Stevens Community Medical Center Inc.

“FIRE SAFETY An annual Life Safety Code survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on 03/06/2025. At the time of this survey, Stevens Community Medical 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 Occupancies 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 Stevens Community Medical Center - Hospital is licensed as a Critical Access Hospital and is a 2 story building with partial basement. The Stevens Community Medical Center - Hospital was built at three different times. The original building was built in 1952 and was determined to be type II(111) construction, in 1977 an addition was added to the hospital and was determined to be type II(111) construction. In 1989 the facility added the clinic addition that was determined to be type II(111) construction. In 2015 The expansion, renovation of the OR (2nd floor) addition of is also Type II (111). The original building and the additions meet the requirements of existing construction and were surveyed as one facility. 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 5 at the time of survey. The requirement at 42 CFR, Subpart 482.41(b) 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 19.2.2.3, and 7.2.2.5.3.1. This deficient finding could have an isolated impact on residents within the facility. Findings include: On 03/06/2025 between 9:00 AM and 1:00 PM, it was revealed by observation that construction materials and equipment were being stored under the egress stairwell in the southwest corner of the building. An interview with the Maintenance Director verified this deficient finding at the time of discovery.”

“Fire Alarm System - Out of Service CFR(s): NFPA 101 Fire Alarm - Out of Service Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.6 This Standard is not met as evidenced by: 49715 Based on a review of available documentation and staff interview, the facility failed to implement a fire alarm out-of-service policy per NFPA 101 (2012 edition), Life Safety Code, section 9.6.1.6. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On 03/06/2025 between 09:00 AM and 1:00 PM, it was revealed by review of available documentation that the fire alarm system out-of-service policy was incomplete and did not list the appropriate safety measures to follow, including having a fire watch policy, and a list of contacts that need to be contacted about the situation. An interview with the Maintenance Director verified this deficient finding at the time of discovery.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 49715 Based on observation and staff interview, the facility failed to install the fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.5.1 and 9.7.1.1 and NFPA 13 (2010 edition), The Standard for the Installation of Sprinkler Systems, section 8.15.5.3. These deficient findings could have an isolated impact on the residents within the facility. Findings include: On 03/06/2025 between 9:00 AM and 1:00 PM, it was revealed by observation that there was no sprinkler head installed in the following elevator equipment rooms: Elevator Equipment Room 2 in the basement, and the 2nd Floor Elevator Equipment Room in the patient room area across the hallway from the nurses station. An interview with the Maintenance Director 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: 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, sections 5.2.1.1.2(5), and 5.2.2.2. These deficient findings could have a patterned impact on residents within the facility. Findings include: 1. On 03/06/2025 between 9:00 AM and 1:00 PM, it was revealed by observation that sprinkler heads in the main kitchen dish room, and in the laundry area soiled linen room were covered and lint and debris. 2. On 03/06/2025 between 9:00 AM and 1:00 PM, it was revealed by observation that a blue wire was on the sprinkler pipe in Mechanical Room R8. An interview with Maintenance Director verified these deficient findings at the time of discovery.”

“Sprinkler System - Out of Service CFR(s): NFPA 101 Sprinkler System - Out of Service Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service. 18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) This Standard is not met as evidenced by: 49715 Based on a review of available documentation and staff interview, the facility failed to implement a fire sprinkler out-of-service policy per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.5.1, and 9.7.5, and NFPA 25 (2010 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, section 15.5.2. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On 03/06/2025 between 09:00 AM and 1:00 PM, it was revealed by review of available documentation that the sprinkler system out-of-service policy was incomplete and did not list the appropriate safety measures to follow, including having a fire watch policy, and a list of contacts that need to be contacted about the situation. An interview with the 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 Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 49715 Based on observation and staff interview, the facility failed to maintain smoke barriers per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.3, and 8.5.6.2. This deficient finding could have an isolated impact on the residents within the facility. Findings include: On 03/06/2025 between 9:00 AM and 1:00 PM, it was revealed by observation that fire caulking was missing from around a blue wire that was penetrating the smoke barrier wall in Mechanical Room R8. An interview with the Maintenance Director verified this deficient finding at the time of discovery.”

