Mercyone Dyersville Medical Center

“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: 53170 Based on document review, observations, and staff interviews, the Critical Access Hospital (CAH)’s administrative staff failed to ensure hospital staff removed outdated supplies from the supplies available for patient use in the surgical/emergency room storage, laboratory department, as well as 1 of 1 crash carts on the medical floor. Failure to remove outdated supplies could potentially result in staff using the expired items for patient care beyond the manufacturer’s expiration dates, after which the manufacturer can no longer guarantee the safety and quality of the supplies. Findings include: 1. Observation/Tour on 3/24/26 of the Surgical Department at 12:30 PM and Laboratory Department at 1:10 PM, and on 3/25/26 of the Medical Surgical floor at 3:30 PM, revealed the following expired supplies: a. Medical/Surgical Floor: PI surgical gloves size 6 ½, 1 out of 2 expired 2/28/26. b. Surgical/Emergency Room Storage Area: Ready Scrub PVP Providone-Iodine 7.5% solution, 1 of 5 expired 4/25 and 4 of 5 expired 9/25. c. Laboratory: PHizatest-Nitrazine Paper PH 4.5-7.5, 8 of 8 expired 1/26. d. Purple Sani-Cloths, expired 12/25. e. Cotton Tipped applicators 600/1,000, expired 12/15/24. f. Cotton Tipped applicators 1,900/2,000, expired 3/29/25. g. Influenza A&B Pox Control Swab 2 of 3, expired 12/25/25. 2. During an interview on 3/25/26 at 3:15 pm, Staff C confirmed findings of outdated supplies and stated there was no checklist completed when Code Carts were checked for outdated supplies. 3. During an interview on 3/24/26 at 1:09 PM, Staff B confirmed supplies in the Clinical Laboratory were out of date and stated there was no official checklist for outdates. 4. During an interview on 3/24/26 at 12:30 PM, Staff E stated the expired items belong to the Emergency Department (ED) and were expected to be outdated by ED certified nursing assistants (CNAs). 5. In an email on 3/30/26 at 4:04 PM, Staff F stated that there was not a policy in place related to expired supplies for this location.”

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 53170 Based on a review of hospital policies, documents, and interviews with staff, the Critical Access Hospital (CAH)’s administrative staff failed to ensure 6 out of 16 of the selected CAH’s policies and procedures were reviewed biennially. Failure to review policies may lead to noncompliance with local, state, and federal laws that may not reflect current industry and community standards and could result in a lower quality of care and decreased safety for patients presenting to the hospital. Findings include: 1. Review of the selected policy “Assault Precautions & Violence Risk Assessment” on 3/25/26 revealed, the policy “provide an assessment of patients that present to MercyOne Dubuque/Dyersville that may have a potential for violence,” was last approved on 12/18/19 with a next review of the policy on 12/18/21. 2. Review of the selected policy “Staff Response to Unexpected, Non-Emergency Events in Cardiac Rehab” on 3/25/26 revealed the policy “to provide safe and effective guidelines for action in the event of non-emergent and life threatening situations” was last approved on 5/4/21 with a next review of the policy on 5/4/23. 3. Review of selected policy “Food and Nutrition-Colleague Orientation” on 3/31/26 revealed the policy was last approved on 5/16/23 with a next review of the policy on 5/16/26 (a 36-month review interval). 4. Review of the selected policy “General Medical Record Policy” on 3/31/26 revealed the policy was last approved 8/6/20 with a next review of the policy on 8/6/22. 5. Review of the selected policy “IC2 Applicability Compliance and Privacy” on 3/31/26 revealed the policy was last approved 3/23/22 with a next review of the policy on 1/28/28. 6. Review of the policy “Policy Development and Manuals DB& DY” on 3/31/26 revealed the policy did not have approval dates or next review dates on the document. 7. In an interview on 3/25/26 with Staff G at 1:30 pm stated the hospital was trying to catch up on reviewing policies, but had not been able to get through all of them. Staff G stated the hospital would approve them at the board meeting and had gone through a lot of them this month. 8. In an email on 3/31/26 with Staff H at 10:50 am, Staff H wrote “Dyersville has functioned as a department of Dubuque hospital and share many policies. Dubuque has review every 3 years.””

“42 CFR 485.623(d) Mercyone Dyersville Medical Center 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. Mercyone Dyersville Medical Center is a (1) story building that was built in 1967 with an addition in 1995. The building is composed of Type I (442) construction. The facility is fully sprinklered and there is supervised smoke detection located in the corridors and the spaces open to the corridors. The facility has 20 certified beds. At the time of the survey, the census was 2. The requirement at 42 CFR 485.623(d) is NOT MET as evidenced by:”

“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: 49481 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 deficient practice affects all residents, staff, and visitors in 1 of 6 smoke zones. This facility has a capacity of 20 and a census of 2. Findings include: Observation and interview on 03/25/26 at 11:39 a.m., revealed above the fire rated doors between the clinic and the hospital there was a penetration. There is an approximately 1/2-inch gap above the fire door where multiple wires are penetrating the barrier. This hole will need to be sealed with fire rated material. The Maintenance Director verified this observation at the time of the survey process.”