Gundersen Boscobel Area Hospital and Clinics

“PROVISION OF SERVICES CFR(s): §485.635 Condition of Participation: Provision of Services This Condition is not met as evidenced by: 50644 Based on record review, observation and interview, the facility failed to provide a safe quality food program for all patients, staff and visitors in 1 out of 1 kitchen observed. Findings Include: The facility failed to remove expired food items. See Tag 1020. The facility failed to clearly label food expiration dates. See Tag 1020. The facility failed to establish policies and procedures in accordance with nationally recognized standards of practice. See Tag 1020.”

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment This Condition is not met as evidenced by: 43993 Based on observation, staff interviews, and review of maintenance records between December 2 through December 3, 2025, the facility failed to construct, install and maintain the building systems to ensure life safety to patients. Findings include: The facility was found to contain the following deficiencies: K223 Doors with Self-Closing Devices K324 Cooking Facility K345 Fire Alarm System - Testing and Maintenance K353 Sprinkler System - Maintenance and Testing K362 Corridors - Construction of Walls K511 Utilities - Gas and Electric K521 HVAC K907 Gas and Vacuum Piped Systems - Maintenance Program K911 Electrical Systems - Other K912 Electrical Systems - Receptacles Refer to the full description at the cited K tags. The cumulative effect of environment deficiencies result in the Hospital’s inability to ensure a safe environment for the patients.”

“SURGICAL SERVICES CFR(s): If a CAH provides surgical services, surgical procedures must be performed in a safe manner by qualified practitioners who have been granted clinical privileges by the governing body, or responsible individual, of the CAH in accordance with the designation requirements under paragraph (a) of this section. This Condition is not met as evidenced by: 50644 Based on record review, observation and interview, facility staff failed to address fire risk during the time out prior to surgery for 2 out of 5 (Patients #14 and #17) surgical patients; failed to complete competency based training for surgical technologists (STs) for central sterilization for 4 out of 4 STs (ST V, ST GG, ST HH and ST II); failed to prevent cross contamination in the decontamination process of surgical instrumentation and scopes in 1 of 1 decontamination rooms; failed to clean instruments at the point of use in 1 out of 1 decontamination room; failed to cover dirty instruments and scopes during transport in 1 of 1 surgical departments; failed to clean instruments and scopes using correct cleaning concentrations per manufacturers guidelines (MFUs) in 1 of 1 surgical departments; and failed to follow manufacturer guidelines for reprocessing of scopes every 7 days in 1 out of 1 surgical services departments observed. Findings Include: A review of facility procedure #SURG-267 titled, “Scope of Surgical Services” last revised 04/2025 revealed, “...Standards of Practice and Methods used to meet patient care needs: The AORN (Association of Preoperative Registered Nurses), ASPAN (American Society of Peri-anesthesia Nurses), Association for the Advancement of Medical Instrumentation (AAMI), the Center for Disease Control (CDC) and Public Health Department standards are references used in the formulation and review of policies, procedures and standards of practice in the surgical services department...” Examples of failing to address fire risk: A review of facility policies revealed no policy that addresses completing a fire risk assessment or discussing fire risk with the team during the time out. A review of AORN “Fire Risk Assessment and Education” guidelines published on 6/27/2024 revealed, “A fire risk assessment should be done prior to the start of every case, and the fire risk should be discussed with the entire surgical team during the time out.” During an observation of a procedure time out for a colonoscopy and surgical skin tag removal for Patient #17 on 12/02/2025 at 10:46 AM, observed OR (Operating Room) RN (Registered Nurse) Y perform a surgical time out, stating patient’s name, patient’s date of birth and patient’s allergies. There was no mention of fire risk level discussed. A review of Patient #14’s medical record revealed that Patient #14 had an excision of a left upper extremity lesion on 11/03/2025. There was no documentation of a fire risk assessment completed or that it was discussed during the time out process. During an interview on 12/02/2025 at 10:48 