Sanford Chamberlain Medical Center

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 45383 Based on record review, interview, and policy review, the provider failed to ensure the patient’s nutritional needs were assessed and documented for two of two sampled obstetric patients (1 and 2) according to the provider’s policy. Findings include: 1. Review of patient 7’s electronic medical record (EMR) revealed: *She was admitted on 7/10/25 to the labor and delivery unit. *The admission navigator (an admission assessment tool) questions for an obstetric (OB) patient had been completed on 7/10/25. *A nutrition assessment had not been completed during her hospitalization. 2. Review of patient 4’s EMR revealed: *She was admitted on 7/13/25 to the labor and delivery unit. *The OB admission navigator had been completed on 7/13/25. *A nutrition assessment had not been completed during her hospitalization. 3. Interview on 7/16/25 at 2:30 p.m. with OB manager D regarding nutrition assessments for OB patients revealed: *Staff would have completed the OB admission navigator upon a patient’s admission to the facility. *She agreed a nutrition assessment had not been included with the OB admission navigator questions and should have been completed. *OB manager D stated all OB patients had not had a nutrition assessment completed. 4. Interview on 7/16/25 at 4:30 p.m. with registered nurse (RN) C regarding the OB admission navigator questions revealed: *She would have completed the OB admission navigator with a patient upon the patient’s admission to the facility. *She agreed there was no nutrition assessment in the OB admission navigator and should have been completed. Review of the provider’s July 2024 Patient Nutrition Assessment and Screening policy revealed: *”Nursing will screen patients within 24 hours of admission and record information in the EMR.” *”The admission navigator will be utilized for each patient. Nutrition areas to be addressed include:” “-Unable to eat for 3 days.” -“Unintended weight loss > 10 pounds.” -“High Risk OB.””

“INFECTION PREVENT & CONTROL SCOPE & SEVERITY CFR(s): The infection prevention and control program reflects the scope and complexity of the CAH services provided. This Standard is not met as evidenced by: 46511 Based on observation and interview the provider failed to follow infection control practices to ensure: *There was sufficient exhaust air flow for one of one decontamination room. *Six of fifteen medical-surgical equipment items were free of rust in the operating room (OR). Findings include: 1. Observation on 7/15/25 at 9:30 a.m. revealed air from inside the decontamination room was flowing through the door into the hallway. Observation and interview on 7/15/25 at 9:35 a.m. with surgical technologist G revealed: *She confirmed the air was coming out of the decontamination room and into the hallway. *She had noticed the air coming out of the decontamination room a while ago. *She agreed that the decontamination room should have been negatively pressured. Observation and interview on 7/16/25 at 3:45 p.m. with maintenance director H revealed: *He was not aware the decontamination room was positively pressured. *The decontamination room pressurization was adjusted and balanced on 7/24/24 by a contracted company. *Maintenance staff had not checked the airflow in the decontamination room since it was last balanced on 7/24/24. *He agreed that the decontamination room should have been negatively pressured. *He was unsure of how long the decontamination room had been positively pressured. A policy regarding air flow for the decontamination room was requested on 7/16/25 at 3:45 p.m. The provider had been unable to provide the requested policy by the end of the survey. 2. Observation in the OR on 7/16/25 at 7:45 a.m. revealed: *Three IV poles had rust on the legs and casters. *Two metal tables had rust on the legs and casters. *One ring stand had rust on the casters. Interview on 7/16/25 at 7:50 a.m. with surgical technologist G revealed: *She confirmed the equipment items above contained rust and were not cleanable surfaces. *Equipment containing rust should not have been used or available for use in the OR. 45383 Interview on 7/16/25 at 9:35 a.m. with OR manager D regarding the rusted equipment items in the OR and the decontamination room revealed: *She had been aware of the rusted equipment in the OR and scope room. *The maintenance employees had been working on removing the rust from the equipment, but had to stop to attend to other projects. *She had thought a rusted surface would have been a cleanable surface, but she had not researched the issue. *OR manager D had not been aware that the decontamination area for surgical instruments required a negative airflow. Interview on 7/16/25 at 10:00 a.m. with infection control coordinator B regarding the cleanability of a rusted surface revealed he had thought a rusted surface was uncleanable. Interview on 7/16/25 at 3:15 p.m. with discharge planner E regarding rusted equipment revealed: *Staff had placed rusted equipment in her office for removal from use. *She agreed if equipment was rusted, it was not cleanable and should have been removed from use. Interview on 7/16/25 at 3:55 p.m. with director of nursing (DON) A regarding rusted equipment revealed: *She agreed rusted equipment should have been removed from use. *DON A had not been aware that there was rusted equipment in the OR and the scope room that had remained in use. Request for a policy on the removal of equipment from service had been requested, but the provider did not have a policy that indicated rusted equipment should have been removed from service.”

