Electra Memorial Hospital

“. An on-site Life Safety Code (LSC) Re-Survey was conducted on 05/18/2026. An entrance conference was held for the Director of Maintenance and the Chief Executive Officer on the morning of 05/18/2026 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 05/18/2026 with Director of Maintenance. 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. .”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 35939 . Fire Alarm System was yellow tagged. Based on record review and interview, the facility failed to ensure the Fire Alarm System was free of defects in accordance with the NFPA 72, 2010 edition, 14.2.1.2.2 The Fire Alarm system was yellow tagged at the Fire Alarm Control Panel. A Yellow Tag means there are non-critical deficiencies with the fire alarm panel but repairs need to be conducted to bring fire alarm panel back to normal status. This deficient practice could expose patients to smoke inhalation and fire related injuries in the event of a fire due to delayed fire alarm signaling and notification. Findings include: Record review of the Fire Alarm inspection report dated 04/21/2026 indicated the system had issues during the inspection. Further review of tags posted by the inspector on the Fire Alarm Control Panel indicated a yellow tag was placed on the system. The date on the yellow tag was 04/21/2026. In an interview at the end of record review, the Maintenance Director and the CEO were informed of the current yellow tag on the system and the need for repairs of the fire alarm system. Reference(s): NFPA 72, 2010 edition. 14.2.1.2 Impairments. 14.2.1.2.1 The requirements of Section 10.19 shall be applicable when a system is impaired. 14.2.1.2.2 System defects and malfunctions shall be corrected. 14.2.1.2.3 If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner’s designated representative shall be informed of the impairment in writing within 24 hours. .”

“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: 35939 . Based on observations and interviews, the facility failed to maintain smoke barrier walls to resist the passage of smoke as required by NFPA 101, Life Safety Code, 19.3.7 and 8.5. This deficient practice could result in failure to contain toxic products of combustion to all smoke compartments, thus placing the patients, staff, and visitors of multiple smoke compartments in jeopardy in the event of a fire. The inspector observed, while accompanied by the Director of Maintenance on 05/18/2026 from 11:30 AM to 1:30 PM, the following: 1) The smoke barrier wall by Dining 305 had unsealed penetrations. 2) The smoke barrier wall by Kitchen 309 had unsealed penetrations. Verify ALL rated construction is free of defects. In an interview at the time of each finding, the Director of Maintenance was informed of each deficiency, and he was able to observe the deficiencies. . Code Reference(s): NFPA 101, 2012 edition 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-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. .”

“Evacuation and Relocation Plan CFR(s): NFPA 101 Evacuation and Relocation Plan There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2. 18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3 This Standard is not met as evidenced by: 35939 . Based on record review and interview, the facility failed to produce an updated copy of a written plan for the protection of all patients and for their evacuation in the event of an emergency in accordance with NFPA 101, 2012 edition, 19.7.2.1.2 and 19.2.2. The facility did not have an updated printed copy of a written evacuation plan. This deficient practice could result in a delayed evacuation in the event of an emergency, exposing patients to smoke inhalation, or other fire related injuries. Findings included: Record Review of the printed evacuation plan presented by the Director of Maintenance indicated it was last reviewed in March 03, 2016. Interview with the Director of Maintenance on 05/18/2026 at approximately 11:50 am revealed there was a newer electronic version of the Emergency Preparedness Plan which had not been printed nor signed by the appropriate parties. The electronic version was not printed and was not in the designated Emergency Preparedness binder(s). .”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 35939 . Based on record review of facility documents and staff interview, the facility failed to ensure fire drills were conducted at expected and unexpected times under varying conditions, at least quarterly on each shift as required by the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition 19.7.1.6. Findings included: Record review of Fire Exit Drill Record forms dated from 2025 to 2026 reflected fire drills were conducted on the following dates and times: 04/10/2026 at 8:11 PM 04/09/2026 at 8:45 AM 01/08/2026 at 5:00 PM 12/08/2025 at 10:00 PM 10/16/2025 at 10:00 AM 07/21/2025 at 9:30 AM 05/27/2025 at 5:59 PM 04/14/2025 at 9:30 AM During an interview at the time of record review, the Director of Maintenance was made aware of the missing documents and confirmed they were aware of the missing fire drills and he was unable to locate any additional documentation indicating the required fire drills had been completed. Reference(s): NFPA 101, 2012 edition 19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. 19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. .”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 35939 . Based on record review and interview, the facility failed to ensure fire door assemblies were inspected and tested at least annually in accordance with NFPA 80, 2010 edition. There were no records available indicating fire door assemblies were inspected and tested in accordance with NFPA 80. This deficient practice could result in fire doors malfunctioning, exposing patients to smoke inhalation and other fire related injuries. Findings included: Record review during the inspection revealed there were no reports available to verify fire door assemblies were inspected and tested at least annually. There was no record indicated how many (if any) fire door assemblies are located in the hospital. In an interview at the time of record review, the Director of Maintenance was informed of the missing document and he was unable to provide documentation indicating inspection of fire door assemblies were inspected and tested at least annually. Reference(s): NFPA 80, 2010 edition. 5.2* Inspections. 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 5.2.3 Functional Testing. 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. .”

