Morrison Community Hospital

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 45373 Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on March 24, 2026, the surveyor finds that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code. See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated March 24, 2026.”

“NURSING SERVICES CFR(s): A registered nurse or, where permitted by State law, a physician assistant, must supervise and evaluate the nursing care for each patient, including patients at a SNF level of care in a swing-bed CAH. This Standard is not met as evidenced by: 40079 Based on document review and interview, it was determined for 4 of 4 (Pt. #27, #28, #29 and #30) clinical records reviewed for blood transfusions, the hospital failed to ensure administration of blood transfusions was appropriate, as required. Findings include: 1. On 03/19/2026. the hospital’s policy titled, “Blood/Blood Product Administration” (revised 04/2023) was reviewed and included, “Purpose: To provide guidelines for administration of blood and blood products... Procedure Upon Notification that Cross Match is complete: 1. Verify physician’s order for blood component required, the amount to be administered, the rate, and reason for the transfusion.” 2. The clinical record of Pt. #27 was reviewed. Pt.#27 was admitted on 01/21/26 with a diagnosis of medical management postoperative. The clinical record included a physician’s order dated 01/22/26 for two (2) units of PRBC (Packed Red Blood Cells-concentrated blood product used to treat severe anemia or blood loss). The clinical record indicated that Pt. #27 received blood transfusion on 01/22/26. However, the physician’s order lacked the rate of infusion and the indication for the blood transfusion. 3. The clinical record of Pt. #28 was reviewed. Pt.#28 was admitted on 01/02/26 with a diagnosis of anemia (low levels of hemoglobin, cells that carry oxygen). The clinical record included a physician’s order dated 01/02/26 for two (2) units of PRBCs. However, the physician’s order lacked the rate of infusion and the indication for the blood transfusion. The clinical record indicated that Pt.#28 received a blood transfusion on 01/02/26. 4. The clinical record of Pt. #29 was reviewed. Pt.#29 was admitted on 12/03/25 with a diagnosis of altered mental status. The clinical record included a physician’s order dated 12/03/25 for one (1) unit of PRBCs, documentation indicated that Pt. #29 received blood transfusion on 12/03/25. However, the physician’s order lacked the rate of infusion and the indication for the blood transfusion. 5. The clinical record of Pt. #30 was reviewed. Pt.#30 was admitted on 01/22/26 with a diagnosis of medical management postoperative. The clinical record included a physician’s order dated 01/23/26 for one (1) unit of PRBCs, documentation indicated that Pt. #30 received blood transfusion on 01/23/26. However, the physician’s order lacked the rate of infusion and the indication for the blood transfusion. 6. The findings were discussed with the Chief Nursing Officer (E #1) on 03/19/2026 at 2:00 PM. E #1 stated that there should be a complete physician’s order before the blood product is administered. E #1 stated that the physician’s order should include the number of units, the type of blood product, reason for infusion, and rate of infusion. E#1 stated that if this information is not on the order, the nurse must contact the physician for to obtain a complete order.”

“NURSING SERVICES CFR(s): §485.635(d)(3) All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. This Standard is not met as evidenced by: 40079 Based on document review, observation, and interview, for 1 of 1 Certified Registered Nurse Anesthetist (CRNA/E#8) observed in the Operating Room (OR) while administering medications, the hospital failed to ensure that staff cleaned the intravenous tubing (IV) port prior to administering medications to prevent contamination. Findings include: 1. The hospital’s policy titled, “Standard Precautions” (revised 04/2024) was reviewed and required, “Standard Precautions are designed for the protection of patients and staff during the care of all patients regardless of their diagnosis or presumed infection status in any setting where healthcare services are delivered ... incorporate a consistent practice of infection prevention using Standard Precautions during the care of all patients. The policy guidelines shall be based on recommendations form the CDC (Centers for Disease Control), APIC (Association for Professionals in Infection Control & Epidemiology), & IDPH (Illinois Department of Health) regulations.” 2. The hospital’s policy titled, “Medication Administration Policy” (revised 03/2025) was reviewed and required, “Medication Administration Steps ... 8. Administer the medication by the prescribed route using appropriate technique.” 3. During observation in the Operating Room on 03/18/2026 between 9:20 AM and 9:30 AM, a staff (CRNA/E#8) was observed administering intravenous (IV) medications to a patient (Pt.#15) that was being prepared for surgery on three (3) occasions. E#8 did not use alcohol to disinfect the port on the IV tubing prior to administering the medications as required. 4. An interview was conducted with the OR Lead Nurse (E#4) on 03/18/2026, at approximately 9:50 AM. E#4 stated that when administering any medication via IV, the port should be disinfected with alcohol prior to introducing the needle into the port to reduce the risk of infection.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 40079 Based on observation, document review, and interview, it was determined that for 4 of 5 staff (E#4/Lead Operating Room-OR Nurse, E#5/Surgical Scrub Technician, E#7/OR Nurse, and E#9/OR Nurse) observed in the OR, the hospital failed to ensure that staff adhered to the surgical attire requirement. Findings include: 1. On 03/18/2026, an observational tour was conducted in Operating Room (OR) #3, where a sterile field was open between 9:15 AM through 9:35 AM, approximately 3-4 inches of E#4’s, E#5’s, E#7’s and E#9’s hair on the sides and back of their heads were uncovered. 2. The hospital’s policy titled, “Surgical Attire” (revised 09/2025) was reviewed and required, “The purpose of surgical attire is to promote patient safety by helping to prevent environmental contamination to the patient procedure, reduce the risk of surgical site infection (SSI) ...3. Surgical hats are required. Personnel entering the semi-restricted and restricted areas will cover the head, hair, ears, and facial hair.” 3. On 03/18/2026 at approximately 10:35 AM, the findings were discussed with the OR Lead Nurse (E#4). E#4 stated that staff must keep all hair covered while in the semi-restricted and restricted areas of the OR to prevent contamination.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (5) Address outcome indicators related to improved health outcomes and the prevention and reduction of medical errors, adverse events, CAH acquired conditions, and transitions of care, including readmissions. This Standard is not met as evidenced by: 40079 Based on document review and interview it was determined that the hospital failed to ensure quality data for readmission rates in order to track and trend performance was completed per policy. Findings include: 1. The hospital’s “Organization Wide Quality Improvement Plan” (revised 2025) was reviewed and included, “The Quality Director shall be the program’s manager and is given this responsibility to ensure that continuity and standardization exists within the overall program... All departments and services report to the Quality Council ... 1. The monitoring and evaluation of the quality and appropriateness of patient care and the clinical performance of all individuals with clinical privileges through: a. Monthly meetings of the departmental staff to consider findings from the ongoing monitoring activities of the department staff... 2. The quality and appropriateness of patient care and other services are monitored and evaluated... h. Social Work Services ... Monitoring and Evaluation: ... 2. The process for monitoring, evaluation, and problem solving is designed to allow the hospital to effectively utilize its resources to manage the quality of care it provides.” 2. The hospital’s “Quality Council Meeting Minutes” and the “Project Improvement Reports for 01/15/2025 to 02/18/2026, were reviewed. The meeting minutes and the Project Improvement Reports did not include data about readmission rates. 3. On 03/18/2026 at approximately 11:30 AM, an interview was conducted with the Chief Nursing Officer (E#1). E#1 stated that the hospital does not track readmission rates. 4. On 03/18/2026 at approximately 1:45 PM, an interview was conducted with the Social Worker (E#10). E#10 that the hospital does not track readmission rates.”

