider was notified.” 2. Review of the 9/5/25 medication error report for Patient #3 (P3) revealed staff administered vancomycin (an antibiotic) after a 4.5 hour delay. Staff failed to document the date and time they discussed the event with P3 ’ s provider. Staff failed to document the date and time of the discovery and the occurrence of the medication error. 3. Review of the 9/13/25 medication error report for Patient #4 (P4) revealed staff administered an incorrect dose of pregabalin (an anti-epileptic medication). Staff failed to document the date and time the physician was notified. Staff also failed to document the time of the discovery. 4. During an interview on 6/2/26 at 9:00 AM, the Director of Quality and Risk Management reported the missing information of the medication error reports was not marked as mandatory so it was not always completed. They will work to make the categories on the medication error report forms to be mandatory.”

“ORGAN, TISSUE, & EYE PROCUREMENT CFR(s): §485.643(a) Incorporate an agreement with an OPO designated under part 486 of this chapter, under which it must notify, in a timely manner, the OPO or a third party designated by the OPO of individuals whose death is imminent or who have died in the CAH. The OPO determines medical suitability for organ donation and, in the absence of alternative arrangements by the CAH, the OPO determines medical suitability for tissue and eye donation, using the definition of potential tissue and eye donor and the notification protocol developed in consultation with the tissue and eye banks identified by the CAH for this purpose; This Standard is not met as evidenced by: 50440 Based on a review of hospital policies, documents, and interviews with staff, the Critical Access Hospital (CAH) ’ s administrative staff failed to ensure hospital staff documented timely notice to the donor network and funeral home for 3/3 sampled patients. Failure to document and report timely notice to the donor network and funeral home, in accordance with hospital policies and procedures, could result in the decrease of suitability for organ donation, delays in organ procurement, and delay viable organ transportation, thereby increasing potential recipient patients’ risk of experiencing a serious adverse health outcome. Findings include: 1. Review of the 4/18/25 policy “Organ, Tissue, and Eye Donation” revealed in part: “Policy: ...to notify Iowa Donor Network (IDN) of every death in the hospital, including out of hospital deaths that are brought to the hospital emergency department (ED). Procedure: 1. Nursing staff will call the IDN ... after an individual has died ... 2. Document calls ... in the Death Flow Sheet. 3. Nursing staff will not release the body to the funeral home until IDN has verified donation status and made appropriate calls to facilitate donation. IDN will communicate with nursing staff when it is appropriate for the body to be released. Definitions: Timely Notification - Within one (1) hour of cardiac death, or of meeting criteria for imminent death. 2. Review of death records on 1/11/26 for Patient #11(P11) revealed staff did not document the date and time the IDN and Funeral Home was notified. 3. Review of death records on 12/23/25 for Patient #12 (P12) revealed staff did not document the date and time the IDN and Funeral Home was notified. 4. Review of death records on 12/18/25 for Patient #13 (P13) revealed staff did not document the date and time the IDN was notified. 5. During an interview on 6/2/26 at 2:15 PM, Regulatory and Safety Specialist reported they were working now to change the assessment to add the information.”

“42 CFR 485.623(d) Floyd County Memorial Hospital 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. Floyd County Memorial Hospital is a 2 story building that was built in 1963 with additions in 1972, 1990, 2000, 2015, and 2026. The building is composed of Type I & 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 15. The requirement at 42 CFR 485.623(d) is NOT MET as evidenced by:”