AM, OR RN Y stated that fire risk should be discussed as part of the time out process. During an interview on 12/02/2025 at 12:14 PM, Surgery Manager W stated that fire risk is something that should be discussed as part of the time out process, but they “haven’t really enforced it.” She stated that fire risk is also charted in the patient’s medical record as part of the time-out. Examples of not completing competency based training for surgical technologist into the central sterilization department: A review of facility “Surgical Technologist Orientation Checklist” revealed no evidence of competency based training for decontamination and sterilization process for surgical instruments. A review of facility procedure, “Medivator CER/Flexible Endoscope Reprocessing Procedure” last revised 01/02/2025 revealed “...Competency For Endoscopy Cleaning...Employee will demonstrate competency in cleaning of Endoscopic Equipment.” A review of personnel files revealed no evidence of a completed “Competency for Endoscopy Cleaning” or a sterile processing orientation checklist for ST V, ST GG, ST HH, and ST II. During an interview on 12/03/2025 at 1:32 PM, Outpatient Director C stated that there is no documentation of endoscope processing training or competency-based training for decontamination and central sterilization for the staff responsible for these tasks. Examples of cross contamination in the decontamination process: A review of facility policy #19074592 titled, “Asepsis- General Overview” last approved 12/2025 revealed, “Aseptic technique involves...preventing direct contamination of materials and supplies.” During an observation of a scope cleaning on starting at 12/02/2025 at 11:18 AM, upon entering decontamination, observed the layout of the room to not allow for contaminated instruments and endoscopes to follow a flow of dirty to clean. Observed no splash guards between clean and dirty areas to prevent cross contamination of clean and dirty. Observed the clean wash counter where clean instruments are stored until the next step in processing on the first counter as you walk in, then the dirty wash sinks and dirty scope sink and then the clean scope disinfector. Observed ST V enter the decontamination area with a dirty endoscope and pass through the “clean” area to access the dirty endoscope wash sink. During an interview on 12/02/2025 at 11:18 AM, ST V stated that the setup is not ideal as the flow moves clean to dirty, not dirty to clean as it should in the decontamination room. She stated that they have to bring their dirty instruments and scopes past the clean area to process. During an interview on 12/02/2025 at 3:07 PM, Surgery Manager W stated that there is supposed to be 3 feet space between each of the clean and dirty areas and is “well aware of possible cross contamination potential in the decontamination area but there is no space, and they do there best to do what they can with the space they have.” Surgery Manager W stated, “It is a broken system.” Examples of failing to complete point of use cleaning of instruments: A review of facility records revealed no policy regarding cleaning and care of surgical instruments. A review of AORN “Guidelines for Perioperative Practice, 2025 Edition...Guidelines for cleaning and care of surgical instruments” revealed, “Treat instruments with an instrument cleaner according to the instrument or device manufacturer’s written IFU (Instructions for use) before transport.” During an interview on 12/02/2025 at 11:18 AM with ST V, ST V stated that dirty instruments do not get cleaned at point of use, they do not have enzymatic cleanser in the OR to spray the instruments. ST V stated that instruments are not always immediately handled when they get to decontamination and may sit with bioburden (bacteria and tissue) present. During an interview on 12/02/2025 at 3:07 PM Surgical Services Manager W stated that the staff are not spraying instruments. Examples of not covering/labeling dirty instruments during transport: A review of facility policies and procedures revealed no policy on transporting of dirty instruments. A review of AORN Guidelines, “Guidelines of cleaning and care of surgical instruments” 2025 Edition, revealed, “Transport soiled instruments to the decontamination area in a closed container or enclosed transport cart that is leak-proof, puncture-resistant...labeled with fluorescent orange or orange-red label containing a biohazard legend that is securely affixed...” During an observation of transporting of a scope to the decontamination area starting on 12/02/2025 at 11:18 AM, observed ST V place the