“DISCHARGE PLANNING CFR(s): (7) The CAH must assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were readmitted within 30 days of a previous admission, to ensure that the plans are responsive to patient post-discharge needs. This Standard is not met as evidenced by: 40079 Based on document review and interview it was determined that the hospital failed to assess its discharge planning process for patients who were readmitted within 30 days of a previous admission. Findings include: 1. The hospital’s “Project Improvement Reports” from 01/2025 to 02/2026 were reviewed. The reports indicated that for discharge planning, the hospital is not monitoring or tracking patients with readmissions within 30 days of a previous admission. 2. On 03/18/2026 at approximately 11:30 AM, an interview was conducted with the Chief Nursing Officer (E#1). E#1 stated that the social worker is responsible for discharge planning. E#1 stated that the hospital does not track readmission rates. 3. On 03/18/2026 at approximately 1:45 PM, an interview was conducted with the Social Worker (E#10). E#10 stated that E#10 will meet with the patient and their family soon after being admitted or within 24 hours, since these patients are usually discharged anywhere from 24 - 96 hours. E#10 that the hospital does not track readmission rates.”

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 45373 Based on document review and staff interview, the Emergency Policy, Procedure and Preparedness Documents are not being reviewed and updated at least every 2 years in accordance with 42 CFR 485.623. Failure to review the documents per code requirements can result in affecting all occupants during an emergency fire/smoke event. Findings include: On 3/24/2026, at 12:15 pm while in the company of the PMD, it was observed that the following documents were not reviewed and updated at least every 2 years: A. Covid Policy B. Water Shut Down”

“On March 24, 2026, the Life Safety Code portion of a Critical Access Hospital Recertification Survey was conducted. The surveyors were accompanied during the survey walk-through by the following provider representatives: Plant Maintenance Director = PMD Maintenance Staff = MS The building, constructed in 1943, was observed to include 2 stories plus a basement. An addition was completed in 2021. The building was observed to be of Type II (000) construction and to be fully covered by an automatic sprinkler system. The facility was surveyed under new and existing health care occupancies under the 2012 Edition of the NFPA 101 Life Safety Code, including Chapter 18 & 19. Unless otherwise noted, those code sections listed herein that do not include a reference to a specific NFPA code and year of issue (such as NFPA 70 2011) are taken from the 2012 Edition of the NFPA 101 Life Safety Code. Unless otherwise noted, all deficiencies cited herein were found through observation during the survey walk-through, staff interview, or document review. The requirements of 42 CFR Subpart 485.623 Physical Plant and Environment are NOT MET.”

“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: 45373 Based on observation, not all egress doors are installed and maintained as required. This deficient practice could affect patients, staff and visitors using the egress paths because their egress under emergency conditions could be impeded if they are not properly installed and maintained. Findings include: A. On 03/24/2026 at 3:40pm, while in the company of the MS, it was observed that stair door at the west side of the exam room corridor has signage indicating a 15 second delay. The door opens without delay. This condition does not comply with 7.2.1.6.1.1. B. On 03/24/2026 at 3:42pm, while in the company of the MS, it was observed that stair door at the west side of the exam room corridor contains conflicting signage including “Emergency Exit Only” vs. “Please Keep Door Closed”. This condition does not comply with 7.10.”

