Sturgis Hospital

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 38018 Based on record review and interview, the facility failed to establish the role of the facility under a Waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. This deficient practice could affect all occupants. Findings Include: On 04/01/2026 at approximately 08:10 AM record review revealed that the Emergency Preparedness Plan had no policy or procedures for the 1135 waiver in the plan. Interview with the Emergency Department (ED) Nurse Manager at this time revealed they did not know what the 1135 Waiver was and the plan contained no information on the 1135 Waiver in the plan.”

“On March 31, 2026, and April 1, 2026, a Life Safety Recertification Survey was conducted by the Michigan Department of Licensing and Regulatory Affairs, Bureau of Survey and Certification. At the survey, Sturgis Hospital was found not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 482.41(b), Life Safety from Fire and the applicable provisions of the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code and the 2012 Edition of NFPA 99, Health Care Facilities Code. The facility is a 3 story building of type I (3,3,2) construction, built in 1969 and 2006. The building is partially sprinklered.”

“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: 53254 Based on observation and interview, the facility failed to ensure 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 19.3.5.9. Doors shall be self-closing or automatic-closing. This deficient practice could affect all occupants in the event of an emergency or fire. Findings Include: On 3/31/26 at approximately 03:17 PM, observation revealed a fire door leading to machine room #2 was propped open. This door is open to the corridor. Maintenance Director confirmed these findings during interview at the time of observation.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 53254 Based on observation and interview, the facility failed to ensure cooking facilities are protected in accordance with NFPA 96. This deficient practice could affect all occupants in the event of an emergency or fire. Findings Include: 1) On 3/31/26, at approximately 01:27 PM, observation revealed the commercial cooking stove on wheels does not have a tethering device to limit travel and prevent flexible gas line damage during movement. 2) On 3/31/26, at approximately 01:28 PM, observation revealed the commercial cooking flat top grill on wheels does not have a tethering device to limit travel and prevent flexible gas line damage during movement. Maintenance Director confirmed these findings during interview at the time of observation.”

“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: 38018 Based on record review and interview, the facility failed to provide sprinkler system maintenance and testing as required by NFPA 25. This deficient practice could affect approximately all occupants. Findings Include: On March 31, 2026, at approximately 1:10 PM, record review revealed no records for the quarterly flow test in the 4th quarter of 2025 and no quarterly flow test for the 1st quarter of 2026. The last recorded quarterly flow test was on 7/25/25. No additional documents were provided by the survey exit. On March 31, 2026, at approximately 1:18 PM, record review revealed no records showing the last inspection and testing of the Check Valve and no records showing the last Internal Pipe inspection, both tests are required every 5 years. No additional documents were provided by the survey exit. Interview with the Maintenance Director at the time of record review revealed the facility had been in the process of changing vendors and has not been completed at this time.”

“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: 53254 Based on observation and interview, the facility failed to ensure spaces open to corridors meet all provisions required by 19.3.6. This deficient practice could affect all occupants in the event of an emergency or fire. Findings Include: On 03/31/26 at approximately 01:19 PM, observation revealed that the kitchen door was held open to the corridor by a door wedge. Maintenance Director confirmed these findings during interview at the time of observation.”

“Corridors - Construction of Walls CFR(s): NFPA 101 Corridors - Construction of Walls 2012 EXISTING Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area. 19.3.6.2, 19.3.6.2.7 This Standard is not met as evidenced by: 53254 Based on observation and interview, the facility failed to ensure corridors are separated from use areas by walls of at least 1/2-hour fire resistance rating or meet the requirements of smoke partitions in smoke compartments protected throughout by a supervised, automatic sprinkler system as required by 19.3.6.2 and 19.3.6.2.7. This deficient practice could affect all occupants in the event of an emergency or fire. Findings Include: 1) On 3/31/26 at approximately 1:48 PM, observation revealed an approximate 1-inch gap around the gas line where the gas line penetrates the ceiling tiles and a rectangular opening in the same ceiling tile measuring approximately 1 inch by 10 inches. 2) On 3/31/26 at approximately 03:19 PM, observation revealed an open equipment hatch in the ceiling approximately 20 inches by 20 inches. The Maintenance Director closed the hatch during this observation. 3) On 3/31/26 at approximately 03:28 PM, observation revealed a missing 2 foot by 2 foot ceiling tile in the registration office. Maintenance Director confirmed these findings during interview at the time of observation.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 53254 Based on observation and interview, the facility failed to ensure equipment using gas or gas-related piping complies with NFPA 54, and electrical wiring and equipment complies with NFPA 70. This deficient practice could affect all occupants in the event of an emergency or fire. Findings Include: 1) On 3/31/26 at approximately 03:47 PM, observation revealed a multiplug quad box plugged into a duplex outlet in emergency room 5. 2) On 3/31/26 at approximately 03:49 PM, observation revealed a multiplug quad box plugged into a duplex outlet in emergency room 8. 3) On 3/31/26 at approximately 03:52 PM, observation revealed a multiplug quad box plugged into a duplex outlet in emergency room 9. Maintenance Director confirmed these findings during interview at the time of observation.”

