Fleming County Hospital

“42 CFR 485.544(c)(1) K3 BUILDING: 0101 K6 PLAN APPROVAL: 2006 K7 SURVEY UNDER: 2012 Existing K8 SNF/NF Type of Structure: Two (2) story with a partial basement, (2006), Type II (222), protected noncombustible construction with seven (7) smoke compartments and a complete automatic wet sprinkler system. A Life Safety Code Recertification Survey was initiated on 05/28/2026 and concluded on 05/28/2026, in accordance with 42 Code of Federal Regulations, Part 485.544 (c)(1) Requirements for Rural Emergency Hospitals. During this Recertification Survey, Fleming County Hospital was found not to be in compliance with the Requirements for Participation in Medicare and Medicaid. The requirement at 42 CFR, Subpart 485.544 (c)(1) is NOT MET as evidenced by:”

“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: 50086 Based on record review, and interview, the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect one (1) of one (1) automatic sprinkler system, staff, and all patients. The findings include: Record review, of the sprinkler system documentation for the 12 months prior to the survey on 05/28/2026 at 12:05 PM, revealed the facility failed to conduct a five (5) year internal pipe inspection of the sprinkler system. Further record review revealed the date of the last internal pipe inspection was completed in July 2020. Interview, on 05/28/2026 at 12:06 PM with the Market Director of Plant Operations, revealed the facility was not aware the internal pipe inspection had not been conducted. The finding was verified by the Market Director of Plant Operations at the time of record review and the Chief Executive Officer at the exit conference on 05/28/2026. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Actual NFPA Standard: NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, (2011) 4.3.1* Records. Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. 5.1.1.1 This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. 5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. Table 5.1.1.2 Summary of Sprinkler System Inspection, Testing, and Maintenance 5.1 General. 5.1.1 Minimum Requirements. 5.1.1.1 This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. 5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. Gauges (dry, preaction, and deluge systems) Weekly 5.2.4.2, 5.2.4.3, 5.2.4.4 Control valves Table 13.1 Waterflow alarm devices Quarterly 5.2.5 Valve supervisory alarm devices Quarterly 5.2.5 Supervisory signal devices (except valve supervisory switches) Quarterly 5.2.5 Gauges (wet pipe systems) Monthly 5.2.4.1 Hydraulic nameplate Quarterly 5.2.6 Buildings Annually 4.1.1.1 Hanger/seismic bracing Annually 5.2.3 Pipe and fittings Annually 5.2.2 Sprinklers Annually 5.2.1 Spare sprinklers Annually 5.2.1.4 Information sign Annually 5.2.6.1 Fire department connections Table 13.1 Valves (all types) Table 13.1 Obstruction, internal inspection of piping 5 years 14.2”

“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: 50086 Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly for each shift in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice affected two (2) of eight (8) fire drills, staff, and all patients. The findings include: Record review, of the facility’s fire drill records for the 12-month period prior to the survey on 05/28/2026 at 11:53 AM, revealed the facility had no documentation for fire drills completed during the third (3rd) and fourth (4th) quarter of 2025 during second (2nd) shift hours. Interview, on 05/28/2026 at 11:54 AM with the Market Director of Plant Operations, revealed the facility was not aware the fire drills were not completed during second (2nd) shift hours. The finding was verified by the Market Director of Plant Operations at the time of record review and the Chief Executive Officer at the exit conference on 05/28/2026. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 20.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.”

“Fundamentals - Building System Categories CFR(s): NFPA 101 Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99) This Standard is not met as evidenced by: 50086 Based on record review and interview, the facility failed to develop a Risk Assessment in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect one (1) of one (1) Risk Assessment, staff, and all patients. The findings include: Record review, of the NFPA 99 Risk Assessment Log for the 12 months prior to the survey on 05/28/2026 at 12:35 PM, revealed the facility had failed to perform a NFPA 99 Risk Assessment. Interview, on 05/28/2026 at 12:36 PM with the Market Director of Plant Operations, revealed the facility was not aware an NFPA Risk Assessment was required for the facility. The finding was verified by the Market Director of Plant Operations at the time of record review and the Chief Executive Officer at the exit conference on 05/28/2026. Actual NFPA Standard: NFPA 99 Health Care Facilities Code, (2012) Chapter 4 Fundamentals 4.1* Building System Categories. Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code. 4.1.1* Category 1. Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code. 4.1.2* Category 2. Facility systems in which failure of such equipment is likely to cause minor injury to patients or caregivers shall be designed to meet system Category 2 requirements as defined in this code. 4.1.3 Category 3. Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers, but can cause patient discomfort, shall be designed to meet system Category 3 requirements as defined in this code. 4.1.4 Category 4. Facility systems in which failure of such equipment would have no impact on patient care shall be designed to meet system Category 4 requirements as defined in this code. 4.2* Risk Assessment. Categories shall be determined by following and documenting a defined risk assessment procedure. 4.3 Application. The Category definitions in Chapter 4 shall apply to Chapters 5 through 11.”

