Brookings Health System

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 50715 Based on observation, policy review, review of manufacturer’s instruction for use (IFU), and interview, the provider failed to ensure: *Three of three observed glucometers had been cleaned and disinfected properly prior to patient use. *Multiple surgical instruments wrapped with surgical tape were free of cracks, rips, tears, and discoloration. *Multiple surgical instruments had surgical tape wrapped around the instrument, applied flat, and without gaps per manufacturer’s IFU. *All contaminated instruments containing blood and bodily fluids from two of two tables in the operating room (OR) had been transported in a sealed, puncture resistant, leak proof container. *There was sufficient exhaust air flow for one of one soiled linen room attached to the laundry. Findings include: 1. Observation and interview on 3/4/25 at 10:40 a.m. with director nursing-women’s center A in the clean storage room in the OB (obstetrics) unit revealed: *One glucometer placed in a docking station revealed it had visible blood near the glucometer strip insertion site. *The docking station used to store the glucometer had visible dust and debris on it. *Glucometers placed in the docking station meant they had been cleaned, disinfected, and were ready for patient use. *She: -Confirmed there was visible blood on the glucometer and had not been cleaned properly prior to docking it in the station. -Confirmed the docking station had dust and debris and had not been a part of their cleaning process. *She had removed the bloody glucometer to disinfect it. Observation and interview on 3/4/25 at 1:10 p.m. with director of inpatient care B in the North medication room revealed: *A glucometer placed in a docking station had a brown substance near the glucometer strip insertion site. *The docking station used to store the glucometer had a thick layer of dust and debris on it. *Director of inpatient care B confirmed the above observations. Observation and interview on 3/4/25 at 1:20 p.m. with director of inpatient care B and registered nurse (RN) clinical care coordinator C in the South medication room revealed: *A glucometer placed in a docking station had visible blood near the glucometer strip insertion site and contained tape residue. *RN clinical care coordinator C verified the visible blood and tape residue and proceeded to clean the glucometer with a disinfectant wipe. *The docking station used to store the glucometer had a thick layer of dust and debris on it. *Director of inpatient care B and RN, clinical care coordinator C confirmed glucometers placed in the docking station meant they had been cleaned, disinfected, and were ready for patient use. *They confirmed the docking station had not been a part of their cleaning process. Interview on 3/4/25 at 3:00 p.m. with director of inpatient care B revealed: *Glucometer machines should have been cleaned with a disinfectant wipe between patients. *Staff should have inspected the glucometer prior to placing it in the docking station to ensure it was appropriately cleaned. Review of the provider’s 8/29/18 Nova StatStrip Glucometer’s policy revealed: *”The meter must be checked for cleanliness; cleaned when necessary before use and cleaned after each use. *Wipe the meter between patients with a disposable Super Sani-Cloth Germicidal agent or hospital based cleaner. Wipe the surface area of the test strip port making sure that no fluid enters the port.” Review of the 2024 StatStrip Glucose Meter instructions for use manual revealed: *”The StatStrip Glucose Hospital Meters should be cleaned and disinfected after each patient use to minimize the risk of transmission of blood-borne pathogens between patient and healthcare professionals. *1. Clean the Meter. -Remove a fresh germicidal wipe from the canister. -Wipe the external surface of the meter thoroughly with a fresh germicidal disinfecting bleach wipe. 2. Disinfect the Meter. -Using a new, fresh germicidal bleach wipe, thoroughly wipe the surface of the meter (top, bottom, left, and right sides) a minimum of 3 times horizontally followed by 3 times vertically avoiding the bar code scanner and electrical connector. -Gently wipe the surface area of the test strip port making sure that no fluid enters the port.” 2. Observation on 3/5/25 at 8:45 a.m. in the sterile core and clean supply area of the OR revealed: *A forcep contained within a sterilized surgical pack and ready for patient use had surgical tape residue and brown discoloration. *A tweezer contained within a surgical pack and ready for patient use had tape residue. *A hip retractor pan containing multiple surgical instruments revealed the surgical tape had: -Been placed flat on the instrument. -Not been wrapped 1.5 times around the instrument per the manufacturer’s IFU. -Not been laid flat without gaps. -Had cracks, tears, and discoloration. Observation and interview on 3/5/25 at 8:50 a.m. with director nursing-surgery D in OR #3 revealed: *A scissor contained within a surgical pack and ready for patient use had two pieces of surgical tape wrapped more than 1.5 times around and had not been laid flat without gaps per the manufacturer’s IFU. *She confirmed the above findings and would have the sterile processing department re-tape the instruments according to the manufacturer’s IFU. *She confirmed