Onecore Health

“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: 12713 Based on record review and interview, the facility failed to maintain and test a complete automatic sprinkler system. Findings: On 01/14/26 at 1:45 p.m. the facility sprinkler records were reviewed. The facility could not supply any completed quarterly sprinkler inspections for the year 2025. Last annual inspection was 06/18/25. 2. The maintenance supervisor was present during the record review on 01/14/26 and stated he was not aware that quarterly sprinkler inspections had not been done.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 12713 Based on observation and interview, the facility failed to maintain 1 of 2 smoke barrier walls to resist the passage of smoke. Findings: On 01/14/26 at 12:45 p.m. the smoke barrier wall by the pain management wing had unsealed penetrations, associated with blue computer wires that were observed above the smoke doors in the attic. 2. The maintenance supervisor and Director of corporate procurement were present when the smoke walls were observed and they acknowledged the unsealed penetrations to the smoke wall.”

“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: 12713 Based on observations and interview, the facility failed to maintain smoke barrier doors on 1 of 2 halls to close properly to resist the passage of smoke. Findings: The smoke doors, located on the inpatient unit had a gap between the doors that would not resist the passage of smoke. 2. The maintenance supervisor and Director of corporate procurement were present acknowledged the smoke doors having a gap between the doors.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 41506 Based on record review and interview the hospital failed to ensure that nursing services were provided in accordance with hospital policy, as evidenced by failing to annually evaluate the skills competency of staff in 2024 and 2025 to reassess their skills competency levels in 7 (Staff A, C, F, H, L, M, N) of 10 staff employee files reviewed. Findings: A review of employee files for Staff A, C, F, H, L, M, N on 10/02/25 at 1:30 p.m. with Staff D and K, revealed no documented evidence of an annual skills competency for these employees in 2024 and 2025 to reassess that the staff had the appropriate qualifications/skills for the tasks they were required to perform. A review of the hospital policy titled “Orientation of Personnel,” revised on 04/2024, read in part, “Initial orientation and training will be ... completed within 30 days of commencement of employment and be provided annually thereafter and when there is an identified need.” On 10/02/25 at 2:30 p.m. Staff K stated the education department was responsible for assuring staff skills competencies were completed by the various department heads and then submitted to the education department for placement in the employee’s files. Staff K stated there was no documented record of a skills competency in the education employee files for Staff A, C, F, H, L, M, and N for 2024 and 2025.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 41506 Based on observation and interview, the hospital failed to ensure 2 of 2 Medical Record file rooms containing original medical records were stored in a manner to protect the medical records from water damage. Findings: On 10/02/25 at 10:00 a.m. an observation of the Medical Record file room #1 showed the file room had original medical records stored on 18 open cabinet shelves with approximately 50 medical records on each shelf. An observation of the Medical Record file room #2 showed the file room had original medical records stored in 50 cardboard boxes with approximately 30 medical records in each box. Further observation of the Medical Record file rooms showed that both Medical Record file rooms had a ceiling sprinkler system in place. Medical Record file room #1 and Medical Record file room #2 showed no evidence of a protective covering or a closed system cabinet in place to protect the medical records from water damage in the event the sprinkler system was activated in a fire. On 10/02/25 at 10:15 a.m. Staff J stated that both Medical Record file rooms stored original patient medical records, as the hospital did not have a scanning system in place. They stated there were over 3000 original medical records stored in the 2 (two) file rooms. Staff J stated that both Medical Record file rooms were fully sprinkled and stated there was no protection in place to protect the medical records from water damage in the event the sprinkler system was activated in a fire. They stated the medical record policy did not address how original medical records would be protected from (water, fire) damage and Staff J stated they were unaware that original medical records had to be protected from (water, fire) damage.