“EMERGENCY ROOM LOG CFR(s): [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 50442 Based on interview, review of the Emergency Department’s (ED) Central Log, review of video footage, review of the website mapquest.com, and review of the facility’s policy, the facility failed to maintain a Central Log on each individual who came to the ED seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for one (1) of 20 sampled patients, Patient (P) 1. The findings include: Review of the facility’s policy titled, “LL.029 EMTALA-Central Log,” effective 09/19/2024, revealed the purpose of the policy was to identify and document everyone who either came to the Dedicated ED seeking treatment for any medical condition or presented on hospital property or premises seeking care for an emergency medical condition (EMC). Further review revealed that a log entry should be made at the first point of contact. Review of the video footage from the facility (Facility 1) revealed P1 entered the ED doors from the parking lot at the time stamp of 07/29/2025 at 15:49 (3:49 PM). P1 was also seen at this time coming into the entry doors to the ED registration area on video footage from the inside camera. Review of a third camera footage showed P1 in the registration office at the 5:50 time mark, but there was no time stamp. P1 was observed sitting and speaking with Registration staff member (REG) 1 until 38:40 minutes into the footage. Then, the footage revealed P1 relocated to the ED waiting room. P1 was seen three times leaving the waiting room and either going to REG1’s desk or the entry hallway in the ED. Per the video footage, P1 spent approximately three hours at the facility and was on the video footage as exiting the facility at 18:46 (6:46 PM). In an interview with the Marketing Director of Facilities Management (MDFM) on 08/27/2025 at 8:30 AM, he stated the time stamp on the video footage from the cameras at the ED entrance both inside and outside were incorrect. He stated the date and time were not correct. He also stated the camera footage from the ED waiting room did not have a time stamp, and he was unsure why. Review of the facility’s ED Central Log revealed P1 was not placed on it, and there was no medical record at the facility (Facility 1) for P1. The State Survey Agency (SSA) Surveyor made telephone calls and left voicemails for both P1 and Family Member (FM) 1 on 08/27/2025 at 3:28 PM and 3:32 PM respectively. The SSA Surveyor requested they return her phone calls to discuss P1’s care at the facility (Facility 1). However, neither responded to the SSA Surveyor’s voicemails. In an interview with Registered Nurse (RN) 1, an ED staff nurse, on 08/25/2025 at 2:32 PM, she stated she was working on the day of the incident (07/28/2025), did not have direct contact with P1, but overheard P1 speaking with REG1. RN1 stated it was the facility’s procedure to register the patient, the nurse would then triage, and the patient was brought back and seen for a medical screening exam (MSE) by the doctor. RN1 stated she overheard a patient come to the registration desk and ask to be admitted to the facility so she could then be discharged to a “nursing home.” She stated no MSE was ever done on P1, and she was not seen in the ED. She stated P1 was asked by REG1 if she wanted to be seen, and P1 stated no because she was not sick. P1 stated she just needed to be admitted to the hospital, and her brother had dropped her off at the ED so she could get admitted to the hospital. RN1 stated P1 told REG1, if the facility could not admit her, she wanted to go somewhere that would. In a later interview on 08/28/2025 at 8:25 AM, RN1 stated when a patient was registered by Registration staff, the patient was then entered on the Central Log. She stated nurses did not place patients on the Central Log. She stated when staff registered a patient, the patient appeared in the computer and then had a medical record. She stated per their policy, she felt the “first interaction” was registration. In an interview with REG1 on 08/25/2025 at 2:41 PM, she stated she had worked in registration at the facility for the past 23 years. She stated, in the case of P1, no information was entered on the Central Log because she was never registered. She stated P1 was informed she had to be seen in the ED first before staff could see about getting her admitted to another hospital. REG1 stated P1 was adamant she needed to be admitted but refused to be seen in the ED. REG1 stated P1 declined to