dirty scope in a clear unlabeled container and transport it without a cover to the decontamination room. During an interview on 12/02/2025 at 11:18 AM, ST V stated that they transport their dirty instruments in a ring stand or on a table uncovered down the hallway to decontamination. During an interview on 12/02/2025 at 3:07 PM with Surgical Services Manager W, she stated that staff are not covering their dirty instruments during transport from the operating room to decontamination. Examples of failing to clean instruments and scopes using correct cleaning concentrations per Manufacturer’s Instructions: A review of facility policy #18660944 titled, “Disinfectant Use and Storage” last approved 05/2025 revealed, “...All disinfectants need to be used per proper “use dilution.” A review of “Stryker -Blue62 Instrument Detergent” IFUs written on 04/2023 revealed, “Concentration...1/3 oz (ounce) concentrate per gallon of water.” During an observation in the surgery department starting on 12/02/2025 at 11:18 AM, observed ST V place the dirty scope in an unmarked clear bin and fill with water to a spot on the bin that ST V “thought the line used to be.” ST V then dispensed soap via the dispenser to the unmeasured bin of water. Also observed 2 bins in the instrument wash sink with no measuring lines to determine amount of water to enzymatic cleaner concentration ratio. During an interview on 12/02/2025 starting at 11:18 AM, ST V stated that water to enzymatic cleaner levels are not identified with ratio markers in the sink bins. She stated that there are also supposed to be levels on the scope bins, but “those have worn off.” During an interview on 12/02/2025 at 3:07 PM, Surgical Services Manager W stated that there is no line to verify concentration levels for cleaning of instruments and scopes. Examples of failure to follow manufacturer guidelines for reprocessing of scopes every 7 days: A review of facility procedure #SURG-245 titled, “Medivator/CER/Flexible Endoscope Reprocessing Procedure” last revised 01/02/2025 revealed, “...Pentax-Manufacturer’s guidelines for care and reprocessing of endoscopic equipment. Applicable to all [Facility] area hospital and clinics. To follow recommended practices and provide guidelines for care, cleaning, decontamination, maintenance, handling, storage, and disinfection of flexible endoscopes and accessories...VI. Transport contaminated endoscope to the decontamination area in a covered rigid container. The transport container must be labeled to indicate biohazardous contents...Tip protector will be marked with date scope was reprocessed.” A review of Pentax manufacturer’s guidelines for endoscopes for standard storing cabinets revealed, “May have a maximum storage time of 5-7 days before repeat reprocessing cycle is necessary.” Review of facility “Scope tracking” log from 09/02/2025 through 12/02/2025 revealed: -Observed the following on 12/02/2025, no evidence of which scopes were reprocessed -Scope 102 was reprocessed on 10/22/2025 and then used on 11/03/2025 (12 days later) and last reprocessed on 11/21/2025 and observed on 12/2/2025 at 4:19 PM, hanging ready to use in storage cabinet. -Scope 103 was reprocessed on 10/22/2025 and used on 11/06/2025 (15 days later) and observed on 12/2/2025 at 4:19 PM, hanging in storage cabinet ready for use. -Scope 104 was reprocessed on 09/04/2025 and used on 09/15/2025 (9 days later), was reprocessed on 09/15/2025 and used on 09/30/2025 (15 days later), and then used again on 11/06/2025 (37 days later). On 11/11/2025 scope 104 was reprocessed and then used on 11/24/2025 (13 days later). -Scope 105 was reprocessed on 07/03/2025 and then used on 10/23/2025 (112 days later), reprocessed on 10/23/2025 and used on 11/03/2025 (11 days later) -Scope 106 was reprocessed on 11/21/2025 and used on 12/01/2025 (10 days later). -Scope 188 was reprocessed on 09/22/2025 and used on 10/20/2025 (28 days later). -Scope 189 was reprocessed on 09/15/2025 and used on 09/29/2025 (14 days later), reprocessed on 09/30/2024 and used on 10/22/2025 (22 days later), reprocessed last on 10/23/2025 and observed on 12/2/2025 at 4:19 PM, hanging in storage cabinet ready to use. During an observation in the surgery department starting on 12/02/2025 at 4:19 PM, observed ST V place disinfected scope in the drying cabinet, there was no evidence of labels being placed on the scopes to identify the reprocessing date, or date of when the scope needs to be reprocessed again. During an interview on 12/02/2025 at 4:19 PM, ST V stated that she does not know when the scopes expire, and that they “went away” from tagging them.”

