Davita Girard Estates Dialysis

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11. 20.2.1, 21.2.1, 7.1.10.1 This Standard is not met as evidenced by: 50804 Based on document review and interview, it was determined the facility failed to provide annual fire door functional/visual test, affecting the entire component. Findings include: Document review on July 23, 2024, at 9:30 a.m. revealed the facility failed to provide documentation of annual fire door inspection. Exit interview with the Administrator and Maintenance Director on July 23, 2024, at 12:00 p.m., confirmed the lack of documentation.”

“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. 20.5.1, 21.5.1, 21.5.1.2, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 50804 Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting the entire component. Findings include: Observation on July 23, 2024, at 11:52 a.m., revealed a blocked electrical panel in the electrical closet. Exit interview with the Administrator and Maintenance Director on July 9, 2024, at 12:00 p.m., confirmed the blocked electrical panel.”

“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: 50804 Based on document review and interview, it was determined the facility failed to provide receptacle testing documentation, affecting the entire component. Findings include: Document review on July 23, 2024, between 9:30 a.m. and 12:00 p.m., revealed the facility failed to provide documentation of receptacle testing. Exit interview with the Administrator and Maintenance Director on July 23, 2024, at 12:00 p.m., confirmed the lack of documentation.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for four continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 50804 Based on document review and interview, it was determined the facility failed maintain and inspect the emergency generator, affecting the entire facility. Findings include: Document Review on July 23, 2024, between 9:30 a.m. and 12:00 p.m., revealed the facility failed to provide documentation of the generator preventative maintenance indicating there was no evidence of wet stacking. Exit interview with the Administrator and Maintenance Director on July 23, 2024, at 12:00 p.m., confirmed the lack of documentation.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 50804 Based on observation and interview it was determined the facility failed to prohibit the improper use of power strips and outlet multipliers, affecting the entire component. Findings include: Observation made on July 23, 2024, at 11:55 a.m., revealed in the teammate lounge, there was a microwave plugged into a power strip. Exit interview with the Administrator and Maintenance Director on July 23, 2024, at 12:00 p.m., confirmed the improper use of power strips.”