Yoakum County Hospital

“PROPER VENTILATION, LIGHTING, AND TEMPERATURE CFR(s): (5) There is proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas. This Standard is not met as evidenced by: 47893 Based on review of facility documentation, observation, staff interview and accepted standard of practice, the facility failed to maintain proper ventilation and temperature control in 2 of 2 operating rooms and an autoclave (sterilization) room. Findings were: Review of the facility policy, “OPERATING ROOMS - TEMPERATURE, HUMIDITY and VENTILATION,” effective 11/22/22, reflected in part, “POLICY: The temperature, humidity and airflow in all operating rooms shall be maintained with acceptable standards in order to inhibit bacterial growth and prevent infection, as well as promote patient comfort and safety. Relative humidity (RH) shall be maintained at 20 to 60 percent as recommended by the American National Standards Institute (ANSI), the American Society of Healthcare Engineers (ASHE) and the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE). Before establishing or re-establishing the low-end design RH levels below 30% in the OR, healthcare facility should assess the impact of lower RH on the equipment and supplies being used ... Temperature of the operating rooms shall be maintained at 68 to 75 degrees Fahrenheit (F) [FGI (Facility Guidelines Institute) ‘s 2014, ANSI (American National Standards Institute)/ASHRAE/ASHE Standard 170 - 2008)]. Each surgical site shall have separate temperature controls. Operating room temperatures shall be logged on a daily basis. Airflow: The Engineering Department shall control the quality of air entering all operating rooms. Air entering operating rooms shall be sequentially filtered through two (2) filters, the filter is rated at 85% efficiency and the second filter is rated at 85%. A minimum of 20 to 25 total air changes per hour shall be maintained. At a minimum, 20% of incoming air shall be from the outdoors (three [3)] air changes per hour) ... HVAC [Heating, Ventilation, and Air conditioning] Failure in the OR: All surgeries in progress shall be completed. All elective procedures shall be placed on hold until the HVAC failure has been repaired ...” Facility logs, “2025 OR,” “2025 GI,” and “2025 Autoclave,”maintained in the respective rooms, documented the following parameters at the bottom of each log: “PARAMETERS FOR OPERATING ROOM VENTILATION, AMERICAN INSTITUTE OF ARCHITECTS, 1996 Temperature 68 (degrees) F - 73 (degrees) F, depending on normal ambient temperatures Relative humidity 30% (percent) to 60% Air movement from “clean to less clean” areas Air changes Minimum 15 total air changes per hour Minimum 3 air changes of outdoor air per hour CDC GUIDELINE FOR PREVENTION OF SSI INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY” Review of logs for temperature and humidity for two operating rooms, “2025 GI” and “2025 OR,” and a “2025 Autoclave,” room, dated January 1 through July 1, 2025, found discrepancies: - temperature and humidity logs reflected parameters for operating room ventilation; temperature, and relative humidity; and reflected [in part], “ ... Temperature 68 to 73 degrees (F), depending on normal ambient temperatures; Relative humidity 30% to 60% ... - parameters for temperature and humidity, as documented in the facility policy, differ from parameters documented on “2025 GI,” “2025 OR,” and “2025 Autoclave” logs. Based on the parameters for humidity and temperature listed on the bottom of the logs, “2025 GI,” “OR” and “Autoclave” room: - “2025 GI,” operating room - Out-of-range humidity found for 71 of 127 days, on which humidity was measured; out-of-range temperature was found for 59 of 127 days, on which temperature was measured. - “2025 OR,” operating room - Out-of-range humidity for operating room, “OR” found 88 of 127 days, on which humidity was measured; out-of-range temperature for “OR” found 92 of 127 days, on which temperature was measured; - “2025 Autoclave,” room - Out-of-range humidity in “Autoclave,” room was found for 109 of 127 days on which humidity was measured; out-of-range temperature in “Autoclave,” room was found for 71 of 127 days on which temperature was measured; - no documentation was provided to reflect staff action when temperature and/or humidity were out-of-range; that temperature and/or humidity was rechecked, and the problem resolved; - temperature and humidity were not documented on weekends or holidays; - no documentation was provided to reflect air movement and changes were evaluated. Observation on the afternoon of 7/1/25, in the autoclave room, accompanied by Operating Room, Director (Staff #12), revealed a digital display temperature reading of 73 degrees (F) and humidity of 50%. In interview on 7/1/25, at the time of this observation, CNO (Staff #16) and Operating Room, Director (Staff #12) provided no documentation of staff corrective action for out-of-range temperature and humidity. CNO (Staff #16) confirmed temperature and humidity were not monitored on weekends/holidays and stated the facility is exploring options for monitoring systems. CNO (Staff #16) was asked about the parameters at the bottom of each temperature and humidity log, for air movement and air changes. CNO (Staff #16) was not aware of how these measures were made, or who maintained this information. According to an article entitled “Relative Humidity Levels in the Operating Room Joint Communication to Healthcare Delivery Organizations 2015,” it was stated [in part]: “Relative humidity may affect the operation of some electro-medical equipment used in the OR, particularly with older model electro-medical equipment. This equipment may malfunction unexpectedly. Too low humidity levels may also impact calibration. Larger electrostatic discharge (ESD) pulses may create a risk of destruction of parts, premature failure, and erratic behavior of software that is “confusion” from ESD pulses. And, in an environment where humidity is low, a person can more easily become “charged” and receive an electrostatic shock when coming in contact with medical equipment.””

