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Based on review of policy, review of Record of Complaint Investigations, and interview, it was determined the facility failed to provide evidence the complainant received a written notice of its decision that contained the name of the Rural Emergency Hospital (REH) contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion for nine (#1, #3-#10) of ten (#1-#10) grievances received since 01/01/2024. By not responding to the patient's grievances, the facility was not honoring the patients' rights to a prompt resolution of their grievances. This failed practice had the likelihood to affect the rights of all patients who file a grievance with the facility. Findings follow:

A. Record review of facility policy titled "Complaints and Grievances," revised 09/18/2024, showed the patient was to receive written notice of its receipt, investigation and outcomes regarding the grievance within 7 days. The written notice shall include the name of the Rural Emergency Hospital (REH) contact person, the steps taken on behalf of the patient to investigate the grievance, results of the process and date of completion.
B. Review of the Record of Complaint Investigation form for Grievances #1 through #10 showed no evidence documented that the complainant received a written notice of its decision that contained the name of the REH contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion for grievances #1, #3-#10.
C. During an interview on 11/20/24 at 9:10 AM, the Chief Quality Officer verified the nine grievances did not have evidence the complainant received a written notice of its decision that contained the name of the REH contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion.


Based on review of facility's Patient Rights and Responsibilities and interview, it was determined the facility failed to provide the patients with accurate information on whom to contact to file a complaint. By not providing accurate information to the patients, the facility was not honoring the patient's right to this information. The failed practice had the likelihood to affect the rights of every patient who would like to file a grievance. Findings Follow:

A. Record review of the facility's "Patient Rights and Responsibilities," on 11/19/2024 showed there was no information provided on the facility's grievance process if they wanted to file a grievance with the facility. Also, they informed patients if they have a Medicare complaint to contact the Department of Public Health in Kentucky instead of the Medicare contact information. Also, they state "lodge a concern with the state, whether you have used the hospital's grievance process or not," but gave no information on how to file a grievance with the state.
B. During an interview on 11/19/2024 at 3:08 PM, the Chief Quality Officer verified the findings at A.

Based on medical record review, policy and procedure review, and interview, the facility failed to maintain accurately documented, complete medical records for 20 of 20 medical records reviewed in that there were no Patient Rights and Responsibilities notifications in the medical records for 20 of 20 (#1-#20) medical records reviewed. The failed practice did not assure completeness of the medical records and had the likelihood of affecting all patients seen in the facility. Findings follow:

A. During medical record review on 11/19/24, there was no evidence provided Patient #1-#20 were provided a copy of their Patient Rights and Responsibilities.
B. Review of Policy and Procedure titled: Patient Rights and Responsibilities reviewed/revised 09/18/24 showed, "It is the policy of (Named) facility to ensure a copy of Patient Rights and Responsibilities is provided to each patient without regard to gender, race, ethnicity, cultural, or religious background. Hospital staff are provided with information regarding patient rights during new employee orientation."
C. During an interview with the Chief Quality Officer on 11/20/24 at 9:30 AM, she confirmed the findings in A and B.

Based on observation, review of National Fire Protection Agency (NFPA) 101 standards , review of facility maintenance logs and interview. It was determined the facility failed to:

1. Provide battery-powered emergency lighting
2. Conduct a weekly generator test
3. Maintain the area adjacent to the generator
4. Ensure bank test switch gear was conducted

The failed practice had the likelihood to affect all patients and staff in that in the event of a power outage emergency there would be no lighting to illuminate the work area and had the likelihood to affect all patients receiving care in the facility. Findings follow:

A. Review of NFPA 101, 2012 guidelines showed:
1) Requirement: Emergency lighting must be provided in all areas where it is necessary for the safety of building occupants in the event of a power failure. This includes illumination for exit routes, exits, and specific areas of the building like stairs or corridors. (chapter 7)
2) NFPA 101 requires that emergency systems (including generators) be regularly tested. Debris can impair the proper functioning of the generator if it clogs filters, exhaust systems, or ventilation areas. Regular testing and inspection of the generator can help identify if debris has become an issue and can be promptly addressed. (Section 7.9)
3) Annual Load Bank Test: NFPA 110 requires that emergency generators undergo a full-load test using a load bank at least once a year to verify that the generator can handle its full rated capacity. The test should run for a minimum of 30 minutes at full load to ensure that the generator can maintain performance and prevent issues like wet stacking (carbon buildup in the engine) or inadequate fuel system operation.

B. Observation of the generator 11/18/2024 at 1:35 PM showed the following:
1) There were no functioning batteries present in the generator backup lights.
2) Generator had a build up of dirt and debris around it.

C. Review of facility maintenance logs showed the following:
1) There is no evidence the generator was tested on a weekly basis
2) There was no evidence that the load bank test was tested through switch gear and was not documented correctly.

D. The findings of A, B, and C were verified with the Director of Maintenance 11/19/2024 at 2:00 PM.

Based on review or facility maintenance records, review of National Fire Protection Agency (NFPA) standards, observation and interview it was determined the facility failed to:

1. Conducted ceiling tile checks monthly.
2. Conducted water temperature checks weekly.
3. Ensure fire extinguishers checks were logged or checked monthly.
4. Ensure boiler temperature checks were documented.
5. Ensure exhaust fan were checked monthly.
6. Ensure emergency exit light checks were conducted monthly.
7. Ensure emergency door checks were conducted.