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 50644 Based on record review, observation and interview facility staff failed to ensure an emergency code cart was immediately available in 1 out 4 departments (Surgery) requiring a code cart per facility policy; and failed to conduct emergency code drills and education for 11 out of 11 surgical staff. A review of facility procedure #SURG-267 titled, “Scope of Surgical Services” last revised 04/2025 revealed, “...Standards of Practice and Methods used to meet patient care needs: The AORN (Association of Perioperative Registered Nurses), ASPAN (American Society of Peri-anesthesia Nurses), Association for the Advancement of Medical Instrumentation (AAMI), the Center for Disease Control (CDC) and Public Health Department standards are references used in the formulation and review of policies, procedures and standards of practice in the surgical services department...” A review of AORN “Guidelines for Perioperative Practice, 2025 Edition” revealed that AORN “mandates that operating rooms have emergency equipment and supplies readily accessible, which includes having fully stocked and properly maintained code carts.” A review of facility “Emergency Operations Manual” last updated on July 2025 revealed “Disaster Supplies...Emergency Crash Carts:...OR (Operating Room)-1 Adult” A review of facility policies revealed that there is no policy for how often code education and drills should be conducted and what staff are educated and participate in drills. During a tour of the surgery department on 12/02/2025 at 11:58 AM observed a defibrillator machine sitting on a cart full of anesthesia airway supplies. No code supplies or medications present on the cart. During an interview on 12/02/2025 at 3:09 PM, Surgery Manager W stated that there is no code cart in the surgery department. She stated that they only have a defibrillator and would have to pull meds from anesthesia machines if needed or go find a code cart in the ED (Emergency Department). Surgery Manager W stated that they didn’t use the code cart often enough, so they disassembled it. During an interview on 12/03/2025 at 10:05 AM, Surgery Manager W stated that surgical staff do not do code drills or education.”

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 43993 Based on observation, staff interviews, and review of maintenance records between December 2 through December 3, 2025, the facility failed to construct, install and maintain the building systems to ensure life safety to patients. Findings include: The facility was found to contain the following deficiencies. K223 Doors with Self-Closing Devices K324 Cooking Facility K345 Fire Alarm System - Testing and Maintenance K353 Sprinkler System - Maintenance and Testing K362 Corridors - Construction of Walls K511 Utilities - Gas and Electric K521 HVAC K907 Gas and Vacuum Piped Systems - Maintenance Program K911 Electrical Systems - Other K912 Electrical Systems - Receptacles Refer to the full description at the cited K tags. The cumulative effect of environment deficiencies result in the Hospital’s inability to ensure a safe environment for the patients.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 47413 52276 Based on observation, record review and interview the facility failed to dispose of expired supplies in 2 patient care departments (ED [Emergency Department] and Outpatient Infusion Area) out of a total of 13 patient care departments observed. Findings include: A review of facility policy #9890838 titled, “Recalling/Disposing Reprocessing of Sterile Outdated Supplies, SURG-025” last revised 06/2019 revealed, “... 2. All outdated purchased items will be pulled from shelves...” During a tour and observation of the Outpatient Infusion Area on 12/03/2025 at 8:12 AM observed the following expired supplies: -(2) Two “Oxygen Tubing” with an expiration date of 10/2025. During an observation of the ED code cart and airway cart on 12/03/2025 at 8:25 AM observed the following expired supplies: - “Corrugated tubing” (used with breathing machines) with an expiration date of 05/31/2025. -“Oral Airway” (used to assist with ventilation of the patient in an emergent situation) with an expiration date of 11/30/2025. During an interview on 12/03/2025 at 8:24 AM with Medical Surgical Supervisor R, she stated that she would remove the tubing from the unit. During an interview on 12/03/2025 at 8:30 AM with ED RN EE, she stated nurses are responsible for restocking and checking expiration dates on supplies.”