“INFECTION PREVENT & CONTROL ORG & POLICIES CFR(s): Infection prevention and control program organization and policies. The CAH must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body, or responsible individual, as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 47893 Based on interviews and facility documents, the facility failed to have an individual who is qualified through training or certification in infection prevention and control, responsible for the infection prevention and control program. Findings were: In an interview on the afternoon of 7/1/25, in a facility conference room, Infection Control & Employee Health Nurse, Staff #8, reported he/she held neither credential nor certification in Infection Prevention and Control. “ ... I have participated in online Association for Professionals in Infection Control and Epidemiology (APIC) conferences and have reached out to professional contacts for information ...” In an e-mail communication on 7/1/25, Staff #15 confirmed no infection control certification or training was documented in Infection Control & Employee Health Nurse (Staff #8’s) personnel file. In an interview on the afternoon of 7/1/25, Chief Executive Officer (Staff #1) stated, “Traditionally, the Governing Body does not appoint that position [referring to the Infection Control & Employee Nurse]. [Staff #8] was interviewed and hired by two Chief Nursing Officers (CNOs), 2 years ago. We have tried to get outside mentorship, and [Staff #8] participated on a Zoom call a couple of times and was told about APIC.” Review of a job description, “Infection Control & Employee Health Nurse,” signed by Staff #8, undated, documented [in part], “ ... DEPARTMENT: Nursing JOB SUMMARY: Oversees all infection control and prevention related activities within the organization ... Responsible for all functions of the employee health program and for providing clinical employee health services ... JOB QUALIFICATIONS ... D. Experience: 1. Prior Work Experience: Three years of professional nursing experience in a clinical setting and one year in a nursing supervisory role preferred. 2. Technical Training: Current Cardiopulmonary Resuscitation (CPR) certification, Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS) ... ESSENTIAL DUTIES AND RESPONSIBILITIES ... C. Will be required to establish standard methods of care, utilizing evidence-based practice and best practice standards... E. Responsible for policies and procedures within the organization related to infection control and employee health ... L. Responsible for coordinating the infection control program which includes surveillance; analysis of data; developing reports, policies, and procedures ... O. Coordinate with the Infection Prevention and Control Committee to determine the direction of surveillance activities and actively evaluate effectiveness of the Infection Prevention and Control Plan annually ... R. Develop and implement continuously improved patient care procedures and control mechanisms related to quality, compliance, and infectious diseases ... OTHER SIGNIFICANT REQUIREMENTS: ... E. Performs duties in related departmental functions as directed by the Chief Nursing Officer or Department Supervisors ...” Neither credential [training and education] nor certification [competency] in Infection Prevention and Control were described as qualifications a candidate must meet for the position of Infection Control & Employee Health Nurse.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (1) The governing body, or responsible individual, must ensure all of the following: (i) Systems are in place and operational for the tracking of all infection surveillance, prevention and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities. This Standard is not met as evidenced by: 31974 Based on observation, interview, review of facility documents, and review of acceptable standards of practice, the facility failed to maintain a clean and safe environment in patient areas, including temperature and humidity control for 2 of 2 operating rooms and an autoclave room (a room in which surgical equipment and supplies were sterilized); monitor temperature and humidity on holidays and weekends; document staff action to report and resolve out-of-range temperature and/or humidity levels; ensure trained and qualified persons in infection control roles, with continuous nursing supervision and oversight; and develop, implement and enforce a plan to monitor surgical patients, utilizing appropriate criteria, current tools, and monitoring methods for prevention, identification, and reporting of surgical site infection. Findings were: A tour of the facility on the morning of 6/30/25, accompanied by Chief Executive Officer (CEO), Staff #1, revealed: - uncovered linen (towels) were observed on a shelf in a therapy treatment room, in a storage area, and in a linen supply room. Clean linens were not stored in a manner to prevent contamination by dust and debris. - cardboard boxes, containing supplies, were observed in storage and supply rooms. Corrugated boxes cannot be cleaned and may house and provide a food source for pests. Observation in a medication room, on the morning of 6/30/25, accompanied by Chief Nursing Officer (CNO), Staff #16, revealed: - a sharps disposal container, which held discarded needles and/or other medical devices that go into skin), atop a