Chi Health St Mary’s

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 52353 Based on observation, policy and procedure review and staff interview, the Critical Access Hospital (CAH) failed to provide ongoing preventative maintenance (PM) for 6 out of 77 sampled pieces of medical equipment. The facility also failed to maintain a daily temperature log on 1 of 1 breast milk refrigerator. This failed practice had the potential to effect all patients of the CAH. The CAH had a monthly average census of 427 emergency room patients, 28 acute care patients and 9 obstetrical patients for the fiscal year ending 12/31/25. Findings are: A. Observation of emergency room (12/3/25 at 9:00AM), acute care unit (12/3/25 at 9:30AM) and obstetrical (relating to child birth) unit (12//3/25 at 9:30AM) revealed all refrigerators used for medication storage did not have a biomedical sticker present to indicate the refrigerators were a part of the preventative maintenance program. -Observation of obstetrical unit (12/3/25 at 9:30AM) revealed refrigerator used for breast milk storage, breast pump (used to obtain breast milk) and blanket warmer did not have a biomedical sticker present to indicate the equipment were a part of the preventative maintenance program. B. Observation of temperature log for breast milk refrigerator (12/3/25 at (9:30AM) lacked evidence of temperature checks on 7/6, 7/7, 8/11, 8/13, 9/16, 9/20. 9/21, 10/13, 10/14 and 10/18. C. Review of policy and procedure titled Medical Equipment Management Plan (last revised on 12/24) stated...”A maintenance strategy will be developed for all medical devices in the hospital.” -Review of policy and procedure titled Point of Care-Temperature Documentation (last revised on 8/22) stated...”For refrigerator temperature, the department will record the following daily...”Temperature.” D. Interview with Quality and Patient Safety Program Manager (12/4/25 at 10:00AM) confirmed the above equipment lacked evidence of preventative maintenance stated “these used to be part of clinical engineering, but is no longer on their list.” -Interview with Inpatient Nursing Supervisor (12/4/25 at 11:40AM) confirmed the temperature log “does not” have temperature recordings for the above listed dates.”

“42 CFR 485.623 The facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code of the National Fire Protection Association. This facility is governed by Chapter 19, Existing Health Care Occupancies of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code. CHI Health St. Mary’s, is a single story Type II (III) construction type, was built in 2014 is fully sprinkled, smoke detection in corridors and spaces open to corridors, there is a 2 hour fire rated separation between the hospital and the medical office clinic. The facility has the capacity of 18 beds with a census of 8 on the day of survey. CHI Health St. Mary’s, was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 485.623, Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition.”

“Multiple Occupancies - Contiguous Non-Health CFR(s): NFPA 101 Multiple Occupancies - Contiguous Non-Health Care Occupancies Non-health care occupancies that are located immediately next to a Health Care Occupancy, but are primarily intended to provide outpatient services are permitted to be classified as Business or Ambulatory Health Care Occupancies, provided the facilities are separated by construction having not less than 2-hour fire resistance-rated construction, and are not intended to provide services simultaneously for four or more inpatients. Outpatient surgical departments must be classified as Ambulatory Health Care Occupancy regardless of the number of patients served. 18.1.3.4.1, 19.1.3.4.1 This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to maintain a 2-hour fire separation between the Nursing Home and Business Occupancy. This deficient practice would allow smoke, fire and gases to migrate from one occupancy into the other, affecting all occupants. The facility has the capacity for 18 beds with a census of 8 on the day of survey. Findings are: Observation on 12-3-25 at 10:00 am revealed, the south 1 1/2-hour fire rated door near the ice machine failed to latch within the doorframe. During an interview on 12-3-25 at 10:00 am, Staff A confirmed the fire rated door failed to latch.”