“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: 38018 Based on record review and interview, the facility failed to ensure heating, ventilation and air conditioning is in compliance with 9.2. This deficient practice could affect all occupants in the event of fire. Findings Include: On March 31, 2026, at approximately 1:34 PM, record review revealed the last fire damper testing report was dated 1/24/2020 and no new test report was available for review. The fire damper testing in hospitals is required every 6 years. Interview with the Maintenance Director at this time revealed they were having difficulties in scheduling the required service.”

“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: 38018 Based on observation, record review and interview, the facility failed to inspect and test annually in accordance with NFPA 101, 19.7.6, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives 5.2, 5.2.3. This deficient practice could affect all occupants in the event of a fire emergency. Findings Include: On March 31, 2026, at approximately 1:55 PM, record review revealed the last annual fire door inspection was dated October 2024, with 26 doors listed as deficient. Interview with the Maintenance Director at this time indicated they had quotes and were ready to begin the door repairs and conduct a new annual door inspection.”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This Standard is not met as evidenced by: 38018 Based on observation, record review and interview, the facility failed to ensure the gas and vacuum systems are inspected and tests and records are maintained as required by NFPA 99. This could affect all patients requiring medical gases or vacuum systems. Findings Include: On March 31, 2026, at approximately 2:01 PM, record review revealed the last annual Med Gas and Vacuum System inspection and testing report was dated 10/08/2024. No newer or additional report was provided by the survey exit. Interview with the Maintenance Director at the time of record review revealed no newer report was available.”

“Electrical Systems - Receptacles CFR(s): NFPA 101 Electrical Systems - Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 53254 Based on observation and interview, the facility failed to ensure power receptacles comply with the requirements of 6.3.2.2.6.2(F) and 6.3.2.4.2 of NFPA 99. This deficient practice could affect all occupants in the event of an emergency or fire. Findings Include: On 3/31/26 at approximately 03:52 PM, observation revealed a non-ground fault circuit interrupter within 3 feet of a wash sink in the Omni Cell room. The Maintenance Director confirmed this finding during interview at the time of observation.”

“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: 38018 Based on record review and interview, the facility failed to ensure generators or other alternative power source are in accordance with NFPA 110, NFPA 99, NFPA 111 and NFPA 70. This deficient practice could affect all occupants in the event of a power outage. Findings Include: On March 31, 2026 at 1:20 PM, during record review, records revealed no test data available for review, the last test data was dated 02/02/2018 and no current records for Diesel Fuel testing were provided as required by NFPA 110. No additional documents were provided by the survey exit. Interview with the Maintenance Director confirmed the findings at the time of record review.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 53254 Based on observation, record review and interview, the facility failed to ensure power strips are in compliance with NFPA 99 and NFPA 70. This deficient practice could affect all occupants in the event of an emergency or fire. Findings Include: 1) On 3/31/26, at approximately 02:52 PM, observation revealed a box fan in the ceiling of the maintenance shop table that was plugged into an extension cord used as permanent wiring. 2) On 3/31/26 at approximately 02:53 PM, observation revealed an extension cord being used as permanent wiring in the maintenance office to the left of the door leading into the mechanical equipment room. Tie wraps were observed in place to secure the extension cord for future use. Maintenance Director confirmed these findings during interview at the time of observation.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 53254 Based on observation, record review and interview, the facility failed to ensure storage of nonflammable gasses meet all requirements of NFPA 99. This deficient practice could affect all occupants in the event of an emergency or fire. Findings Include: On 03/31/26 at approximately 03:40 PM, observation revealed oxygen tanks stored directly adjacent to combustible materials (2) chairs and ordinary combustible materials in the oxygen storage room. Maintenance Director confirmed these findings during interview at the time of observation.”

“Physical environment. CFR(s): The REH must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special services appropriate to the needs of the community. This Condition is not met as evidenced by: 48030 Based on observation, interview and record review, the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 485.544(c), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include: See tags: O-0960 Safety from fire”

“Safety from fire. CFR(s): (c)(1) Except as otherwise provided in this section, the REH must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served, 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). This Standard is not met as evidenced by: 48030 Based on observation, interview and record review (make sure the finding types match what is referenced in standard DPS statements), the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 485.544(c), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include: See K tags: K0321 K0324 K0353 K0361 K0362 K0511 K0521 K0761 K0908 K0912 K0918 K0920 K0923”