Liberty Dayton Regional Medical Center

“. An on-site Life Safety Code (LSC) Re-Survey was conducted on 01/28/2026. An entrance conference was held for the VP of Compliance and the Director of Maintenance on the morning of 01/28/2026 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 01/28/2026 with the VP of Compliance and the 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. .”

“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 VP of Compliance and the Director of Maintenance on 01/28/2026 from 10:20 AM to 1:00 PM the following: The smoke barrier wall by Rooms 127/128 and 116/125 had unsealed penetrations, penetrations sealed with materials of unknown fire resistivity, and/or sealed in a manner not compliant with a listed firestopping system. The smoke barrier wall by the Outpatient Lobby had unsealed penetrations, penetrations sealed with materials of unknown fire resistivity, and/or sealed in a manner not compliant with a listed firestopping system. In an interview at the time of each finding, VP of Compliance and the Director of Maintenance were informed of each deficiency, and he was able to observe the deficiencies. In an exit interview at approximately 1:00 PM on 01/28/2026, these deficiencies were discussed with the VP of Compliance and the Director of Maintenance. 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 VP of Compliance indicated it was last reviewed in February 2023. Interview with the VP of Compliance on 01/28/2026 at approximately 11:00 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). .”

“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 fire doors not being maintained, exposing patients to smoke inhalation and other fire related injuries. Observations included: Record review during the inspection revealed a report with multiples items was available. One of the subject lines stated “doors” and a check mark next to it; however, there was no indication if these were fire rated assemblies, smoke rated assemblies, etc., and there was also no indication that the inspection of these door assemblies were inspected in accordance with NFPA 80. The available report did not indicate who inspected the doors, what was inspected, nor how many fire door assemblies are present in the facility (inventory). In an interview after the record review of the report presented to the inspector, the VP of Compliance confirmed the inspection of the doors in the report did not reflect the requirements of NFPA 80. 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 did not have an NFPA 99 Building System Category Risk Assessment. In an interview at the time of the record review, the VP of Compliance stated he could not locate a Building System Category Risk Assessment. Reference(s): 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 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 VP of Compliance confirmed there was no report of inspection of electrical receptacles in all patient care areas. 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. .”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99) This Standard is not met as evidenced by: 35939 . Based on observation and interview, the facility failed to ensure a Generator remote annunciator was provided at a location where it can be constantly monitored by staff (usually Nurses Station where other alarms and annunciators (such as fire alarm) are located) in accordance with NFPA 99, 2012 edition. There was no remote generator annunciator inside the facility at a constantly monitored location. This deficient practice could result in unannounced generator malfunction, exposing patients to lapse in patient care services. Findings included: Observations at 11:25 a.m. on 01/25/2026 revealed the generator was not provided with a remote annunciator inside the facility where it can be constantly monitored by staff. Further observations revealed that the only annunciator was on the generator itself, which is located outdoors and away from the facility. In an interview at the time of the observation, the VP of Compliance confirmed the generator was not provided with a remote annunciator inside the facility in a location where it can be constantly be monitored by staff. Furthermore, it was revealed that that the generator had been replaced with a generator of greater capacity approximately 3 to 4 years ago. Reference(s): NFPA 99, 2012 edition 6.4.1.1.17 Alarm Annunciator. A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see 700.12 of NFPA 70, National Electrical Code). The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows: (1) Individual visual signals shall indicate the following: (a) When the emergency or auxiliary power source is operating to supply power to load (b) When the battery charger is malfunctioning (2) Individual visual signals plus a common audible signal to warn of an engine?generator alarm condition shall indicate the following: (a) Low lubricating oil pressure (b) Low water temperature (below that required in 6.4.1.1.11) (c) Excessive water temperature (d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply (e) Overcrank (failed to start) (f) Overspeed 6.4.1.1.17.1* A remote, common audible alarm shall be provided as specified in 6.4.1.1.17.4 that is powered by the storage battery and located outside of the EPS service room at a work site observable by personnel. [110:5.6.6] 6.4.1.1.17.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm has been silenced, it reactivates after the fault condition has been cleared and has to be restored to its normal position to be silenced again. [110:5.6.6.1] 6.4.1.1.17.3 In lieu of the requirement of 5.6.6.1 of NFPA110, a manual alarm-silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action. [110:5.6.6.2] 6.4.1.1.17.4 Individual alarm indication to annunciate any of the conditions listed in Table 6.4.1.1.16.2 shall have the following characteristics: (1) It shall be battery powered. (2) It shall be visually indicated. (3) It shall have additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. (4) It shall have a lamp test switch(es) to test the operation of all alarm lamps. 6.4.1.1.17.5 A centralized computer system (e.g., building automation system) shall not be permitted to be substituted for the alarm annunciator in 6.4.1.1.17 but shall be permitted to be used to supplement the alarm annunciator. .”