“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: 52836 K211 This standard is not met as evidenced by: Based on observation and interview, the provider failed to ensure one exit door and three exit access corridors were maintained free of obstructions which could impede egress during an emergency (e.g., a fire event). Findings include: 1. Observation on 7/15/25 at 11:30 a.m. revealed the laundry/maintenance exit access corridor contained a large variety of obstructions, including combustibles (items in cardboard boxes). 2. Observation on 7/15/25 at 11:50 a.m. revealed the back hallway exit access corridor contained a variety of obstructions, including combustibles. 3. Observation on 7/15/25 at 12:25 p.m. revealed the exit door from the loading dock storage room was partially blocked by obstructions appearing to be refuse on the floor, including combustibles (items in cardboard boxes). 4. Observation on 7/15/25 at 12:30 p.m. revealed the exit access corridor between the hospital and dialysis center contained a variety of obstructions, including large furniture items which did not have flame spread ratings. Interview with the Finance Director and Maintenance Supervisor at the time of those observations confirmed those findings. This deficiency compromised one of ten building exit doors and three of seven exit access corridors.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 52836 This standard is not met as evidenced by: Based on observation and interview, the provider failed to maintain two hazardous area enclosure doors. Findings include: 1. Observation on 7/15/25 at 10:50 a.m. revealed the door separating the boiler room, a hazardous area, from the mechanical/electrical room was held open by a rope tied between the doorknob and a conduit on the wall. The door was equipped with a closer. 2. Observation on 7/15/25 at 11:25 a.m. revealed the door separating the laundry room, a hazardous area, from the employee locker room did not self-close or latch. The door was equipped with a closer. Interview with the Finance Director and Maintenance Supervisor at the time of those observations confirmed those findings. These deficiencies compromised two of seven smoke compartments.”

“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: 52836 This standard is not met as evidenced by: Based on observation and interview, the provider failed to maintain the smoke resistant partitions for four hazardous area enclosures. Findings include: 1. Observation on 7/15/25 at 11:20 a.m. revealed one approximately two-inch open pipe penetration through the ceiling of the boiler mechanical room for the instrument sanitizer. 2. Observation on 7/15/25 at 11:35 a.m. revealed four open spaces around approximately six-inch pipe penetrations through the west wall of the maintenance shop. 3. Observation on 7/15/25 at 12:15 p.m. revealed six open spaces around pipe penetrations of various sizes through the north wall of the biohazard storage room. 4. Observation on 7/15/25 at 12:40 p.m. revealed three open spaces around pipe penetrations of various sizes through upper wall areas near the northwest corner of the long-term dialysis storage room. Interview with the Finance Director and Maintenance Supervisor at the time of those observations confirmed those findings. These deficiencies compromised three of seven smoke compartments.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 52836 This standard is not met as evidenced by: Based on observation and interview, the provider failed to properly store oxidizing gases with a combined total volume of approximately 1,500 cubic feet. Findings include: 1. Observation on 7/15/25 at 12:00 p.m. revealed two S-size cylinders containing 65 pounds each of nitrous oxide, which were co-located with various other medical gases (e.g., nitrogen), and 18 E-size and 3 B-size cylinders containing oxygen which were in a rack approximately 20 feet away from the nitrous oxide and other gas cylinders. There were a number of combustibles located within five feet of both cylinder collections including cardboard, cloth blankets and towels, plastics, and wooden furniture. Interview with the Finance Director and Maintenance Supervisor at the time of the observation confirmed the finding. This deficiency compromised one of seven smoke compartments.”