counter. The portals in the top of the sharps disposal container were in the open position. Open portals potentially exposed nursing staff’ fingers/hands to needle sticks. - a spray bottle containing liquid which was identified as an environmental cleaning solution; a stick deodorant, intended for individual use; and travel-size bottles of hygiene products were observed on/near a shelf in a shower room, located on the medical/surgical hallway. In interview at the time of the observation on 6/30/25, CNO (Staff #16) reported the shower room is used by patients who may have mobility issues. Staff #16 confirmed the spray bottle may contain a liquid that should not come into contact with skin and/or mucous membranes; and that personal use hygiene items, which could potentially transmit germs and bacteria from one patient to another, would be removed from the shower room. In interview on the afternoon of 7/1/25, in a facility conference room, Infection Control & Employee Health Nurse (Staff #8), when asked to describe the facility’s infection surveillance, prevention and control, and antibiotic use activities, reported the hospital followed CDC (U.S. Centers for Disease Control and Prevention) and APIC (Association for Professionals in Infection Control and Epidemiology) standards. Staff #8 was asked for documentation of surveillance activities and stated, “I’ve been trying to determine how to do my surveillance and get it onto paper. I know it’s something we are supposed to be doing, and I just need to get it together to get it done.” Infection Control & Employee Health Nurse (Staff #8) stated, “Infections would be reported in Quality Assurance Performance Improvement (QAPI) meetings. Staff #8 revealed: - infection control environmental rounds were not scheduled; - he/she had no audit tools for infection control/environmental rounds; - education was provided to hospital and clinic staff; however, Staff #8 did not consistently document staff participation; - he/she did not review logs which documented temperature and humidity readings for the facility’s two operating rooms and autoclave room; and that out-of-range temperature and humidity readings would be reported to maintenance staff; - surgical patients were monitored for infection at their clinic appointment, following their surgery; - 30-day, 60-day, and 90-day surveillance of surgical patients (inpatients and outpatients) was not conducted; and - the facility’s infection control plan had not been updated since 2019. When asked for documentation of infection surveillance, prevention and control, and antibiotic use activities, Staff #8 stated, “... provided a computer-generated “NHSN (National Healthcare Safety Network) 13.2.06 View Monthly Reporting Plan,” for April 2025, in which the facility identified procedure-associated modules for cesarean section and abdominal hysterectomy were performed by the facility; however , no patient-specific information was provided. In interview on the afternoon of 7/1/25, CNO (Staff #16) described persistent problems with the facility’s air handlers [air handling units condition, clean, and circulate air and are crucial for maintaining a healthy and safe environment]. Observation on the afternoon of 7/1/25, in the autoclave room, accompanied by Operating Room, Director (Staff #12), revealed a digital display temperature reading of 73 degrees Fahrenheit (F) and humidity of 50%. In interview on 7/1/25, at the time of this observation, CNO (Staff #16) and Operating Room, Director (Staff #12) provided no documentation of staff corrective action for out-of-range temperature and humidity. CNO (Staff #16) confirmed temperature and humidity were not monitored on weekends/holidays and stated the facility is exploring options for monitoring systems. CNO (Staff #16) was asked about the parameters at the bottom of each temperature and humidity log, for air movement and air changes. CNO (Staff #16) was not aware of how these measures were made, or who maintained this information. Review of the facility policy, “OPERATING ROOMS - TEMPERATURE, HUMIDITY and VENTILATION,” effective 11/22/22, reflected in part, “POLICY: The temperature, humidity and airflow in all operating rooms shall be maintained with acceptable standards in order to inhibit bacterial growth and prevent infection, as well as promote patient comfort and safety. Relative humidity (RH) shall be maintained at 20 to 60 percent as recommended by the American National Standards Institute (ANSI), the American Society of Healthcare Engineers (ASHE) and the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE). Before establishing or re-establishing the low-end design RH levels below 30% in the OR, healthcare facility should assess the impact of lower RH on the equipment and supplies being used ... Temperature of the operating rooms shall be maintained at 68 to 75 degrees (F) [FGI (Facility Guidelines Institute) ‘s 2014, ANSI (American National Standards Institute)/ASHRAE/ASHE Standard 170 - 2008)]. Each surgical site shall have separate temperature controls. Operating room temperatures shall be logged on a daily basis. Airflow: The Engineering Department shall control the quality of air entering all operating rooms. Air entering operating rooms shall be sequentially filtered through two (2) filters, the filter is rated at 85% efficiency and the second filter is rated at 85%. A minimum