“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: 17359 Based on observation and interview, the facility failed to label delayed egress doors in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.2.1.6.1(4)), 2012 Edition. This deficient practice affects approximately 25 residents, staff, and visitors in 1 of 5 smoke zones. This facility has a capacity of 25 and a census of 15. Findings include: Observation and interview on 05/27/26 at 12:15 p.m., revealed the Maternity Ward contained a 15-second delayed egress lock. The facility failed to provide signage indicating that this door was equipped with a 15-second delayed egress lock. The Maintenance Director verified this observation at the time of the survey process.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 17359 Based on record review and interview, the facility failed to maintain a commercial cooking suppression system in accordance with National Fire Protection Association (NFPA) Standard 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (Section-11.2.1), 2011 Edition. This deficient practice affects approximately 3 staff in the Kitchen. This facility has a capacity of 25 and a census of 15. Findings include: Record review and interview on 05/27/1266 at 12:20 p.m., revealed the facility failed to have the Ansul Suppression System for the kitchen hood inspected and cleaned on a timely semi-annual interval. The Maintenance Director verified this observation at the time of the survey 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: 17359 Based on record review and interview, the facility failed to test the fire alarm system in accordance with National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Section-14.4.5), 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 15. Findings include: 1. Record review and interview on 05/27/26 at 10:00 a.m., revealed the fire alarm had been tested and maintained only once in the past year. Fire alarm testing was last completed on 7/21/25 by an outside contractor. 2. Observation, interview, and record review on 05/27/26 at 10:15 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. 3. Observation and interview during the survey process on 05/27/26 at 12:10 p.m., revealed the Fire Alarm Control Panel (FACP) was in trouble mode. The Maintenance Director advised the trouble was due to construction additions to the sprinkler system attached to the FACP. The Maintenance Director witnessed these findings during the survey process.”

“Fire Alarm System - Out of Service CFR(s): NFPA 101 Fire Alarm - Out of Service Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.6 This Standard is not met as evidenced by: 17359 Based on record review and interview, the facility failed to provide an adequate fire watch policy for the fire alarm system being out of service in accordance with National Fire Protection Association (NFPA 101), Life Safety Code (Section-9.6.1.6), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 15. Findings include: Record review and interview on 05/27/26 at 12:30 p.m., revealed the provided Fire Watch Policy for the fire alarm system being out of service for 4 or more hours in a 24 hour period did not include contact information for the fire marshals office, the Department of Inspections and Appeals, or the facility insurance carrier. 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: 17359 Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-5.2.1.1.1), 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 15. Findings include: Observation and interview on 05/27/26 at 12:00 p.m., revealed the new storage room accross from the nurses station was not provided sprinkler coverage. The Maintenance Director verified this observation at the time of the survey process.”

“Sprinkler System - Out of Service CFR(s): NFPA 101 Sprinkler System - Out of Service Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service. 18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) This Standard is not met as evidenced by: 17359 Based on record review and interview, the facility failed to provide an adequate outage policy for the sprinkler system being out of service in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-15.5.2), 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 15. Findings include: Record review and interview on 05/27/26 at 12:30 a.m., revealed the provided Sprinkler Outage Policy for the system being out of service for 10 or more hours in a 24 hour period did not contain contact information for the State Fire Marshal, Department of Inspections and Appeals, or the facility’s insurance company. 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: 17359 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 deficient practice affects approximately 15 residents, staff, and visitors in 1 of 6 smoke zones. This facility has a capacity of 25 and a census of 15. Findings include: Observation and interview on 05/27/26 at 12:15 p.m., revealed a door wedge being used on the corridor door of the second floor cardio-pulmonary therapy room. The Maintenance Director verified this observation at the time of the survey process.”

“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: 17359 Based on record review and interview, the facility failed to inspect fire door assemblies in accordance with National Fire Protection Association (NFPA) 80, Standard for Fire Doors and Other Opening Protectives (Section-5.2.1), 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 15. Findings include: Record review and interview on 05/27/26 at 11:00 a.m., revealed the facility was unable to provide documentation for annual inspection and testing of the 2-hour fire rated door assembiles. The Maintenance Director 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: 17359 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-8.4.2), 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 15. Findings include: 1. Record review and interview on 05/27/26 at 10:20 a.m., revealed that during monthly load testing of the facility ’ s diesel powered Emergency Generator for all month ’ s prior to August 2018, the facility was not documenting the generator battery being tested. 2. Record review and interview on 05/27/26 at 10:25 a.m., revealed the facility was unable to provide documentation for weekly inspections of the battery, belts, and hoses for their emergency generator. 3. Record review and interview on 05/27/26 at 10:45 a.m., revealed that the facility was unable to provide documentation for 4-hour continuous under load testing within the past 36 months for the facility ’ s diesel powered emergency generator. 4. Record review and interview on 05/27/26 at 10:50 a.m., revealed the facility was unable to provide documentation for the annual testing of fuel for the facility ’ s diesel powered emergency generator. 5. Record review and interview on 05/27/26 at 11:45 a.m., revealed that the facility was unable to provide documentation for annual inspection and exercising of the main and feeder circuit breakers for their emergency generator. The Maintenance Director verified this observation at the time of the survey process.”