“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: 49715 Based on a review of available documentation and staff interview, the facility failed to conduct fire drills per NFPA 101 (2012 edition), Life Safety Code sections 19.7.1.6. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On 03/06/2025 between 9:00 AM and 1:00 PM, it was revealed by a review of available documentation that at the time of the survey the facility could not provide documentation showing that a fire drill was conducted during the third shift of the 3rd quarter of 2024. 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: 49715 Based on observation and staff interview, the facility failed to maintain fire door assemblies and hardware per NFPA 101 (2012 edition), Life Safety Code, sections 19.7.6, and 4.6.12.1, and NFPA 80 (2010 edition), Standard for Fire Doors and Other Opening Protectives, section 5.2.4.2(7). This deficient finding could have an isolated impact on residents within the facility. Findings include: On 03/06/2025 between 9:00 AM and 1:00 PM, it was revealed that the coordinator above the fire barrier doors leading to the 2nd floor lobby for Elevator 3 was not adjusted properly preventing the doors from closing as designed. An interview with the Maintenance Director verified this deficient finding 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: 49715 Based on a review of available documentation and staff interview, the facility failed to maintain the emergency generator per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.4.4.1.1.3, and NFPA 110 (2010 edition), Standard for Emergency and Standby Power Systems, sections 8.3.4, 8.4.1, 8.4.2, and 8.4.9. These deficient findings could have a widespread impact on the residents within the facility. Findings include: 1. On 03/06/2025 between 9:00 AM and 1:00 PM, it was revealed by a review of available documentation that at the time of the survey the facility could not provide documentation showing a four (4) hour load bank test has been completed within the last 36 months for the generator. 2. On 03/06/2025 between 9:00 AM and 1:00 PM, it was revealed by a review of available documentation that at the time of the survey the facility could not provide documentation showing that weekly and monthly generator operational inspection and testing had been occurring prior to July 18, 2024. An interview with the Maintenance Director verified these deficient findings at the time of discovery.”

“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: 40614 Based on interview and document review, the hospital failed to provide An Important Message from Medicare (IM) within two days of admission, and/or two calendar days prior to discharge, for 4 of 15 patients (P13, P16, P17, P19) reviewed who had Medicare coverage while an inpatient at the hospital. Findings include: P13’s face sheet indicated P13 admitted inpatient on 10/31/24, and discharged on 11/3/24. Primary insurance was Medicare. P13’s medical record identified a signed admission IM on 10/31/24. The medical record lacked evidence a discharge IM was provided within the required timeframe. P16 P16’s face sheet indicated P16 was admitted into outpatient observation bed 10/30/24, inpatient on 11/1/24 and discharged on 11/3/24. Primary insurance was Medicare. P16’s medical record lacked evidence an IM was provided at admission or 48 hours prior to discharge. P17 P17’s face sheet indicated P17 admitted inpatient on 11/1/24, and discharged on 11/4/24. Primary insurance was Medicare. P16’s medical record identified an admission IM was signed on 11/1/24. The medical record lacked evidence a discharge IM was provided within the required timeframe. P19 P19’s face sheet indicated P19 admitted inpatient on 11/23/24, and discharged on 11/28/24. Primary insurance was Medicare. P19’s medical identified an admission IM was signed on 11/1/24. The medical record lacked evidence a discharge IM was provided within the required timeframe. During an interview on 3/5/24 at 10:30 a.m., registered nurse (RN)-E was unsure who was responsible for providing the IM and contacted the registration department who indicated they give the initial notice only. During an interview on 3/5/24 at 12:03 p.m., health information management (HIM)-I, also identified as director, indicated her staff obtained the consent for treatment and admission but was unsure who provided the IM to the patients. During an interview on 3/5/25 at 12:05 p.m., registration staff (RS)-J, also identified as supervisor of patient registration, stated registration staff provided and had patients sign the initial IM, but do not give a second notice. During an interview on 3/5/25 at 12:10 p.m., registered nurse (RN)-F, also identified as charge nurse, indicated nursing was responsible to give the patients notice of Medicare for Outpatient Observation Notice (MOON) to the patients, but registration was responsible for the IM for all admissions. During an interview on 3/5/25 at 12:12 p.m., the director of nursing (DON) stated nursing staff did not give a second IM 48 hours prior to discharge if required. The DON stated she was not aware one was required. A policy related specifically to IM notices was requested; however, none was provided.”

