North Runnels Hospital

“Protection - Other CFR(s): NFPA 101 Protection - Other List in the REMARKS section any LSC Section 18.3 and 19.3 Protection 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: 35320 The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:30 pm to 4:00 pm on 04/02/2025 that the sprinkler head 18-inch clearance rule was violated in Central Storage. “The clearance between the deflector and the top of storage shall be 18-inches or greater.” - NFPA 13, 2010: 8.5.6.1.”

“Interior Wall and Ceiling Finish CFR(s): NFPA 101 Interior Wall and Ceiling Finish 2012 EXISTING Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted. 10.2, 19.3.3.1, 19.3.3.2 Indicate flame spread rating(s). _____________________ This Standard is not met as evidenced by: 35320 The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:30 pm to 4:00 pm on 04/02/2025 that flame spread documents for interior wall and ceiling finishes were not available for review.”

“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: 35320 The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:30 pm to 4:00 pm on 04/02/2025 that flame spread documents for Draperies, Curtains, and Loosely Hanging Fabrics were not available for review.”

“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: 35320 The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:30 pm to 4:00 pm on 04/02/2025 that oxygen cylinders were being stored in a non-ventilated and non-fire rated closet. The hospital must verify that the combined volume of these cylinders does not exceed 3,000 cubic feet. Storage must also meet the following requirements. Storage ? 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. (Min. 1 hour enclosure) > 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. ? 300 cubic feet in a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of ? 300 cubic feet are not required to be stored in an enclosure.”

“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: 46427 Based on record review and interview, the facility failed to ensure the Registered Nurse (Personnel #12, #20, #21, #22, #23) and Licensed Vocation Nurse (Personnel #6, #24, #25) assigned to provide direct patient care held specialized qualifications and competencies as required. The facility failed to: 1. provide a competency verification. 2. provide a general hospital orientation. Finding Included: Record review of Personnel files #6, #12, #20, #21, #22, #23, #24, #25 on 02/04/2025 and 02/06/2025 failed to contain the following: Record review of Personnel #12 file did not evidence a documented competency verification as Chief Nursing Officer. Record review of Personnel files #6, #12, #21, # 22 did not evidence a documented competency verification. Record review of Personnel files #6, #12, #20, #21, #22, #23, #24, and #25 did not evidence a documented general hospital orientation as required by policy. Policy and Procedure titled “Initial Period of employment”, Policy number “NRHD-HR-002, effective date revised 05/17/2021 ... ORIENTATION AND TRAINING: New employees will participate in a general orientation program ...The department head will be responsible for providing adequate training required by their specific department.” In an interview with Personnel #12 on the afternoon of 02/04/2025 confirmed competency verifications were not consistently being performed on staff. Personnel #12 was unable to provide documentation that evidenced staff had participated in a general hospital orientation program.”