“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: 13879 Based on record review and interview, the facility failed to maintain a cleaning schedule for 2 of 2 kitchen exhaust hoods. This deficient practice would increase the potential for a fire, affecting all occupants. The facility has the capacity for 18 beds with a census of 8 on the day of survey. Findings are: Record review on 12-3-25 at 10:51 am revealed, no surface cleaning of the interior of the kitchen hoods or filters was provided. During an interview on 12-23-25 at 10:51 am, Kitchen Staff A confirmed the no written schedule was provided for hood cleaning”

“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: 13879 Based on observation and interview, the facility failed to provide smoke detection in the sleep lab room. This deficient practice would not alert occupants of a fire and would affect approximately 2 occupants. The facility has the capacity for 18 beds with a census of 8 on the day of survey. Findings are: Observations on 12-3-25 at 10:15 am revealed the lack of a smoke detector in the sleep lab room. During an interview on 12-3-25 at 10:15 am, Staff A confirmed the lack of smoke detection in the sleeping 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: 13879 Based on observation and interview, the facility failed to assure fire sprinklers were not covered in foreign material or corrosion. This deficient practice increased the potential of delayed sprinkler activation resulting in a larger fire that could spread outside of the room of origin affecting all occupants. The facility has the capacity for 18 beds with a census of 8 on the day of survey. Findings are: Observation on 12-3-25 at 11:11 am revealed, several sprinklers in the kitchen covered in foreign material and corrosion. During an interview on 12-3-25 at 11:11 am, Staff A confirmed the foreign material and corrosion on sprinklers in the kitchen.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 13879 Based on observations and interview, the facility failed to assure that smoke doors closed and latched within the doorframe. This deficient practice would increase the potential for fire, smoke and gases to spread into another smoke compartment affecting all occupants. The facility has the capacity for 18 beds with a census of 8 on the day of survey. Findings are: Observations on 12-3-25 at 10:10 am revealed, the south smoke door next to the EVS breakroom failed to latch within the doorframe. During an interview on 12-3-25 at 10:10 am, Staff A confirmed the smoke door did not latch.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to prohibit the use of space heaters. This deficient practice increased the potential of a fire, affecting approximately 8 occupants. The facility has the capacity for 18 beds with a census of 8 on the day of survey. Findings are: Observation on 12-3-25 at 10:30 am revealed, a space heater under the nurse’s station desk in the emergency department. During an interview on 12-3-25 at 10:30 am, Administration Staff A confirmed the space heater.”