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 40614 Based on observation, interview and document review, the critical access hospital (CAH) failed to ensure emergency supplies had not expired and were available for use in the labor and delivery department. Findings include: During a tour on 3/3/25, from 10:40 a.m. until approximately 11:20 a.m., an initial tour of the obstetrics unit, and nursery revealed an obstetrics (OB) emergency cart that included a Bakri Balloon (used to provide temporary control of post-partum hemorrhaging). The product did not have an expiration date on the box. The director of nursing (DON), opened the box and on the product packaging the expiration date was located and product expired on 2/24, with packaging date of 2/22. The DON confirmed the product was expired and should not be used. During an interview on 3/4/25 at 11:07 a.m., the DON indicated the Bakri balloon was expired and removed from the OB emergency cart and a new one was placed in the crash cart. The DON confirmed products should have been opened and inspected further with the cart checks and removed from service upon expiration. A facility policy was requested for Bakri Balloon use, product expirations or Post-Partum hemorrhage. A Hemorrhage, Antepartum, and Postpartum, Abnormal Bleeding, Possible Placenta Previa, Abruptio Placentae was received with effective date of 2/28/24. The policy included: - The facility will provide safe, effective and efficient care to all laboring patient and have standardized emergency procedures in place in case a complication occurs. - For all deliveries, the OB emergency cart, the nursery emergency cart and the cooler with methergine and Hemabate are placed in the patients room. There was a hemorrhage kit in the drawer of the OB emergency cart. The drawer was labeled “hemorrhage kit”.”

“DRUGS AND BIOLOGICALS ARE APPROPRIATELY STORE CFR(s): (3) Drugs and biologicals are appropriately stored; This Standard is not met as evidenced by: 48583 Based on observation, interview and document review, the critical access hospital (CAH) failed to ensure needles, syringes and medications were secured and inaccessible to patients receiving services in radiology and emergency rooms. Findings include: During a tour on 3/4/25 at 9:39 p.m., with director of nursing (DON) of the Stevens Community Medical Center’s emergency department (ED), ED exam rooms two, three, four, five, six, seven, eight, and trauma room one were found to have unsecured medications, needles and syringes in drawers and cupboards without locking mechanisms. Unsecured items in treatment rooms included: - Intravenous therapy (IV) start supplies (cannula’s of all sizes and 10 millimeter (ml) saline flushes) Unsecured items in trauma room on and exam room two included: - Intravenous therapy (IV) start supplies (cannula’s of all sizes and 10 millimeter (ml) normal saline (NS) flushes) - Needles of all sizes and syringes - Cautery (medical device that burns tissue to close or remove a wounds) - Scalpels (small and extremely sharp bladed instrument used for cut the skin) - Spinal needles - Ethyl chloride (used to prevent pain caused by injections and minor surgical procedures) - Rubbing Alcohol - Intraosseous (IO) insertion kit (used to provide fluids and medication when intravenous access is not available or not feasible) - Razors - Skin stapler - IV and IO Fluids: NS, lactated ringers (LR) and , NS advantage - Hydrogen peroxide - Hibi-clens (an antiseptic solution used for wounds) - NS irrigation - Lumbar puncture tray containing needles (used for the back) - Pneumothorax kit containing needles (used for the lungs) - Thoracentesis tray containing needles (used for the abdomen) - Sterile chest tube insertion kit containing needles - Exam room two contained an unlocked laceration (cut to the body) cart During an interview on 3/5/25 at 11:30 a.m., registered nurse (RN)-C confirmed the above findings and stated patients in the ED would have access to all the items listed above. RN-C further stated patients having access to these medical items could pose a safety concern for patients and staff. Review of the facility’s ED items list on 3/5/25 at 3:19 p.m., quality director (QD) confirmed the items listed above were all located in the rooms identified. 34083 During an observation and interview on 3/4/25 at 11:35 a.m., with the radiology director identified an open round caddy containing a variety of syringes, needles, intravenous needles, and supplies on a small table positioned on the right side of the computed tomography (CT) unit. The area where the radiology technician was located was across the room behind a glass shield, and during the time the surveyor and director were in the room, the tech was working with a computer. The director confirmed the caddy was not secured and was easily accessible to anyone entering the room or waiting for a CT scan to be performed. During an observation and interview on 3/4/25 at 11:55 a.m., with the radiology director identified a wall cabinet in the Radiology storage area which contained ten 120 milliner (ml) bottles of Gastrografin (a contrast medium which is taken internally to show on X-rays or CT scans), with expiration dates of 2/2025. She identified the Gastrografin was outdated and should have been noted when staff were restocking the cabinet. 