“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: 47061 Based on observation and interview, the infection control officer failed to implement the Infection Control Plan policy requirements for the Infection Prevention and Control Program Committee Meetings. Findings Included: During an interview on 02/04/2024 at 1:30 PM, Personnel # 5 and Personnel # 12 stated the following, we cannot provide documented evidence that the Infection Control Committee has been meeting. Personnel # 5 stated the last Infection Control Committee Meetings took place prior to the COVID [Coronavirus Disease] pandemic in 2019. No minutes from the Infection Control Committee were provided by Personnel # 5 and Personnel # 12 for surveyor review. Review of the 2024 and 2025 Governing Body Minutes, Medical Meeting Minutes, and Quality Assurance and Performance Improvement Program [QAPI] Meeting Minutes did not evidence minutes of Infection Control Committee Meeting reporting or issues. No other quality minutes were available for surveyor review. Personnel # 5 and Personnel # 12 stated we have an Infection Control Committee Meeting scheduled for 02/19/2025. A review of the “North Runnels Hospital Infection Control Plan 2023-2024”, reflected the following, “POLICY: 1. The North Runnels Hospital (“the Hospital”) Board of Directors, Administration, Medical Staff, and other hospital leaders are committed to activities directed toward safe, effective, quality patient care to include employees and visitors. 2. The hospital has an active, effective hospital-wide program for prevention and control of infection for all patients, health care workers, and visitors that utilizes established guidelines for the prevention of nosocomial infection in patients and prevention of exposure to healthcare workers ... OBJECTIVES: 1. The purpose of the Infection Control Plan is to: a. Establish a comprehensive hospital-wide interdisciplinary program using effective guidelines and methods to identify, report, investigate, control and prevent infections and communicable diseases. b. Provide and maintain a sanitary environment to avoid sources and transmissions of infections and communicable diseases. c. To establish coordination of monitoring and surveillance activities for the prevention and control relative to infections (nosocomial and community acquired) and infection control techniques and practices, with recommendations for prudent infection control measures based on data analysis ...h. To ensure employees compliance with federal rules and regulations, blood-borne pathogen standards, APIC [The Association for Professionals in Infection Control and Epidemiology] guidelines, Centers for Medicare and Medicaid Services guidelines and CDC [Centers for Disease Control and Prevention] recommendations for infection control through effective surveillance and educational programs ... RESPONSIBILITY: 1. The assurance of a safe hospital environment that provides necessary resources to prevent and control infections is the ultimate responsibility of the Board of Directors, Chief Executive Officer, Infection Control Committee, and the Medical Staff. 2. The Infection Control Committee is an interdisciplinary committee and is responsible for infection control activities. a. All activities of the Infection Control Committee are reported to the Governing Board through the Medical Staff. b. The Infection Control Committee meets at least quarterly or more often if necessary. c. Minutes of the meeting are recorded and maintained in the infection control office for a minimum of 2 years ... 4. The Infection Control Practitioner is responsible for: ... d. Assuring at least quarterly meetings of the Infection Control Committee are held, with minutes recorded ... COMMUNICATION OF INFORMATION: 1. The Infection Control Practitioner will report all data and results of surveillance activities to the Infection Control Committee and to the other medical staff sections as needed. The Infection Control Committee will report the minutes of the meeting to Medical Staff, who will report to the Board of Directors ...””

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (2) Be ongoing and comprehensive. (3) Involve all departments of the CAH and services (including those services furnished under contract or arrangement). This Standard is not met as evidenced by: 47061 Based on observation and interview, the facility failed to ensure the hospital-wide Quality Assurance and Performance Improvement Program [QAPI] addressed activities and/or issues identified by the Infection Control Officer. Findings Included: During an interview on 02/04/2024 at 1:30 PM, Personnel # 5 and Personnel # 12 stated the following, we cannot provide documented evidence that the Infection Control Committee has been meeting. Personnel # 5 stated the last Infection Control Committee Meetings took place prior to the COVID [Coronavirus Disease] pandemic in 2019. No minutes from the Infection Control Committee were provided by Personnel # 5 and Personnel # 12 for surveyor review. Review of the 2024 and 2025 Governing Body Minutes, Medical Meeting Minutes, and Quality Assurance and Performance Improvement Program [QAPI] Meeting Minutes did not evidence minutes of Infection Control Committee Meeting reporting or issues. No other quality minutes were available for surveyor review. Personnel # 5 and Personnel # 12 stated we have an Infection Control Committee Meeting scheduled for 02/19/2025. A review of the “Infection Prevention and Control Committee Policy” last reviewed 10/06/2022, reflected the following, “POLICY ...6. The Infection Prevention and Control Committee shall meet quarterly. Meetings shall be documented in the Infection Prevention and Control Committee minutes, including any identified problems, opportunities for improvement, actions taken, recommendations and evaluation of previous actions. Minutes shall be forwarded to Performance Improvement Department or Governing Body, as necessary ...” A review of the “Quality Assurance and Performance Improvement Program (QAPI)” last reviewed 10/10/2023, reflected the following, “PURPOSE: To develop, implement, and maintain an effective, ongoing, organization-wide, data-driven quality assessment and performance improvement program ...Collecting Data of Performance ...At a minimum, the organization will collect data in the following areas ...Processes as defined in the organizations Infection Control Program ...””