St Andrew’s Hospital

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 42397 OUTDATED MEDICATIONS1. Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the removal of outdated medications from 1 of 3 crash carts (Nurses’ Station) and 1 of 1 operating room (OR) medication storage room observed. Failure to remove outdated medications may result in patients receiving expired and ineffective medications. Findings include: Review of the facility policy titled “Disposal of Medications and Hazardous Substances” occurred on 03/11/26. This undated policy stated, “. . . Expired pharmaceuticals are considered unusable. . . . Medications. . . which are unusable are removed from usable stock . . .” Review of the facility policy titled “Medication & [and] Chemical Storage” occurred on 03/11/26. This policy, dated 02/24/09, stated, “. . . All drugs will be stored according to established standards to maintain their integrity, stability, and effectiveness. . . . Outdated or otherwise unusable drugs are identified and removed from distribution to prevent administration. . . .” Review of the facility policy titled “Multi-dose Eye Drops” occurred 03/11/26. This policy, dated April 2019, stated, “. . . To provide guidelines for the safe administration of multi-dose eye drops in the pre/intra/post-operative surgical setting. . . . eye drop medications in multi-dose bottles must be labeled with a 28-day beyond use date from the date the bottle was first opened and used. . . . Pharmacy staff will be responsible for stocking all eye drop preparations for use during surgery. This will include regularly checking expiration dates when restocking eye drop medications in the surgical area. . . . Surgical staff in pre/intra/post-operative areas are to regularly maintain and monitor the proper use, labeling and expiration date of all eye drop medications. . . . Contaminated eye drops are not to be used on any surgery patients. Dropper bottles are considered contaminated when: . . . An open/used bottle exceeds the 28 day [sic] beyond use date. . . .” Observation of the Nurses’ station crash cart occurred on 03/09/26 at 2:57 p.m. with pharmacist (#2). The crash cart had a locked drawer containing medications used in the event of a patient cardiac or respiratory arrest. Review of the contents of the drawer showed two vials of Heparin (a blood thinner) 5000 units per milliliter with expiration dates of January 31, 2026. During an interview on 03/09/26 at 3:00 p.m., the pharmacist (#2) confirmed the medication was expired, and it is the duty of the pharmacy technician to check the crash cart monthly for expired medications. Observation of the OR medication storage room occurred on 03/10/26 at 11:00 a.m. with administrative nurses (#1 and #3). The room contained a locked cupboard which contained several multi-dose eye drops/ointments used for cataract surgery. Review of the contents of the cupboard showed one container of Phenylephrine HCL (Hydrochloride) 2.5% (percent) ophthalmic solution with an expiration date of February 28, 2026. The cupboard also contained one container of Tropicamide 1% ophthalmic solution (used to dilate the pupils), one container of Phenylephrine 10% ophthalmic solution (used to dilate the pupils), one container of Apraclonidine 0.5% ophthalmic solution (used to lower elevated eye pressure), one container of Diclofenac sodium ophthalmic solution 0.1% (used to reduce pain, swelling, and light sensitivity following cataract surgery), and one tube of TobraDex (tobramycin 0.3% / dexamethasone 0.1%) 3.5g (gram) ophthalmic ointment (medication combining an antibiotic and a corticosteroid used to treat swelling, redness, and itching while fighting bacteria), all with open dates of 01/08/26. During an interview on 03/10/26 at 11:15 a.m., administrative nurses (#1 and #3) confirmed opened multi-dose eye drops were good for 28 days from the date opened, confirmed the Phenylephrine HCL 2.5% multi-dose eye drops were expired, the remaining multi-dose eye drops/ointments were past the 28-day use by date, and the last cataract surgery was on 02/26/26. MEDICATION STORAGE 2. Based on observation, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff stored drugs and biologicals in accordance with professional principles on 1 of 3 days of survey (March 9-11, 2026). Failure to properly store drugs and biologicals limited the CAH’s ability to prevent unauthorized use of medications and maintain control of medications. Findings include: Review of the facility policy titled “Medication & [and] Chemical Storage” occurred on 03/11/26. This policy, dated 02/24/09, stated, “. . . All drugs will be stored according to established standards to maintain their integrity, stability, and effectiveness. . . .” Review of the facility policy titled “Patient Self-Administration of Medications” occurred on 03/11/26. This undated policy stated, “. . . If medications are to remain at bedside, the prescriber must specify an order for this as well either in writing or verbal direction reduced to writing.” Observation on 03/09/26 at 2:11 p.m. showed Patient #3 seated in a recliner in her room and a Breztri Aerosphere inhaler [used to treat chronic obstructive pulmonary disease] on the patient’s over the bed table. The nurse (#8) prepared and administered the patient’s scheduled oral medication and nebulizer treatment. The nurse (#8) stated, “I don’t know why this is in here” and returned the inhaler to the medication cart. Review of Patient #3’s medical record occurred on all days of survey. A current physician’s order identified Breztri Aerosphere 160 mcg [micrograms] “inhale two puffs twice daily.” The order failed to include instructions for patient self-administration. During an interview on 03/09/26 at 4:45 p.m., administrative nurse (#1) confirmed the facility requires a physician’s order for medications left at bedside or patient self-administration, and Patient #3’s current physician’s order lacked directions for self-administration or to leave at bedside.”