40614 During an observation on 3/3/25 at approximately 10:40 a.m., a cart in the nursery work room had an intravenous bag of 0.9% sodium chloride not in the outer sleeve. During an observation and interview on 3/3/25 at 2:15 p.m., registered nurse (RN)-D was preparing medications for administration. One 100 cc bag, two 50 cc bags of D5W intravenous fluids bag was out of outer sleeve. RN-D indicated she was not aware that they would expire after initial packaging was opened and they went by the expiration date on the bag. During an interview on 3/3/25 at 8:31 a.m., pharmacist (P)-K, also identified as pharmacy director stated once IV bags were removed from their outer sleeve they would expire after 28 days and should no longer be used. During an interview on 3/4/25 at 11:30 a.m., the director of nursing (DON) stated she was not aware that IV fluids expired after being removed from the outer sleeve and staff went by the expiration date on the bag. During an interview on 3/5/25 at 11:40 a.m., DON confirmed the above findings in the ED and stated it could be a safety concern if patients had access to the medical items listed above. Review of facility policy titled Storage in the Emergency Department revised 4/21/24, Exam room number 1 had been designated the “trauma room.” Exam room number 2 contained the laceration cart, which can be moved to any of the exam rooms as necessary. Exam room number 3 was a general ED patient room. All cupboards and shelves in each area of the ED were labeled as to the contents inside them. Sterile instruments were available in the laceration cart and when used were taken to the dirty utility room in OR.”

“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: 48583 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. K0346, K0351, K0353, K0354, K0372, K0712, K0761 and K0918.”

“BUILDING SAFETY CFR(s): Except as otherwise provided in this section, the CAH must meet the applicable provisions and must proceed in accordance with the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5 and TIA 12-6). (1) Chapters 7, 8, 12, and 13 of the adopted Health Care Facilities Code do not apply to a CAH. (2) If application of the Health Care Facilities Code required under paragraph (e) of this section would result in unreasonable hardship for the CAH, CMS may waive specific provisions of the Health Care Facilities Code, but only if the waiver does not adversely affect 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 potentially hazardous areas were secured from unauthorized access. Findings include: During an observation on 3/4/25 at 1:56 p.m., with the maintenance director identified a short hall located directly opposite the exterior exit door which exited to the upper facility parking lot. Patients were observed entering and exiting through this door, when going to Dialysis or Therapy. At the other end of the hall was a short hall area with a large door, closed with a bar type latch. A sign was posted on the upper portion of the door which listed No Exit, Restricted area. A large button was mounted about 5 feet above the floor and labeled “Boiler Emergency Shut Off”. There was no form of lock on the door, and when opened revealed a metal mesh platform with a chain around the top that looked into the boiler room. The platform was 5.5 feet above the cement floor. To the left of this door was a secured door for Biohazard storage. A third door located at the edge of the short hall, had signage posted which identified “Restricted Area”, Authorized personnel only, “Fire Alarm Control Panel Inside”. The door had no locking device in place and when opened revealed an electrical panel with large switches, and a electric fuse box for the elevator. The right side of the room contained lockers which were identified as utilized by the dietary staff. Further into this room another door opened with entrance to the left into the maintenance area and access to the facility electrical systems. Directly through the doorsteps led down into the boiler area. During an interview on 3/4/25 at 2:00 p.m., with the maintenance director identified the areas were not secured, but he was not aware of any unauthorized persons attempting to enter the restricted areas. He confirmed this was an older part of the building and the door exiting into the upper parking