“PREMISES ARE CLEAN AND ORDERLY CFR(s): (4) The premises are clean and orderly; and This Standard is not met as evidenced by: 37490 Based on observation, interview and record review, the facility failed to have an effective process to ensure Environment of Care (EOC) round findings are corrected (Lab). Findings include: Observation on 9/9/2025 at 11:33 AM in the lab blood room showed a window unit with dirty side panels secured with duct tape. The window ledge had a 2” area that was missing paint and appeared to be chipped or rotten. Directly to the right of the window was a locked panel box with a 1” diameter hole in the wall at the top left of the panel. The surveyor was able to stick a tape measure 2 feet into the wall through the hole. Also, there was a small spider crawling on the wall that went behind the panel. Review of facility EOC rounding sheets for the lab for March, April, May, June and July 2025 showed the following: wood surrounding window is rotten. Interview with Safety Officer (ID 61) on 9/10/2025 at 10:30 AM confirmed the above findings. He stated that completing the EOC rounds are part of performance improvement (PI) project but confirmed a process has not been developed or implemented to ensure findings are addressed.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (vi) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. All patient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patients or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of § 483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care. This Standard is not met as evidenced by: 23032 Based on interview and record review, the facility failed to develop and implement a consistent process to ensure the nutritional needs of patients are met with respect to obtaining dietitian consults / teaching. -The nursing policy for nutritional screening is not consistent with staff knowledge or available electronic medical record (EMR ) nutritional screening components. Surveyor was not provided a policy that explained the nutrition screening utilized in the EMR: the Malnutrition Screening Tool [MST]. Findings included: Review of facility policy titled “Initial Nutritional Assessment & Nursing Plan of Care,” last review date 01/23/24, showed: PROCEDURE : Nursing will notify dietary via phone or identified via chart check by dietary manager related to identifying patients as being at high nutritional risk. Those patients will have one or more of the following conditions : a. New Onset Diabetes b. Tube feeding (enteral feeding) c. TPN /Hyperal feeding (parenteral feeding) d. Diagnosis of Malnutrition e. Diagnosis of Dehydration f. Poor PO ( “per os-? by mouth) intake for past 3 days g. Unintentional weight loss > 10 pounds over the past month h. Albumin of 2.8 i. Difficulty chewing/swallowing j. Less than 25th Growth & Development Percentile k. Decubitus 2. The Dietary Manager or designee will collect data and further screen patient registered dietitian (RD) to evaluate. 3. If the RD is not on hospital premises, data will be given over the phone or fax to RD for plan of care to be completed within 24 hours. ~~~~~~~~~~~~ During an interview on 9/10/25 at 2:25 PM with Staff ID # 57, RN , she was asked about nursing nutrition screening . Staff #57 explained the nutritional screening process was completed by nursing during the patient’s nursing admission assessment. Two (2) current patient electronic records were reviewed during staff explanation of this process: Patient ID # 3 ; 4. Review of Patient ID # 3’s nursing admission assessment showed a computer screen titled “ Nutrition Screen”-- several categorizes were available to check that included: weight loss; home diet; eating poorly; weight gain; eating difficulties; home feeding, adaptive equipment. Each of these headings has subcategories available to check to specify details. The next electronic screen showed a summary titled: “Nutrition Screen:” -unintentional weight change: Nutrition: no change -Decreased Appetite: Nutrition Screen: No -MST Score: 0 -Home Diet: Diabetic Staff ID # 57 stated that MST was a malnutrition score. If it is greater than 2: it triggers a dietary consult. She was asked the process: Staff ID # 57 said they call the Dietary Manager. Of NOTE: there was no mention in EMR of most all of the conditions stated in the nursing policy that would indicate patients at high nutritional risk; in need of an RD plan of care. ~~~~~~~~~~~~ On 9/10/25 between 2:40 and 3 PM, surveyor interviewed 2 RNs currently working on the Medical Unit: Staff ID # 77, RN and Staff ID # 93. Both were asked how the nutritional screening process worked--with respect to ordering a dietician consult? Staff ID # 77: said normally we would call the Dietary Manager-who then contacts the Dietitian. Staff ID # 94: said she was not completely sure as she hadn ’ t had to do this before and hadn’t been here too long. Both nurses said if they saw a nutritional need in a patient-such as not eating , etc.. -they would call for a dietary consult. None of the nurses interviewed mentioned any of the 11 conditions in contained in the polity tilted “Initial Nutritional Assessment & Nursing Plan of Care,” that would trigger an RD consult.”

“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: 23032 Based on record review and interview, the facility failed to include and /or evaluate contract services through the facility Quality Assessment Performance Improvement Program. Findings included: Review of facility “2025 Quality Assurance & Performance Improvement Plan (QAPI)”, showed: “Guiding Principle # 3: In our organization, QAPI includes all employees, all departments, and all services provided.” Review of a sample of signed agreements for current contracted services showed the following: -Tri-County Mental Health-Mental Retardation (MHMR)-facility contracts with them to provide mental health assessments in the ER. (contract signed 10/12/2010) -HCA Houston Healthcare Kingwood- facility contracts with them to provide telemedicine for Neurology services in the ER ( contract signed 3/22/2022). -LifeGift: federally designated Organ Procurement Organization (OPO). Facility contracts with them to manage the process for referrals of potential donors of organs, tissues, and /or eyes. Review of QAPI and Medical Executive Committee (MEC) meeting minutes for 2024 and 2025 year-to-date , failed to show any data/ metrics reported and evaluated for the above 3 listed contracted services. These findings were verified at the time of review with Staff ID # 55, Chief Quality Officer (CQO). During an interview on 9/10/2025 at 9:30 AM with Staff ID # 55, CQO, she said the hospital submits quarterly mortality reports to LifeGift. LifeGift provides performance reports to the facility. The CQO said that she emails the LifeGift data to nursing for improvement efforts. She has not included any data reported by Life Gift to QAPI Committee or MEC.”