“NURSING SERVICES CFR(s): A nursing care plan must be developed and kept current for each inpatient. This Standard is not met as evidenced by: 19410 Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff developed nursing care plans to address the needs of the patients for 16 of 16 closed acute care records reviewed (Patients #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20). Failure to address the needs of the patients on the nursing care plans limited the CAH’s ability to communicate treatment approaches, assist the patient to attain/maintain their highest physical, mental, and psychosocial well-being, and ensure continuity of care. Findings include: Review of policy titled, “Patient Care Plans”, occurred on 03/11/26. This policy, dated May 2024, stated, “POLICY: A patient care plan will be developed for each patient admitted to the Acute Care Unit in coordination with the patient and appropriate health care personnel . . . Standardized care plans may be utilized but must be individualized to the patient’s needs . . . The initial assessment must begin upon admission, and the patient care plan must be developed and implemented consistent with patients’ needs. . . “ Medical record review occurred on all days of survey. Facility staff failed to develop care plans for Patients #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20. During an interview on 03/11/26 at 10:00 a.m., a supervisory nurse (#9) confirmed the electronic medical records had no documentation of care plans and the nursing staff failed to enter a care plan for the patients.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 37620 FOOD STORAGE 1. Based on observation, review of facility policy, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff stored laboratory chemical supplies in a way that prevented cross-contamination of foods in 1 of 1 lab freezer. Failure to keep personal food items away from laboratory chemicals has the potential to result in potentially contaminated food. Findings include: Review of policy titled, “Infection Control in Laboratory Services”, occurred on 03/11/26. This policy, dated 03/14/24, stated, “. . . Smoking, eataing, drinking . . . are prohibited in all work areas. . . .” Observation of the facility laboratory on 03/09/26 at 2:05 p.m., with the lab supervisor (#10), showed a freezer that contained lab slides and calibration controls for the Vitros lab machine (used to complete different blood tests). Upon observation, the freezer also contained two frozen pizzas in their original plastic wrapping. The lab supervisor immediately removed the two frozen pizzas and confirmed staff should not store food in the lab freezer. FOLLOW MANUFACTURER’S INSTRUCTIONS 2. Based on observation, review of manufacturer’s instructions, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed manufacturer’s instructions for the use of a chemical for cleaning and disinfecting equipment and supplies for 1 of 1 shower room (South Hall) observed. Failure to follow manufacturer’s instructions for cleaning and disinfection of equipment and supplies limited the CAH’s ability to ensure proper sterilization. Findings include: Observation of the CAH shower room occurred on 03/09/26 at 2:36 p.m. with certified nurse aide (CNA) (#5). The observation showed two showers, one for staff to assist patients, and one for patients to use independently and a spray bottle of quaternary solution (Quat-Stat-5) for cleaning and disinfecting the showers. The CNA (#5) stated staff sprays the shower, scrubs the shower with a brush, then rinses the shower with water. The CNA did not know the kill time of the quaternary solution. The Quat-Stat-5 