“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: 45373 Based on observation during the survey walk-through, battery powered emergency lighting system is not maintained in accordance with Code requirements. Failure to properly perform maintenance activities can result in failure of the lighting systems due to lack of periodic inspection and maintenance affecting all occupants during an emergency event. Findings include: On 03/24/2026 at 2:42pm, while accompanied by the MS, corridors, it was observed that a Battery-Operated Emergency Light was not provided at the Sprinkler Riser Room in order to maintain a light level for egress within this essential room to comply with 19.2.9, 7.8.2.2 and 7.9.”

“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: 45373 Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. Failure to provide exit signs to identify exit access can prevent occupants from reaching a required exit if the primary exit is blocked by a fire/smoke condition. Findings include: On 03/24/2026, while accompanied by the MS, corridors were observed to lack exit signs to clearly identify access to at least two remote means of egress from the building to comply with 19.2.4.3, 19.2.10 and 7.10. Locations observed: 1. At 2:10pm basement corridor across from elevator the sign is not visible from corridor. 2. At 04:20pm first floor family care hallway containing the nurses’ station lacks compliance with 7.10.1.8 for visibility.”

“Vertical Openings - Enclosure CFR(s): NFPA 101 Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box. This Standard is not met as evidenced by: 45373 Based on observation the facility failed to maintain compartment separations between floors/areas. This deficient practice could affect patients, staff and visitors to safely reach an exit on a floor level during a fire event on a separate level. Findings include: On 03/24/2026 at 3:20pm, while accompanied by the MS, the second-floor west stair door was observed to not be a self-closing fire door to comply with 7.1.3.2.1(8).”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 45373 Based upon observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material to block exiting. Findings include: On 03/4/2026, while accompanied by the MS hazardous areas were not maintained as fire and smoke proof enclosures to comply with 19.3.2. Locations include: 1. At 1:50 pm: lower-level corridor near maintenance rooms contained combustible material including two four-wheeled heavy-duty bins containing a minimum of 30 garage bags. Observed within same corridor were 12 stacked cardboard boxes. These conditions do not comply with 19.3.2.1. 2. At 2:00 pm: lower-level bio-hazard room is not separated from the means of egress corridor due to a door that does not comply with 19.3.2.1.3. 3. At 1:45 pm: lower-level morgue room was observed to be used as a storage room. The room is not separated from the means of egress corridor due to a door that does not comply with 19.3.2.1.3. 4. At 2:05 pm: lower-level maintenance storage room was observed not separated from the means of egress corridor due to a door that does not comply with 19.3.2.1.3. 5. At 2:15 pm: lower-level janitor storage room is not separated from the means of egress corridor due to the integrity of the door. The door is not smoke-tight which does not comply with 19.3.2.1.3. 6. At 2:50 pm: lower-level x-ray storage room was observed with a hole in the floor above. The holes were filled with combustible materials. This condition does not comply with 19.3.2.1.2. 7. At 1:52pm, while accompanied by the MS, observation determined the lower-level corridor doors to the boiler room do not latch to a closed position which does not comply with 19.3.6.3.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 45373 Based on observation, the facility failed to provide a complete automatic sprinkler system where installed. This deficient practice could affect patients, staff, and visitors in the building because the automatic sprinkler system may fail to extinguish a fire if it is not properly installed. Findings include: On 03/24/2026, while accompanied by the MS, observation determined that materials are being stored less than 18 inches below standard pendant sprinkler heads as prohibited by NFPA 13-2010 8.5.6.1. Locations include: 1. At 2:35 pm: lower-level purchasing room. 2. At 2:40 pm: lower-level medical records room.”

“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: 45373 Based on observation and document review, the sprinkler system is not being inspected, tested and maintained in accordance with Code requirements. Failure to properly inspect, test and maintain the sprinkler system can result in failure of the system to operate as required when needed to control a fire event. Findings include: A. On 3/24/2026, while in the company of the PMD and MS, it was observed that the following documentation was not available for review: 1. At 5:30 pm, the Monthly Sprinkler System Pressure Gauges Inspection as required by 2011 Edition of NFPA 25, Table 5.1.1.2. 2. At 5:31 pm, the Quarterly Inspection of the Waterflow Alarms and Supervisory Devices or Pressure Switches as required by 2011 Edition of NFPA 25, Section 5.2.1. 3. At 5:32 pm, the Annual Sprinkler System Inspection as required by 2011 Edition of NFPA 25, Section 5.2.1. 4. At 5:33 pm, the 5-Year Fire Sprinkler Pressure Gauges Calibration/ Replacement as required by 2011 Edition of NFPA 25, Section 13.2.4.2. 5. At 5:34 pm, the 5-Year Check Valves Inspection (FDC check valve, fire pump discharge check valve, fire pump bypass check valve, jockey pump check valve) as required by 2011 Edition of NFPA 25, Section 13.4.2.1. 6. At 5:35 pm, the 5-Year Internal Obstruction Inspection of Piping as required by 2011 Edition of NFPA 25, Section 14.2. 7. At 5:36 pm, the 5-Year Fire Department Connection (FDC) Hydrostatic Piping Test as required by 2011 Edition of NFPA 25, Section 6.3.1, Section 6.3.2.1 and Table 13.8.1. B. On 3/24/2026, while in the company of the MS, it was observed that sprinkler heads were coated with dust/ debris in several areas and do not comply with NFPA 25-2011 5.2.1.1.2 (5). Sample Locations Include: 1. At 2:32pm lower-level clean linen room. 2. At 2:42pm lower-level laundry room.”

