Bucktail Medical Center

“Establishment of the Emergency Program (EP) CFR(s): §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: 19375 Based on documentation review and interview, it was determined the facility failed to develop an emergency preparedness program, affecting the entire facility. Finding include 1. Review of documentation on December 15, 2025, between 11:20 a.m., and 11:40 a.m., revealed the facility failed to establish and maintain a comprehensive emergency preparedness program in accordance with 42 CFR 485.625 condition of participation to include the following standards: (a) Emergency Plan (b) Policies and Procedures (c) Communication Plan (d) Training and Testing (e) Emergency and Standby Power Systems Exit interview with the Director of Nursing and the Facilities Manager on December 15, 2025, between 11:45 a.m., and 11:50 a.m., confirmed the emergency preparedness deficiencies.”

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain building construction requirements in four locations, affecting one of one floor. Findings include: 1. Observation on December 15, 2025, between 10:33 a.m., and 11:03 a.m., revealed the following: a. 10:33 a.m., a residential-style air conditioning unit’s exhaust discharged into interstitial spaces within the IT Room, and the fire damper was located approximately eighteen inches above the exhaust opening within the ceiling. b. 10:40 a.m., the suspended ceiling portion of the rated ceiling assembly had been removed in Room 108. c. 10:42 a.m., the suspended ceiling portion of the rated ceiling assembly had been removed is Room 110. d. 11:01 a.m., the suspended ceiling portion of the rated ceiling assembly had been removed in Room 210. e. 11:03 a.m., rated ceiling tiles were missing/dislodged within Room 208. Exit interview with the Director of Nursing and the Facilities Manager on December 15, 2025, between 11:45 a.m., and 11:50 a.m., confirmed the building construction deficiencies.”

“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: 19375 Based on documentation review and interview, it was determined the facility failed to maintain cooking facilities in one instance, affecting one of one floor. Findings include: 1. Observation on December 15, 2025, at 11:22 a.m., revealed the facility lacked documentation to support one of two required semi-annual, kitchen exhaust hood duct cleanings. Exit interview with the Director of Nursing and the Facilities Manager on December 15, 2025, between 11:45 a.m., and 11:50 a.m., confirmed the cooking facilities deficiency.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to properly install automatic sprinkler heads in three locations, affecting one of one floor. Findings include: 1. Observation on December 15, 2025, between 10:40 a.m., and 11:10 a.m., revealed the following rooms lacked upright sprinkler head assemblies (ceilings removed): a. 10:40 a.m., Room 108. b. 10:41 a.m., Room 110. c. 11:08 a.m., Room 210 Exit interview with the Director of Nursing and the Facilities Manager on December 15, 2025, between 11:45 a.m., and 11:50 a.m., confirmed the automatic sprinkler system deficiencies.”

“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: 19375 Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in two locations, affecting one of one floor. Findings include: 1. Observation on December 15, 2025, between 10:12 a.m., and 10:22 a.m., revealed the following: a. 10:12 a.m., a missing escutcheon plate, located within the Break Room. b. 10:22 a.m., storage items located within eighteen inches of an adjacent sprinkler head assembly, located within the Team Leader’s Office. Exit interview with the Director of Nursing and the Facilities Manager on December 15, 2025, between 11:45 a.m., and 11:50 a.m., confirmed the automatic sprinkler system deficiencies.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain corridor openings in three locations, affecting one of one floor. Findings include: 1. Observation on December 15, 2025, between 10:13 a.m., and 10:28 a.m., revealed the following: a. 10:13 a.m., the Dietary door required adjustment to fully latch. b. 10:15 a.m., the ER door required adjustment to fully latch. c. 11:28 a.m., the Patient Room 108 door was not smoke-tight. Exit interview with the Director of Nursing and the Facilities Manager on December 15, 2025, between 11:45 a.m., and 11:50 a.m., confirmed the corridor opening deficiencies.”

