W J Mangold Memorial Hospital

“COMPLIANCE STATE AND LOCAL LAWS AND REGS CFR(s): All patient care services are furnished in accordance with applicable State and local laws and regulations. This Standard is not met as evidenced by: 31690 Based on observation, interview, and record review, the facility failed to maintain and meet the standards at Texas Administrative Code, Title 26 section 505.41 (d)(1)(A), when the facility’s Dietary Manager failed to have current Food Service Manager certification. Findings include: Review of the Texas Administrative Code, Title 26 section 505.41 (d)(1)(A) reflects the following: “(A) The hospital shall have a full-time employee who is qualified by experience or training to serve as director of the food and dietetic service and be responsible for the daily management of the dietary services.” Review of the facility policy “Dietary Manager Job Description” last revised 3/28/25 reflected the following “... The Dietary Manager must have graduated from an approved Dietary Manager’s course and have taken their Servsafe Manager’s course and passed the exam ...” Review of the Staff #24’s, Dietary Manager, Servsafe Certification reflected an expiration of 4/17/2022. During an interview, on the morning of 9/30/25 Staff #24 reported that she had not been able to pass the test. During an interview, on the afternoon of 9/30/25 Staff #1 reported that he was unaware of this issue.”

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 31690 Based on review of records and interview, the facility failed to ensure that the policies pertaining to a critical access hospital (CAH) were reviewed and subsequently scheduled to be reviewed every two years by members of the hospital’s professional healthcare staff, including one or more Doctor of Medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists on staff. Reviews of 3 of 3 infection control policies showed that the policies had not been updated in the last 7 years. Findings included: The following 3 policies were provided by the facility as current policies in use: POLICY #1 Title: Infection Control Monitoring the Process Department: Hospital Wide Originated date: May 31, 1999 Revised date: March 1, 2006 POLICY # 2 Title: Antibiotic Stewardship Program Department: Pharmacy Date Revised: September 17th, 2016 Policy # 3 Title: W.J. Mangold Memorial Hospital and Clinics Hand and Fingernail Hygiene Policy Department: Hospital Wide Originated date: 12/25/05 Reviewed: 2/1/2013 Revised: 11/03/2016 Revised: 2/26/2018 During an interview, on the morning of 9/30/2025 Staff #1, #2, and #3 verified these findings.”

“A life safety code LSC survey was conducted on site on 08/28/2025. An entrance conference was held for the hospital ’ s CEO, CNO, Asst. CNO and Maintenance Supervisor, on the morning of 08/28/2025 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 08/28/2025 in the hospital. In attendance were the CEO, CNO, Asst. CNO and Maintenance Supervisor. 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.”

“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: 30174 Based on observations made during the survey of the facility while accompanied by the hospital’s CEO, CNO, Asst. CNO and Maintenance Supervisor it was observed that an exterior Egress Door was equipped with a surface mounted sliding dead bolt. This added dead bolt lock is not acceptable for an exterior Egress Door and must be removed. The exterior Egress Door is located near the DINING area and is being utilized for an Employee Entrance.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 30174 Based on observations made during the survey of the facility while accompanied by the hospital’s CEO, CNO, Asst. CNO and Maintenance Supervisor it was observed that the double-egress door location near CENTRAL SUPPLY ROOM is missing a required EXIT SIGN.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 30174 Based on observations made during the survey of the facility while accompanied by the hospital’s CEO, CNO, Asst. CNO and Maintenance Supervisor it was observed that the 60 minute fire-rated double door location near the RAMP leading from LEVEL 1 to BASEMENT LEVEL is configured with a T-Astragal device on one of the 2 door leaves. There is currently no control regarding which door leaf is going to close first, and if the door leaf with the T-Astragal closes first then the remaining door leaf is unable to fully close and compromises the protection required. This rated door opening is part of a fire-rated separation wall and is required to fully closed upon release from the magnetic hold-open devices in a fire emergency.”

“Health Care Facilities Code - Other CFR(s): NFPA 101 Health Care Facilities Code - Other List in the REMARKS section any NFPA 99 requirements (excluding Chapter 7, 8, 12, and 13) that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Health Care Facilities Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 30174 Based on observations made during the survey of the facility while accompanied by the hospital’s CEO, CNO, Asst. CNO and Maintenance Supervisor the facility was unable to confirm that the required “GEN SET” for the EMERGENCY GENERATOR was being powered from the LIFE SAFETY BRANCH of the EES System. The “GEN SET” components shall be powered by the Life Safety Branch of the EES. These components of the “GEN SET” to be powered by the LIFE SAFETY BRANCH are as follows: a. LIGHT with a charging component must have 90-minute battery back-up capability. b. RED RECEPTACLE. NFPA 99, 2012: 6.4.2.2.3.2. The life safety branch shall supply power for the lighting, receptacles, and equipment as follows: (4) Generator Set Location as follows: (a) Task illumination (b) Battery charger for emergency battery-powered lighting unit(s)”