“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: 47413 52276 Based on observation, interview and record review the facility failed to ensure that food was labeled upon opening per facility policy and not expired in 2 of 2 areas (Kitchen and Inpatient Kitchenette) where patient food is stored. Findings include: A review of facility policy, “Food Safety Requirement” no revision date revealed, “3.C.iv.Labeling, dating and monitoring refrigerated food, including but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; and V. Keeping foods covered or in tight containers.” A review of facility policy titled, “Labeling and Discarding of Nutritional Supplements” (no revision date) revealed, “ 6. All outdated food will be discarded immediately once it is outdated.” During an observation on 12/02/2025 at 10:39 A.M., observed the Kitchen and Inpatient Kitchenette that had food items not labeled upon open, closed or expired: Freezer: -Two (2) bags asparagus not dated -One (1) ½ bag mixed vegetables no open date -One (1) ½ bag yellow beans no open date -One (1) ½ bag peas no open date -One (1) open bag with 8 hotdogs not covered or in tight containers -One (1) open bag with sausage patties not covered or in tight containers -Thirty (30) single serve ice cream cups In a container with no dates. -Two (2) open bags of frozen pepperoni -One (1) open bag of frozen chicken breasts -One (1) open bag of frozen chicken breast filets Kitchen: -Ten (10) bottles unopened lemon juice with an expiration date of 11/29/2025 -Seventeen (17) packets “Ken’s Fat Free Honey Dijon” dressing packets with an expiration date of 05/03/2025. -One (1) box of “Ken’s Fat Free French” dressing packets with an expiration date of 10/27/2025. -One (1) box of lemon juice concentrate packets with an expiration date of 10/27/2025. -One (1) bin with 3 sections. Sections with salt pepper and sugar packets with no date Inpatient Kitchenette: -Three (3) individual container peanut butter with an expiration date of of 11/30/2025 -Ten (10) individual container peanut butter with an expiration date of 09/18/2025 During an interview on 12/02/2025 at 10:47 AM Cook U stated that all food should be labeled when it is opened and packaging closed.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 47413 Based on observation, interview and record review, facility staff failed to remove gloves and/or perform hand hygiene as per policy in 1 of 6 patient care observations (Patient #3) and in 1 of 1 observations of dietary staff preparing patient food (Director Food Services P). Findings Include: A review of facility policy #19399256 titled, “Hand Hygiene” last revised 12/2025 revealed, “... Procedures: All staff will use the hand-hygiene techniques... Before coming on duty; When hands are soiled; Before each patient encounter; After contact with... supplies in patient areas...” During the tray line observation on 12/02/2025 at 11:50 AM, Director Food Services P was observed handling a small bowl of shredded carrots without gloved hands, put her hand in the bowl, removed some of the carrots with her bare hands then placed the bowl on the tray to be served to a patient. During an observation on 12/03/2025 at 9:01 AM Certified Nursing Assistant (CNA) C was observed performing catheter care on Patient #3. CNA C donned clean gloves, moved the patient’s garbage can to the patient’s bedside with the same clean gloves and then performed catheter care on Patient #3 without performing hand hygiene or changing gloves. During an interview on 12/02/2025 at 11:30 AM with Cook U, she stated that hand hygiene needs to be performed before preparing patients’ food. During an interview on 12/03/2025 at 9:20 AM with CNA C, she stated that she missed doing hand hygiene and that it should be performed after she touched the patient’s garbage can. 52276”

“EXERCISE OF RIGHTS CFR(s): The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §§ 489.100, 489.102, and 489.104 of this chapter. This Standard is not met as evidenced by: 47413 Based on record review and interview, the facility failed to review advance directives with 5 of 5 surgical patients (Patients #14, 17, 18, 19, 20) in a total of 20 medical records reviewed. Findings Include: A review of facility policy #18746401 titled, “Advance Care Planning and Advanced Directives, GB- 12156” last revised 10/2025 revealed, “... 4. Document advance care planning review in EMR (electronic medical record) ‘ACP document’ activity...” A review of Patient #14’s medical record revealed she presented to the facility on 12/2/2025 for a colonoscopy. Review of the medical record revealed no advance directive review was documented. A review of Patient #17’s medical record revealed she presented to the facility on 10/20/2025 for a colonoscopy. Reveal of the medical record revealed no advance directive review was documented. A review of Patient #18’s medical record revealed she presented to the facility on 11/24/2025 for an umbilical hernia repair. Review of the medical record revealed no advance directive review was documented. A review of Patient #19’s medical record revealed he presented to the facility on 10/24/2025 for a right total shoulder replacement. Review of the medical record revealed no advance directive review was documented. A review of Patient #20’s medical record revealed she presented to the facility on 11/3/2025 for an excision of a lesion on the upper left extremity. Review of the medical record revealed no advance directive review was documented, During an interview on 12/2/2025 at 10:08 AM, when asked if the facility discussed advance directives with her upon admission, Patient #14 stated, “What is that?” Patient #14 stated that no one at the facility had a discussion with her about advanced directives upon admission or during a pre-op phone call. During an interview on 12/3/2025 at 10:18 AM with Pre-Operative Registered Nurse X, she stated that she does not review advance directives with patients. She stated that it is on the admitting checklist but she she skips over it. During an interview on 12/3/2025 at 12:03 PM with Patient Liaison FF, she stated that they do not ask surgical patients about advance directives when they come in.”