of 20 to 25 total air changes per hour shall be maintained. At a minimum, 20% of incoming air shall be from the outdoors (three [3)] air changes per hour) ... HVAC [Heating, Ventilation, and Air conditioning] Failure in the OR: All surgeries in progress shall be completed. All elective procedures shall be placed on hold until the HVAC failure has been repaired ...” Facility logs, “2025 OR,” “2025 GI,” and “2025 Autoclave,”maintained in the respective rooms, documented the following parameters at the bottom of each log: “PARAMETERS FOR OPERATING ROOM VENTILATION, AMERICAN INSTITUTE OF ARCHITECTS, 1996 Temperature 68 (degrees) F - 73 (degrees) F, depending on normal ambient temperatures Relative humidity 30% (percent) to 60% Air movement from “clean to less clean” areas Air changes Minimum 15 total air changes per hour Minimum 3 air changes of outdoor air per hour CDC GUIDELINE FOR PREVENTION OF SSI INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY” Review of logs for temperature and humidity for two operating rooms, “2025 GI” and “2025 OR,” and a “2025 Autoclave,” room, dated January 1 through July 1, 2025, found discrepancies: - temperature and humidity logs reflected parameters for operating room ventilation; temperature, and relative humidity; and reflected [in part], “ ... Temperature 68 to 73 degrees (F), depending on normal ambient temperatures; Relative humidity 30% to 60% ... - parameters for temperature and humidity, as documented in the facility policy, differed from parameters documented on “2025 GI,” “2025 OR,” and “2025 Autoclave” logs. Based on the parameters for humidity and temperature listed on the bottom of the logs, “2025 GI,” “OR” and “Autoclave” room: - “2025 GI,” operating room - Out-of-range humidity found for 71 of 127 days, on which humidity was measured; out-of-range temperature was found for 59 of 127 days, on which temperature was measured. - “2025 OR,” operating room - Out-of-range humidity for operating room, “OR” found 88 of 127 days, on which humidity was measured; out-of-range temperature for “OR” found 92 of 127 days, on which temperature was measured; - “2025 Autoclave,” room - Out-of-range humidity in “Autoclave,” room was found for 109 of 127 days on which humidity was measured; out-of-range temperature in “Autoclave,” room was found for 71 of 127 days on which temperature was measured; - no documentation was provided to reflect staff action when temperature and/or humidity were out-of-range; that temperature and/or humidity was rechecked, and the problem resolved; - temperature and humidity were not documented on weekends or holidays; - no documentation was provided to reflect air movement and changes were evaluated. In review of a job description (undated), “Infection Control & Employee Health Nurse,” stated [in part]: ... ESSENTIAL DUTIES AND RESPONSIBILITIES ... O. Coordinate with the Infection Prevention and Control Committee to determine the direction of surveillance activities and actively evaluate effectiveness of the Infection Prevention and Control Plan annually ...” The CDCs, NHSN (National Healthcare Safety Network), Surgical Site Infection Event (SSI),” dated January 2025, found at cdc.gov, included definitions, detailed information, and requirements, and stated [in part], “Settings: Surveillance of surgical patients will occur in any inpatient facility and or hospital outpatient procedure department (HOPD) where the selected NHSN operative procedure(s) are performed ... Requirements: Perform surveillance for SSI following at least one NHSN operative procedure category (using the associated NHSN operative procedure codes) as indicated in the Patient Safety Monthly Reporting Plan (CDC 57.106) ... All procedures included in the NHSN monthly surveillance plan are monitored for superficial incisional, deep incisional, and organ/space SSI events and the type of SSI reported must reflect the deepest tissue level where SSI criteria are met during the surveillance. An SSI event is attributed to the facility in which the NHSN operative procedure is performed ... Surveillance Methods: SSI monitoring requires active, patient-based, prospective surveillance. Concurrent and post-discharge surveillance methods should be used to detect SSIs following inpatient and outpatient operative procedures for example, these methods include review of medical records or surgery clinic patient records ... - Visit the ICU and wards - talk to primary care staff - Surgeon surveys by mail or telephone - Patient surveys by mail or telephone ... Any combination of these methods or other methods identified by the facility with the capacity to identify all SSIs is acceptable for use; however, NHSN criteria for SSI must be used ...” No information was provided to support the facility identified or provided information to the Governing Body to promote and ensure: - trained and qualified persons in infection control roles, with continuous nursing supervision and oversight; - a clean and safe environment in patient areas; including environments which require control of temperature, humidity; air movement; and air exchange (i.e., operating and sterilization rooms); - concurrent and post-surgical surveillance of surgical inpatients and outpatients, utilizing appropriate criteria; current tools and monitoring methods for prevention; identification; and reporting of surgical site infection.”