“Fundamentals - Building System Categories CFR(s): NFPA 101 Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99) This Standard is not met as evidenced by: 35939 . Based on record review and interview, the facility failed to ensure a Building System Category Risk Assessment was available for review in accordance with NFPA 99, 2012 edition, Chapter 4. The facility did not have an NFPA 99 Category Risk Assessment. This deficient practice could expose patients to physical harm or injuries in the event of an emergency such as a loss of power. Findings included: Record review of the facility’s documentation revealed the facility provided a risk assessment which did not comply with the NFPA 99 Building System Category Risk Assessment. In an interview at the time of the record review, the Maintenance Director confirmed a Building System Category Risk Assessment that meets the requirements of NFPA 99, chapter 4, Building System Category Risk Assessment was not available for review. Reference(s): NFPA 99, 2012 edition. Chapter 4 Fundamentals 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. 4.1.1* Category 1. Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code. 4.1.2* Category 2. Facility systems in which failure of such equipment is likely to cause minor injury to patients or caregivers shall be designed to meet system Category 2 requirements as defined in this code. 4.1.3 Category 3. Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers, but can cause patient discomfort, shall be designed to meet system Category 3 requirements as defined in this code. 4.1.4 Category 4. Facility systems in which failure of such equipment would have no impact on patient care shall be designed to meet system Category 4 requirements as defined in this code. 4.2* Risk Assessment. Categories shall be determined by following and documenting a defined risk assessment procedure. 4.3 Application. The Category definitions in Chapter 4 shall apply to Chapters 5 through 11. .”

“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: 35939 . Based on record review and interview, the facility failed to ensure hospital-grade AND non-hospital-grade receptacles at patient care locations were tested as required and records were maintained and available for review. There were no records available indicating receptacles in patient care areas have ever been tested. This deficient practice could result in receptacle malfunction in patient care areas, exposing patients to electrical shocks, smoke inhalation or other fire related injuries. Observations included: Record review during the inspection revealed there was no report to review inspection of electrical receptacles in all patient care areas. In an interview after the record review, the Director of Maintenance was informed of the missing document, and he was unable to provide any additional documentation indicating receptacles in patient care areas had been tested. Reference(s): NFPA 99, 2012 edition 6.3.4 Administration of Electrical System. 6.3.4.1 Maintenance and Testing of Electrical System. 6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. 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. 6.3.4.1.5 After any repair or renovation to an electrical distribution system, the LIM circuit shall be tested in accordance with 6.3.3.3.2. 6.3.4.2 Record Keeping. 6.3.4.2.1* General. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. .”