manufacturer’s instructions, reviewed 03/10/26 at 11:20 a.m., stated, “. . . Apply use-solution to hard, nonporous surfaces, thoroughly wetting surfaces with . . . sprayer . . . Treated surfaces must remain wet for 5 [five] minutes. . . .” During an interview on 03/10/26 at 11:20 a.m., an administrative nurse (#4) confirmed the solution should remain on the surface for five minutes to achieve appropriate disinfection. HAND HYGIENE 3. Based on observation, review of facility policy, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed standard infection control practices for 1 of 1 patient (Patient #25) observed during cares and 1 of 1 patient (Patient #1) observed for intravenous (IV) medication administration. Failure to perform hand hygiene after removal of gloves, and when moving from one area of the CAH to another has the potential to spread infection to other patients, staff, and visitors. Findings include: Review of the facility policy titled “Policy & Procedures for Isolation Precautions” occurred on 03/11/26. This undated policy stated, “. . . Hand washing . . . Wash hands immediately after gloves are removed . . . to avoid transfer of microorganisms to other patients or environments . . .” -Observation on 03/10/26 at 9:33 a.m. showed a contact precautions sign on Patient #25’s door, the patient seated on the commode, and a certified nurse aide (CNA) (#6) present in the room wearing a gown and gloves. Another CNA (#9) performed hand hygiene, applied a gown and gloves, and entered the patient’s room. The CNAs (#6 and #9) assisted the patient to stand with a mechanical sit to stand lift. The CNA (#6) performed bowel movement (BM) cares, and without removing the soiled gloves, applied a clean brief, pulled up the patient’s pants, positioned the wheelchair behind the patient, and assisted the patient to sit in the wheelchair. The CNA (#6) emptied and rinsed the commode, moved the commode into the bathroom, moved the sit to stand lift into the bathroom, and gathered the garbage. The CNA (#9) positioned the patient beside the bed and placed the call light. Both CNAs (#6 and #9) removed the soiled gowns and gloves, performed hand hygiene, and exited the room. The CNA (#6) failed to change gloves and perform hand hygiene after performing BM cares and before touching other items. -Observation on 03/10/26 at 12:00 p.m. showed a nurse (#7) prepared an antibiotic for IV administration. The nurse performed hand hygiene, applied gloves, reconstituted the antibiotic with saline, drew the antibiotic into a syringe, labelled the syringe and laid it on top of the medication cart. The nurse (#7) removed the gloves, and without performing hand hygiene, pushed the medication cart to Patient #1’s room. The nurse entered the room, without performing hand hygiene, applied clean gloves, obtained the medication scanner from the medication cart, scanned Patient #1’s wristband, returned the scanner to the medication cart, retrieved the antibiotic syringe and a normal saline flush syringe from the medication cart, and returned to the patient. The nurse cleaned the IV connector with an alcohol swab, connected the flush syringe, flushed the IV with saline, connected the antibiotic syringe, and administered it over three minutes. The nurse reconnected the saline flush syringe and flushed the IV with additional saline, disconnected the syringe, disposed of both syringes, removed the soiled gloves, performed hand hygiene and exited the room. The nurse (#7) failed to perform hand hygiene after glove removal and before touching other items, and before applying clean gloves prior to administering Patient #1’s IV antibiotic. 42397”