“A standard Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on December 2 and 3, 2025. Gundersen Boscobel Area Hospital and Clinics was found out of compliance with the following applicable regulations for hospital participation in Medicare-Medicaid: 42 CFR 485.623 Condition of Participation: Physical Environment was NOT MET 42 CFR 485.623(d) Standard: Life Safety from Fire was NOT MET NFPA 101 (2012 edition) Life Safety Code NOT MET Gundersen Boscobel Area Hospital and Clinics, a Critical Access Hospital, is a two-story structure built in 1952, 1965, 1994, and 2004. The single story, Emergency Department Addition was built in 2007 with Type II (222) construction and is titled the ED Building. This building contained a total of (7) smoke compartments. The Emergency Department Addition is fully sprinklered and included smoke detection within its single (1) smoke compartment. The facility is connected to two emergency generators, shared between the Emergency Department Addition and the rest of the hospital, which provided power for emergency loads. Gundersen Boscobel Area Hospital and Clinics is licensed for 25 beds, with a census of 6 inpatients on 12/02/2025 and a census of 6 inpatients on 12/03/2025 at the time of the survey. The facility was surveyed under the 2012 Life Safety Code, Chapter 19 for an existing health care occupancy. A total of three federal deficiencies of the Life Safety Code were cited for the 2007 Emergency Department Addition.”

“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: 43993 Based on observation and interview, the facility did not maintain doors with self-closing doors or automatic closing devices complying with NFPA 101, 2012 edition, Sections 19.1.1.3.1, 19.2.2.2.7, 19.2.5.6, 19.3.6.3.10, 7.2.1.8.2, 8.4.3.2, 4.6.12, and 4.6.12.3. Findings include: On 12/02/2025 at 11:14 AM, observation in the Oxygen Storage Room, between OR1 and OR2, revealed the corridor door equipped with a self-closing device, but the door did not fully close after three attempts. The room stored (2) Type “E” oxygen cylinders, (2) “Type E” carbon dioxide cylinders, (2) “Type E” Nitrogen dioxide cylinders, (4) Type “K” Nitrogen Dioxide cylinders, (4) Type “K” Nitrogen cylinders, and (4) Type “K” Compressed Air cylinders equating to less than 300 cbft of flammable gases. This deficient practice was confirmed by Staff D at the time of discovery.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 43993 Based on observation and interview, the facility did not maintain cooking facilities in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.2.5.5, 9.2.3, 9.7.5, 9.7.6, 9.7.7, and 9.7.8; NFPA 96, 2011 edition, Sections 10.2.6, 10.5.1, 10.9.2, and 11.2.2, as well as NFPA 25, 2011 edition, Sections 4.1.4.1, 4.1.9, and 4.3. Findings include: On 12/03/2025 at 4:56 PM, observation in the Main Ground Floor Kitchen revealed that the manual activation pull-ring for the fire suppression system, adjacent to the Dish Area, was not readily accessible as the pull-ring was located between 10 and 20 ft from the protected kitchen appliance(s) in the path of egress but was approximately 56 inches above the floor. This deficient practice was confirmed by Staff D at the time of discovery.”