“A life safety code (LSC) survey was conducted on site on 07/24/2025. An entrance conference was held for the Maintence Supervisor, and the RN Risk Manager on 07/24/2025 to discuss the purpose of the LSC survey, and the survey process was explained. Instructions were provided on writing plans of correction. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital’s compliance. An LSC exit conference was conducted on 07/24/2025 in the hospital. In attendance were the Maintence Supervisor and the RN Risk Manager. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.”

“General Requirements - Other CFR(s): NFPA 101 General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 50678 At the time of the inspection, multiple maintence documents were request for review it was found the facility was not maintaining required documentation, or documentation was behind or inadequate for the required survey period. Missing included, All Electrical and Emergency EES weekly and monthly inspections and documentation, Basic Life Safety Facility Plan and updated Evacuation Routes, ALL Heating, Cooling Ventilation and Process Systems maintenance records, Risk Assessment by Building System Categories, All Medical Gas System Testing and Documentation.”

“Multiple Occupancies - Construction Type CFR(s): NFPA 101 Multiple Occupancies - Construction Type Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows: * The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1 * The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters. 18.1.3.5, 19.1.3.5, 8.2.1.3 This Standard is not met as evidenced by: 50678 Upon inspection at the time of the survey, the Two Hour Fire Wall Separation between the Hospital and the Rehab Clinic was not intact, and not constructed to meet NFPA-101 8.2.1.3 NFPA-101 8.2.1.3 Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on one of the following: (1) Separate buildings, if a 2-hour or greater vertically aligned fire barrier wall in accordance with NFPA 221, Standard for High Challenge Fire Walls, Fire Walls, and Fire Barrier Walls, exists between the portions of the building”

“Means of Egress Requirements - Other CFR(s): NFPA 101 Means of Egress Requirements - Other List in the REMARKS section any LSC Section 18.2 and 19.2 Means of Egress requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. 18.2, 19.2 This Standard is not met as evidenced by: 50678 At the time of the survey, the facility was unable to produce a Life Safety Plan denoting wall rating, location of Smoke Barrier Walls, and egress routes.”

“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: 50678 At the time of the survey, the inspector found Smoke Barriers and Rated Wall Assemblies had applied (“Scabbed-On”) sheetrock not installed per ASTM/UL rated assembly in multiple locations. NFPA-101 19.3.7.3.? Smoke Barrier Walls had opening which were not sealed. NFPA-101 19.3.7.3? Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum ½-hour fire resistance rating, unless otherwise permitted by one of the following: (1)?This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a)?Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c). (b)?Not less than two separate smoke compartments shall be provided on each floor, (2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.”

“Draperies, Curtains, and Loosely Hanging Fabr CFR(s): NFPA 101 Draperies, Curtains, and Loosely Hanging Fabrics Draperies, curtains including cubicle curtains and loosely hanging fabric or films shall be in accordance with 10.3.1. Excluding curtains and draperies: at showers and baths; on windows in patient sleeping room located in sprinklered compartments; and in non-patient sleeping rooms in sprinklered compartments where individual drapery or curtain panels do not exceed 48 square feet or total area does not exceed 20 percent of the wall. 18.7.5.1, 18.3.5.11, 19.7.5.1, 19.3.5.11, 10.3.1 This Standard is not met as evidenced by: 50678 At the time of the survery and upon physical inspection, the inspector was unable to identify Flame Spread and Smoke Development rating on Cubical Curtains and Furnishings. Hospital does not have a purchasing policy regarding FF&E. NFPA- 101 10.3.1* Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall meet the flame propagation performance criteria contained in NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. NFPA-101 19.7.5.1* Draperies, curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1 (see 19.3.5.11), and the following also shall apply: (1)?Such curtains shall include cubicle curtains.”