“This survey used the 2012 edition of NFPA 101, Life Safety Code, Chapter 19-Existing Health Care Occupancies and the 2012 edition of NFPA 99, Health Care Facilities Code in compliance with 42 CFR 485.623(d)(e). The findings that follow demonstrate noncompliance with these standards. The facility was located in a two-story building of Type II (222) construction. A clinic, an assisted living building and a congregate housing apartment building were attached to the hospital and separated with two-hour fire rated occupancy separation walls. Note: A Fire Safety Evaluation System (FSES) was conducted as a result of the 03/10/2026 Life Safety Code survey. The FSES was specifically used as an alternative safety method for Tags K271 (Discharge from Exits) and K362 (Corridor Walls). St Andrews Health Center-CAH did not meet the Life Safety Code requirements for exit access and corridor wall construction. The facility passes the FSES when all other deficiencies have been corrected.”

“Discharge from Exits CFR(s): NFPA 101 Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7 This Standard is not met as evidenced by: 31888 The facility failed to provide all occupants with safe access to a public way. Exits must terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge must be of required width and size to provide all occupants with safe access to a public way. 7.7.1 To ensure adequate exit capability, CMS requires asphalt or concrete surfaces from exterior exits to public ways. CMS S&C-07-05 Observation determined the northeast exterior exit from St Andrews Health Center - CAH traversed the lawn to get to a public way. Failure to ensure means of egress provide safe access to a public way increases the risk of death or injury due to fire. This deficiency affected one (1) of nine (9) required exits from the building.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 31888 The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72, National Fire Alarm Code. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1 A fire alarm system required for life safety shall be installed, tested and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 9.6.1.3 System defects and malfunctions shall be corrected. NFPA 72 14.2.1.2.2 Record review of the fire alarm system annual test conducted on 04/17/2025 by an outside company indicated the west heat detector in the Center Boiler Room had failed and had not been replaced at the time of the survey. Failure to install, test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire. The deficiency affected one (1) of numerous heat detectors in the facility. The fire alarm system serves the entire facility.”

“Corridors - Construction of Walls CFR(s): NFPA 101 Corridors - Construction of Walls 2012 EXISTING Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area. 19.3.6.2, 19.3.6.2.7 This Standard is not met as evidenced by: 31888 The facility failed to ensure corridors were separated from use areas by walls constructed with at least a 1/2-hour fire resistance rating. Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than1/2-hour. 19.3.6.2.1 Observation determined the fire rated corridor walls stopped at the ceiling and did not extend to the floor/ceiling or ceiling/roof assembly. 1) The plaster covering the clay tile corridor walls throughout the facility stopped at the suspended ceiling and was not applied to the clay tile block located in the interstitial space between the suspended ceilings and the floor/ceiling or the ceiling/roof decks. Without the plaster, the clay tile walls cannot attain a minimum 1/2-hour fire resistance rating. 2) A section of the second-floor dining room corridor wall was not constructed with gypsum board on the room side of the wall. The gypsum board on the dining room side of the wall stopped at the suspended ceiling and did not extend to the ceiling/roof assembly. Without gypsum board applied to both sides of the wall, this section of the corridor wall cannot attain a minimum 1/2-hour fire resistance rating. Failure to separate corridors from other areas increases the risk of death or injury due to fire. This deficiency affected all exit corridors in the facility.”

