Lakewood Health Center

“FIRE SAFETY An annual Life Safety recertification survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on 08/13/2025. At the time of this survey, CAH - Lakewood Health Center was found not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR, Subpart 483.70(a), Life Safety from Fire, and the 2012 edition of National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care and the 2012 edition of NFPA 99, Health Care Facilities Code. THE FACILITY’S POC WILL SERVE AS YOUR ALLEGATION OF COMPLIANCE UPON THE DEPARTMENT’S ACCEPTANCE. YOUR SIGNATURE AT THE BOTTOM OF THE FIRST PAGE OF THE CMS-2567 FORM WILL BE USED AS VERIFICATION OF COMPLIANCE. UPON RECEIPT OF AN ACCEPTABLE POC, AN ONSITE REVISIT OF YOUR FACILITY MAY BE CONDUCTED TO VALIDATE THAT SUBSTANTIAL COMPLIANCE WITH THE REGULATIONS HAS BEEN ATTAINED IN ACCORDANCE WITH YOUR VERIFICATION. PLEASE RETURN THE PLAN OF CORRECTION FOR THE FIRE SAFETY DEFICIENCIES (K-TAGS) TO: IF PARTICIPATING IN THE E-POC PROCESS, A PAPER COPY OF THE PLAN OF CORRECTION IS NOT REQUIRED. Healthcare Fire Inspections State Fire Marshal Division 445 Minnesota St., Suite 145 St. Paul, MN 55101-5145, OR By email to: FM.HC.Inspections@state.mn.us THE PLAN OF CORRECTION FOR EACH DEFICIENCY MUST INCLUDE ALL OF THE FOLLOWING INFORMATION: 1. A detailed description of the corrective action taken or planned to correct the deficiency. 2. Address the measures that will be put in place to ensure the deficiency does not reoccur. 3. Indicate how the facility plans to monitor future performance to ensure solutions are sustained. 4. Identify who is responsible for the corrective actions and monitoring of compliance. 5. The actual or proposed date for completion of the remedy. The hospital was inspected as one building. Lakewood Health Center was constructed in 2000. Building 01 the main hospital is a 1-story building with a partial basement. The building, was determined to be of Type II (000) construction and is attached to the old hospital building, the clinic and the care center, which are all separated with 2- hour fire barriers. This building is divided into 2 smoke zones by 1- hour fire barrier. This building is fully sprinkler protected with quick response heads and has a manual fire alarm system with corridor smoke detection and smoke detection in spaces open to the corridors that is monitored for automatic fire department notification. The sleeping rooms have single smoke detectors installed and hazardous areas have automatic fire detection. The facility has a capacity of 15 beds and had a census of 4 at the time of the survey. The requirements at 42 CFR, Subpart 483.70(a), are NOT MET as evidenced by:”

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This Standard is not met as evidenced by: 45748 Based on observation and staff interview, the facility did not properly maintain enclose stairways used for exits and smoke proof enclosures in accordance with NFPA 101 (2012), Life Safety Code, section 7.1.3.2.1. These deficient findings could an isolated impact on the residents within the facility. Findings include: On On 08/13/2025 at 11:09am, it was revealed by observation that storage materials had been placed in the emergency exit vestibule in the emergency exit in told hospital south stairwell. Based on observation and staff interview, the facility failed to maintain stairwell arrangement and markings per NFPA 101 (2012 edition), Life Safety Code, section 7.7.3.4. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On 08/13/2025 at 11:59am, it was revealed by observation that an emergency exit egress gate must be placed in the stairwell leading to the main boiler room to prevent emergency egress beyond the low level exit. An interview with the Director of Maintenance verified these deficient findings at the time of discovery.”

“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: 45748 Based on observation and staff interview, the facility failed to maintain hazardous storage rooms per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.1.3 and 7.2.1.8.1. These deficient finding could have a patterned impact on the residents within the facility. Findings include: On On 08/13/2025 at the following times, it was revealed by observation that listed storage rooms were missing and/or did not have a self-closing device; 1) At 11:06am on 2nd floor, storage room 222 2) At 12:01pm on Lower Level, storage room G8 3) At 12:11pm on Main level, clean storage room off Care Ctr. An interview with the Director of Maintenance verified these deficient findings at the time of discovery.”

“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: 45748 Based on observation, a review of available documentation, and staff interview, the facility failed to install the required safety features for cooking equipment per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.5.3 (9) and 19.3.2.5.4. This deficient finding could have an isolated impact on the residents within the facility. Findings include: On 08/13/2025 at 10:59am, it was revealed by observation that the residential stove located on 2nd floor kitchen was not equipped with a lock-out switch and was not on a timer, not exceeding a 120-minute capacity, that automatically deactivates the cook-top or range, independent of staff action. An interview with the Director of Maintenance verified these deficient findings at the time of discovery.”

“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: 45748 Based on observation and staff interview, the facility failed to maintain spacing between storage and the sprinkler system per NFPA 101 (2012 edition), Life Safety Code, Section 9.7.5, NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 5.2.1.2, and NFPA 13 (2010 edition), Standard for the Installation of Sprinkler Systems, Sections 8.6.5.3.2 and 8.15.9. These deficient findings could an isolated impact on the residents within the facility. Findings include: On 08/13/2025 at 11:46am, it was revealed by observation that storage materials had been placed on a storage rack, bringing the storage materials within the required 18 inch clearance area under the sprinkler heads. These obstructions were found in the pharmacy office. Based on observation and staff interview, the facility failed to maintain the automatic fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, section 9.7.5, and NFPA 25 (2011 edition), the Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, section 5.4.1.4, and 5.4.1.4.2. This deficient finding could have an isolated impact on the residents within the facility. Findings include: On 08/13/2025 at 11:48am, it was revealed by observation that there were unsecured fire sprinkler heads that were not protected from being damaged, stored loosely within the spare sprinkler head boxes located by the fire sprinkler riser. An interview with the Director of Maintenance verified these deficient findings at the time of discovery.”