“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: 43993 Based on record review and interview, the facility did not perform the semi-annual inspection and testing of the fire alarm system in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.4, 9.6.1.3, and 9.6.1.5, as well as NFPA 72, 2010 edition, Sections 14.4.2.2, 14.4.5, 14.6, and 14.6.2.4. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: On 12/02/2025 at 12:36 PM, record review of fire alarm inspection and testing documents revealed that the required annual inspection and testing activities were performed by the facility on 02/06/2025 through 02/10/2025 but did not include a load voltage test of the fire alarm system batteries. The terminal voltage shall be measured, with the charger disconnected, while supplying the maximum load required by the system. The semi-annual inspection and testing completed by facility staff. When asked if semi-annual testing and inspection included testing the load voltage of fire alarm control panel batteries with the charger disconnected, Staff A stated, “it does not appear so.” This deficient practice was confirmed by Staff D at the time of discovery.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 43993 Based on observation and interview, the facility did not maintain the automatic sprinkler system in accordance with NFPA 101, 2012 edition, Sections 19.3.5.1, 19.3.5.4, 19.3.5.7, 8.4.2, 8.4.4, 8.4.5, 9.7.1.1, and 9.7.5; NFPA 13, 2010 edition, 8.6.4.1, 8.6.5.3, and 26.1; as well as NFPA 25, 2011 edition, Sections 4.7, 5.1.1.2, 5.2.1.1, and 5.2.1.1.1. Findings Include: On 12/03/2025 at 11:05 AM, observation in the ER Dictation Room 2323 revealed that a sprinkler head was not kept free of lint and other foreign material. This deficient practice was confirmed by Staff D at the time of discovery.”

“Corridors - Construction of Walls CFR(s): NFPA 101 Corridors - Construction of Walls 2012 EXISTING Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area. 19.3.6.2, 19.3.6.2.7 This Standard is not met as evidenced by: 43993 Based on observation and interview, the facility did not provide smoke barrier corridor wall separations as required in NFPA 101, 2012 edition, Sections 19.3.6.2, 19.3.6.2.5, 8.4.2, and 8.4.4. This deficient practice could affect an undetermined number of staff and visitors. Findings include: 1. On 12/02/2025 at 11:17 AM, observation in the Oxygen Storage Room, between OR1 and OR2, revealed (2) 1/4 inch diameter copper pipe penetrating the corridor wall that was not properly fire stopped according to an approved method. 2. On 12/03/2025 at 3:43 PM, observation in the Ground Floor Storage Room 1211 revealed a two inch by 4 inch penetration in the corridor wall that was not properly fire stopped according to an approved method. These deficient practices were confirmed by Staff D at the time of discovery.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 43993 Based on observation and staff interview, the facility did not ensure the electrical wiring and equipment met the requirements of NFPA 101, 2012 edition, Sections 19.5.1.1 and 9.1.2, as well as NFPA 70, 2011 edition, Articles 110.8, 110.26, and 408.20. Findings Include: On 12/02/2025 at 11:12 AM, observation in the Sterile Corridor between OR1 and the Soiled Utility Room revealed an electrical breaker box, in a publicly accessible space, which was not securely protected from accidental contact by unqualified persons. The electrical box included Line isolating Monitoring for OR1. This deficient practice was confirmed by Staff D at the time of discovery.”

“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: 43993 Based on observation and staff interview, the facility did not provide proper ventilation in a room in accordance with ASHRAE Standard 170 Part 6 Table 7-1, AIA Guidelines for Design and Construction of Health Care Facilities, and CDC guidelines. This deficient practice had a potential of contamination of air in clean spaces with undesirable contaminants. Findings Include: On 12/03/2025 at 10:12 AM, observation in the Corridor 2299A outside of Clean Room 2210, part of the OR Sterile Area, revealed air was moving from the ‘dirty’ Corridor into the Clean Room. Airflow is required to be from clean to dirty. This deficient practice was confirmed by Staff D at the time of discovery.”