“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: 31888 The facility failed to conduct fire drills as required. Fire drill records review determined: 1) All fire drills did not include the simulation of an emergency phone call to the fire department. 2) No fire drill was conducted on the PM Shift during the third quarter in the past year. Failure to conduct fire drills as required increases the risk of death or injury due to fire. The deficiency affected eleven (11) of twelve (12) drills in the past year.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 31888 The facility failed to ensure the electrical system was inspected, tested and maintained in accordance with NFPA 99 Health Care Facilities Code. Electrical systems shall be inspected, tested and maintained in accordance with the applicable requirements of NFPA 99 Health Care Facilities Code. 6.3.3.2, 6.3.3.2.1, 6.3.3.2.2, 6.3.3.2.3, 6.3.3.2.4, 6.3.4.1 Receptacle inspection and testing in patient care rooms shall include the following: 1) The physical integrity of each receptacle shall be confirmed by visual inspection. 2) The continuity of the grounding circuit in each electrical receptacle shall be verified. 3) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 4) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). Failed receptacles at patient bed locations shall be replaced with hospital grade outlets, per NFPA 70 National Electrical Code, 517.18 (B). These tests need to be completed at least annually on all non-hospital grade outlets in patient care rooms. Observation, record review, and interview with staff determined there was no documentation of inspection and testing of the non-hospital grade electrical receptacles at patient bed locations in the past year. Failure to inspect, test and maintain electrical receptacles in accordance with NFPA 99 increases the risk of death or injury due to fire. The deficiency affected numerous electrical receptacles in resident rooms in the facility.”

“PERIODIC REVIEW OF CLINICAL PRIVILEGES CFR(s): §485.631(d) Standard: Periodic review of clinical privileges and performance. The CAH requires that- (1) The quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners, clinical nurse specialist, and physician assistants at the CAH are evaluated by a member of the CAH staff who is a doctor of medicine or osteopathy or by another doctor of medicine or osteopathy under contract with the CAH. (2) The quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH are evaluated by- (i) One hospital that is a member of the network, when applicable; (ii) One Quality Improvement Organization (QIO) or equivalent entity; (iii) One other appropriate and qualified entity identified in the State rural health care plan; (iv) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH’s patient under an agreement between the CAH and a distant-site hospital, the distant-site hospital; or (v) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH’s patients under a written agreement between the CAH and a distant-site telemedicine entity, one of the entities listed in paragraphs (d)(2)(i) through (iii) of this section. (3) The CAH staff consider the findings of the evaluation and make the necessary changes as specified in paragraphs (b) through (d) of this section. This Standard is not met as evidenced by: 20497 Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to have a network hospital or Quality Improvement Organization (QIO) evaluate the quality and appropriateness of the diagnosis and treatment furnished to the CAH’s inpatients by physicians for 7 of 7 quarters reviewed (January 2022 - September 2023). Failure to have a network hospital or QIO evaluate the quality and appropriateness of the diagnosis and treatment provided by physicians limited the CAH’s ability to ensure the physicians furnished quality and appropriate care to the CAH’s patients. Findings include: Review of the policy “Peer-to-Peer Review for Quality of Care” occurred on 12/19/23. This policy, dated 08/2021, stated, “Policy: To maintain quality of care . . . St. Andrew’s Medical Staff will take part in periodic provider Peer Review which will be performed either by Medical Staff physicians, or by a third party under contract as required by regulation. Procedure: I. Chart selection A. On a quarterly basis, chart selection will be completed by the Medical Record Director/Designee selecting a random sample of: a. 2 inpatient charts from each physician . . . II. Routing of Charts for Peer Review A. After selection of the charts, the Medical Records Director/Designee will route the charts in the following manner: a. Physician charts will be routed to [name of network hospital], or other tertiary facility as dictated by contract. . . .” Reviewed on 12/19/23, the 2022-2023 peer review records failed to include evidence a network hospital or QIO evaluated the quality and appropriateness of the diagnosis and treatment furnished to the critical access hospital inpatients by physicians. Upon request on 12/20/23, the CAH failed to provide further evidence of these evaluations. During interview on 12/20/23 at 8:15 a.m., an administrative health information management staff member (#3) confirmed the CAH had failed to send out records of physicians providing hospital inpatient treatment/care to a network hospital or QIO for evaluation to ensure provision of quality and appropriate diagnosis and treatment in 2022-2023. During interview on 12/20/23 at 8:30 a.m., an administrative staff member (#1) confirmed physicians provided treatment/care to the CAH’s inpatients and the CAH had not sent inpatient records for evaluation by a network hospital or QIO.”