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 41506 Based on observation, record review, and interview, the hospital failed to ensure medications/supplies were maintained according to acceptable pharmacy standards of practice as evidenced by expired medications/supplies and/or opened MDV or opened single dose vials being available for other patient use in 2 of 2 immediate patient treatment areas. Findings: An observation on 10/01/25 at 11:15 a.m. in OR #2’s anesthesia cart revealed the following opened MDV and/or opened single dose vials still available for other patient use: Labetalol 20 ml MDV Lidocaine 2% 20 ml x2 MDV Rocuronium 5 ml MDV Marcaine 0.25% single dose vial Marcaine 0.50% single dose vial An observation on 10/01/25 at 2:00 p.m. in the ER triage room revealed the following expired medications still available for other patient use: Hibiclens prep solution 4 fluid ounces x2 expired on 07/2025. Hibiclens prep solution 0.5 fluid ounces x1 expired on 06/2025. A review of the hospital policies titled “Multiple Dose Vials” and “Outdated Medications Procedure,” both policies revised on 04/2024, read in part, “Immediate patient treatment area examples are patient rooms, or bays, and operating/procedure rooms ... If a multiple dose vial enters the immediate patient treatment area, it should be dedicated to that patient only and discarded after use ... Single dose vials should not be used for more than one patient and should be discarded after use ...The Drug Room supervisor and/or designee will inspect all medication storage areas and remove all expired medications.” On 10/01/25 at 11:25 a.m. Staff G stated that since the anesthesia cart was locked that the opened MDVs were still able to be used for another patient. Staff G had no comment regarding the opened single dose vials in the anesthesia cart. On 10/01/25 at 2:00 p.m. Staff I stated the ER triage room was checked for outdates 2 (two) months ago and the expired Hibiclens solutions were overlooked.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 41506 Based on observation, record review, and interview, the hospital failed to ensure a functional and sanitary environment, according to acceptable professional standards of infection control practice as evidenced by 2 of 2 clean supply/medication rooms with sterile supplies and medication preparation activities being located near a functional sink. Findings: An observation on 10/01/25 at 11:45 a.m. of the surgery medication drug room and an observation on 10/01/25 at 3:45 p.m. of the postoperative medication drug room, revealed a functional sink was located on the same counter within 3 (three) feet of medication preparation activities and where sterile supply bins were also located. A review of the CDC Guidelines for Infection Prevention and Safe Injection Practices, read in part, “Avoid preparing medications or storing clean/sterile supplies within a 3-foot splash zone to prevent contamination. ... For areas with limited space, such as near medication preparation areas or sterile supplies, a physical barrier like a splash guard should be used to keep supplies and medication preparation activities away from the sink and its splash zone ... A minimum of a 3-foot splash zone around sinks and other drains help prevent the spread of infections, defining this area as where contamination could occur ... install splash guards (or partitions) between the sink and adjacent medication preparation or supply areas if there is not a 3-foot space. A review of the CMS Hospital Infection Control Worksheet, read in part, “Medications should not be prepared near areas of splashing water (e.g. within 3 feet of a sink). Alternately when space is limited, a splash guard can be mounted beside the sink.” On 10/01/25 at 4:00 p.m. Staff C stated that both rooms used for medication preparation and storing sterile supplies were small and staff had to use the counter space next to the sink for medication preparation and for locating some of the bins that contained sterile items.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 41506 Based on observation, record review, and interview, the hospital failed to ensure the staff followed acceptable professional standards of practice governing surgical services as evidenced by: 1. failing to ensure staff processed surgical items according to acceptable sterilization guidelines and/or manufacturer’s IFU when processing and sterilizing surgical items in paper-plastic peel pouches in observations of 10 of 10 paper-plastic peel pouches that were not light weight or low profile when processed, and 2. failing to ensure staff discarded all unused items from the single-use sterile surgical packs used during patient procedures, as evidenced by 30 blue towels from the sterile surgical packs being stored in 1 (OR#2) of 2 ORs for other uses. Findings: 1. failing to ensure staff processed surgical items according to acceptable sterilization guidelines and/or manufacturer’s IFU when processing and sterilizing surgical items in paper-plastic peel pouches in observations of 10 of 10 paper-plastic peel pouches that were not light weight or low profile when processed, On 10/01/25 at 11:30 a.m., observations in the surgical sterile supply room revealed several sterile items processed in paper-plastic peel pouches that were not low profile with visible tenting and creasing of the sterile packages. Observations further revealed several sterile items processed in paper-plastic peel pouches that were not light weight with visible stress on the package’s sealed seams. A review of the AORN Guidelines for Perioperative