the hip retractor pan was not owned by the provider and was supplied per the surgeon’s preference. *She agreed instruments brought into the facility should have been taped according to the manufacturer’s IFU. Observation and interview on 3/5/25 at 1:30 p.m. with director nursing-surgery D and certified surgical technician (CST) E in the sterile processing revealed: *A counter containing multiple surgical instruments with surgical tape from various specialty clinics had been cleaned and needed to be inspected. *The surgical instrument’s contained tape that had been: -Lying flat on the instrument. -Not wrapped 1.5 times around. -Wrapped more than 1.5 times around. -Cracked, frayed, and were not lying flat without gaps. *CST E confirmed: -The specialty clinic staff were to tape their own instruments. -She was not sure if the clinic staff had been properly trained to tape surgical instruments according to the manufacturer’s IFU . -Instruments in the OR should not have contained surgical tape. *Director of nursing-surgery D and CST E agreed with the above findings and those issues created the potential of bacteria to remain on surgical instruments. Interview on 3/6/25 at 8:20 a.m. with clinic director H revealed: *The sterile processing department would have done the taping on the instruments for the specialty clinics. *Each specialty clinic was assigned a specific color of tape so when the instruments were sent for sterilization, the instruments are returned to the correct clinic. *Clinic staff had not been trained to properly tape surgical instruments. *Staff were educated to inspect the instruments prior to use which included identifying tape issues. Interview and observation on 3/6/25 at 8:30 a.m. with RN I in the general surgery clinic revealed: *In the procedure room, there was a cabinet containing packaged sterilized instruments ready for patient use. *Two packaged instruments that had been pulled randomly out of bins had not been taped according to manufacturer’s IFU. *She confirmed taping was done by the sterile processing department. Interview and observation on 3/6/25 at 8:40 a.m. with RN J and clinic director H in the podiatry clinic revealed: *In the procedure room, there were multiple surgical instruments that had been sterilized and packaged. *The surgical instrument’s contained tape that had been: -Lying flat on the instrument. -Not wrapped 1.5 times around. -Wrapped more than 1.5 times around. -Cracked, frayed, and were not lying flat without gaps. *RN J confirmed staff had not been trained to apply tape to surgical instruments according to the manufacturer’s IFU. *Clinic director H confirmed the above findings and would reach out to sterile processing to correct tape issues on the instruments. Review of the provider’s 8/17/2021 Care of Instruments in Non-Surgical Departments policy revealed: “Visually inspect the entire instrument, paying close attention to grooves, hinges, lumens textured surfaces, and taped areas.” Review of the provider’s 2/2021 Care of Instruments policy revealed: *”Loaner instruments are checked, cleaned, and sterilized before use.” *It did not mention caring for instruments that had been taped. Review of the manufacturer’s revised 2024 Key Surgical Identification Tape IFU revealed: *”Wrap tape 1.5 times on a stainless-steel instrument. Tape should lay flat without gaps. *Inspect tape prior to each use. Identification tape is not intended as a permanent mark and will discolor, break, chip, or flake over time. *Replace as soon as these are noticed.” 3. Observation and interview on 3/5/25 at 11:30 a.m. with CST F in OR #1 revealed: *Multiple surgical instruments including scissors, dilators, and clamps were on a long table with wheels. *Several contaminated instruments had not been placed in containers and were lying flat on a blue surgical towel on the table. *Two round containers with no lids were filled with water sitting on top of the table. *A large red drape containing a biohazard label was then draped over the entire table containing the contaminated instruments and container filled with water and was pushed from the OR into the OR corridor and then rolled to the decontamination room. *She confirmed: -The containers for transporting the used surgical instruments and water did not have lids. -Some instruments could have punctured the drape if they fell off the table. -The above process had been their practice for transporting contaminated instruments to the OR. Interview on 3/5/25 at 11:45 a.m. with CST E in the decontamination room revealed: *Surgical instruments used during the operation were placed into containers with no lids on them. *Some instruments may have been placed on the table in no containers. *Water was transported in containers with no lids. *The needles and sharp objects had been separated and discarded separately. *The red drape covering the instruments was not sealed, leak proof, or puncture resistant. *She confirmed instruments could have punctured or fell through the drape if they fell off the table. *She confirmed sealed, leak proof containers had not been used to transport contaminated surgical instruments. *The provider followed the Association of perioperative Registered Nurses (AORN) to guide their practice. Observation on 3/5/25 at 2:30 p.m. with CST F from OR #2 to the decontamination room revealed: *Several laparoscopic instruments