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 37620 Based on observation, policy and procedure review, inventory form, professional reference review, and staff interview, the Critical Access Hospital (CAH) failed to follow their malignant hyperthermia policy and professional standards. Failure to maintain a complete supply of Dantrolene or Ryanodine for possible malignant hyperthermia as per facility policy, limited the facility’s ability to treat patients in the event of a malignant hyperthermia crisis. Findings include: Review of the policy, “Malignant Hyperthermia Cart” occurred on 12/20/23. This undated policy, stated, “The Surgical Services Department will have a cart stocked for the treatment of malignant hyperthermia at all times. . . . The malignant hyperthermia cart will be inspected once a month or immediately following a MH [malignant hyperthermia] crisis for inventory . . . DRUGS: Dantrolene 36 vials . . .” An undated article from the Malignant Hyperthermia Association, found at mhaus.org, stated, “. . .The following anesthetic agents are known triggers of MH [Malignant Hyperthermia]: Inhaled General Anesthetics . . . Succinylcholine (warning) [skeletal muscle relaxant]. A second article posted 2018, page 26, stated, “Most MH cases are triggered by the administration of a volatile anesthetic agent with or without succinylcholine, but in a small percentage of cases MH appears to be triggered by succinylcholine alone in the absence of a volatile agent. Events reported to the North American Malignant Hyperthermia Registry (NAMHR) were triggered by succinylcholine alone . . . . Dantrolene [muscle relaxant] must be available for all anesthetizing locations where MH trigger agents are used. Furthermore, MHAUS [Malignant Hyperthermia Association of the United States] recommends that centers stock a minimum of 36 20-mg [milligram] vials of Dantrium [Dantrolene] or Revonto (total dose 720-mg), or three 250-mg vials of Ryanodex (total dose 750-mg). These amounts of Dantrolene were originally determined by the analysis of MH event data showing that some cases of acute MH required up to or more than 10-mg/kg [killogram] body weight, and therefore, these total dose amounts would suffice for the majority of average-sized patients that develop MH. . . .” Observation of the surgical unit on 12/18/23 at 4:02 p.m., with a surgical nurse (#5) and administration nurse (#2), identified 12 vials of Dantrium (Dantrolene) 20 mg and 1 vial of Ryanodex 250 mg in a locked Malignant Hyperthermia cart. Observation of the emergency room the afternoon of 12/19/23 with a facility nurse (#6) and administrative nurse (#2), identified 4 vials of Succinylcholine 200mg/ml (milliliters) in the locked Pyxus refrigerator. A Device Inventory Form observed in the emergency room identified Succinylcholine 200mg/10ml quantity 4. A Pharmacy Expiration Tracking for the operator room Malignant Hyperthermia Cart identified “Dantrolene 20mg 6 boxes with expiration dates of 02/25 and 11/25. During interview the afternoon of 12/19/23, an administrative nurse (#2) confirmed the facility failed to maintain a complete Malignant Hyperthermia kit.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 27221 Based on observation, review of a professional reference, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff stored utensils in a way that prevented cross-contamination of foods in 1 of 1 kitchen. Failure to remove utensils from storage bins containing dried goods has the potential to result in cross-contamination of foods and/or illness. Findings include: The facility failed to provide a copy of their policy addressing infection control practices in the kitchen as requested. The SERVSAFE Manager, 7th Edition Revised, pages 4.2, 5.10, and 6.2, stated, “. . . Pathogens . . . can be spread from food or unwashed hands to prep areas, equipment, utensils, or other food. . . . you need to store items in a way that prevents cross-contamination. . . . No matter what type of food you are prepping, you should . . . Make sure . . . utensils are clean and sanitized. . . .” Observation of the kitchen on 12/18/23 at 2:35 p.m. and 12/19/23 at 8:35 a.m., showed staff left scoops in storage bins containing flour, rice, and sugar. During an interview on 12/20/23 at 9:30 a.m., a dietary staff member (#4) agreed staff should not leave scoops in storage bins containing dried goods.”

