Floyd Valley Healthcare

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 49848 Based on document review, observation, and staff interviews, the Critical Access Hospital (CAH) staff failed to removed outdated supplies from supplies available for patient use in 1 of 1 crash carts on the medical floor and 1 of 1 crash cart and patient supply cabinet in the Emergency Department (ED). Failure to remove outdated supplies could potentially result in staff using the expired items for patient care beyond the manufacturer ’ s expiration dates, after which the manufacturer will no longer guarantee the safety and quality of the supplies. Findings: 1. Review of the policy, “Outdated Meds/Supplies Inventory”, approved 12/2025, revealed in part, a. “...On a monthly basis at the beginning of the month, the Nurse Manager or RN supervisor will designate someone to complete outdated med/supplies inventory in all patient care areas ...” b. “... Any outdated meds/supplies will be removed at the time of inventory and properly disposed of or returned to either Materials Management or Pharmacy as indicated ...” c. “...Completed quality assurance checklist will be routed to the Clinical Excellence Manager ...” 2. Observation/Tour on 1/13/2026, of the Emergency Department at 1:30 PM and Medical Surgical floor at 3:30 PM, revealed the following expired supplies: Medical/Surgical Floor, Crash Cart a. 1 of 5 tracheal tube 6.0 mm, expired 3/8/25 b. 2 of 3 yankauer suction handle expired 3/31/25 and 12/1/25 c. LMA silicone cuff size 4 and size 3 2 of 5 expired 12/18/25 and 8/19/25 d. Nasopharyngeal Airway 6 mm 2 of 3 expired 9/10/25 e. Suction tubing, 1 of 1 expired 1/1/26 f. Insyte Autoguard 18 gauge 1.16 in 3 of 3 expired 4/1/22 g. Insyte Autoguard 16 gauge 1.16 in 2 of 2 expired 11/1/24. Emergency Department Patient Care Cupboards h. Lumbar puncture tray 3 of 3 expired 12/1/25 Trauma Bay 1 emergency crash cart i. 4.0 endotracheal tube 1 of 2 expired 12/9/25 j. 3.5 endotracheal tube 1 of 2 expired 10/05/25 k. IV stopcock 1 of 1 expired 12/25. 3. Review of document “Code cart checklist” revealed; the emergency department crash cart was last checked for emergency supplies on 1/13/2026. The Medical Surgical Code cart was last checked 1/13/26. This checklist is for items on the top or outside of the crash cart. Another form for ED is ER/Clinic Outdates and lists the year on top and the checklist shows the month but no date this checklist if for the cupboards and patient supplies in the ED rooms nothing for the inside of the ED crash cart. The Medical/Surgical floor has a similar checklist titled Cleaning Checking for outdated and restocking showing last checked 12/1/25. 4. Interview on 1/14/26 at 2:00 PM with (Staff A), RN MHA, Chief nursing Officer, recalled; Text message from Nursing Supervisor Staff B, RN (Staff B) who stated; “carts are checked monthly but thinks staff are only doing the top of the cart and not opening the cart drawers to check supplies.” 5. Interview on 1/13/26 at 1:30 PM with (Staff E), ED/RN supervisor recalled; I check the supplies and medications during my shift routinely, removing any outdated supplies and medications. Notify Materials or Pharmacy for replacement needs. “The crash cart is checked frequently as we use the crash cart quite a bit for codes.” Crash cart is checked and restocked after each code or incident when opened. Supplies are replenished and medications restocked if used.”

“42 CFR 485.623(d) Floyd Valley Healthcare 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 Valley Healthcare is a two-story building that was built in 1974 with additions in 1996, 2001, 2013 & 2014. The building is composed of Type II protected 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 25 certified beds. At the time of the survey, the census was 12. The requirement at 42 CFR 485.623(d) is NOT MET as evidenced by:”

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 26377 Based on observation and interview, the facility failed to maintain minimum construction requirements in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.1.6), 2012 Edition. This deficient practice affects occupants in the area of the Kitchen Storage in the Basement. This facility has a capacity of 25 and a census of 12. Findings include: Observation and interview on 01/14/26 at 10:31 a.m., revealed a hole in the ceiling tile in the Basement Kitchen Storge Room. This deficient was verified by the Facilities Manager at the time of the survey.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 26377 Based on observation and interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.6.1.3), 2012 Edition and National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Section-10.5.5.3), 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 12. Findings include: Observation and interview on 01/14/26 at 10:15 a.m., revealed the circuit breaker for the Fire Alarm System located in Panel NLSA Life Safety Branch did not contain a mechanical protective device that would prevent the breaker from inadvertently being turned off. There was a lockout device located next to the electrical panel. It appeared that the fire alarm inspection company failed to put it back in place when they completed their inspection. The Facilities Manager 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 observation and interview, the facility failed to maintain sprinklers in accordance with National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems (Section-6.2.7.2), 2010 Edition. This deficient practice affects employees in the area of the Kitchen Storage Room in the basement. This facility has a capacity of 25 and a census of 12. Findings include: 1. Observation and interview on 01/14/26 at 10:30 a.m., revealed that the quick response sprinkler located in the Basement Kitchen Storage Room was missing the escutcheon ring. 2. Observation and interview on 01/14/26 at 12:08 p.m., revealed fire alarm inspection report dated 12/12/25 by Thompson Electric noted that 20 out of 384 alarm notification devices failed. The facility is waiting for the delivery of the notification devices so they can replace the failed ones. The Facilities Manager 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 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 12. Findings include: 1. Record review and interview on 01/14/26 at 11:53 a.m. while reviewing the fire drill documentation revealed the facility was missing fire drills for both shifts in the 2nd quarter and had no drills in the 3rd quarter. The nursing staff work 12 hour shifts. 2. Record review and interview on 01/14/26 at 11:53 a.m. while reviewing the fire drill documentation revealed the facility was missing the times of the fire drills conducted on 10/31/25 and 8/26/25. 3. Record review and interview on 01/14/26 at 11:53 a.m. while reviewing the fire drill documentation revealed the facility was not verifying they were contacting the fire alarm company before and after the fire drill to put off line then to place the facility back on line. They were also not documenting who the operator was that assisted them with these tasks. 4. Record review and interview on 01/14/26 at 11:53 a.m. while reviewing the fire drill documentation revealed the facility was not testing the fire alarm the next day following a “silent drill”. The Facilities Manager verified these findings at the time of the survey.”