lot was open during the day but locked at night. He agreed a person could enter through the outside door and enter the restricted areas, if they chose to do so. During an interview on 3/5/25 at 12:10 p.m. with the Quality Coordinator (QC) identified she had concerns with security and the ability for unauthorized persons to access restricted areas of the facility due to lack of security measures. During an interview on 3/5/25 at 1:30 p.m., with the chief executive officer (CEO) identified there were no security measures in place to prevent unauthorized access to restricted areas which included the boiler room and areas containing electrical components for the facility. A policy for security of restricted areas of the facility was requested however was not provided by the end of the survey period.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (2) Be ongoing and comprehensive. (3) Involve all departments of the CAH and services (including those services furnished under contract or arrangement). This Standard is not met as evidenced by: 34083 Based on interview and record review the Critical Access Hospital (CAH) failed to ensure Dietary services, identified current quality improvement concerns with investigation and a plan for improvement through the quality assurance program. Findings include: During an interview and document review on 3/3/25 at 3:06 p.m., with the certified dietary manager (CDM) identified she was aware of the facility expectation to review, identify, and develop a current Quality Assurance and Performance Improvement (QAPI) project for dietary however, indicated she had not done so. During an interview on 3/6/25 at 12:55 p.m., with the director of quality identified department heads were expected to identify a current quality improvement project, but the dietary manager had not done so as of the date of survey. Review of the 4/11/24, Quality and Performance Improvement Plan, (QAPI) identified all departments participated and evaluated areas for improvement in their departments. The department director or their designee were identified as responsible for developing expectations, plans, priorities and management of the identified performance improvement process for their department. Evaluation of quality and performance improvement was to be conducted by the Quality Council.”

“FREEDOM FROM ABUSE, NEGLECT & EXPLOITATION CFR(s): Freedom from abuse, neglect and exploitation (§483.12(a)(1), (a)(2), (a)(3)(i), (a)(3)(ii), (a)(4), (b)(1), (b)(2), (c)(1), (c)(2), (c)(3), and (c)(4) of this chapter). “ §483.12(a)(1) Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms.(a) The facility must-(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; “ §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. “ §483.12(a)(3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. “ §483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. “ §483.12(b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, “ §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This Standard is not met as evidenced by: 40614 Based on interview and document review, the critical access hospital (CAH) failed to develop an abuse policy and procedure for its Swing Bed Unit to include immediate (not to exceed 2 hours) notification to the State Agency (SA) for all alleged violations involving abuse, mistreatment or severe bodily injury. This deficient practice had the potential to affect all current Swing Bed patients and all future Swing Bed patients receiving services by the CAH. Findings include: During an interview on 3/5/24 at 2:35 p.m., registered nurse (RN)-B and licensed practical nurse (LPN)-A indicated they would notify the director of nursing (DON) or in her absence the charge nurse. RN-B and LPN-A both stated they were able to file a state report and both were required to be completed within 24 hours of the alleged abuse report. During an interview on 3/5/24 at 3:43 p.m., the DON stated staff would notify her as soon as possible after the alleged abuse, and she would notify the administrator. The DON reviewed the policy and indicated no time frame was present but believed the report was required within 24 hours. The DON indicated she thought there was another policy and procedure for reporting of Swing Bed resident abuse but was not able to locate it. Facility policy titled Vulnerable Adult Abuse Prevention Plan, effective 2/4/25, directed any individual observing incident or having knowledge of maltreatment, must understand that failure to report will result in disciplinary action; should report situation immediately to supervisor, charge nurse, quality or administration; must make a vulnerable adult abuse report. Immediately is defined as soon as possible, but in no event longer than 24 hours from the time of the initial knowledge or suspicion of the maltreatment.”