The failed practice did not ensure a safe environment for the patients and staff and had the likelihood to affect all patient receiving care in the facility and staff. Findings follow:

A. Review of NFPA standards showed the following:
1) NFPA requirements for conducting ceiling tile checks, as outlined in NFPA 101 (Life Safety Code), stipulate that ceiling tiles must be inspected regularly to ensure they are properly secured and do not obstruct fire protection systems, such as sprinklers, or interfere with safe egress routes.
2) NFPA requirements for conducting water temperature checks, as outlined in NFPA 13 (Standard for the Installation of Sprinkler Systems), mandate that the water temperature in sprinkler systems must be regularly checked to ensure it remains within the specified range to prevent freezing or damage to the system, ensuring its reliable operation in an emergency.
3) NFPA requirements for conducting fire extinguisher checks, as outlined in NFPA 10 (Standard for Portable Fire Extinguishers), mandate that fire extinguishers must be inspected monthly to ensure they are fully charged, properly mounted, and free of obstruction, with a thorough annual maintenance check to verify their operational readiness.
4) NFPA requirements for conducting boiler checks, as outlined in NFPA 85 (Boiler and Combustion Systems Hazards Code), mandate that boilers must be regularly inspected, tested, and maintained to ensure safe operation, including checking safety devices, controls, and combustion systems, in accordance with the manufacturer's recommendations and applicable codes.
5) NFPA requirements for conducting exhaust fan checks, as outlined in NFPA 90A (Standard for the Installation of Air-Conditioning and Ventilating Systems), mandate that exhaust fans be regularly inspected and tested to ensure they are operating properly, free of obstructions, and capable of effectively ventilating smoke or fumes during an emergency.
6) NFPA requirements for conducting emergency light checks, as outlined in NFPA 101 (Life Safety Code), mandate that emergency lighting systems be tested monthly to ensure they are operational, with a full-duration test conducted annually to verify they provide adequate illumination for at least 90 minutes during a power outage.
7) NFPA requirements for conducting emergency door checks, as outlined in NFPA 101 (Life Safety Code), mandate that emergency doors be inspected regularly to ensure they are unobstructed, properly functioning, and capable of being opened easily without the use of a key or special knowledge, especially during a fire or evacuation situation.


B. Review of facility maintenance records on 11/19/2024 at 11:30 AM showed the following:
1) There was no evidence the facility conducted ceiling tiles checks
2) There was no evidence the facility conducted water temperature checks
3) Fire extinguisher checks weren't logged correctly monthly
4) Boiler temperature checks weren't documented correctly daily
5) There was no evidence of exhaust fan checks
6) There was no evidence of emergency exit light checks
7) There was no evidence of fire wall penetration checks
8) There was no evidence of emergency door checks since 2022

C. The finding of A and B were verified with the Director of Maintenance on 11/19/24 at 2:15 PM



Based on observation of the kitchen, Emergency Department, Obstetrics Department, Women and Children, and A-wing and interview, it was determined the facility failed to maintain the building physical structure, safety, environment, and equipment in a state of good repair. The failed practice promoted the spread of infection and/or placed the patients at risk of fire. The failed practice had the likelihood to affect all patients, staff and visitors, Findings follow:

A. Observation of the kitchen on 11//19/2024 at 10:49 AM showed the following :
1) Wall penetration in the dry food pantry
2) Ansul (fire suppression) hasn't been properly been checked since 2021 and 2022 through the fire department
3) Tray warmer exceeded temperature of 165 in that the temperature was 175 degrees
4) Pipe penetration next to vent hood had a hole that needed to be sealed
5) Ceiling tiles throughout dietary needed to be changed due to being cracked and stained
6) Vents need cleaning in dietary contained dust and debris

B. The finding of A were verified with the Director of Maintenance on 11/19/24 at 2:20 PM

C. Observation of the Emergency Department on 11//19/2024 at 11:25 AM showed the following:
1) Damaged cabinet doors in Room 2A/2B were hanging off hinge and no door handle
2) Floor needed to be repaired in Room 2A/2B due to cracked floor tile
3) Items were stored under the sink in Room 2A/2B
4) Ceiling tiles damaged in main entrance of Emergency Department were cracked and stained
5) Emergency receptacles were not labeled to show they have properly been checked yearly (NFPA requirements for polarity and tension testing on emergency receptacles, as specified in NFPA 70 (National Electrical Code) and NFPA 99 (Health Care Facilities Code), mandate that emergency receptacles must be tested to ensure correct polarity and proper tension, ensuring they function reliably during an emergency to provide power for critical equipment).
6) Throughout the emergency department were damaged baseboards that were falling off, missing, and cracked
7) Fire double doors leading into Emergency Department did not latch completely (NFPA requirements for fire door latching, as outlined in NFPA 80 (Standard for Fire Doors and Other Opening Protectives), specify that fire doors must be equipped with a latching mechanism that ensures the door remains securely closed under normal conditions, and the latch must be capable of holding the door closed during a fire, preventing the spread of smoke and flames).

D. The finding of C were verified with the Director of Maintenance on 11/19/24 at 2:20 PM.

E. Observation of the Obstetrics Department on 11/19/2024 at 12:00 PM showed the secured door would not open with badge access.

F. The finding of E was verified with the Director of Maintenance on 11/19/24 at 2:20 PM.

G. Observation of the A-wing on 11//19/2024 at 12:20 PM showed the fire door would not close properly.

J. The finding of I was verified with the Director of Maintenance on 11/19/24 at 2:20 PM.