Pondera Medical Center

“Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 485.623(d) for Critical Access Hospitals (CAHs), a life safety code (LSC) recertification survey was performed on 4/1/24. Under this regulatory requirement, the facility must meet the applicable provisions of the National Fire Protection Association’s (NFPA) 101 LSC, 2012 Edition, and those mandatory Codes referenced by that edition. The facility was surveyed specifically using Chapter 19 Existing Health Care Occupancies. The building construction type was found to be Type V (111) and contains five main floor smoke compartments and one basement smoke compartment. There has been no new construction since the last survey of the facility on 4/5/17. The Long-Term Care (LTC) facility is connected to a CAH and a two hour separation is present; however, the LTC was surveyed because some CAH services are located in the LTC building. The LTC facility is licensed for 59 beds and at the time of the survey 37 residents was the census. The CAH is licensed for 20 beds and at the time of the survey the census was 1. The facility has historically received a citation for K271 for no hard surface pathway to the public way. K271 has been remedied and is no longer subject to an FSES. These requirements were not met as evidenced by the following deficiencies:”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Sections 7.1.10.1 and 19.2.3.4(5). Findings include: 1. During an observation on 4/1/24 at 2:20 p.m., the LTC corridor near the clinic exit was inspected. There were two chairs in the corridor which were not fastened to the floor or the wall. Furniture groups are allowed in the corridor as long as they are secured to the floor or wall so they do not move and impede egress during a fire or emergency.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to ensure all exit passageways were marked in accordance with NFPA 101 2012 Edition, Section 7.7.3.2. Findings include: 1. During an observation on 4/1/24 at 2:08 p.m., the OR suite was inspected. The suite was found to be lacking any exit signage. There were many doors in the suite, and exit during panic and/or fire would not be obvious.”

“Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8). Findings include: 1. During an observation on 4/1/24 at 1:44 p.m., patient room 105-1 was inspected. There was an ABHR dispenser mounted over the light switch immediately inside the door of the room. 2. During an observation on 4/1/24 at 1:47 p.m., patient room 109 was inspected. There was an ABHR dispenser mounted over the light switch immediately inside the door of the room. 3. During an observation on 4/1/24 at 1:49 p.m., patient room 115 was inspected. There was an ABHR dispenser mounted over the light switch immediately inside the door of the room.”

“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: 32381 Based on observation, the facility failed to maintain sprinkler heads free of foreign materials per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.1.1.1, and failed to ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1(3). Findings include: 1. During an observation on 4/1/24 at 1:15 p.m., the laundry was inspected. The sprinkler head above the dryers was found to be choked with debris and there was paint and spackle on a sprinkler head in the soiled side of the laundry. 2. During an observation on 4/1/24 at 1:20 p.m., the dish room adjacent to the kitchen was inspected. The sprinkler head in the dish room was found to be corroded and the bulb had turned white. You could not see the color of the fluid in the bulb. 3. During an observation on 4/1/24 at 1:40 p.m., the custodial closet in the helicopter hall was inspected. The sprinkler head in the closet was missing the escutcheon ring. 4. During an observation on 4/1/24 at 1:53 p.m., the ER vestibule was inspected. The sprinkler head in the area was missing the escutcheon ring.”

“Electrical Systems - Receptacles CFR(s): NFPA 101 Electrical Systems - Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to maintain the electrical system in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-12(B). Findings include: 1. During an observation on 4/1/24 at 1:51 p.m., the pantry in the acute care area of the hospital was inspected. A high voltage junction box was found to be missing the cover plate.”