“Upholstered Furniture and Mattresses CFR(s): NFPA 101 Upholstered Furniture and Mattresses Newly introduced upholstered furniture meets Class I or char length, and heat release criteria in accordance with 10.3.2.1 and 10.3.3, unless the building is fully sprinklered. Newly introduced mattresses shall meet char length and heat release criteria in accordance with 10.3.2.2 and 10.3.4, unless the building is fully sprinklered. Upholstered furniture and mattresses belonging to nursing home residents do not have to meet these requirements as all nursing homes are required to be fully sprinklered. Newly introduced upholstered furniture and mattresses means purchased on or after the LSC final rule effective date. 18.7.5.2, 18.7.5.4, 19.7.5.2, 19.7.5.4 This Standard is not met as evidenced by: 50678 At the time of the inspection, the inspetor was unable to identify Flame Spread and Smoke Development rating on Furnishings. Hospital does not have a purchasing policy regarding FF&E. NFPA-101 19.7.5.2? Newly introduced upholstered furniture within health care occupancies shall comply with one of the following provisions, unless otherwise provided in 19.7.5.3:”

“Gas and Vacuum Piped Systems - Other CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 5 (NFPA 99) This Standard is not met as evidenced by: 50678 At the time of the inspection, the inspector noted that Medical Gas Cylinders where not labeled (In-Use, Empty, etc), or chained to prevent falling within the Medical Gas Room. NFPA-99 5.1.3.3.2(7)?They shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected, unconnected, full, or empty. K902 At the time of inspection, the inspector noted the medical gas storage room did not have proper ventilation (Mechanical or Natural Ventilation) per NFPA-99 Chapter 9. NFPA-99 9.3.7.5? Indoor storage or manifold areas and storage or manifold buildings for medical gases and cryogenic fluids shall be provided with natural ventilation or mechanical exhaust ventilation in accordance with 9.3.7.5.1 through 9.3.7.8. 9.3.7.5.1* For the purposes of this section the volume of fluid (gas and liquid) to be used in determining the ventilation requirements shall be the volume of the stored fluid when expanded to standard temperature and pressure (STP) of either the largest single vessel in the enclosed space or of the entire volume of the connected vessels that are on a common manifold in the enclosed space, whichever is larger. 9.3.7.5.2? Natural Ventilation. 9.3.7.5.2.1? Natural ventilation shall consist of two nonclosable louvered openings, each having an aggregate free opening area of at least 155 cm2/35 L (24 in.2/1000 ft3) of the fluid designed to be stored in the space and in no case less than 465 cm2 (72 in.2). 9.3.7.5.2.2? One opening shall be located within 30 cm (1 ft) of the floor, and one shall be located within 30 cm (1 ft) of the ceiling. 9.3.7.5.2.3? The openings shall be located to ensure cross ventilation. 9.3.7.5.2.4? Natural ventilation openings shall be directly to the outside atmosphere without ductwork. 9.3.7.5.2.5? Mechanical ventilation shall be provided if natural ventilation requirements cannot be met. 9.3.7.5.3? Mechanical Ventilation. 9.3.7.5.3.1? Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously, unless an alternative design is approved by the authority having jurisdiction. 9.3.7.5.3.2? Mechanical exhaust shall be at a rate of 1 L/sec of airflow for each 300 L (1 cfm per 5 ft3 of fluid) designed to be stored in the space and not less than 24 L/sec (50 cfm) nor more than 235 L/sec (500 cfm). 9.3.7.5.3.3? Mechanical exhaust inlets shall be unobstructed and shall draw air from within 300 mm (1 ft) of the floor and adjacent to the cylinder or containers. 9.3.7.5.3.4? Mechanical exhaust air fans shall be supplied with electrical power from the essential electrical system. 9.3.7.5.3.5? Dedicated exhaust systems shall not be required, provided that the system does not connect to spaces that contain combustible or flammable materials. 9.3.7.5.3.6? The exhaust duct material shall be noncombustible. 9.3.7.5.3.7? A means of make-up air shall be provided according to one of the following: (1) Air shall be permitted via noncombustible ductwork to be transferred from adjacent spaces, from outside the building, or from spaces that do not contain combustible or flammable materials (2) Air shall be permitted to be transferred from a corridor under the door up to the greater of 24 L/sec (50 cfm) or 15 percent of the room exhaust in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. (3) Supply air shall be permitted to be provided from any building ventilation system that does not contain flammable or combustible vapors.”