“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: 45373 Based on observation, the facility failed to document inspection of all facility portable fire extinguishers. This deficient practice could affect patients, staff and visitors during a fire event. Findings include: On 3/24/2026, at 12:30 pm while in the company of the PMD, it was observed that the documentation for the Annual Fire Extinguishers Inspection and maintenance as required by 2010 Edition of NFPA 10, Section 7.3.1.1, was not available for review.”

“Corridors - Areas Open to Corridor CFR(s): NFPA 101 Corridors - Areas Open to Corridor Spaces (other than patient sleeping rooms, treatment rooms and hazardous areas), waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are in accordance with the criteria under 18.3.6.1 and 19.3.6.1. 18.3.6.1, 19.3.6.1 This Standard is not met as evidenced by: 45373 Based on observations, spaces open to the exit access corridor are not provided with protective features in accordance with Code requirements. Failure to provide protective features can compromise the use of the corridor when prompt notification of a fire/smoke event occurring within the space open to the exit corridor is not provided. Findings include: On 03/24/2026, while accompanied by the MS, waiting rooms, not visually supervised, do not have smoke detection to comply with Section 19.3.6.1 (1)(c). Locations include: 1. At 3:30pm: first floor OR waiting room was observed to be open to the corridor and not be supervised or smoke detected. 2. At 3:15pm: second floor waiting room across from elevator was observed to be open to the corridor and not be supervised or smoke detected.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 45373 Based on observation and document review, the HVAC system is not being inspected, tested and maintained in accordance with Code requirements. This deficient practice may affect all patients, staff and visitors within the building should a component of an essential system fail during a fire event. Findings include: On 3/24/2026, at 12:35 pm while in the company of the PMD, it was observed that the documentation for 6-Year Maintenance and Inspection of Fire and Smoke Dampers as required by 2010 Edition of NFPA 80, Section 19.4.1.1 - 19.4.11; was not available for review.”

“Elevators CFR(s): NFPA 101 Elevators 2012 EXISTING Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter’s Service is operated monthly with a written record. Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter’s Service Requirements of ASME/ANSI A17.3. (Includes firefighter’s service Phase I key recall and smoke detector automatic recall, firefighter’s service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.) 19.5.3, 9.4.2, 9.4.3 This Standard is not met as evidenced by: 45373 Based on observation and interview, the facility failed to ensure that elevators equipped with Fire Fighter’s Emergency Operation were tested monthly as required. This deficient practice could affect patients, staff and visitors during a fire event. Findings include: On 3/24/2026, at 12:45 pm while in the company of the PMD, it was observed that the documentation for Monthly Elevator Fire Fighter’s Service Testing for elevators equipped with recall capabilities to comply with Section 19.5.3 and 9.4.6.2, and 2007 Edition of ASME A17.1, was not available for review.”

“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: 45373 Based upon record review and staff interview, fire drills are not conducted and documented in accordance with Code requirements. Failure to conduct required fire drills can result in lack of training for staff to respond correctly during a fire/smoke condition. Findings include: On 3/24/2026, at 11:45 am while in the company of the PMD, Facility’s Fire Drill documentation for the past 12 months did not indicate the following to comply with Section 19.7.1. A. Documentation was not available to confirm fire drills are conducted quarterly of each shift to comply with Section 19.7.1.6. B. Documentation was not available to confirm fire drills are conducted at least one drill per year per shift during sleeping hours to comply with Section 19.7.1.7. C. Documentation of acknowledgment regarding transmission of a signal and signal receipt by the Fire Department or monitoring agency was not available to comply with Section 19.7.1.4.”

“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: 45373 Based on observation and document review, fire and smoke doors are not maintained in accordance with Code requirements. Failure to conduct and document fire and smoke door inspection and maintenance can compromise the safety of any building occupants if the door assemblies are not maintained as intended to restrict the spread of fire & smoke during a fire emergency. Findings include: On 3/24/2026, at 12:40 pm while in the company of the PMD, it was observed that the documentation for the Annual Fire and Smoke Door Inspections as required by Section 19.7.6, 8.3.3.1, 7.2.1.15, and 2010 Edition of NFPA 80, Section 5.2.4.2 was not available for review.”

“Gas and Vacuum Piped Systems - Central Supply CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Central Supply System Operations Adaptors or conversion fittings are prohibited. Cylinders are handled in accordance with 11.6.2. Only cylinders, reusable shipping containers, and their accessories are stored in rooms containing central supply systems or cylinders. No flammable materials are stored with cylinders. Cryogenic liquid storage units intended to supply the facility are not used to transfill. Cylinders are kept away from sources of heat. Valve protection caps are secured in place, if supplied, unless cylinder is in use. Cylinders are not stored in tightly closed spaces. Cylinders in use and storage are prevented from exceeding 130 degrees Fahrenheit, and nitrous oxide and carbon dioxide cylinders are prevented from reaching temperatures lower than manufacture recommendations or 20 degrees Fahrenheit. Full or empty cylinders, when not connected, are stored in locations complying with 5.1.3.3.2 through 5.1.3.3.3, and are not stored in enclosures containing motor-driven machinery, unless for instrument air reserve headers. 5.1.3.2, 5.1.3.3.17, 5.1.3.3.1.8, 5.1.3.3.4, 5.2.3.2, 5.2.3.3, 5.3.6.20.4, 5.6.20.5, 5.3.6.20.7, 5.3.6.20.8, 5.3.6.20.9 (NFPA 99) This Standard is not met as evidenced by: 45373 Based on observation, the facility failed to install and maintain its piped- in medical gas system. This deficient practice could affect patients, staff, and visitors in the building because the medical gas system could fail to operate when needed if not properly installed and maintained. Findings include: On 03/24/2026 at 2:55pm, while accompanied by the MS, observation determined the lower-level medical gas manifold room is not separated from the rest of the building by a minimum of 1-hour fire resistive construction, to comply with NFPA 99-2012, 5.1.3.3.2. (4). There are holes in the floor above filled with combustible material.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 45373 Based on observation, not all basic electrical components are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the electrical system could fail to operate properly when needed if the electrical components are not properly installed and maintained. Findings Include: A. On 03/24/2026 at 1:55pm, while accompanied by the MS, observation determined that the basement life safety panel labeled MDP-LS contains functions including compressors and dryers. This condition does not comply with NFPA 99-2012 6.4.2.2.3 for items allowed on the life safety branch. B. On 03/24/2026, at 3:00pm, while accompanied by MS, it was determined that there is no evidence that the medical gas piping is bonded. This condition is not compliant with NFPA 70-2011 250.104 (B). C. On 03/24/2026, at 4:50pm, while accompanied by MS, it was observed that OR #2 and OR#3 do not contain battery powered lighting to comply with NFPA 99-2012 6.3.2.2.11.1”