“Features of Fire Protection - Fire Loss Preve CFR(s): NFPA 101 Features of Fire Protection - Fire Loss Prevention in Operating Rooms Periodic evaluations are made of hazards that could be encountered during surgical procedures, and fire prevention procedures are established. When flammable germicides or antiseptics are employed during surgeries utilizing electrosurgery, cautery or lasers: * packaging is non-flammable * applicators are in unit doses * Preoperative “time-out” is conducted prior the initiation of any surgical procedure to verify: o application site is dry prior to draping and use of surgical equipment o pooling of solution has not occurred or has been corrected o solution-soaked materials have been removed from the OR prior to draping and use of surgical devices o policies and procedures are established outlining safety precautions related to the use of flammable germicide or antiseptic use Procedures are established for operating room emergencies including alarm activation, evacuation, equipment shutdown, and control operations. Emergency procedures include the control of chemical spills, and extinguishment of drapery, clothing and equipment fires. Training is provided to new OR personnel (including surgeons), continuing education is provided, incidents are reviewed monthly, and procedures are reviewed annually. 15.13 (NFPA 99) This Standard is not met as evidenced by: 13879 Based on documentation review and interview, the facility failed to assure that all OR staff were trained and provided with the policies for fire prevention in the operating room. This deficient practice failed to assure the safety of all occupants in the Operating Room. The facility has the capacity for 18 beds with a census of 8 on the day of survey. Findings are: Documentation review on 12-3-25 at 11:25 am revealed that the policy of fire prevention in the operating room failed to include Surgeons. During an interview on 12-3-25 at 11:25 am, Nurse Staff A confirmed that the surgeons were not included in fire prevention training.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 48575 Based on the suicide precaution policy the facility failed to ensure 1 (Patient 10) of 1 emergency department (ED) psychiatric sampled patient was monitored one-to-one (a staff member within line of sight and arms reach designated to one patient to watch safety) for suicidal thoughts with a plan (a patient who voiced how they will end their life) per facility policy. The facility failed to ensure 1 of (Patient 10) 1 transfer consent form was complete with last vital signs and patient-specific risks and benefits by the physician. This failed practice has the potential to cause harm or death to any patient who presents to the facility for care. According to facility provided data the ED saw an average of 422 patients per month, and transferred an average of 34 patients per month. See citation A2407 and A2049, that also resulted in A2400 to not be met.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 48575 Based on policy review, medical record review and medical staff interview the facility failed to ensure a suicidal precaution one-to-one order and interventions were placed for 1 (Patient 10) of 1 emergency department (ED) psychiatric sampled patient with an emergency medical condition (EMC) (a condition that requires the patient to receive emergent care) high risk suicidal ideation with two plans (a person with thoughts of harm who voice the way they will end their own life) per facility policy. This failed practice has the potential to cause harm or death to any patient who presents to the facility for care. According to facility provided data the ED saw an average of 422 patients per month. See citation A2400, that also resulted in A2407 and A2409 to not be met. Findings include: A. Review of facility policy, Suicide Screening and Precautions, last approved 4/2025 revealed, suicide risk levels are determined based on patient responses using the Columbia-Suicide Severity Rating Scale (C-SSRS) tool (a screening tool that defines the suicide risk level for a patient with interventions for staff to follow. The risk levels include: no risk, low risk, moderate risk and high risk). Interventions for patients at high risk for suicide include: -Notify the physician to discuss level of risk. -Implement one-to-one monitoring. -Document initiation of one-to-one monitoring. -Document every 15-minute safety visual checks while on one-to-one monitoring. -One-to-one monitoring continues until a psychiatric physician, nurse practitioner or primary physician sees and assesses the patient and order discontinuation of one-to-one monitoring. One-to-one monitoring is defined as one observer to one patient within line of sight and arms reach, with no physical barriers in the same room or area. B. Review of P10’s medical record revealed, P10 presented to the critical access hospital on 2/13/2025 at 9:28AM via car, walk in, with a chief complaint of suicidal thoughts. At 9:35AM Registered Nurse-A (RN-A) documented P10’s C-SSRS score as high risk. At 9:39AM RN-A documented P10’s suicidal plans of cutting or suffocation. P10’s medical screening exam (MSE) (an exam from a physician that determines whether or not an emergency medical condition exists) started at 9:45AM by Physician-A. P 10’s medical record lacked evidence of nurse to physician notification regarding the C-SSRS high risk level. P10’s medical record lacked evidence of a suicidal precaution one-to-one monitoring order, confirmed by Administrator-A. P10’s medical record lacked evidence of suicidal one-to-one monitoring documentation per facility policy, confirmed by Administrator-A. P10’s medical record lacked evidence of patient-specific risks and benefits on the physician certification transfer form. C. During an interview on 6/4/2025 at 8:55AM, Physician-A confirmed P10’s medical record lacked a suicide precaution order and documentation of one-on-one monitoring of safety on 2/13/2025 from 9:28AM to 1:30PM until transferred to another facility for inpatient psychiatric care.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1-2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 48575 Based on policy review, and medical record review the facility failed to ensure 1 (Patient 10) of 1 transfer consent form was complete with patient-specific risks and benefits by the physician and last vital signs. This failed practice has the potential to cause negative outcomes for any patients who require transfer to a higher level of care. According to facility provided data the ED transferred an average of 34 patients per month. See citation A2407 and A2049, that also resulted in A2400 to not be met. A. Review of facility policy, Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department (EMTALA), last approved 8/2024 revealed, “physician certification refers to the written certification signed by a physician prior to ordering the transfer of an individual with an EMC (Emergency medical condition), or if a physician is not physically present at the time of transfer, signed by a QMP (qualified medical professional) after consultation with a physician, who subsequently signs the certification. All Physician Certifications shall include a summary of the benefits and risks upon which the certification is based.” -The hospital will send to the receiving facility copies of all pertinent medical records available at the time of transfer, including......(8) a copy of the completed applicable sections of the “Transfer Consent.” B. Review of P10’s medical record revealed, P10 presented to the critical access hospital on 2/13/2025 at 9:28AM via car, walk-in, with a chief complaint of suicidal thoughts. The patient was accepted by a capable facility for transfer to a higher level of care. P10’s medical record lacked evidence of patient-specific risks and benefits on the physician certification transfer form. P10’s medical record transfer consent form lacked evidence of vitals prior to departure and time [blank].”