Practice 2025 edition: Guidelines for Packaging Systems, read in part, “Use peel pouches (i.e., paper-plastic, polyethylene material, polyester film) according to a manufacturer IFU and/or according to AORN packaging guidelines ... Sterile items processed in peel pouches should be light weight and low profile to maintain the sterility of the package contents and not compromise the package or the seal integrity (caused by heavy items or tenting) ... Sterility is event-related and not time-related. The sterility of an item does not change with the passage of time, but may be affected by events such as, amount of handling, improper storage, and properties of the packing material.” On 10/01/25 at 11:40 a.m. Staff H stated they knew that items processed in paper-plastic peel pouches were supposed to be low profile and light weight. They further stated the hospital did not have a policy specific on paper-plastic peel pouch guideline requirements when packaging these items for sterilization or a policy stating the manufacturer’s IFU guidelines. 2. failing to ensure staff discarded all unused items from the single-use sterile surgical packs used during patient procedures, as evidenced by 30 blue towels from the sterile surgical packs being stored in 1 (OR #2) of 2 ORs for other uses. An observation on 10/01/25 at 11:15 a.m. revealed over 30 blue surgical towels from the single-use sterile surgical packs were being stored in OR #2. A review of the label on the sterile surgical packs used by the hospital revealed that the contents of the pack were single use only. A review of the AORN Guidelines for Perioperative Practice 2025: Guidelines for Sterile Technique, read in part, “All sterile items or supplies once opened onto a sterile field during patient procedures are considered contaminated and should be discarded after the procedure.” On 10/01/25 at 11:15 a.m. Staff F stated staff saved the unused blue surgical towels from the (single-use) sterile surgical packs that were opened for patient procedures instead of discarding them and stored them in the ORs. Staff F stated staff used the towels for other non-patient uses and physicians would sometimes take the towels home. On 10/01/25 at 11:45 a.m. Staff C and F stated the hospital followed the AORN Perioperative Nursing Scope and Standards of Practice: Guidelines for Perioperative Practice.”

“CARE OF PATIENTS - MD/DO ON CALL CFR(s): 482.12(c)(3) [ ...the governing body must ensure that the following requirements are met:] A doctor of medicine or osteopathy is on duty or on call at all times. This Standard is not met as evidenced by: 50779 Based on record review and interview, the hospital failed to ensure enforcement of policy for on call physician facility arrival for four (Patients #9, #10, #13, and #18) of 15 patients reviewed. Findings: Review of policy #4.322 titled “Provider coverage in the ER.” read in part, “The provider should be physically present at the hospital within 20 minutes after being called in.” A review of the Emergency Department log showed the following. Patient #9: On 08/13/23, the nurse called the provider at 11:30 a.m. and the provider arrived at 12:00 p.m., (10 minutes late) Patient #10 On 09/14/23 the nurse called the provider at 12:30 p.m. and the provider arrived at 1:00 p.m. (10 minutes late) Patient #13 On 11/03/23 the nurse called the provider at 11:20 a.m. and the provider arrived at 11:50 a.m. (10 minutes late) Patient #18 On 12/21/23 the nurse called the provider at 11:15 a.m. and the provider arrived at 12:40 p.m. (85 minutes late) On 01/03/25 at 1:00 p.m. Staff F stated: 1. The physician rules and regulations gave the provider 20 minutes to arrive at the facility once they were called. 2. We have had some difficulty with certain providers arriving at the facility in the alotted time and I have discussed it with them. 3. This has not been brought up in Governing Body or the Medical Executive committee but it will be moving forward.”

“CONTENT OF RECORD: HISTORY & PHYSICAL CFR(s): 482.24(c)(4)(i)(A) All records must document the following, as appropriate: (i) Evidence of-- (A) A medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(4)(i)(C) of this section. The medical history and physical examination must be placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 50779 Based on record review and interview, the hospital failed to ensure timely completion of the medical history and physical for two ( Patient # 2 and # 5 ) of five patients reviewed. Findings: A review of policy # 4.5 titled “History and Physical” read in part, “Patients having outpatient procedures must have a History and Physical that has been completed within 30 days of admission, an update note must be documented within 24 hours of the procedure by the physician.” Patient # 2 A review of medical records showed an admission date of 09/11/24 and did not show a History & Physical was completed. ( 114 days past due ). Patient # 5 A review of medical records showed an admission date of 11/05/24 and showed a History & Physical was completed on 11/08/24 ( three days past due ). On 01/03/25 at 8:15 a.m. Staff O stated: History & Physicals are to be signed within 24 hours of the procedure or admission.”