“CLINICAL RECORDS CFR(s): §485.638 Condition of Participation: Clinical Records This Condition is not met as evidenced by: 51905 . Based on observation, record review, and staff interviews, Facility A failed to provide a document recording the patient’s informed consent for procedures and treatment in the medical record for 4 of 20 patients. (Patients #4, #5, #12, and #17). . Review of Patient #4’s Medical Record On 07/11/2025 at 4:00 P.M., Patient #4 presented to Facility A’s emergency department with a chief complaint of hyperglycemia [elevated blood glucose]. Patient #4 had vital signs taken, was placed on the cardiac monitor, received a 1-liter bolus of Normal Saline fluids, administered 10 units of insulin, and had multiple blood glucose tests. Patient #4 was diagnosed with Hyperglycemia. Patient #4’s medical record did not have documentation of a consent for treatment. . Review of Patient #5’s Medical Record On 08/26/2025 at 9:33 A.M., Patient #5 presented to Facility A’s emergency department with a chief complaint of chest pain. Patient #5 had vital signs taken, was placed on the cardiac monitor, received an electrocardiogram [EKG], administered 30 milligrams of Toradol [pain medication] and 40mEq of Potassium, lab work, and a chest x-ray. Patient #5 was diagnosed with Non-Cardiac Chest Pain. Patient #5’s medical record did not have documentation of a consent for treatment. . Review of Patient #12’s Medical Record On 11/13/2025 at 8:15 P.M., Patient #12 presented to Facility A’s emergency department with a chief complaint of altered mental status. Patient #12 had vital signs taken and a urine drug screen performed. Patient #12 left against medical advice [AMA]. Patient #12’s chart did contain documentation of leaving AMA. Patient #12’s medical record did not have documentation of a consent for treatment. . Review of Patient #17’s Medical Record On 12/01/2025 at 1:57 P.M., Patient #17 presented to Facility A’s emergency department with a chief complaint of left lower extremity weakness. Patient #17 had vital signs taken, received an electrocardiogram [EKG], was placed on the cardiac monitor, had a CTA [computed tomography angiography scan], was administered 1-liter of Normal Saline fluids, and was transferred to another facility. Patient #17’s chart contained a memorandum of transfer. Patient #17 was diagnosed with a Cerebrovascular Accident [CVA - Stroke] in Evolution. Patient #17’s medical record did not have documentation of a consent for treatment. . Review Medical Staff Rules and Regulations, Effective Date Unknown, Page 4: “MEDICAL STAFF RULES AND REGULATIONS 22.A general consent form, signed by or on behalf of every patient admitted to the hospital must be obtained at the time of admission, except in emergency situations.” . Review of Facility A’s Acknowledgment Form, Page 1: “Consent for Treatment I consent to treatment and care by [Facility A] and by their physicians, employees and/or authorized agents of [Facility A]. This may include examinations, medical and surgical treatments, diagnostic radiology and laboratory procedures, including HIV [human immunodeficiency virus] testing if deemed necessary by the provider, and medication administration.” . Interviews: 1. 12/30/2025 at 3:03 P.M., Chief Clinical Officer, Staff E, reviewed Patient #4’s medical record with the surveyor and stated that there was no acknowledgement form for a consent for treatment and notice of patient rights. This was also confirmed by the Chief Compliance Officer, Staff F, at 3:30 P.M., after looking for the consent. Staff E confirmed that the consent for treatment includes financial responsibility and patient rights. 2. 12/30/2025 at 3:13 P.M., Chief Clinical Officer, Staff E, reviewed Patient #5’s medical record with the surveyor and stated that there was no acknowledgement form for a consent for treatment and notice of patient rights. This was also confirmed by the Chief Compliance Officer, Staff F, at 3:39 P.M., after looking for the consent. 3. 12/30/2025 at 4:00 P.M., Chief Clinical Officer, Staff E, reviewed Patient #12’s medical record with the surveyor and stated that there was no acknowledgement form for a consent for treatment and notice of patient rights. 4. 12/30/2025 at 4:43 P.M., Chief Clinical Officer, Staff E, reviewed Patient #17’s medical record with the surveyor and stated that there was no acknowledgement form for a consent for treatment and notice of patient rights. .”