“Gas and Vacuum Piped Systems - Categories CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Categories Medical gas, medical air, surgical vacuum, WAGD, and supply air systems are designated: o Category 1 - Systems in which failure is likely to cause major injury or death. o Category 2 - Systems in which failure is likely to cause minor injury. o Category 3 - Systems in which failure is not likely to cause injury, but can cause discomfort. Deep sedation and general anesthesia are not to be administered using a Category 3 medical gas system. 5.1.1.1, 5.2.1, 5.3.1.1, 5.3.1.5 (NFPA 99) This Standard is not met as evidenced by: 50678 At the time of the inspection and upon request, the facility could not provide a “Risk Assessment” of the Medical Gas System per NFPA-99 NFPA-99 4.1* Building System Categories. Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code.”

“Gas and Vacuum Piped Systems - Central Supply CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Central Supply System Identification and Labeling Containers, cylinders and tanks are designed, fabricated, tested, and marked in accordance with 5.1.3.1.1 through 5.1.3.1.7. Locations containing only oxygen or medical air have doors labeled with “Medical Gases, NO Smoking or Open Flame.” Locations containing other gases have doors labeled “Positive Pressure Gases, NO Smoking or Open Flame, Room May Have Insufficient Oxygen, Open Door and Allow Room to Ventilate Before Opening.” 5.1.3.1, 5.2.3.1, 5.3.10 (NFPA 99) This Standard is not met as evidenced by: 50678 At the time of the inspection, the inspector found no warning or information signs where at the Medical Gas Storage Room. NFPA-99 5.1.3.1.8? Locations containing positive pressure gases other than oxygen and medical air shall have their door(s) labeled as follows: Positive Pressure Gases NO Smoking or Open Flame Room May Have Insufficient Oxygen Open Door and Allow Room to Ventilate Before Entering 5.1.3.1.9? Locations containing central supply systems or cylinders containing only oxygen or medical air shall have their door(s) labeled as follows: Medical Gases NO Smoking or Open Flame”

“Gas and Vacuum Piped Systems - Maintenance Pr CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Maintenance Program Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040. 5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99) This Standard is not met as evidenced by: 50678 At the time of inspection, and upon request the facility was unable to provide maintenance documents to verify maintenance and required testing of the Medical Gas System. NFPA-99 5.1.14.2.1* General. Health care facilities with installed medical gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed. 5.1.14.2.2? Maintenance Programs. 5.1.14.2.2.1? Inventories. Inventories of medical gas, vacuum, WAGD, and medical support gas systems shall include at least all source subsystems, control valves, alarms, manufactured assemblies containing patient gases, and outlets. 5.1.14.2.2.2* Inspection Schedules. Scheduled inspections for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction. 5.1.14.2.2.3? Inspection Procedures. The facility shall be permitted to use any inspection procedure(s) or testing methods established through its own risk assessment. 5.1.14.2.2.4? Maintenance Schedules. Scheduled maintenance for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction.”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This Standard is not met as evidenced by: 50678 At the time of inspection the facility was unable to provide testing documentation for review for the Medical Gas Systems. NFPA-99 5.1.14.2.3? Inspection and Testing Operations. 5.1.14.2.3.1? General. The elements in 5.1.14.2.2.2 through 5.1.15 shall be inspected or tested as part of the maintenance program as follows: (1)*Medical air source, as follows: (a)?Room temperature (b)?Shaft seal condition (c)?Filter condition (d)?Presence of hydrocarbons (e)?Room ventilation (f)?Water quality, if so equipped (g)?Intake location (h)?Carbon monoxide monitor calibration (i)?Air purity (j)?Dew point (2)*Medical vacuum source - exhaust location (3)?WAGD source - exhaust location (4)*Instrument air source - filter condition (5)*Manifold sources (including systems complying with 5.1.3.5.10, 5.1.3.5.11, 5.1.3.5.12, and 5.1.3.5.13), as follows: (a) Ventilation (b)?Enclosure labeling (6)?Bulk cryogenic liquid source inspected in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code (7)?Final line regulation for all positive pressure systems - delivery pressure (8)*Valves - labeling (9)*Alarms and warning systems - lamp and audio operation (10)?Alarms and warning systems, as follows: (a)?Master alarm signal operation (b)?Area alarm signal operation (c)?Local alarm signal operation (11)*Station outlets/inlets, as follows: (a)?Flow (b)?Labeling (c)?Latching/delatching (d)?Leaks”

