Avera Granite Falls

“COMPLIANCE FED, ST, AND LOCAL LAWS AND REGS CFR(s): The CAH is in compliance with applicable Federal laws and regulations related to the health and safety of patients. This Standard is not met as evidenced by: 34083 Based on observation and interview, the critical access hospital (CAH) failed to ensure signage was posted in all visible areas of the Emergency Department (ED) and at the front clinic entrance identifying a medical doctor was not on duty 24 hours a day, 7 day a week. This had the potential to affect all patients seen in the ED and/or admitted to the CAH. Findings include: On 3/10/25, at 3:00 p.m., registered nurse (RN)- A identified two trauma rooms, divided by a curtain, and two adjacent rooms, located behind the nursing station and room with cardiac monitors. These two rooms had glass sliding doors and curtains were utilized for ED patients needing more intensive monitoring, but neither contained signage identifying the absence of a physician (MD or DO), present in the facility for 24 hours 7 days per week. The main entrance which was identified as the Emergency Entrance did not have prominent signage of the lack of physician in the facility 24/7. A laminated 8 x 11 notice was taped to the surface of the registration desk, away from the area a person entering the ED and registering would normally observe. Observation on 3/11/25, at 8:00 a.m., of the West clinic entrance which could also access the hospital areas, did not have posted signage identifying lack of MD coverage 24 hours per day, 7 days per week. Interview on 3/10/25 at 3:30 p.m., with RN-A confirmed the absence of posted notification in the above referenced locations, and reported she was not aware of the lack of postings. She reported the admission paperwork contained the notice but was not aware of the need to have notices posted in areas visible to patients and persons entering the identified areas. Interview on 3/11/25 at 10:30 a.m., with the director of nursing (DON) identified she was not aware of the requirement for posting of notice of the lack of 24/7 MD presence in prominent areas of the facility such as the ED and main entrance areas. A policy was requested, and the DON reported the facility did not have a policy for posting of 24/7 lack of MD/DO presence in the facility.”

“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: 34083 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: K0225, K0353, and K0374 for additional information.”

“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: 48583 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 2 of 7 patients (P28 and P31) reviewed for surgical procedures. Findings include: P28’s operative note dated 2/12/25, indicated P28 had a tonsillectomy (removal of the tonsils) on 2/25/25. P28’s electronic medical record (EMR) lacked a discharge summary for P28. P31’s operative note dated 1/15/25, indicated P31 had a adenoids (removal of the adenoids) and right myringotomy (draining of fluid from the middle ear) and ventilation tube placement on 1/15/25. P31’s electronic medical record (EMR) lacked a discharge summary for P31. During an interview on 3/12/25 at 4:24 p.m., operating room manager (ORM) and director of nursing (DON) confirmed the above findings and indicated discharge summaries were not completed for surgical procedures other than scopes. ORM indicated the surgeons only placed discharge orders when the surgical procedure was completed. ORM and DON stated they both understood the importance of discharge summaries. Requested facility policy on discharge summaries however, ORM stated they did not have one.”

“FIRE SAFETY A Life Safety Code survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on 03/12/2025. At the time of this survey, Avera Granite Falls 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. Avera Granite Falls is licensed as a Critical Access Hospital and is a 2 story building with partial basement. Avera Granite Falls was constructed in 1983 and was determined to be of Type II(000) construction. The CT addition was built in 2005 and was determined to be of Type II(111) construction. The Labor and Delivery addition was built in 2007 and was determined to be of Type II(111) construction. Because the 2 additions are of the same type of construction and meet the construction type allowed for new buildings, the facility was surveyed as one building. The facility is fully fire sprinkler protected. The facility has a fire alarm system with full corridor smoke detection and spaces open to the corridors that is monitored for automatic fire department notification. The facility has a capacity of 25 certified beds and had a census 3 at the time of survey. The requirement at 42 CFR, Subpart 483.70(a) is 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: 49715 Based on obeservation and staff interview, the facility failed to maintain stairways and smokeproof enclosures per NFPA 101 (2012 edition), Life Safety Code, sections 7.2.1.1.1, and 7.2.1.15.8 . This deficient finding could have an isolated impact on residents within the facility. Findings include: On 03/12/2025 between 9:15 AM and 12:15 PM, it was revealed by observation that Basement Stairway Door #7 did not properly close and latch. An interview with the Maintenance Director verified this deficient finding at the time of discovery. The Maintenance Director stated that a new door had already been ordered and they were waiting for it to arrive to replace the existing door that was not working properly.”

“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: 49715 Based on observation and staff interview, the facility failed to inspect and maintain the fire sprinkler system per NFPA 101 (2012 edition), Life Saftey Code, section 9.7.5, and NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, section 5.2.1.1.2(5). This deficient finding could have an isolated impact on residents within the facility. Findings include: On 03/12/2025 between 9:15 AM and 12:15 PM, it was revealed by observation that sprinkler heads in the 2nd floor staff kitchen were covered in lint and debris. An interview with Maintenance Director verified this deficient finding at the time of discovery.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 49715 Based on observation and staff interview, the facility failed to maintain smoke barrier doors per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.8, and 8.5.4.1. This deficient finding could have an isolated impact on the residents within the facility. Findings include: On 03/12/2025 between 9:15 AM and 12:15 PM, it was revealed by observation that Fire and Smoke Barrier Door 17 did not close completely when released from the magnetic hold-open device leaving a gap between the door leaves. An interview with the Maintenance Director verified this deficient finding at the time of discovery.”