Cass County Memorial Hospital

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 42934 Based on record review and interview, the facility failed to provide a policy for an 1135 waiver in accordance with the Code of Federal Regulations (CFR) at §483.73(b)(8). This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 21 and a census of 11. Findings include: Record review and interview on 04/07/2025 at 12:17 p.m., revealed that the facility was unable to provide a written policy in its Emergency Preparedness Plan to address how to apply for an 1135 waiver and the role of the facility under an 1135 waiver in the provision of care and treatment at an alternate care site identified by emergency management officials. The Emergency Preparedness Manager verified this observation at the time of the survey process.”

“42 CFR 485.623(d) Cass County Health System 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. Cass County Health System is a partial two story building that was built in 1968 with major additions in 1978, 2020 and 2024. The building is composed of Type (I) (332) 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 8 certified beds. At the time of the survey, the census was 5. 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: 42934 Based on observation and interview, the facility failed to maintain emergency lighting fixtures in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.9), 2012 Edition. This deficient practice affects approximately patients, staff, and visitors in the affected smoke zones. This facility has a capacity of 21 and a census of 11. Findings include: 1. Observation on 04/04/2025 at 10:58 a.m., revealed that Emergency Light fixture #8 located in the Hallway across from the kitchen entrance did not illuminate when the battery backup was tested. 2. Observation on 04/04/2025 at 11:10 a.m., revealed that Emergency Light fixture #6 did not illuminate when the battery back up was tested. 3. Observation on 04/04/2025 at 11:50 a.m., revealed that Emergency Light fixture #54 located in the 2nd Floor, Med Vac Mechanical Room did not illuminate when the battery backup was tested. The Maintenance representative verified these observations at the time of the survey process.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 42934 Based on observation and interview, the facility failed to maintain exit signage in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.10.5.1), 2012 Edition. This deficient practice affects approximately 8 residents, staff, and visitors in 1 of 9 smoke zones. This facility has a capacity of 21 and a census of 11. Findings include: 1. Observation on 04/04/2025 at 12:15 p.m., revealed that the Exit Sign fixture #76 located in the 2nd floor, Med Spa area did not illuminate when the battery backup was tested. 2. Observation on 04/04/2025 at 12:49 p.m., revealed exit signage needed to be installed to at the south end of the north/south Hallway to direct occupants to the southeast exit door of the Senior Life Solutions Building. The Maintenance Representative verified these observations 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: 42934 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 21 and a census of 11. Findings include: Observation, interview, and record review on 04/07/2025 at 11:25 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. Documentation provided the dampers were last inspected on 09/12/2015. The Maintenance Supervisor verified this observation at the time of the survey process.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 42934 Based on record review and interview, the facility failed to maintain portable fire extinguishers in accordance with National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers (Section-7.2.1.2), 2010 Edition. This deficient practice affects approximately all patients, staff, and visitors in the affected smoke zones. This facility has a capacity of 21 and a census of 11. Findings include: Record review and interview on 04/04/2025 at 11:40 a.m., revealed fire extinguisher #14 located in the IT Server Room was missed when February and March 2025 monthly visual inspections were conducted and documented. The Maintenance Representative verified this observation at the time of this survey.”

“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: 42934 Based on observation, record review and interview, the facility did not ensure corridor doors were not held open with a door stop or other impediments, are smoke resisting and are positive latching as required by National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.3.6.3/19.3.6.3. This deficient practice affected approximately 3-4 staff members in the kitchen in one of five smoke zones, as the doors would not prevent the spread of fire and smoke. This facility had a capacity of 21 and a census of 11 residents at the time of the survey. Findings include: Observation on 04/04/2025, at 11:02 a.m., revealed a bungee cord was being used to secure the Food Pantry Room door in the open position. This door had an automatic closure device installed and the bungee cord was preventing this door to remain in the shut position when not in use. The Maintenance Representative confirmed this finding at the time of this survey.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 42934 Based on observation and interview, the facility failed to maintain electrical junction boxes in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.1.2), 2012 Edition and National Fire Protection Association (NFPA) 70, National Electrical Code (Section-314.25) , 2011 Edition. This deficient practice affects approximately staff in the affected smoke zone. This facility has a capacity of 21 and a census of 11. Findings include: On 04/04/2025 at 11:16 a.m., revealed an missing face plate cover on an electrical junction box located in the Generator Transfer Switch Room. The Maintenance Representative confirmed this observation at the time of this survey.”

“Evacuation and Relocation Plan CFR(s): NFPA 101 Evacuation and Relocation Plan There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2. 18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3 This Standard is not met as evidenced by: 42934 Based on interview and record review, the facility failed to provide a complete fire plan in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1/19.7.1 and 18.7.2/19.7.2. The deficient practice affected all smoke zones and all occupants. This facility had a capacity of 21 and a census of 11 residents at the time of the survey. Findings include: Record review on 04/07/2025, at 12:02 p.m. revealed the fire plan did not address the following information: The plan did not address all the types of fire extinguishers located in the facility. The plan did not include the presence of the Ansul hood suppression system located in the Kitchen. The fire plan policy should include the proper use of this system and that all kitchen personnel are trained on its purpose and how to activated its use. The Emergency Preparedness Manager verified this finding at the time of the survey.”

“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: 42934 Based on record review and interview, the facility is not conducting drills on a random basis and varied times in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.1.4), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity 21 and a census of 11. Findings include: Record review and interview on 04/07/2025 at 11:50 a.m., revealed the facility conducted fire drills during the second shift (3:00 p.m.-11:00 p.m.) and third shift (11:00 p.m.-7:00 a.m.) at essentially the same time of day during the four quarters of 2024-2025 inspection period. During the second shift, fire drill were conducted on 04/10/2024 at 4:30 p.m., 07/24/2024 at 3:30 p.m., 10/29/2024 at 3:15 p.m. and 01/28/2025 at 3:15 p.m.. During the third shift, fire drills were conducted on 04/26/2024 at 11:30 p.m., 07/18/2024 at 11:00 p.m., 10:26/2024 at 9:08 p.m. and 03/06/2025 at 10:55 p.m.. The Emergency Preparedness Manager verified this documentation at the time of the survey process.”