“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: 45373 Based on document review and staff interview, required essential electrical equipment inspection and testing is not being conducted. This deficient practice could affect patients, staff and visitors during a utility outage or fire event. Findings include: On 3/18/2026, while in the company of the PMD, it was observed that the following documentation was not available for review: A. At 11:40 am, the Automatic Transfer Switch Test as required by 2010 Edition of NFPA 110, Section 8.4.6. B. At 11:45 am, the 3-Year 4-Hour Generator Load Test as required by 2010 Edition of NFPA 110, Section 8.4.9.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (vi) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. All patient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patients or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of § 483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care. This Standard is not met as evidenced by: 36774 Based on observation, document review, and interview, for 2 of 2 freezers and 1 of 3 refrigerators in the Food and Dietary Department, the hospital failed to ensure that food was properly labeled when opened, as required by policy. Findings include: 1. On 8/06/2025 between 1:45 PM through 2:15 PM, an observational tour of the hospital’s Food and Dietary Department was conducted with E #5 (Food Director). During the tour, the following were observed: - Fifteen uncooked hamburger patties inside the double-door freezer that had no label or use by date. - Four uncooked pizza burger patties, dated 6/26/2025, and one bag of blueberries dated 6/27/2025 inside the three-door freezer. - A bag of shredded mozzarella and another bag of cheddar cheeses with opened dates of 7/8/2025 and 7/21/2025 dates, respectively. There were also seven hardboiled eggs that had a 7/31/2025 date inside the two-door refrigerator (#2). 2. On 8/06/2025, the hospital’s policy titled, “Storage Guidelines” (3/2021) was reviewed and included, “ ... To comply with regulatory guidelines, to prevent spoilage and to have adequate supplies available ... B. Refrigerated and Frozen Product Storage Guidelines ... i. All opened items (such as refrigerated leftovers) are dated and labeled with a specific label. This label contains the date of preparation or opening and product name. j. The general rule of thumb in the Dietary Department for leftovers items is ‘three days and out’ with the exception of condiments ...” 3. On 8/06/2025, findings were discussed with E #5 (Food Director). E #5 stated that the opened food items found inside the freezers and refrigerators should have been properly labeled and tossed out.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 30461 Based on document review, observation and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24. Findings include: 1. The hospital failed to ensure that EMTALA signage was posted at the ambulance bay entrance where it would be visible to individuals arriving by ambulance. (See A-2402). 2. The hospital failed to ensure that they followed the process for arranging transportation, to prevent potential delay in the evaluation and treatment. (See A-2408). 3. The hospital failed to ensure that the Receiving Hospital (Hospital B) had the available space and agreed to accept the patient, and that the transfer was arranged with the appropriate transportation (See A-2409).”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 39802 Based on document review, observation, and interview, it was determined that for 1 of 1 emergency department (ED), the hospital failed to ensure that EMTALA signage was posted at the ambulance bay entrance where it would be visible to invididuals arriving by ambulance. Findings include: 1. The hospital’s policy titled, “EMTALA (Cobra)(Transfers)” (effective 2018), was reviewed and required, “ ...The hospital shall post signs in the areas designated, which specifies patient rights under EMTALA ...” 2. A tour of the Emergency Department (ED) was conducted on 04/21/2025 at approximately 2:00 PM. The required EMTALA signage was posted at the check-in desk in both English and Spanish; however, there was no signage posted from the ambulance bay entrance, which enters directly into the ED treatment area, bypassing the check-in desk. 3. An interview was conducted with ED Nurse (E#6) on 04/21/2025, at approximately 2:30 PM. E#6 stated that patients brought in by ambulance would generally be roomed right away and not brought to the waiting room unless they didn’t have any beds. E#6 stated that there were no EMTALA signs posted by the ambulance bay entrance, in the rooms, or any where else besides at the check-in desk.”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 7 patients’ (Pt. #1) clinical records reviewed requiring transfer to another hospital, Hospital A (Transferring Hospital) failed to ensure the process for arranging transportation was followed, to prevent potential delay in the evaluation and treatment of Pt. #1. Findings include: 1. On 4/21/2025, the clinical record for Pt. #1 was reviewed. On 11/14 2024, Pt. #1 went to Hospital A’s ED due to cough. The clinical record included: - On 11/14/2024 at 1:15 PM, E #3’s (ED RN/Registered Nurse) progress note indicated that Pt. #1 walked into Hospital A’s ED due to cough for two days. Pt. #1’s initial vital signs as follows: Blood Pressure 113/65 (low blood pressure is below 90/60, high blood pressure 130/80 and above); Pulse 89 (Normal 60-100); Respiration 24 (Normal 12-20); Temperature 98-degree Fahrenheit (Normal 