“This survey used the 2012 edition of NFPA 101, Life Safety Code, Chapter 19-Existing Health Care Occupancies and the 2012 edition of NFPA 99, Health Care Facilities Code in compliance with 42 CFR 485.623(d)(e). The findings that follow demonstrate noncompliance with these standards. The facility was located in a two-story building of Type II (222) construction. A clinic, an assisted living building and a congregate housing apartment building were attached to the hospital and separated with two-hour fire rated occupancy separation walls. Note: A Fire Safety Evaluation System (FSES) was conducted as a result of the 12/19/2023 Life Safety Code survey. The FSES was specifically used as an alternative safety method for Tags K362 (Corridor Walls) and K271 (Discharge from Exits). St Andrews Health Center-CAH did not meet the Life Safety Code requirements for corridor wall construction and exit access. The facility passes the FSES when all other deficiencies have been corrected.”

“Discharge from Exits CFR(s): NFPA 101 Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7 This Standard is not met as evidenced by: 31888 Exits must terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge must be of required width and size to provide all occupants with safe access to a public way. 7.7.1 To ensure adequate exit capability, CMS requires asphalt or concrete surfaces from exterior exits to public ways. CMS S&C-07-05 Observation determined the northeast exterior exit from St Andrews Health Center - CAH traversed the lawn to get to a public way. Failure to ensure means of egress provide safe access to a public way increases the risk of death or injury due to fire. This deficiency affected one (1) of nine (9) required exits from the building.”

“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: 31888 Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Automatic wet chemical fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer’s instructions, and NFPA 17A, Standard for Wet Chemical Extinguishing Systems. 19.3.2.5.1, 9.2.3, NFPA 96 10.2.6(4). 1) The facility failed to install cooking equipment in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. A readily accessible means for manual activation shall be located between 1067 mm and 1219 mm (42 in. and 48 in.) above the floor, be accessible in the event of a fire, be located in a path of egress, and clearly identify the hazard protected. 19.3.2.5.1, 9.2.3, NFPA 96 10.5.1. Observation determined the manual actuation device for the fire-extinguishing system serving the Kitchen exhaust hood was mounted at a height of more than forty-eight (48) inches above the floor. The manual pull was 56 inches above the floor. 2) The facility failed to inspect, test and maintain the wet chemical extinguishing system in the Kitchen in accordance with NFPA 17A, Standard for Wet Chemical Extinguishing Systems and NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. On a monthly basis, inspection shall be conducted in accordance with the manufacturer’s listed installation and maintenance manual or the owner’s manual. At a minimum, this quick check or inspection shall include verification of the following: (1) The extinguishing system is in its proper location. (2) The manual actuators are unobstructed. (3) The tamper indicators and seals are intact. (4) The maintenance tag or certificate is in place. (5) No obvious physical damage or condition exists that might prevent operation. (6) The pressure gauge, if provided, shall be inspected physically or electronically to ensure it is in the operable range. (7) The nozzle blowoff caps, where provided, are intact and undamaged. (8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated. If any deficiencies are found, appropriate corrective action shall be taken immediately. Where the corrective action involves maintenance, it shall be conducted by a trained service technician. Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions. At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained for the period between the semiannual maintenance inspections. NFPA 17A 7.2.1 through 7.2.6 Review of documentation and interview with staff determined the monthly inspections of the wet chemical extinguishing system in the Kitchen had not been completed during the past four months. This deficiency affected one (1) of one (1) wet chemical extinguishing system in the facility.”