with sharp scissors on the end had been placed in containers with no lids on a long table with wheels. *A large red drape containing a biohazard label was draped over the table and was pushed from the OR into the OR corridor and then rolled to the decontamination room. *The laparoscopic instruments could have punctured or fell through the drape. *The red drape covering the instruments was not sealed, leak proof, or puncture resistant. Observation and interview on 3/5/25 at 2:40 p.m. with CST G from OR #2 to the decontamination room revealed: *A large red drape containing a biohazard label had been draped over a table with wheels containing contaminated instruments, disposable sharps, and containers filled with water, and it was pushed from the OR into the OR corridor and then rolled to decontamination room. *Multiple surgical instruments including clamps, scissors, and disposable sharps (needles, scalpels) were lying on top of the table. *One round container with no lid had been filled with water and placed on the table. *The instruments and disposable sharps had not been placed in sealed, leak proof, puncture resistant containers. *She confirmed disposable sharps were transported to the decontamination room because the larger biohazard bins were stored there for staff to dispose of them properly. *She confirmed their process had always been to transport contaminated instruments and water without lids or containers. *She confirmed instruments, and disposable sharps could have punctured or fell through the drape if they fell off the table. Interview on 3/5/25 at 3:20 p.m. with director nursing-surgery D revealed she: *Confirmed contaminated surgical instruments and containers filled with water had not been transported in sealed, leak proof, and puncture resistant containers. *Agreed sharp instruments could have punctured through the red drape and potentially exposed staff to blood-borne pathogens. *Agreed AORN had recommended this practice, and she had been unsure of when this regulation changed. *Confirmed their process had not followed AORN guidelines. 4. Interview on 3/6/25 at 9:25 a.m. with infection preventionist K revealed: *Staff were educated yearly on cleaning of glucometers by clinical coordinator staff and during a skills fair. *Staff were to clean glucometers at the point of use with an alcohol pad and a disinfectant wipe. *Audits were conducted at random during surveillance rounds to ensure compliance with the cleaning process. *She agreed blood left on glucometer machines after having been disinfected put staff and patients at risk for blood-borne pathogens. *She stated, “Our SOP {standards of practice} states not to use tape on instruments. I swear we have always had a no tape instrument SOP.” -She confirmed the provider did not have that stated in their policy. *If tape was used on instruments, she would have expected staff to follow the manufacturer’s IFU. *Contaminated surgical instruments were to be placed in an enclosed, rigid tote, labeled biohazard during transportation. *She had thought that was how surgery staff had been transporting contaminated instruments and sharps. Review of the provider’s 2/2021 Care of Instruments policy revealed: *”Contaminated instruments: -Contain during transport in a timely manner, transport to decontamination as soon as possible.” The provider’s policy had not specified to transport contaminated instruments in an enclosed, leak proof, puncture resistant container, labeled biohazard. Review of AORN’s 2024 Guidelines for Perioperative Practice: Transport to the Decontamination Area pg. 415 revealed: *”7.2. Contaminated instruments must be transported to the decontamination area in a closed container or enclosed transport cart that is: -leak proof, -puncture resistant, -large enough to contain all contents, and -labeled with a fluorescent orange or orange-red label contained a biohazard legend.” 25107 5. Observation on 3/5/25 at 9:00 a.m. revealed when the door between the corridor and the soiled linen room attached to the laundry was opened, air from inside the soiled linen room rushed out into the corridor. Observation and interview on 3/5/25 at 9:30 a.m. with environmental services director M regarding the airflow between the soiled linen room and the corridor revealed: *He confirmed the air was coming out of the soiled linen room and into the corridor. *He was not aware the soiled linen room was positively pressured in relation to the corridor. *He agreed the soiled linen room should have been negatively pressured in relation to the corridor. Interview on 3/5/25 at 9:40 with the laundry supervisor O revealed: *She had noticed the air coming out of the soiled linen room and into the corridor about 4 months ago. *She had not told maintenance staff of the issue. Interview on 3/6/25 at 8:30 a.m. with maintenance supervisor N revealed: *He was not aware the soiled linen room was positively pressured in relation to the corridor. *Maintenance staff went on the roof and maintained the exhaust vent for the soiled linen room quarterly. Maintenance staff would ensure it was working. *Maintenance staff never checked to make sure the exhaust airflow from the soiled linen room was sufficient to maintain a negative pressure in the room in relation to the corridor. *He agreed the soiled linen room should have been negatively pressured in relation to the corridor.”

