Stewart Memorial Community Hospital

“42 CFR 485.623(d) Stewart Memorial Community 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. Stewart Memorial Community Hospital is a two-story building that was built in 1961 with additions in 1975, 1983 and 2025. The building is composed of Type I (332) construction. The facility is fully sprinklered and there is supervised smoke detection located in the corridors, patient rooms, and the spaces open to the corridors. The facility has 20 certified beds. At the time of the survey, the census was five. 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: 26377 Based on observation, interview, and testing the facility failed to maintain delayed egress locking doors in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.2.1.6.1.1 (1)), 2012 Edition. This deficient practice affects all patients, staff, and visitors throughout the facility. This facility has a capacity of 20 and a census of five. Findings include: Observation, interview, and testing on 07/23/26 at 1:30 p.m., revealed the 15-second delayed egress doors located at each end of the OB corridor from failed to alarm and release within 15 seconds. The doors would only release with a staff badge and at the time of the survey, it was undetermined if these doors released open with the fire alarm system. 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: 26377 Based on record review 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-5.1.1.2), 2011 Edition. This deficient practice affects all patients, staff, and visitors throughout the facility. This facility has a capacity of 20 and a census of five. Findings include: Record review and interview on 07/23/26 at 11:30 a.m., revealed the facility failed to have the required quarterly testing of the sprinkler system. The Maintenance Director verified this observation at the time of 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: 26377 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 patients, 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 20 and a census of five. Findings include: Record review and interview on 07/23/26 at 12:30 p.m., revealed the facility failed to conduct multiple required fire drills within the last 12 months; there were no drills documented for the 3rd or 4th quarter on all three shifts. The CEO and Maintenance Director verified these findings during 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: 26377 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 patients, staff, and visitors throughout the facility. This facility has a capacity of 20 and a census of five. Findings include: Record review and interview on 07/23/26 at 10:26 a.m., revealed the facility was unable to provide documentation for annual inspection and testing of all fire doors located throughout the facility. Documentation dated 8/4/25 noted that four fire doors in OB had been inspected and tested. However, a complete list of fire doors showed an inspection date of 3/14/24. The Maintenance Supervisor 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: 26377 Based on record review and interview, the facility failed to inspect 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 patients, staff, and visitors throughout the facility. This facility has a capacity of 20 and a census of five. Findings include: Record review and interview on 07/23/26 between 10:00 and 11:00 a.m., revealed the following generator deficiencies: 1. Missing weekly visual inspections for the following months in 2025: Aug. (1), Sept. (3), Oct. (1), Nov. (1) and Dec. (1). 2. The monthly generator testing was missing the following information: stop time, beginning and ending meter readings, transfer time (in seconds), specific date of test (not just the month). 3. Weekly visual inspection--all four required items not being checked each time. 4. Missing monthly inspections from August to December 2025. The Maintenance Director verified these observations at the time of the survey process.”