“Smoke Detection CFR(s): NFPA 101 Smoke Detection 2012 EXISTING Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1. 19.3.4.5.2 This Standard is not met as evidenced by: 31888 In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1, A.17.7.4.1 The facility failed to ensure the smoke detection system was in compliance with NFPA 72, National Fire Alarm and Signaling Code. Observation determined one (1) smoke detector in the Emergency Room was installed within 36 in. of a return air opening. Failure to install the smoke detection system as required increases the risk of death or injury due to fire. This deficiency affected one (1) of numerous smoke detectors in the facility. The smoke detection system serves the entire facility.”

“Corridors - Construction of Walls CFR(s): NFPA 101 Corridors - Construction of Walls 2012 EXISTING Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area. 19.3.6.2, 19.3.6.2.7 This Standard is not met as evidenced by: 31888 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than1/2-hour. 19.3.6.2.1 The facility failed to ensure corridors were separated from use areas by walls constructed with at least a 1/2-hour fire resistance rating. Observation determined the fire rated corridor walls stopped at the ceiling and did not extend to the floor/ceiling or ceiling/roof assembly. 1) The plaster covering the clay tile corridor walls throughout the facility stopped at the suspended ceiling and was not applied to the clay tile block located in the interstitial space between the suspended ceilings and the floor/ceiling or the ceiling/roof decks. Without the plaster, the clay tile walls cannot attain a minimum 1/2-hour fire resistance rating. 2) A section of the second-floor dining room corridor wall was not constructed with gypsum board on the room side of the wall. The gypsum board on the dining room side of the wall stopped at the suspended ceiling and did not extend to the ceiling/roof assembly. Without gypsum board applied to both sides of the wall, this section of the corridor wall cannot attain a minimum 1/2-hour fire resistance rating. Failure to separate corridors from other areas increases the risk of death or injury due to fire. This deficiency affected all exit corridors in the facility.”

“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: 31888 Ground-fault circuit-interruption for personnel shall be provided as required. The ground-fault circuit-interrupter shall be installed in a readily accessible location. All 125-volt, single-phase, 15- and 20-ampere receptacles located in bathrooms, kitchens, rooftops, outdoors, indoor wet locations, locker rooms with associated showering facilities, garages and where receptacles are installed within 6 ft. of the outside edge of the sink shall have ground-fault circuit-interrupter protection for personnel. 19.5.1.1, 9.1.2, NFPA 70, 210.8, 210.8(B) The facility failed to ensure electrical wiring and electrical equipment met the requirements of NFPA 70, National Electrical Code. Observation determined numerous electrical receptacles in the Kitchen were not ground-fault circuit-interrupter protected. Failure to provide electrical wiring and equipment in accordance with NFPA 70 increases the risk of injury or death due to fire. The deficiency affected numerous electrical receptacles in the facility.”

“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: 31888 The facility failed to conduct fire drills as required. Fire drill records review determined no fire drills were conducted on the PM Shift during the third quarter in the past year. Failure to conduct fire drills as required increases the risk of death or injury due to fire. The deficiency affected one (1) of twelve (12) drills in the past year.”

“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: 31888 The facility failed to ensure the emergency generator was in compliance with NFPA 99, Health Care Facilities Code and NFPA 110, Standard for Emergency and Standby Power Systems. Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. (2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating. Diesel-powered EPS installations that do not meet the requirements shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. NFPA 99 6.4.4.1.1.4, NFPA 110 8.4.2, 8.4.2.3 1) Review of generator test records and interview with staff did not indicate the minimum exhaust temperature provided by the manufacturer was achieved and that the monthly exercise of the 500 kW diesel generator loaded the generator to at least 30% (150 kW) of the nameplate rating. The facility did not perform annual supplemental load exercises as required when diesel generators are not loaded to 30% of nameplate rating or manufacturer’s recommended temperature during the required monthly exercises. 2) Review of generator test records and interview with staff determined the emergency generator was not exercised under load for 4 continuous hours in the past 36 months. Failure to inspect, test and maintain the emergency generator in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire. The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.”