get registered and seen by the ED staff multiple times. In a later interview on 08/27/2025 at 1:38 PM, REG1 stated, if a patient would not let her register them, they were not put on the Central Log. She stated she was unaware of the facility’s policy which stated that a patient should be put on the Central Log at the first point of contact, not as part of registration. In an interview on 08/27/2025 at 3:12 PM with RN3, an ED staff RN, she stated if a patient was not registered, they were not put on the Central Log. She stated, to be seen, a patient must register and be put on the Central Log. She stated individuals could refuse to be seen in the ED, and if they did so, they would not appear on the Central Log. She stated that was the case with P1. She stated, to her, registration would be considered the first point of contact with a patient. In an interview on 08/27/2025 at 3:22 PM with RN4, an ED staff RN, she stated, in her opinion, registration was considered the first point of contact with any patient. She stated if there was no registration, the individual did not get put on the Central Log. When asked if P1’s request to be admitted to the hospital was a first contact or not, she stated it was, and she was unable to answer why P1 was not placed on the Central Log. She stated if she had encountered a patient like P1, who only wanted to be admitted but did not want to be seen in the ED for an MSE by the doctor, she would have explained to her that she needed to be registered and seen for staff to assess if they could transfer her to another hospital for admission. In an interview with the Director of Nursing/Quality Manager (DON/QM) on 08/25/2025 at 3:00 PM, she stated P1 was dropped off outside the ED by her brother who left her there and went to work. The DON/QM stated P1 lived with her brother and had only recently moved there to live with him. She stated P1 told staff she needed to be admitted so she could then discharge to a nursing home, and her doctor told her that was the way to get admitted to a nursing home. The DON/QM stated P1 told staff she had no medical complaints and did not wish to be seen in the ED. She stated P1 was at the facility for several hours, and she tried to figure out where she lived and what to do with her. The DON/QM stated she tried several times to get P1 to come into the ED from the waiting room so staff could assess her, but P1 would always go and sit back down in the waiting room. The DON/QM stated eventually she and other staff pooled money and called a cab from a neighboring town (the town where the facility was located did not have a cab company) to take her to another hospital, Facility 2, where P1 possibly could be admitted. Review of the website, www.mapquest.com, revealed the approximate distance between Facility 1 and Facility 2 was 18 miles and a 21-minute drive. Review of P1’s medical record from Facility 2 revealed P1 arrived at Facility 2 on 07/28/2025 at 3:36 PM with the primary diagnosis of leg pain. Her presenting complaint was she wanted to be admitted for three days to the hospital, so she could go to the nursing home. Per the record, P1 stated she needed to go to the nursing home because she was having problems with her right knee. The record stated an MSE was performed on her at 4:13 PM, and oral pain medications of oxycodone and acetaminophen 5/325 milligrams (mg) was given at 5:16 PM and gabapentin 800 mg was given at 5:40 PM. She was discharged home where she lived with her brother at 5:49 PM in a cab paid for by Facility 2. In a second interview with the DON/QM on 08/27/2025 at 1:45 PM, she stated she had never had a patient come to the ED and not want to be seen in the ED. In an interview with the Chief Nursing Officer (CNO) on 08/25/2025 at 3:13 PM, she stated P1 presented at the ED asking to be admitted to the facility, but she would never let staff register her, triage her, or perform an MSE. She stated that was why P1’s name would not be on the Central Log. The CNO also stated it was the hospital’s practice not to place anyone on the Central Log unless they were registered. The SSA Surveyor made telephone calls and left voicemails for the facility’s Medical Director three times, on 08/28/2025 at 8:45 AM, 9:00 AM, and 9:45 AM. The voicemails asked him to return a phone call to the SSA Surveyor to discuss P1’s care. Also, on 08/28/2025 at 8:45 AM, a text message was sent asking him to call to discuss P1. However, he did not respond to the SSA Surveyor’s voicemails or text.”