“NOTICE OF RIGHTS CFR(s): A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under state law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible This Standard is not met as evidenced by: 51905 . Based on observation, record review, and staff interviews, Facility A failed to provide a document recording the patient’s notification of patient rights in the medical record for 4 of 20 patients. (Patients #4, #5, #12, and #17). . Review of Patient #4’s Medical Record On 07/11/2025 at 4:00 P.M., Patient #4 presented to Facility A’s emergency department with a chief complaint of hyperglycemia [elevated blood glucose]. Patient #4 had vital signs taken, was placed on the cardiac monitor, received a 1-liter bolus of Normal Saline fluids, administered 10 units of insulin, and had multiple blood glucose tests. Patient #4 was diagnosed with Hyperglycemia. Patient #4’s medical record did not have documentation of receiving patient rights. . Review of Patient #5’s Medical Record On 08/26/2025 at 9:33 P.M., Patient #5 presented to Facility A’s emergency department with a chief complaint of chest pain. Patient #5 had vital signs taken, was placed on the cardiac monitor, received an electrocardiogram [EKG], administered 30 milligrams of Toradol [pain medication] and 40mEq of Potassium, lab work, and a chest x-ray. Patient #5 was diagnosed with Non-Cardiac Chest Pain. Patient #5’s medical record did not have documentation of receiving patient rights. . Review of Patient #12’s Medical Record On 11/13/2025 at 8:15 P.M., Patient #12 presented to Facility A’s emergency department with a chief complaint of altered mental status. Patient #12 had vital signs taken and a urine drug screen performed. Patient #12 left against medical advice [AMA]. Patient #12’s chart did contain documentation of leaving AMA. Patient #12’s medical record did not have documentation of receiving patient rights. . Review of Patient #17’s Medical Record On 12/01/2025 at 1:57 P.M., Patient #17 presented to Facility A’s emergency department with a chief complaint of left lower extremity weakness. Patient #17 had vital signs taken, received an electrocardiogram [EKG], was placed on the cardiac monitor, had a CTA [computed tomography angiography scan], was administered 1-liter of Normal Saline fluids, and was transferred to another facility. Patient #17’s chart contained a memorandum of transfer. Patient #17 was diagnosed with a Cerebrovascular Accident [CVA - Stroke] in Evolution. Patient #17’s medical record did not have documentation of receiving patient rights. . Review of Facility A’s Acknowledgment Form, Page 1: “Patient Rights and Patient Concern Policy/Patient Visitation Policy [Facility A] is committed to protecting and promoting each patient’s basic rights and to notifying each patient of such rights and recourse available in the event there are concerns regarding those rights or other issues. I acknowledge receipt of a copy of the Patient Rights and Patient Concern Policy and the Patient Visitation Policy.” . Review of Facility A’s Patient Rights and Concern Policy, Effective Date Unknown, Page 1: “Notification of Patient Rights and Concerns Policies [Facility A] is committed to protecting and promoting each patient’s basic rights. The purpose of this document if [sic] to notify each patient of such rights and resources available to them in the event they have concerns regarding these rights or other rights. . Interviews: 1. 12/30/2025 at 3:03 P.M., Chief Clinical Officer, Staff E, reviewed Patient #4’s medical record with the surveyor and stated that there was no acknowledgement form for a consent for treatment and notice of patient rights. This was also confirmed by the Chief Compliance Officer, Staff F, at 3:30 P.M., after looking for the consent. Staff E confirmed that the consent for treatment includes financial responsibility and patient rights. 2. 12/30/2025 at 3:13 P.M., Chief Clinical Officer, Staff E, reviewed Patient #5’s medical record with the surveyor and stated that there was no acknowledgement form for a consent for treatment and notice of patient rights. This was also confirmed by the Chief Compliance Officer, Staff F, at 3:39 P.M., after looking for the consent. 3. 12/30/2025 at 4:00 P.M., Chief Clinical Officer, Staff E, reviewed Patient #12’s medical record with the surveyor and stated that there was no acknowledgement form for a consent for treatment and notice of patient rights. 4. 12/30/2025 at 4:43 P.M., Chief Clinical Officer, Staff E, reviewed Patient #17’s medical record with the surveyor and stated that there was no acknowledgement form for a consent for treatment and notice of patient rights. .”