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 32337 Based on review of facility documents and staff interview (EMP), it was determined that the facility failed to ensure the emergency preparedness plan was updated every two years and the facility failed to ensure policies and procedures were revised as needed for five of five policies and procedures reviewed. Findings include: Review on December 11, 2025, of the “Bucktail Medical Center Policy and Procedure Issuing Department: Administration Category: General Subject: Departmental Policy Manuals and Changes,” last revised June 29, 2005 and last reviewed January 29, 2025, revealed “Policy: All departments are required to develop and maintain a policy and procedure manual specific to that department’s operations, which shall contain the information necessary to meet requirements of the Commonwealth of Pennsylvania and Department of Health. Procedure: 1. All manuals shall be revised as needed and reviewed on an annual basis with documented proof of review. ... 3. The facility recognizes as circumstances and situations change, our policies and procedures must reflect those changes. ...” Review on December 11, 2025, of the “Bucktail Medical Center Disaster Manual Telephone Chain of Command in the Event of Major Disasters,” last reviewed January 29, 2025, revealed “ ... Contact Person: ... Director of Nursing: OTH1 ... Registration: OTH2 ... Social Service: OTH3 ... Use this list and check off the staff that were called for the disaster ...”, “Bucktail Medical Center Disaster Manual Telephone Chain Of Command In The Event Of Major Disasters”, last revised February 2012 and last reviewed January 29, 2025, revealed “Contact Person ... 1. Administrator: OTH4 ... 2. Safety Director: OTH5 ... 3. Maintenance: OTH6 If not there... OTH7 ... 5. Director of Nursing: Acute OTH8 ... SNF OTH9 ... OTH10 ... 6. X-ray Tech On-Call: OTH11 ... 7. Laboratory Tech On-Call: OTH12 ... 8. Registration: OTH13 ... 9. Purchasing: OTH14 ... 10. Pharmacy: OTH15 ...11. Social Services: OTH16 ... 12. Housekeeping/Diet: OTH17 ... OTH18 ... Use this list and check off as people are called in for a disaster. ... Bucktail Medical Center ... Function ... Personnel Responsible,” last revised February 2025, revealed “... Staff and Conduct Blood Bank: OTH19 ... Patient/Family Liaison: OTH3 Progress Reports: OTH20 ... Prepare Food: OTH21 ...” Interview with EMP3 on December 11, 2025, at 1600 verified the findings noted above. EMP3 confirmed OTH1, OTH2, OTH3, OTH4, OTH5, OTH6, OCT7, OTH8, OTH9, OTH10, OTH11, OTH12, OTH13, OTH14, OTH15, OTH16, OTH17, OTH18, OTH19, OTH20 and OTH21 are no longer employeed at the facility. EMP3 confirmed the disaster phone chain of command and function personnel responsible did not contain the correct responsible staff names. Interview with EMP2 on December 11, 2025, at 1610 verified the findings noted above. EMP2 confirmed OTH4, OTH5, OTH6, OTH11, OTH12, OTH15, OTH16, and OTH17 left several years ago, OTH7, OTH8 and OTH21 left in 2022, OTH13 and OTH20 left in 2023, OTH2 left June 2024, OTH1 and OTH18 left April 2025, OTH9, OTH10, and OTH19 left May 2025, OTH3 left August 2025, and OTH14 left October 2025. EMP2 confirmed the Contact list was not current. Review on December 9, 2025, of the “Bucktail Medical Center Disaster Preparedness and Emergency Response Plan,” revealed the last update was July 30, 2019. Interview with EMP1 on December 9, 2025, at 1215 confirmed the facility did not update the Emergency Preparedness Plan in the past two years. A request was made of EMP1 on December 9, 2025, for a policy specific to the update of the Emergency Preparedness Plan. None was provided. Interview with EMP1 on December 9, 2025, at 1215 revealed the facility does not have a policy specific to the update of the Emergency Preparedness Plan.”