“MEDICAL STAFF RESPONSIBILITIES - H&P CFR(s): 482.22(c)(5)(i) [ The bylaws must:] Include a requirement that-- (i) A medical history and physical examination be completed and documented for each patient 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)(5)(iii) of this section. The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oral and maxillofacial surgeon, or other qualified individual in accordance with State law and hospital policy. This Standard is not met as evidenced by: 18559 48106 Based on record review, medical staff bylaws review, and interviews, the provider failed to ensure a presurgical history and physical (H&P) had been performed within thirty days prior to surgery for one of two sampled patients (36) who had a colonoscopy. Findings include: 1. Review of the patient 36’s record revealed: *He had been admitted on 12/2/24 for a colonoscopy. *The colonoscopy was performed by Surgeon Q. *His H&P performed on 1/11/24. *There was a date of 12/2/24 with some writing and a signature at the end of the H&P. * The signature at the end of the H&P was ineligible and not timed to support when it had been reviewed. Review of the provider’s 12/18/24 Bylaws of the Medial Staff revealed on page 22, “A complete admission history and physical examination or equivalent medical consultation shall be performed and recorded no more than 30 (thirty) days prior to admission or within 24 (twenty-four) hours after admission. The medical history and physical examination must be placed in the medical record within twenty-four (24) hours after admission. This report should include all pertinent findings resulting from an assessment of all the systems of the body. An updated examination of the patient must be documented in the chart by the attending physician or surgeon, to include any changes in the patient ‘s condition if the History & Physical exam is completed within 30 days before admission.” Interview on 3/6/25 at 10:20 a.m. with Director of Nursing-Surgery D revealed: *Surgeon Q would have signed the patient’s H&P that was older than two months if the patient was healthy. *She agreed that the surgeon’s documentation on the patients 36’s H&P that was used was illegible, with no time documented of when the H&P was reviewed. Interview on 3/6/25 at 11:26 a.m. with Chief Nursing Officer L revealed she: *Confirmed that their policy was to have a H&P performed within 30 days of a patient’s surgical procedure. *Agreed that the facility was not meeting the Bylaws of the Medical Staff.”

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 25107 Based on observation and interview, the provider failed to maintain: *The cleanliness of the walk-in-cooler fan guards and cooling fins in the kitchen. *The cleanliness of the walk-in-freezer fan guards, cooling fins, floor, and ceiling in the kitrchen. *The cleanliness of the top of the convection oven in the kitchen. *The smooth and easily cleanable surface of the floor in front of the convection oven in the kitchen. *The smooth and easily cleanable surface of three of three observed chopper/scraper handles in the kitchen . *The cleanliness of the walls behind the three-compartment sink in the kitchen. *The cleanliness of the walls east of the grill in the cafeteria area. *The cleanliness of the door seals and bottom of the reach-in-freezer west of the grill in the cafeteria area. *The cleanliness of the door seals for the reach-in- cooler in the cafeteria area. Findings include: 1. Observation and interview on 3/5/25 at 3:00 p.m. with dietary manager P of the walk-in cooler in the kitchen revealed: *The fan guards on the front of the cooling unit were covered with a moderate amount of a grey fuzzy residue. *The cooling fins on the back of the cooling unit were completely covered with a grey fuzzy residue. *The fire sprinkler head for the walk-in cooler was also covered with a grey fuzzy residue. *She had not noticed the grey fuzzy residue in those areas. 2. Observation and interview on 3/5/25 at 3:05 p.m. with dietary manager P in the walk-in freezer revealed: *There was a puddle of red ice on the floor where something had spilled. *There was about six inches thickness of frost building up in the southeast and southwest corners of the ceiling. *There was about ten inches of an icicle forming from the frost and starting to freeze on a box of food. *The fan guard on the front of the cooling unit had clumps of grey fuzzy residue on the bottom third of the fan guard. *She was not aware of the grey fuzzy residue in the fan grates. *She was aware of the frost and ice on the floor. *She had not found a good time yet to take the walk-in freezer out of service to defrost and clean it. 3. Observation and interview on 3/5/25 at 3:15 p.m. with dietary manager P at the convection oven in the kitchen. *There was a layer of food crumbs and grease residue approximately a sixteenth of an inch deep across the top of the convection oven. *She