“Gas and Vacuum Piped Systems - Maintenance Pr CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Maintenance Program Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040. 5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99) This Standard is not met as evidenced by: 43993 Based on record review, observation, and interview, the facility did not have documented maintenance program for oxygen gas system denoting a risk assessment, inspection and maintenance schedule in accordance with NFPA 99, 2012 edition, Sections 5.1.14.2.1, 5.1.14.2.2.2, 5.1.14.2.2.4, 5.1.14.2.3.1, 5.1.14.4.4, and 5.1.14.4.7. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: 1. On 12/02/2025 at 2:52 PM, record review revealed the facility had a written risk assessment, dated December 17 to 18, 2024, which included testing methods and result records. The results from Evergreen Medical demonstrated deficiencies in 2 of the 26 master alarm panel signals and suggested repairs. Upon interview with Staff D if the repairs had been made, they responded, “we have not completed the repairs.” No further documentation of repairs was available for review. 2. On 12/03/2025 at 10:48 AM, observation revealed the gas and vacuum piped system monitor alarm for ZVB#1 within in ER was not functioning properly. These deficient practices were confirmed by Staff D at the time of discovery.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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 6 (NFPA 99) This Standard is not met as evidenced by: 43993 Based on observation and interview, the facility did not provide and maintain a clear working space in front of electrical panels in accordance with the requirements of NFPA 101, 2012 edition, Section 19.5.1.1 and 9.1.2; as well as NFPA 70, 2011 edition, Sections 110.26 and 408.18. Findings include: On 12/03/2025 at 8:59 AM, observation in the Med Surge Kitchenette Rom 2101 revealed one electrical panel had less than the minimum required 3 foot clearance around the panel. A 8 inches wide by 24 inches long by 28 inches high metal trash can and a 14 inches wide by 18 inches long by 30 inches high metal cart were stored 6-inches from the front of the electrical panels. This deficient practice was confirmed by Staff D at the time of discovery.”

“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: 43993 Based on observation and staff interview, the facility did not ensure the electrical wiring and equipment met the requirements of NFPA 101, 2012 edition, Sections 19.5.1.1 and 9.1.2; NFPA 99, 2012 edition, Sections 6.3.2.1, 6.3.2.1.1, 6.3.2.2.4.2, 6.3.2.2.6.1, and 10.2.2.2; as well as NFPA 70, edition 2011, Articles 110.3(B), 110.8, and 210.8(B). Findings include: 1. On 12/03/2025 at 9:40 AM, observation in the Director of Inpatient Operations Office Room 2237 revealed a non-ground fault circuit intercepted electrical receptacle within a light, located in a wet location, and approximately three feet above the sink. The facility was not able to confirm that listed, ground-fault circuit-interrupter (GFCI) protection was provided within 6 feet from the outside edge of a sink. 2. On 12/03/2025 at 9:58 AM, observation in the Radiology Suite 2222 revealed a non-ground fault circuit intercepted electrical receptacle located in a wet location, approximately one foot from the sink. The facility was not able to confirm that listed, ground-fault circuit-interrupter (GFCI) protection was provided within 6 feet from the outside edge of a sink. 3. On 12/03/2025 at 11:35 AM, observation in the Doctor Sleep Room 2258 revealed a non-ground fault circuit intercepted electrical receptacle within a light, located in a wet location, and approximately three feet above the sink. The facility was not able to confirm that listed, ground-fault circuit-interrupter (GFCI) protection was provided within 6 feet from the outside edge of a sink. 4. On 12/03/2025 at 11:37 AM, observation in the Doctor Sleep Kitchenette, between Rooms 2258 and 2260, revealed a non-ground fault circuit intercepted electrical receptacle located in a wet location, approximately two feet from the sink. The facility was not able to confirm that listed, ground-fault circuit-interrupter (GFCI) protection was provided within 6 feet from the outside edge of a sink. These deficient practices were confirmed by Staff B the time of discovery.”