“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: 45748 Based on observation and staff interview, the facility failed to secure electrical panels per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.3.2.2.1.3 and failed to maintain the Gas and Utility System per NFPA 101 (2012 edition), Life Safety Code section 9.2.2 and NFPA 54 (2012 edition), National Fuel Gas Code, sections 9.2.2 and 10.3.2.2. These deficient findings could have a widespread impact on the residents within the facility. Findings include: On 08/13/2025 at following times, it was revealed by observation that the electrical panels in the following areas were unlocked; 1) At 11:00am - electrical panel located in 2nd floor kitchen area was not locked. 2) At 11:08am - electrical panel located by Apartment #8 was not locked. An interview with the Director of Maintenance verified these deficient findings at the time of discovery.”

“Rubbish Chutes, Incinerators, and Laundry Chu CFR(s): NFPA 101 Rubbish Chutes, Incinerators, and Laundry Chutes 2012 EXISTING (1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5. (2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7. (3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.) (4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use. 19.5.4, 9.5, 8.4, NFPA 82 This Standard is not met as evidenced by: 45748 Based on observation and staff interview, the facility failed to secure the laundry chute door per NFPA 101 (2012 edition), Life Safety Code section 19.5.4.1. These deficient findings could have a widespread impact on the residents within the facility. On 08/13/2025 at 12:18pm, it was revealed by observation that the laundry chute did not have a self closing door located on lower level. This device is required to close laundry chute in the event of a fire at bottom of chute. On 08/13/2025 at 12:22pm, it was revealed by observation that the laundry chute did not have the required automatic extinguishing protection in accordance per NFPA 101 (2012 edition), Life Safety Code section 9.7. An interview with the Maintenance Director verified this deficient finding at the time of discovery.”

“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: 45748 Based on a review of available documentation and staff interview, the facility failed to inspect fire doors per NFPA 101 (2012 edition), Life Safety Code section 8.3.3.1, and NFPA 80 (2010 edition), Standard for Fire Doors and Other Opening Protectives, section 5.2.1. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On On 08/13/2025 at following times, it was revealed by observation that the following fire doors and/or fire door frames were missing and/or had painted over door rating tags. 1) At 11:05am Fire doors leading to 2nd floor - Painted door tags 2) At 11:07am Fire doors by apartment #5 - missing tags on door frames 2) At 11:19am Fire doors off Operating Room - missing tags on door frame An interview with the Director of Maintenance verified these deficient findings at the time of discovery.”

“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: 45748 Based on observation and staff interview, the facility failed to provide a battery-operated light in the generator room per NFPA 101 (2012 edition), Life Safety Code, section 7.9.2.3 and NFPA 110 Section 7.3. This deficient finding could have an isolated impact on the residents within the facility. Findings include: On 08/13/2025 @ 1020, it was revealed by observation that the Emergency Generator Room is missing the required battery-operated emergency light and/or light testing documentation. An interview with the Director of Maintenance verified these deficient findings at the time of discovery.”

“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: 40948 Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital. Findings include: Please refer to the Life Safety Code inspection tags: K-0225, K-0321, K-0324, K-0353, K-0511, K-0541, K-0761 and K-0918.”

“RECORDS SYSTEM CFR(s): For each patient receiving health care services, the CAH maintains a record that includes, as applicable-- (i) Identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient; This Standard is not met as evidenced by: 40948 Based on interview and document review, the facility failed to ensure a discharge summary was completed within 30 days after the day of the surgical procedure for 7 of 7 patients (P21, P22, P23, P24, P25, P26, P27) reviewed for surgical procedures. Findings include: P21’s operative report dated 3/20/25, identified P21 had a right inguinal hernia repair on 3/20/25. P21’s electronic medical record (EMR) lacked a discharge summary for P21. P22’s operative report dated 4/10/25, identified P22 had a colonoscopy on 4/10/25. P22’s EMR lacked a discharge summary for P22. P23’s operative report dated 4/10/25, identified P23 had an esophagogastroduodenoscopy (EGD) (a procedure where a thin, flexible tube with a camera (endoscope) is inserted through the mouth to examine the lining of the esophagus, stomach, and part of small intestine.) on 4/10/25. P23’s EMR lacked a discharge summary for P23. P24’s operative report dated 4/30/25, identified P24 had a colonoscopy on 4/30/25. P24’s EMR lacked a discharge summary for P24. P25’s operative report dated 4/30/25, identified P25 had a colonoscopy on 4/30/25. P25’s EMR lacked a discharge summary for P25. P26’s operative report dated 6/2/25, identified P26 had a left carpal tunnel release (a surgery on the left wrist to help relieve pain) on 6/2/25. P26’s EMR lacked a discharge summary for P26 P27’s operative report dated 6/5/25, identified P27 had a right inguinal hernia repair on 6/5/25. R27’s EMR lacked a discharge summary for P27. During an interview on 3/13/25 at 4:58 p.m., the vice-president of patient care services confirmed the facility had not completed discharge summaries on the above identified surgical patients. They stated it was something the facility should have had in place. A policy regarding provider documentation following discharge was request however, none was received.”