97-99); Oxygen Saturation/Level 74% (Normal 92-100%) on Room Air. Oxygen 4 liters per minute via nasal cannula was administered to Pt. #1 causing Pt. #1’s oxygen level to go up to 94%. E #3 rated Pt. #1’s ESI (Emergency Severity Index) as 2 (Critical). - On 11/14/2024 at 1:29 PM, MD #1’s (ED Attending Physician) progress note indicated, “non-productive cough ... We did request records from (Hospital E) ... found that (Pt. #1) was diagnosed with a right-sided pneumonia (chest x-ray read by radiology as pneumonia versus atelectasis/lung collapse versus pulmonary edema/fluids in the lungs). (Pt. #1 had) a mild elevation of ... white (blood) count (indicator for infection) ... electrolyte panel (minerals) showed a creatinine (test for kidney function) in the 1.7 range (Normal 0.5-1.1) ... troponin (test to identify heart damage) of 0.55 (Normal 0.06 and below)and a BNP (B-type natriuretic peptide/test for heart failure) of 240 (Normal 100 and below) ...Final Impression: Pneumonia, elevated D-dimer (test to detect clot in the lungs), acute hypoxic respiratory failure (type of respiratory problem), acute kidney injury ... elevated troponin ...” - On 11/14/2024 at 4:15 PM, MD #1 documented, “ ... talked with (Name of Hospital A’s Hospitalist) ...Based on the elevated d-dimer ... inability to do a CT scan (imaging test) or VQ scan (test to identify clot in the lungs) ... elevated troponin and (Pt. #1) requiring a large amount of oxygen, (Pt. #1) was not felt to be appropriate for admission (at Hospital A) ...” - On 11/14/2024 at 5:00 PM, MD #1 documented, “ ... contacted (Hospital F) for potential transfer... At 6:30 PM, (discussed Pt. #1 with name of physician at Hospital F) who (accepted Pt. #1’s transfer) ...” - On 11/14/2024 at 6:33 PM, E #4 (ED RN) documented that Pt. #1 received bed assignment (Room 437 at Hospital F). At 6:37 PM, E #4 documented, “ (Private Ambulance A) has no available ambulances for 4 hours. - On 11/14/2024, E #4’s succeeding documentation as follows: At 6:38 PM, “Spoke to (Private Ambulance B), they are able to transport (Pt. #1) if (Pt. #1) is able to pay $500 downpayment. Will call back after talking to (Pt. #1) ...” At 6:56 PM, “(Pt. #1) has the downpayment. $400 cash with $100 (credit card). Per (Private Ambulance B), that is acceptable and will be here in 60-70 minutes. ETA (Expected Time of Arrival) 8 PM ... report given to (Name of staff at Hospital F) ... “ - The transfer records indicated that Pt. #1’s mode of transfer was affected through Private Ambulance B with ALS/advance life support capabilities. Reasons included: Pt. #1 requiring higher level of care, intravenous heparin drip/blood thinner, oxygen device, and cardiac monitoring. Pt. #1’s medical diagnoses included NSTEMI (Non-ST elevated myocardial infarction/type of heart attack), ARF (Acute Renal Failure), and elevated D-dimer. - The clinical record did not indicate that Hospital A’s ambulance crew was requested to transfer Pt. #1 to Hospital F. 2. On 4/22/2025, the clinical record for Pt. #1 at Hospital F was reviewed. The clinical record indicated that Pt. #1 was admitted at Hospital F on 11/14/2024 at 9:32 PM (2 hours and 59 minutes when Hospital A received bed from Hospital F). 3. On 4/22/2025, the hospital’s document titled, “EMTALA (Cobra)(Transfers)” (reviewed by the Hospital on 3/2024) indicated, “ ... Procedure: A patient coming to the Emergency Department (ED) seeking emergency care shall receive an appropriate medical screening exam (MSE) to determine whether an emergency medical condition exists. Treatment shall not be delayed regardless of ability to pay ...” 4. On 4/22/2025, the hospital’s document titled, “(Name of Hospital A) Summary of Services” (undated) indicated, “ ... Emergency Services ... (Hospital A) owns and operates its own ambulance services within (Hospital A’s) District. (Hospital A’s) Ambulance Services is staffed 24/7 and consists of 911 response, emergency, and non-emergency transfer ...” 5. On 4/22/2025, the hospital’s document titled, “Transfer of a Patient” (reviewed by the Hospital on 8/2022) indicated, “ ... To ensure the safe and timely transfer of patients to a higher level of care for further diagnostic evaluation or treatment ... 3. Arranging Transportation. Nursing contacts (Hospital A’s) ambulance crew to request paging for a second crew if needed. If (Hospital A’s ambulance) is unavailable, begin contacting alternate ambulance services ... Notify selected transport service directly (nursing or designee may delegate to EMS if appropriate) ...” 6. On 4/22/2025 at approximately 9:45 AM, a telephone interview was conducted with MD #1 (ED Attending Physician). MD #1 stated that Pt. #1 had an emergency medical condition and needed a higher level of care for further evaluation and treatment. 7. On 4/22/2025 at approximately 10:37 AM, an interview was conducted with E #5 (EMS Director/Ambulance Service). E #5 stated, “We are an ALS provider meaning we have a paramedic on board at all times. We transfer patients when we have staff. When the hospital has a transfer, the ED staff would contact us, and we would page our crew to come in. We do not transfer to (Hospital E/OSH). It takes us out of our service area.” When asked for documentation, E #5 was unable to provide proof that Hospital A does not transfer patients to Hospital E. 8. On 4/22/2025 at approximately 11:40 AM, a telephone interview was conducted with MD #4 (ED Medical Director), MD #4 stated that it is not appropriate to ask payment from patients while evaluation and treatment are being conducted, including patients needing higher level of care. 9. On 4/22/2025 at approximately 3:00 PM, a telephone interview was conducted with E #4 (ED RN). E #4 stated, “Regarding transferring of patients to another hospital, it depends on their clinical status. If non-critical, we will call private ambulances. If the ambulance would require payment, we will ask the patient.” E #4 was not sure if it was appropriate to ask a patient for payment before providing the ambulance service in order for a patient to receive further evaluation and treatment at another hospital. 