was not aware of the buildup of residue on top of the convection oven. 4. Observation and interview on 3/5/25 at 3:17 p.m. with dietary manager P of the floor in front of the convection oven revealed: *There were five (four inch by four inch) tiles missing from the floor. *Where the tiles were missing was a black layer of what appeared to be thinset mortar approximately one quarter of an inch thick. *There were pieces of the black layer missing in two areas. One was about four inches by four inches. The other about two inches by two inches. Where the black layer was missing you could see another tile floor. *The missing tiles and missing black layer created an uneven surface that was not easy to clean. *There was a grey, brown residue around the edges where there was a level change. *The floor was damaged before she started working there in October of 2024. *She was not aware if the previous dietary manager had submitted any work orders to have the floor repaired. *She had not put in any work orders to have the floor repaired. *She agreed it should have been repaired. 5. Observation and interview on 3/5/25 at 3:20 p.m. with dietary manager P regarding three of three observed chopper/scrapers revealed: *Each chopper/scrapper had melted plastic handles. The plastic was not smooth and easily cleanable where the plastic was melted. One had a crack in the plastic down to the blade. *She agreed those handles were no longer cleanable. 6. Observation and interview on 3/5/25 at 3:30 p.m. with dietary manager P regarding the wall behind the three-compartment sink revealed: *There were multiple small spots of dried food stuck to the wall. *It was unknown when the last time the wall had been cleaned. *That wall was not on a cleaning schedule. 7. Observation and interview on 3/5/25 at 3:35 p.m. with dietary manager P regarding the wall in the cafeteria east of the grill revealed: *The wall had a yellowish sticky residue covering it. There was a slight grey fuzzy residue over the yellow sticky residue. *It was unknown when the last time the wall had been cleaned. *That wall was not on a cleaning schedule. 8. Observation and interview on 3/5/25 at 3:40 p.m. with dietary manager P regarding the reach-in-freezer west of the grill in the cafeteria area revealed: *The inside bottom of the freezer had a moderate of brown breadcrumbs and shredded cheese covering it. *The door seal also had brown breadcrumbs and shredded cheese filling the grooves. *It was unknown when the last time the freezer had been cleaned. *That freezer was not on a cleaning schedule. 9. Observation and interview on 3/5/25 at 3:45 p.m. with dietary manager P regarding the reach-in-cooler in the cafeteria area revealed: *There was a moderate amount of shredded cheese and breadcrumbs in the grooves of the door seal. *It was unknown when the last time the reach-in-cooler had been cleaned. *That reach-in-cooler was not on a cleaning schedule. 10. Interview on 3/5/25 at 4:00 p.m. with dietary manager P regarding the items listed above revealed: *She had been dietary manager since October of 2024. *She agreed the items found should have been cleaned and were not on a cleaning schedule. *She agreed she should have contacted maintenance regarding the floor and frost build up in the walk-in-freezer.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 18087 Based on record review and interview, the provider failed to conduct a large-scale exercise for emergency preparedness in 2023 or 2024. Findings include: 1. Record review on 3/5/25 at 9:15 a.m. revealed no documentation that indicated a large-scale exercise was conducted to test the provider’s emergency plan in 2023 or 2024. Records indicated a large-scale exercise had last been performed in 2019. Interview with the environmental services director and maintenance supervisor on 3/5/25 at 11:30 a.m. confirmed that finding.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 18087 Based on observation and interview, the provider failed to provide egress doors as required at three randomly observed EXIT door locations (the corridor at Inpatient Care to OB). Findings include: 1. Observation beginning on 3/4/25 at 2:00 p.m. revealed the corridor between Inpatient Care to OB had three sets of cross-corridor doors. All three sets of doors were equipped with magnet locks and were identified with EXIT signs. The doors also had an extra sign approximately three inches tall and eight inches wide affixed to the doors stating “NOT AN EXIT”. EXIT doors may not be labeled as non-EXITs. It was not determined at the time of the survey how each magnetically locked door functioned (card-swipe, delayed-egress, or access-controlled). Interview at the time of the observation with the maintenance supervisor confirmed that condition. Failure to provide egress doors as required increases the risk of death or injury due to fire. The deficiency affected 100% of the smoke compartment occupants.”