“PRIVACY AND SAFETY CFR(s): The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 40614 Based on observation, interview, and document review, the critical access hospital (CAH) failed to ensure a safe environment in the labor and delivery, postpartum and nursery units in an effort to prevent the risk of infant abduction. This deficient practice had the potential to affect all infants born at the CAH. Findings include: During an observation on 3/3/25 from 10:40 a.m. until approximately 11:20 a.m., an initial tour of the obstetrics unit, and nursery (also identified as OB unit) was conducted with the director of nursing (registered nurse [RN]-A). There currently were no patients in the OB unit or nursery. The following was observed: -The OB unit and nursery were at the end hallway of the medical surgical unit (med/surg) and was not separated by any doors. -The OB unit had 2 labor and delivery (L&D) rooms, which also served as post-partum rooms, and the nursery was located across the hallway. -There were double doors at the end of the hallway approximately 25 feet from the nursery and L&D rooms which were locked with key card access entry and exit only. -There was a single door exit which was locked, on the other end of the hallway approximately 75 feet, which was also badge entry and exit only. -The nursery had 2 entry points with a nurse’s station (not secured) on the corner. One door entered the nursery from inside the nurses station and the other from the hallway across the hall from the L&D rooms. Both nursery doors were secured with key pad locks present. -The med/surg unit had 2 double doors that were open to enter the unit which was rectangular in shape. The main nurses station was towards the end of the 1st hallway entered and had multiple desks with open entry (no doors) from either hallway. The main desk faced forward with the nursery and OB unit down a hallway to the left approximately 100 feet. During an interview on 3/3/25 at 11:21 a.m., the DON stated there was no entry or exit from the OB unit and nursery area without coming through med/surg area and visitors would have to pass by the nurses’ station to get there. The DON stated “the nurses desk was attended to by a ward clerk or a charge nurse at all times”. The DON indicated babies were encouraged to room in with the mother and usually only went to the nursery for lab draws, procedures or x-rays. The DON did state if a mother requested the baby in the nursery to rest, they would allow that and at those times, the nursery was then attended to by a nurse at all times. The DON indicated the med/surg unit doors were open at all times and not locked and the facility locked all entrance doors from 6:00 p.m. until 6:00 a.m. every day. The DON stated the nurses have security cameras for viewing and were able to unlock the front door or emergency department door when someone presented after hours. The DON confirmed the facility had no security system for infant security such as bands that alarmed if an infant was removed from the unit. During an interview on 3/3/25 at 1:14 p.m., licensed practical nurse (LPN)-B confirmed the facility did not have an electronic infant security alarm system but stated the doors were locked to the nursery. LPN-B indicated the baby’s stayed mostly in the rooms with the mom. LPN-B stated the back hallway doors where OB department and nursery were located were locked and key card access was required to enter or leave through those doors. LPN-B added if the fire alarms went off, the doors would automatically unlock and someone was required to monitor the doors until the alarms went off and they would automatically lock again. Double doors by nursery hallways and back entry single door were verified to be locked from inside and outside hallway. LPN-B added the nursery and post-partum moms were generally assigned to an LPN who did not work in the emergency department. During an interview on 3/4/25 at 10:30 a.m., registered nurse (RN)-C indicated staff were in attendance at all times when a baby was in the nursery. RN-C stated visitors were only able to leave the unit through the nurses’ station however, employees with badge access could enter or exit through the double or single door by the OB unit. RN-C was not aware the doors would unlock if fire alarms were activated. RN-C indicated the nurses completed bedside report and introduced the mom to the oncoming nurse, so they were always aware who their nurse was. RN-C could not state the nursery nurses’ station was staffed 24/7 when there was a mom and baby present. RN-C indicated there might have been short periods of time when it was unattended if staff were needed elsewhere for an emergency but would be a short period of time identified as less than five minutes and staff would ensure newborn was with the mother prior to leaving the unit. During a follow-up interview on 3/5/25 at 8:38 a.m., the