10. On 4/22/2025 at approximately 3:29 PM, findings were discussed with E #2 (Chief Nursing Officer). E #2 stated, “The patient should not be asked to pay. If that happens, the ED staff is expected to tell me or the CEO.””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1-2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 39802 Based on document review and interview, it was determined that for 1 of 7 transferred patient (Pt. #2) records reviewed, the Transferring Hospital (Hospital A) failed to ensure that the Receiving Hospital (Hospital B) had the available space and agreed to accept the patient, and that the transfer was arranged with the appropriate transportation. Findings include: 1. The Transferring Hospital’s policy titled, “EMTALA (Cobra)(Transfers)” (effective 2018), was reviewed and required, “ ...If a patient is found to have an emergency medical condition or is in active labor, the hospital shall provide: A. Staff and facilities needed to stabilize the medical condition or manage the active labor OR B. Transfer of the patient to another facility ... A transfer may be arranged providing the following conditions are met: 1. The receiving facility has: a. available space and qualified personnel for the treatment of the individual; b. agree to accept the patient; c. the transferring hospital sends to the receiving facility all medical records or copies related to the emergency condition; and d. the transfer is effected through qualified personnel and transportation ...” 2. The Transfering Hospital’s (Hospital A) clinical record of Pt. #2’s Emergency Department (ED) visit on 12/16/2024 was reviewed on 04/21/2025. Pt. #2 presented to the ED on 12/16/2024 at 5:34 AM with a chief complaint of recheck/abnormal lab. The record included the following: The Medical Screening Examination/MSE completed by ED Physician (MD#2) on 12/16/2024 at 9:04 PM included “ ...patient presented with shortness of breath ongoing and progressive for approximately 4 weeks. [Pt. #2] was seen at an outpatient clinic today for these symptoms and underwent some testing including a CBC [complete blood count]. [Pt. #2] was called with the results of the CBC and told to go to the ED for evaluation. Patient reports that [Pt. #2] feels short of breath today which is not significantly different from past week but has slowly and progressively increased over the course of the past month. Most noticeable with exertion and gets tired walking a short distance from car parking lot to the clinic. Denies chest pain with dyspnea [difficulty breathing]. Dyspnea improves somewhat with rest but does not resolve completely. [Pt. #2] also endorses lower extremity swelling but feels this is a chronic problem and that [Pt. #2] self discontinued Lasix [a diuretic] many months ago which was due to frequent urination and preceded this more recent dyspnea. [Pt. #2] also has experienced some night sweats over the past weeks ... Patient Disposition: Xfer [Transfer] Acute Care Hospital ... Condition: Serious ...” Hematology Labs, dated 12/16/2024 at 9:05 PM, included the following: - White Blood Count/WBC [normal range 3.90-13]: 186.05 [High] - Hemoglobin/Hgb [normal range: 11-18]: 6.2 [Low] - Platelet Count [normal range 150-450]: 67 [Low] MD#2’s Progress Notes included the following: - Re-evaluation #1 at 9:47 PM: “breathing comfortably on 2L NC [2 Liters per min oxygen via nasal cannula].” - Re-evaluation #3 at 10:53 PM: “Discussed with [Receiving Hospital] transfer center, awaiting call back from heme onc [hematology / oncology]. Discussed with heme onc and hospitalist; would accept to general medicine floor but no availability now and wound not accept to ICU [intensive care unit].” MD#2’s Medical Decision Making Narrative, signed 12/17/2024 at 5:51 AM, included “...Given the severity of these blood count derangements and acute nature, there is potential for development of severe potential life threatening cardiac, vascular, neurologic, infectious sequelae [a pathological condition resulting from disease]; the patient may also be a candidate for emergent interventions including [but] not limited to plasmaphoresis [procedure that separates plasma from blood cells and replaces it with another solution or returns it to the body]/leukophoresis [procedure healthcare providers use to remove white blood cells from the blood]. For these reasons, emergent transfer was promptly pursued for heme onc specialist consultation and admission to an ICU for close monitoring. Patient has acute on subacute dyspnea and was newly hypoxic in the ED requiring supplemental oxygen (2L NC) to maintain acceptable sats [saturations between 95%-100%] even at rest. [Pt. #2] does not have evidence of an acute associated cardiopulmonary, metabolic, or infectious source to explain [Pt. #2’s] dyspnea and new O2 [oxygen] requirements. However, [Pt. #2] is at high risk for developing any of these complications... Patient is pending transfer at this time ...” The ED Nursing Note, dated 12/17/2024 at 8:46 AM included “[Receiving Hospital] called, they