“Aisle, Corridor, or Ramp Width CFR(s): NFPA 101 Aisle, Corridor or Ramp Width 2012 EXISTING The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5. 19.2.3.4, 19.2.3.5 This Standard is not met as evidenced by: 18087 Based on observation and interview, the provider failed to maintain the required exit corridor width at one location (therapy wing exit). Findings include: 1. Observation on 3/4/25 at 9:50 a.m. revealed the therapy wing on the ground floor was eight feet wide and had approximately six chairs in the corridor along the wall on one side. The chairs were not affixed in place. The chairs could be easily moved to obstruct the path of egress to the exterior EXIT. Interview with the maintenance supervisor at the time of the observation confirmed that finding. He stated he was unaware the chairs needed to be affixed in place. The deficiency has the potential to affect egress exit ability for all occupants of that smoke compartment.”

“Dead-End Corridors and Common Path of Travel CFR(s): NFPA 101 Dead-End Corridors and Common Path of Travel 2012 EXISTING Dead-end corridors shall not exceed 30 feet. Existing dead-end corridors greater than 30 feet shall be permitted to be continued to be used if it is impractical and unfeasible to alter them. 19.2.5.2 This Standard is not met as evidenced by: 18087 Based on observation, testing, and interview, the provider failed to maintain corridors without dead-ends greater than 30 feet in length for one randomly observed corridor (ER Entrance south side). Findings include: 1. Observation on 3/4/25 at 2:20 p.m. revealed the corridor to the ER entrance on the south side from two sets of cross-corridor doors was over 100 feet in length and did not have a second path of egress. The two sets of cross-corridor doors (each for different corridors) were key-card access only and were not marked as Exits. Interview with the maintenance supervisor at the time of the observation confirmed that condition. The deficiency had the potential to affect 100% of the smoke compartment occupants.”

“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: 18087 Based on observation and interview, the provider failed to maintain one randomly observed hazardous area (kitchen pantry storage room) as required. Findings include: 1. Observation on 3/4/25 at 11:45 a.m. revealed the kitchen pantry storage room was over 100 square feet in area and contained combustible items (canned goods, cardboard boxes, plastic-wrapped items). The egress corridor door was not equipped with a closer. Interview with the maintenance supervisor at the time of the observation confirmed that finding. He stated it appeared the door had been equipped with a closer at one time but it had been removed (holes remained in the door). The deficiency affected one of numerous requirements for hazardous storage rooms and had the potential to affect 100% of the occupants of the smoke compartment.”

“HVAC - Any Heating Device CFR(s): NFPA 101 HVAC - Any Heating Device Any heating device, other than a central heating plant, is designed and installed so combustible materials cannot be ignited by device, and has a safety feature to stop fuel and shut down equipment if there is excessive temperature or ignition failure. If fuel fired, the device also: * is chimney or vent connected. * takes air for combustion from outside. * provides for a combustion system separate from occupied area atmosphere. 19.5.2.2 This Standard is not met as evidenced by: 18087 Based on observation and interview, the provider failed to maintain combustion (fresh) air in one randomly observed area (laundry). Findings include: 1. Observation of the four commercial Speed Queen natural gas-fired dryers in the laundry room on 3/4/25 at 10:15 a.m. revealed the following: *There were several staff working in the laundry room which had ventilation into the room from overhead ductwork. *Each dryer had an individual metal exhaust duct to the exterior of the building. *There was not any dedicated combustion (fresh) air ductwork provided for the operation of the four natural gas-fired commercial clothes dryers. Each dryer had a rating of 165,000 BTU/hr input. *The gas-fired dryers were taking combustion air from the occupied room itself as a result. Interview with the environmental services director on 3/5/25 at 11:00 a.m. confirmed that finding. He stated the dryers had never been equipped with separate combustion air. The deficiency affected one of several requirements for fuel-fired devices.”