Crete Area Medical Center

“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. Crete Area Medical Center is a one story Type II (000) fully sprinkled, with smoke detection in the corridor. The Hospital has a two hour fire rated separation between the attached Health Clinic and the hospital. Crete Area Medical Center 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 Hospital and the Clinic. This deficient practice would allow smoke, fire and gases to migrate from one occupancy into the other. The facility has the capacity for 24 beds with a census of 6 on the day of survey. Findings are: Observation on 4-14-26 at 9:35 am revealed the 1 1/2-hour fire rated door leading into Clinic D failed to latch within in the doorframe. During an interview on 4-14-26 at 9:35 am, Staff A confirmed the fire rated door failed to latch within the frame.”

“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: 13879 Based on observation and interview, the facility allowed exits to be obstructed. This deficient practice would delay egress in the case of fire or another emergency. The facility has the capacity for 24 beds with a census of 6 on the day of survey. Findings are: Observation on 4-14-26 at 10:24 am revealed, a hand sanitizer pole obstructing the exterior exit in the lobby area. During an interview on 4-14-26 at 10:24 am, Staff A confirmed the hand sanitizer pole obstructing the exit. NFPA Standard: 2012 NFPA 101, 19.2.1 Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. 2012 NFPA 101, 7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.”

“Protection - Other CFR(s): NFPA 101 Protection - Other List in the REMARKS section any LSC Section 18.3 and 19.3 Protection requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to minimize the possibility of a fire in the facility by not ensuring that Kitchen staff were trained to extinguish a fire under the exhaust hood. This deficient practice would increase the potential for larger fires to spread. The facility has the capacity for 24 beds with a census of 6 on the day of survey. Findings are: Observations on 4-14-26 at 12:27 pm revealed, Kitchen Staff A failed to know the procedure to extinguish a fire under the hood suppression system or the use of a Class K fire extinguisher. During an interview on 4-14-26 at 12:27 pm, Staff A confirmed that Kitchen Staff failed to be familiar with the procedure for manual activation of the hood suppression system or which fire extinguisher to use.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to provide self-closing devices on the door for hazardous areas to separate them from the rest of the facility. This deficient practice would allow fire, smoke, and gases to migrate into the exit corridor. The facility has the capacity for 24 beds with a census of 6 on the day of survey. Findings are: Observation on 4-14-26 at 10:24 am revealed, the storage room door near CNO office failed to provide a self-closing device. During an interview on 4-14-26 at 10:24 am, Staff A confirmed the findings.”

“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 observation and interview, the facility failed to assure wheeled cooking appliance under the hood provided gas line restraint and failed to provide hood surface and filter cleaning reports. This deficient practice increases the potential for a fire. The facility has the capacity for 24 beds with a census of 6 on the day of survey. Findings are: Observation on 4-14-26 at 12:53 pm revealed: 1. The wheeled stove/oven under the hood failed to provide a gas line restraint. 2. No cleaning schedule was provided for the surface and filters. During an interview on 4-14-26 at 12:53 pm, Staff A confirmed the lack of gas line restraint and the lack of a cleaning schedule for the kitchen hood.”

“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 obstructed. This deficient practice increased the potential of delayed sprinkler activation resulting in a larger fire that could spread outside of the room of origin. The facility has the capacity for 24 beds with a census of 6 on the day of survey. Findings are: Observation on 4-14-26 at 10:53 am and 12:21 pm revealed: 1. The sprinkler in the IT closet in the acute area was obstructed with cables. 2. The sprinkler in the kitchen walk in freezer was covered with foreign material. 3. The sprinkler in the kitchen walk in cooler was covered with foreign material. During an interview on 4-14-26 at 10:53 am and 12:21 pm, Staff A confirmed the foreign material and obstruction.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to assure portable fire extinguishers were not obstructed. This deficient practice would delay the extinguishment of a fire. The facility has the capacity for 24 beds with a census of 6 on the day of survey. Findings are: Observation on 4-14-26 at 9:38 am revealed, the fire extinguisher in the north-east corner of the Lab was obstructed. During an interview on 4-14-26 at 9:38 am, Staff A confirmed the obstructed fire extinguisher.”

“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 observation and interview, the facility failed to assure the smoke compartments doors would latch which would allow smoke, fire, and gases to migrate to other smoke compartments. The facility has the capacity for 24 beds with a census of 6 on the day of survey. Findings are: Observation on 4-14-26 at 10:15 am revealed, the north smoke door to the Acute Care area failed to close and latch within the doorframe. During an interview on 4-14-26 at 10:15 am, Staff A confirmed the door failed to latch, due to air flow.”

“Building Services - Other CFR(s): NFPA 101 Building Services - Other List in the REMARKS section any LSC Section 18.5 and 19.5 Building Services requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 13879 Based on documentation review and interview, the facility failed to maintain a cleaning schedule for dryer vent/duct. These deficient practices would increase the potential for a fire. The facility has the capacity for 24 beds with a census of 6 on the day of survey. Findings are: Documentation review on 4-14-26 at 11:39 am revealed: 1. No dryer vent/duct cleaning schedule/inspection report. During an interview on 4-14-26 at 11:39 am, Staff A confirmed the lack of inspection reports.”

“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: 13879 Based on documentation review and interview, the facility repeatedly failed to hold fire drills under varied conditions for all shifts reviewed. This deficient practice would not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels. The facility has the capacity for 24 beds with a census of 6 on the day of survey. Findings are: Fire drill documentation review on 4-14-26 at 1:14 pm revealed: 1. Third shift drills were discussions and not simulated drills. 2. Drills were not conducted in random locations. 3. Drills were not conducted at random times. During an interview on 4-14-26 at 1:14 pm, Staff A confirmed the fire drills were not random and were discussions.”

“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: 13879 Based on record review and interview, the facility failed to provide testing documentation for the line isolation monitor “LIM” in the Operating Room “OR” and Procedure Room. This deficient practice would create electrical injury and fire hazards. The facility has the capacity for 24 beds with a census of 6 on the day of survey. Findings are: Documentation review on 4-14-26 at 10:48 am revealed, the facility failed to provide documentation for testing of the LIM in OR and Procedure Room. During an interview on 4-14-26 at 10:48 am, Staff A confirmed the lack of documentation for LIM testing, and stated they were not aware of the requirement. NFPA Standard: 2012 NFPA 99, 6.3.3.3.2 The line isolation monitor (LIM) circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor whose value is 200 × V (ohms), where V equals measured line voltage. The visual and audible alarms (see 6.3.2.6.3.2) shall be activated. 6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. 6.3.4.1.5 After any repair or renovation to an electrical distribution system, the LIM circuit shall be tested in accordance with 6.3.3.3.2. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification. 6.3.2.6.3.6 A reliable test switch shall be mounted on the line isolation monitor to test its capability to operate (i.e., cause the alarms to operate and the meter to indicate in the “alarm on” zone). This switch shall transfer the grounding connection of the line isolation monitor from the reference grounding point to a test impedance arrangement connected across the isolated line; the test impedance(s) shall be of the appropriate magnitude to produce a meter reading corresponding to the rated total hazard current at the nominal line voltage, or to a lesser alarm hazard current if the line isolation monitor is so rated. The operation of this switch shall break the grounding connection of the line isolation monitor to the reference grounding point before transferring this grounding connector to the test impedance(s), so that making this test will not add to the hazard of a system in actual use; nor will the test include the effect of the line-to-ground stray”