DON stated they had evaluated and budgeted for an infant security system, but due to low volume of deliveries, and high cost of equipment they had not purchased one. The DON added they have had no issues in the past, and always had staff in/by the nursery and had the back doors to the OB unit area and nursery locked. During an interview on 3/5/25 at 12:10 p.m., quality director (QD) confirmed the above findings and stated newborn security and abductions had been a concern for the facility. QD further stated an newborn could be taken from the unit because there was very little security within the facility to stop it. The QD shared the last Code Pin drill, which included an acted scenario, ran was 12/2/24, and identified the staff that participated in the drill. The previous Code Pink drill was ran 5/9/24. During an interview on 3/5/25 at 1:04 p.m., housekeeper (HSK)-A stated they did have access to the nursery key code and shared the facility Inpatient 1-2nd Floor and Discharges form that was used for cleaning the nursing care area that had the nursery key pad code present on it. During an interview on 3/5/25 at 1:04 p.m., RN-B stated all the nursing staff had access to the key code for the nursery, was unsure if purchasing, or pharmacy did but knows maintenance were the one who programmed the key pad codes. RN-B was unsure if nursery codes were changed after staff were no longer employed at the facility. During an interview on 3/5/25 at 1:15 p.m., maintenance director (MD)-D confirmed maintenance was responsible for programming any key pad code locks in the building and had a log of all the current codes. MD-D indicated there were five maintenance staff who had access to the codes but they were kept in a locked area. MD-D stated if staff that had the code were no longer at the facility, the nursery key pad should have been changed to ensure security of infants. During an interview on 3/5/25 at 1:17 p.m., maintenance worker (MW)-E and MW-F stated they had never changed the nursery key pad code. MW-E identified MW-F as the person primarily responsible for changing key pad codes. MW-F indicated he had not changed the nursery key pad code since the area was opened in 2007. MW-F indicated it was up to the manager to request any key pad code changes needed. During an interview on 3/5/25 at 2:30 p.m., ward secretary (WS)-G stated one of the monitors at the main med/surg nurses desk had cameras for visuals of the following areas: Employee entrance, lab waiting room, emergency department (ED) waiting room, door to the ED, front door to main entrance, hallway on the 2nd floor where visitors/patients arrive via elevator or stairs, med/surg back hallway (does not show the two L&D rooms or nursery), ED and therapy entrance doors, hallway on 1st floor that leads to x-ray, ED and therapy parking lots, and urgent care entrance. During a follow-up interview on 3/5/15 at 2:45 p.m., the DON stated she has been the DON for about 5 years and had never requested a key pad code change for the nursery. The DON indicated she has had minimal staff leave their positions during this time and none terminated. The DON indicated babies were never left in the nursery alone. The DON stated the facility did have panic buttons which would send a message to the police department immediately, one of which was at the nurses’ station. The police department would present to the hospital to the location where the panic alarm was initiated. The facility had other panic alarms such as: one by every computer in the emergency department and portable pocket panic buttons used in the emergency department. A Infant Security policy last reviewed 2/28/24 included: 1. On admission the obstetric patient will be instructed on the infant security procedures. 2. All nurses caring for the mother and infant will wear a picture identification badge at all times. 3. After delivery, a identification band is placed on the infant’s wrist and ankle. The same band is placed on the mother and father. If father is not present/involved, the fourth band can be placed on the support person designated by the mother (such as a grandparent). The bands will remain on the infant and the parents/designee during the infants hospitalization and the number on the bands is documented. 4. The RN or LPN will instruct the mother that he/she will be the only staff member picking up or bringing the newborn infant to/from her room. Since rooming in occurs, the need for the infant to leave the mother’s room is minimized. 5. When there is a need for the infant to be brought to the nursery, the infant will be transported in the designated bassinet and mother/father or designated support person can be allowed to accompany the infant. If no one accompanies the infant, the nurse ensures the infant’s band matches the band of the individual receiving the infant upon return to the room. 6. Mother and/or designated caregiver will be instructed to not allow anyone else to remove the infant from the room and to call for help if this occurs. 