Muenster Memorial Hospital

“A Life Safety Code (LSC) Re-Certification Survey was conducted at site on 08/21/25. An entrance conference was held for the CEO and Plant Operations Director on 08/21/25 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 08/21/25 in the hospital, attended by the Plant Operations 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.”

“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: 31947 Observation revealed not all required door closers were installed. Please verify the following Department of State Health Services, Title 25 Texas Administrative Code, Chapter 133, Hospital Licensing Rules and codes are achieved: (III) Overhead clearance. Suspended tracks, rails, pipes, signs, lights, door closers, exit signs, and other fixtures that protrude into the path of normal traffic shall not be less than six feet eight inches above the finished floor. NFPA 101, 2003: 18.3.2.1 ..... Any hazardous areas shall be protected in accordance with Section 8.7, and the areas described in Table 18.3.2.1 shall be protected as indicated. The doors shall be a minimum ¾ hour fire rated doors set in rated frames. With that classification, the door’s hardware, including door closers device and latching hardware, must meet the requirement for storage rooms. NFPA 72E, 9-5. All doors in smoke barrier partitions must be control by a smoke detector (device) that is tied to the fire alarm system. The devices shall not be further than five feet of the doors and not closer then one foot of the doors.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 31947 Base on observation, the facility failed to provide fully functioning exhausts at all required locations, which is required by Department of State Health Services, Title 25 Texas Administrative Code, Chapter 133, Hospital Licensing Rules: (i) General ventilation requirements. All rooms and areas in the hospital listed in Table 3 of §133.169(c) of this title shall have provision for positive ventilation. Fans serving exhaust systems shall be located at the discharge end and shall be conveniently accessible for service. Exhaust systems may be combined, unless otherwise noted, for efficient use of recovery devices required for energy conservation. The ventilation rates shown in Table 3 of §133.169(c) of this title shall be used only as minimum requirements since they do not preclude the use of higher rates that may be appropriate. Supply air to the building and exhaust air from the building shall be regulated to provide a positive pressure within the building with respect to the exterior.”

“Construction, Repair, and Improvement Operati CFR(s): NFPA 101 Construction, Repair, and Improvement Operations Construction, repair, and improvement operations shall comply with 4.6.10. Any means of egress in any area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency and compliance with NFPA 241. 18.7.9, 19.7.9, 4.6.10, 7.1.10.1 This Standard is not met as evidenced by: 31947 Observation revealed storage rooms that exceeded 100 square feet did not have properly rateds walls, ceilings, doors, door frames or door hardware. Please renovate all storage rooms greater than 100 square feet to achieve the following: NFPA 101, 2003, 18.3.2.1 .....Any hazardous areas shall be protected in accordance with Section 8.7, and the areas described in Table 18.3.2.1 shall be protected as indicated .....Storage rooms larger than 100 square feet and storing combustible material require 1 hour separation. NFPA 101, 2003, 8.7.1.3 .....Doors in barriers required to have a fire resistance rating shall have a ¾ hour fire protection rating and shall be self-closing or automatic closing in accordance with 7.2.1.8.”

“Electrical Systems - Receptacles CFR(s): NFPA 101 Electrical Systems - Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 31947 Based on observation, the facility failed to provide ground-fault circuit interrupters (GFCI) at electrical receptacles within three feet of a water source at non-patient areas, which does not meet the following Department of State Health Services, Title 25 Texas, Administrative Code, Chapter 133, Hospital Licensing Rules requirement: (J) Ground fault circuit interrupters (GFCI). GFCI receptacles shall be provided for all general use receptacles located within three feet of a wash basin or sink. When GFCI receptacles are used, they shall be connected to not affect other devices connected to the circuit in the event of a trip. Receptacles connected to the critical branch that may be used for equipment that should not be interrupted do not have to be GFCI protected. Receptacles in wet locations, as defined by NFPA 70, §§517.20 and 517.21, shall be GFCI protected regardless of the branch of the electrical system serving the receptacle.”

“Electrical Equipment - Other CFR(s): NFPA 101 Electrical Equipment - Other List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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 10 (NFPA 99) This Standard is not met as evidenced by: 31947 Observation revealed exposed light bulbs, unprotected from breakage. Please provide and instal proper lens or covers to prevent harm from broken glass and to achieve the following requirement of Department of State Health Services, Title 25 Texas Administrative Code Chapter 133, Hospital Licensing Rules: (II) A reading light shall be provided for each patient. Reading light control shall be readily accessible from each patient bed. Flexible light arms, if used, shall be mechanically controlled to prevent the bulb from coming in contact with bed linen. High heat- producing light sources such as incandescent and halogen shall be avoided to prevent burns to patients and/or bed linen. Light sources shall be covered by a diffuser or a lens.”