Mckenzie Health System

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 27408 Based on record review and interview, there was no evidence P-1 received a psychological screening by a physician or other qualified medical personnel resulting in an incomplete Medical Screening Exam (MSE) for 1 (P-1) of 20 patients reviewed, resulting in the potential for unrecognized patient needs and poor patient outcomes. Findings include: On 12/01/25 at 1300, during medical record review it was determined that Patient #1 (P-1) was a 40-year-old female who was brought to the Emergency Department (ED) by local police officers due to being “delusional and psychotic”. The police officers picked up P-1 on a legal “Order for Examination/Transport” signed and dated on 09/19/25, by a local probate judge. P-1 was picked up at her residence and was to be taken to the “nearest hospital” (facility in question) to be “examined by a psychiatrist and a physician or licensed psychologist”. During review of the facility’s plan to treat the patient, it was noted that P-1 started arguing with another patient, became combative, and started using foul language with another patient and all staff members who were present. Police were called and the patient was taken into custody for disorderly conduct. She was taken to the local jail, booked on charges, but was not allowed to stay (jail) due to the fact that she did not receive a “Community Mental Health (CMH)” screening. Review of the medical record for P-1 revlead no evidence of a psychiatric screening exam. On 12/01/25 at 1400, during an interview with the Director of Quality/Risk, Staff B, confirmed that a CMH screening was not completed. On 12/02/25 at 1030, during review of the policy titled “Compliance with EMTALA Regulations” PC-0054, last reviewed 11/2024, it was determined “Medical Screening Exam (MSE) will be performed within the capacity and capabilities of the hospital including ancillary services, resources routinely available, and on call providers as may be indicated. c. The MSE is not an isolated event; it is an ongoing process and should reflect continued monitoring according to the patient’s needs and continue until he/she is stabilized or appropriately transferred.””

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment This Condition is not met as evidenced by: 27408 Based on observation and interview, 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 485.623(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 tag: C-0930 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code”

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 43001 Based on interview and record review, the hospital failed to provide a preventative maintence program for mechanical equipment in the hospital resulting in potential failure of mechanical equipment that could result in bad outcomes for all patients being treated at the hospital. Findings include: On 12/18/24 at approximately 10:00 am, records were requested for preventative maintenance that was performed on the air handling units and exhaust fan units serving the hospital and Staff U could not provide these records. Staff U was asked why a program was not created. Staff U stated that they haven’t been able to create one since they have been recently hired onto the staff of the 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: 27408 Based on observation and interview, 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 485.623(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 specific K tags on the LSC survey: K0291 K0321 K0324 K0908 K0918 K0923”

“On December 17, 2024 a Life Safety Recertification Survey was conducted by the Michigan Department of Licensing and Regulatory Affairs, Bureau of Survey and Certification. At the survey, McKenzie Health System was found not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 485.623(c), Life Safety from Fire and the applicable provisions of the 2012 Edition of the National Fire Protection Agency (NFPA) 101, Life Safety Code and the 2012 Edition of NFPA 99, Health Care Facilities Code. The facility is a single story building of type II (222) construction built in 1966, with a partial basement. The building is partially sprinklered and has supervised smoke detection in the corridors and spaces open to the corridors. The facility has 25 certified beds. At the time of the survey the census was 4. The requirement at 42 CFR, subpart 485.623(c) is NOT MET as evidenced by:”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 36613 Based on record review and interview, the facility failed to ensure automatic emergency lighting in accordance with 2012 NFPA 7.9.3.1.3, 7.10.9.1. This deficient practice could affect all occupants in the event power is lost to the facility. Findings Include: 1. On December 17, 2024, at approximately 2:45 PM record review revealed the battery backup emergency lighting station inspections are not itemized to ensure every light is tested monthly for 30 seconds as required. 2. On December 17, 2024 at approximately 2:50 PM record review revealed the facility cannot produce documentation to verify the illuminated emergency exit signs are tested monthly and annually as required. These findings were confirmed through interview with the maintenance director at the time of record review.”