7. A hand off that includes an introduction will occur at break time or shift change when a different nurse is assigned to the mom and baby. 8. The nursery door is to remain closed and locked at all times for security reasons. The doors closest to the obstetrical unit are also locked at all times and require badge entry as does the emergency exit stairwell door. 9. Upon discharge, the bands on the infant are verified with the band on the mother and verification is documented. 10. If an infant abduction has occurred a “CODE PINK” is announced and Code Pink procedures implemented immediately. See the Code Pink policy for those. Review of facility policy titled Code Pink-Infant Security policy and last approved 4/5/23 included: The Newborn Nursery infant identification policy will be followed regarding banding of infants and mothers. All staff working in the Nursery will follow procedures that address the safety and security of infants. - Assure that the infant taken from the nursery is released only to mother or father, by checking the ID bands of mother and baby. - Infants shall be taken to mothers one at a time. - The nursery door is equipped with a lock to prevent unauthorized access. -Mothers shall be discharged accompanied by a nurse. Anyone leaving unattended carrying an infant shall be reported at once and a Code Pink will be called. CODE PINK ALERT: - The person discovering the missing infant/child is responsible for making the announcement Code Pink and approximate age or size (newborn, infant, etc.) 3 times and call dispatch (ext. 729/911) to alert Morris Police Dept. DO NOT HESITATE TO MAKE THE ANNOUNCEMENT AND CALL IF YOU HAVE ANY REASON TO BELIEVE AN INFANT OR CHILD IS MISSING. Time is critical if the abductor is to be stopped, and you must act immediately!. -All other employees should be on a security alert and respond by immediately securing ALL exits, focusing on those nearest you. No one can be allowed to leave during this time. If someone attempts to or asks why they can’t, explain to them that “we are currently on a security alert and no one is allowed to leave during this time”. -All employees should be aware that if you see someone suspicious (carrying a bundle of any sort, sneaking around or running) cautiously confront them. - If they try to leave, page for assistance by announcing your location. Employees should not jeopardize their own safety. If someone threatens you as you attempt to detain them, pay special attention to details such as looking at people closely so that if the need arises, you could make a positive identification. .-In a real situation, if you need help, and are unable to get to a phone to page - shout for help! If you are able to get to a phone, page SECURITY TO (location) STAT! .-Facility personnel shall protect the crime scene until law enforcement forensic experts arrive for evidence collection. -A facility-wide search of the facility and grounds will be instituted immediately. All exits shall be sealed. -Facility Incident Command will enlist the help of local law enforcement in reporting the details of the abduction accurately. - Information released to the media shall be approved by the Incident Command leader that is in charge of the situation. All facility personnel shall be cautioned not to grant medial interviews, or post to social media, without prior authorization from Incident Command. -An “All Clear” will be paged at the end of a drill or incident -The person who discovered the infant or child missing must complete an RL6 (incident report). If a Code Pink were to occur, this would be considered a sentinel event, and administration and quality must be contacted immediately.”

“Policies/Procedures for Medical Documentation CFR(s): §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(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:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: 34083 Based on interview and document review, the facility failed to include a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records in their policies and procedures in the Emergency Preparedness (EP) plan. This deficient practice had the potential to affect all current patients and future patients in the facility. Findings include: During an interview and document review of the EP plan and policy on 3/6/25 at 12:10 p.m., the quality director (QD) identified the facility’s plan had not included specific information for medical records management during an emergency situation requiring evacuation of patients. Review of the EP plan identified the facility failed to include a plan for medical documentation that preserved patient information, protected confidentiality of patient information, and secured and maintained availability of records included in the EP plan.”