“Electrical Systems - Wet Procedure Locations CFR(s): NFPA 101 Electrical Systems - Wet Procedure Locations Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment conducted by the facility governing body. Operating rooms defined as wet locations are protected by either isolated power or ground-fault circuit interrupters. A written record of the risk assessment is maintained and available for inspection. 6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2 This Standard is not met as evidenced by: 50678 At the time of the inspection, the facility could not provide a risk assesment or designation for Wet Procedure Locations conducted by the governing body. NFPA-99 1.3.4.3? Wet Procedure Locations. It shall be the responsibility of the governing body of the health care organization to designate wet procedure locations. 6.3.2.2.8.4* Operating rooms shall be considered to be a wet procedure location, unless a risk assessment conducted by the health care governing body determines otherwise”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 50678 At the time of the inspection, the Hospital could not document or provide testing information regarding Line Isolation Monitor or Receptacles within the Operating Rooms. NFPA-99 6.3.4 6.3.4.1.4? The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Categories *Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES. *General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES. *Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours. 3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3 This Standard is not met as evidenced by: 50678 At the time of this inspection, the Hospital failed to provide documentation regarding a “Risk Assessment” for the EES per NFPA-99 NFPA-99 4.1* Building System Categories. Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 50678 At the time of inspection, and upon request, the Hospital could not provide documentation, nor verify Monthly testing, or inspection of the EES inclusive of the Emergency Generator. (46 Month Load Bank test was conducted on 3/6/25) NFPA-99 6.4.4.1? Maintenance and Testing of Essential Electrical System. 6.4.4.1.1? Maintenance and Testing of Alternate Power Source and Transfer Switches. 6.4.4.1.1.1? Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenance parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 6.4.1.1.10 and 6.4.3.1. 6.4.4.1.1.2? The 10-second criterion shall not apply during the monthly testing of an essential electrical system. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm the capability of the life safety and critical branches to comply with 6.4.3.1. 6.4.4.1.1.3? Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8. 6.4.4.1.1.4? Inspection and Testing. Criteria, conditions, and personnel requirements shall be in accordance with 6.4.4.1.1.4(A) through 6.4.4.1.1.4(C). (A)* Test Criteria. Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8. (B)? Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. (C)? Test Personnel. The scheduled tests shall be conducted by competent personnel to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 6.4.4.1.2? Maintenance and Testing of Circuitry. $. Annual Circuit Breaker Testing 6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer’s recommendations.”

“Features of Fire Protection - Fire Loss Preve CFR(s): NFPA 101 Features of Fire Protection - Fire Loss Prevention in Operating Rooms Periodic evaluations are made of hazards that could be encountered during surgical procedures, and fire prevention procedures are established. When flammable germicides or antiseptics are employed during surgeries utilizing electrosurgery, cautery or lasers: * packaging is non-flammable * applicators are in unit doses * Preoperative “time-out” is conducted prior the initiation of any surgical procedure to verify: o application site is dry prior to draping and use of surgical equipment o pooling of solution has not occurred or has been corrected o solution-soaked materials have been removed from the OR prior to draping and use of surgical devices o policies and procedures are established outlining safety precautions related to the use of flammable germicide or antiseptic use Procedures are established for operating room emergencies including alarm activation, evacuation, equipment shutdown, and control operations. Emergency procedures include the control of chemical spills, and extinguishment of drapery, clothing and equipment fires. Training is provided to new OR personnel (including surgeons), continuing education is provided, incidents are reviewed monthly, and procedures are reviewed annually. 15.13 (NFPA 99) This Standard is not met as evidenced by: 50678 At the time of inspection, the facility could not provide documentation to indicate Fire Loss Prevention training, or case meetings prior to surgical procedures were completed. NFPA-99 15.13.3.6? A preoperative “time out” period shall be conducted prior to the initiation of any surgical procedure using flammable liquid germicides or antiseptics to verify the following: (1) Application site of flammable germicide or antiseptic is dry prior to draping and use of electrosurgery, cautery, or a laser. (2) Pooling of solution has not occurred or has been corrected. (3) Any solution-soaked materials have been removed from the operating room prior to draping and use of electrosurgery, cautery, or a laser. 15.13.3.7? Whenever flammable aerosols or antiseptics are employed, sufficient time shall be allowed to elapse between deposition and application of drapes to allow complete evaporation and dissipation of any flammable vehicle remaining. 15.13.3.8? Health care organizations shall establish policies and procedures outlining safety precautions related to the use of flammable liquid or aerosol germicides or antiseptics used in anesthetizing locations, as required in 15.14.1, whenever the use of electrosurgery, cautery, or a laser is contemplated.”