“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: 36613 Based on observation and interview, the facility failed to ensure hazardous areas are protected by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing. This deficient practice could affect 10 occupants in the event of a hazardous room fire. Findings Include: On December 17, 2024 at approximately 1:00 PM observation revealed the large central stores materials management room contains a large amount of combustible supplies and is open to the emergency egress corridor. This will allow smoke heat and fire to escape the storage space and enter the emergency egress corridor. These findings were confirmed through interview with the maintenance director 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: 36613 Based on observation, record review and interview, the facility failed to ensure cooking facilities are protected in accordance with 2011 NFPA 96 11.1.1, 11.4, and 2011 NFPA 17A 7.2. This deficient practice could affect all occupants in the event of a fire emergency in the kitchen. Findings Include: 1. On December 17, 2024, at approximately 12:30 PM record review revealed the facility cannot provide documentation to verify the wet chemical suppression system is being inspected monthly by the owners represented party as required. 2. On December 17, 2024 at approximately 1:30 PM record review revealed the facility cannot produce documentation the kitchen hood system is cleaned at a semiannual interval for moderate cooking operations. This may allow grease laden vapors to build-up in the exhaust system fueling a fire event. 3. On December 17, 2024 at approximately 12:10 PM observation revealed the kitchen exhaust fan was off during cooking operations. The exhaust fan must be on during all cooking operations. These findings were confirmed thorough interview with the maintenance director at the time of record review and observation.”

“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: 36613 Based on 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 5.1.14.2.3, 5.1.15, 5.2.14, 5.3.13 and 5.3.13.4 of NFPA 99. This deficient practice could affect all occupants in the event of a medical gas and/or medical vacuum failure. Findings Include: On December 17, 2024 at approximately 3:00 PM record review revealed the facility cannot produce documentation to verify medical vacuum is inspected at least annually. On December 17, 2024 at approximately 3:05 PM record review revealed the facility cannot produce documentation to verify the internal oxygen facility components are inspected at least annually. These findings were confirmed through interview with the maintenance director at the time of record review.”

“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: 36613 Based on observation, interview and record review, the facility failed to ensure generators or other alternative power sources are maintained, inspected, tested and exercised in accordance with NFPA 110, and records are readily available as required by 6.4.4, 6.5.4, and 6.6.4 of NFPA 99, NFPA 110, NFPA 111 and 700.10 of NFPA 70. This deficient practice could potentially affect all occupants in the event the generator is affected as a result of poor quality of fuel. Findings Include: 1. On December 17, 2024 at approximately 2:45 PM record review revealed the facility failed to provide documentation of the required annual diesel fuel sample testing on the facility’s diesel fueled generator diesel supply tank. 2. On December 17, 2024 at approximately 2:00 PM observation revealed the facility generator is equipped with maintenance free batteries. The batteries are not being conductance tested monthly as required. This finding was confirmed by interview with facilities Maintenance Director at the time of record review.”

“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: 36613 Based on observation and interview, the facility failed to ensure storage of nonflammable gasses meet all requirements of NFPA 2012 19.3.2.4 and 2012 NFPA 99 11.3.2.3. This deficient practice could affect 15 occupants in the event of an oxygen fueled fire. Findings Include: 1. On December 17, 2024 at approximately 11:45 AM observation revealed a 4 cylinder oxygen cylinder holder in the medical surge storage room within 5 feet of combustible materials in storage. This may potentially lead to a oxygen fueled fire in the storage space. 2. On December 17, 2024 at approximately 11:50 AM observation revealed an oxygen cylinder inside the dirty soiled utility room. The dirty soiled utility room is not an acceptable storage location for point of use patient care oxygen cylinders. 3. On December 17, 2024 at approximately 12:00 PM observation revealed the Carbon Dioxide cylinder in the main dining room is unsecured. This may lead to cylinder damage or leaking. These findings were confirmed through interview with the maintenance director at the time of observation.”