“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: 32337 Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to label an opened multi-dose vial and failed to remove and dispose of 26 expired medication tablets per facility policy. Review on December 9, 2025, of the facility policy, “Ampules and Multi-Dose Vials”, last reviewed, January 29, 2025, revealed “Policy: It is the policy of the Bucktail Medical Center patients will not receive medication that is not dated, mislabeled, or otherwise unusable. Procedure ... 2. The date opened and the initials of the first person to use a multi-dose vial are recorded on the vial ... “ Observation of the Emergency Department on December 9, 2025, at 1000 with EMP3 revealed a locked cabinet with a multi-dose vial of Lidocaine 1% (local anesthetic) that had been opened and did not have an intact sealed cap. The vial did not contain the date it was opened or the initials of the person who opened the vial. Interview with EMP3 on December 9, 2025, at approximately 1005 confirmed this vial had been opened and should have been labeled with the date it was opened and the initials of the person who opened the vial. Review on December 9, 2025, of the facility policy, “Outdated Drugs, Devices and Supplies”, last reviewed, January 29, 2025, revealed “Policy: Nursing staff will have a method of meeting the responsibility and achieving the goal of identifying and disposing outdated, visibly deteriorated, recalled, discontinued, of [sic] obsolete drugs and supplies. Procedure ...3. Any drug of [sic] supply which is outdated ...will be disposed of according to policy.” Observation of the Pharmacy on December 9, 2025, at 1015 with EMP3 revealed a medication drawer with stock medications. This drawer contained the medication, Metoprolol 50mg tablet. There was a total of 26 Metoprolol tablets with an expiration date of November 25, 2025. Interview with EMP3 on December 9, 2025, at approximately 1015 confirmed the above findings. EMP3 confirmed these tablets were expired and should have been removed from the stock medication drawer.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for:] (ii) All documentation, written or electronic, of the infection prevention and control program and its surveillance, prevention, and control activities. This Standard is not met as evidenced by: 32337 Based on review of facility documents and staff interview (EMP), it was determined that the facility failed to ensure documentation of all attendees at the Infection Control Committee meeting for two of three meetings, and documentation of all attendees at the Pharmacy & Therapeutic Committee meetings for three (3) out of four (4) meetings. Findings include: Review on December 11, 2025 of the Pharmacy & Therapeutic Committee meeting minutes for September 25, 2024, January 24, 2024, and July 30, 2025, and the Infection Control Committee meeting minutes for July 20, 2025 and October 1, 2025, revealed there was no signature of a Pharmacy representative. Interview with EMP2 on December 11, 2025, at 1315, confirmed the findings noted above. EMP2 revealed a pharmacist may attend the meetings onsite or via phone. EMP2 revealed OTH22 was not on the attendee list for the Pharmacy & Therapeutic Committee and the Infection Control Committee meetings.”

“ORGAN, TISSUE, & EYE PROCUREMENT CFR(s): §485.643(a) Incorporate an agreement with an OPO designated under part 486 of this chapter, under which it must notify, in a timely manner, the OPO or a third party designated by the OPO of individuals whose death is imminent or who have died in the CAH. The OPO determines medical suitability for organ donation and, in the absence of alternative arrangements by the CAH, the OPO determines medical suitability for tissue and eye donation, using the definition of potential tissue and eye donor and the notification protocol developed in consultation with the tissue and eye banks identified by the CAH for this purpose; This Standard is not met as evidenced by: 32337 Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure the Gift of Life monthly report was reconciled with the facility death list for two of eight deaths (MR16 and MR17). Findings include: Review on December 11, 2025 of the facility policy, “Organ and/or Tissue Donation”, last reviewed January 29, 2025, revealed “Policy: In accordance with Pennsylvania’s Uniform Anatomic Gift Act as amended December 1994 (PA Act 102), all acute hospitals are required to develop policies and procedures to ensure the routine referral of all deaths or pending deaths to their regional Organ Procurement Organization (OPO) for the determination of medical suitability for organ tissue and eye donations with attending physician or his/her designee. ...” Review on December 11, 2025 of the “Death Summary Report from December 1, 2024 to February 28, 2025,” revealed MR17 expired on February 24, 2025. Review on December 11, 2025, of “Donation & Referral Activity Report for Bucktail Medical Center February 1, 2025 - February 28, 2025,” revealed MR 16 expired on February 7, 2025. Interview with EMP3 on December 11, 2025, at 1115 confirmed the findings noted above. EMP3 revealed the facility death summary report from December 1, 2024 to February 28, 2025, was missing documentation of MR16 death on February 7, 2025. EMP3 revealed the Donation & Referral Activity Report dated February 1, 2025 - February 28, 2025, was missing documentation MR17 death on February 25, 2025. EMP3 confirmed these reports are to be reconciled monthly when the facility receives their OPO report.”