wanted an update on patient’s condition, they do not have room at this time. They will call when they do. If patient goes to other hospital they have asked us to call [them back].” Vitals Sign records on 12/17/2024 at 8:48 AM indicated that Pt. #2 was still receiving oxygen delivery at 2 L/min; however, there was no assessment of the oxygen saturation at this time. Discharge Instructions (written by ED Physician MD#3 per interview) were received by Pt. #2 on 12/17/2024 at 9:18 AM and included, “ ...You were seen today for: Hyperleukocytosis [high WBC], Anemia [low hemoglobin], Thrombocytopenia [low platelets], Acute hypoxemic [low oxygen] respiratory failure ... Additional Instructions: Go directly to [Receiving Hospital] emergency department. Hand them your paperwork and image disc. Call 911 immediately for any concerns. Please show emergency department triage nurse the following statement: Patient with new onset leukocytosis, thrombocytopenia and anemia. Patient was to be admitted to [Receiving Hospital] but there were no beds. Patient drove via private car. Patient needs heme [hematology] onc [oncology] consult and plasmapheresis ....” 3. The Receiving Hospital’s (Hospital B) clinical record of Pt. #2’s ED visit on 12/17/2024 was reviewed on 04/24/2025. Pt. #2 presented to the ED on 12/17/2024 at 11:16 AM with a chief complaint of blood issues. The record included the following: Triage was completed on 12/17/2024 at 11:27 AM and included “Vitals signs: Temp 98.1; Pulse 93; Resp 22; BP 119/70; SpO2 93%; Oxygen status: N/A [not applicable]... Sent here from OSH [outside hospital] for oncology consult following WBC results 186 & hgb 6.2, platelets 67. Reports went to OSH for feeling unwell, night sweats, & fatigue. No blood products given at OSH ... Patient acuity: 2 [Emergent - on a scale of 1-5 where 1 is the most acute/critical and 5 is non-urgent] ...” The Medical Screening Exam, dated 12/17/2024 at 12:33 PM, included “...Patient was seen at an outside facility at which time [Pt. #2’s] labs were abnormal for a leukocytosis of 180, hemoglobin of 6.2 and platelets of 67... Per chart review, outside facility contacted [Receiving Hospital] oncology who stated that patient would require admission but did not need to be emergently transferred. Patient told by outside facility to leave the emergency department and drive here for admission as there was not beds available for direct admission ... Laboratory workup here concerning for tumor lysis syndrome ... Malignant hematology evaluated patient in the emergency department and recommended admission to their service ... Recommended 125 cc [milliliters] of Lactated Ringer’s continuous infusion. Did discuss the large-volume patient will receive as [Pt. #2] is also going to receive 2 units of packed red blood cells. Ordered home Lasix as patient has not yet taken it today ... Bed request placed to malignant hematology ...” Hematology Labs, dated 12/17//2024 at 1:02 PM included WBC 195.4 [high]; Hgb: 5.9 [low]; and Platelets 69 [low]. The History & Physical, dated 12/17/2024 at 3:00 PM, included “[Pt. #2] presented with leukocytosis, anemia and thrombocytopenia suggestive of undiagnosed malignancy ... Admit to malignant hematology when bed available... Per patient and chart review, ...[Pt. #2] was called by [primary care provider] when labs result[ed] ... This provider then recommended patient present to local ED. There [Hospital A] [Pt. #2] received CTA [computed tomography angiogram - imaging of blood vessels] that reportedly demonstrates bulky lymphadenopathy [abnormal enlargement of the lymph nodes]; imaging unavailable at time of note (doesn’t load) ... [Receiving Hospital] was contacted for transfer 12/16-12/17 overnight; given patient’s hemodynamic stability and hospital at critical capacity. Patient was subsequently placed on the transfer list, though was then told by outside facility to discharge from the emergency department and drive to [Hospital B] and present to the ED here ...” The ED timeline on 12/17/2024 indicated that Pt. #2 received 2 units of packed red blood cells as order while in the ED. The record also indicated that a bed was assigned at 6:25 PM, the bed was ready at 7:53 PM, and Pt. #2 was transferred to the inpatient malignant hematology unit at 8:43 PM. 4. A telephone interview was conducted with the ED Physician/ED Medical Director (MD#3) on 04/22/2025, at approximately 11:40 AM. MD#3 stated that when MD#3 took over care of Pt. #2, they were waiting for a bed. MD#3 stated that that morning, the patient voiced not wanting to wait anymore and MD#3 called the transfer center and stated that they were not likely to have a bed anytime soon. MD#3 then had a discussion with the patient, who asked “why can’t we just drive there?” MD#3 stated that the patient called the son to come and didn’t want to stay. MD#3 stated that they couldn’t hold the patient and the patient was stable enough and the son was comfortable driving the patient to [Receiving Hospital]. MD#3 stated that during the day, Pt. #2 had been off oxygen and vital signs were stable. MD#3 stated that since the patient/son insisted on leaving, MD#3 instructed them to go directly to [Receiving Hospital’s] ED and present the paperwork to them. MD#3 stated that MD#3 didn’t realize that MD#3 did not document any notes on MD#3’s evaluations, interactions, and conversations with Pt. #2 and stated that MD#3 should have. MD#3 stated that MD#3 recalled that Pt. #2 was speaking full sentences, was ambulatory, and off oxygen when Pt. #2 was discharged; however, noted that it wasn’t documented.”