Lake Martin Community Hospital

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 49797 Based on observations and interviews with staff during a tour of the hospital by Life Safety Code and health surveyors, it was determined the hospital was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served by this hospital. Findings include: Refer to tags: K-0271, K-0321, K-0324, K-0345, K-0351, K-0353, K-0363, K-0741, K-0781, K-0908, K-0918, K-0923 and health survey citation A-724.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 46293 Based on observation, hospital policy, and interviews, it was determined the hospital failed to ensure expired medications were not available for patient use. This had the potential to negatively affect all patients served by this hospital. Findings include: Hospital policy: Storage of Medications in Patient Care Areas Policy number: None Date effective: 1/1/23 Policy: ...7. Medications bearing an expiration date will not be dispensed or distributed beyond the expiration date. 8. Expired... medications shall be returned to the pharmacy for proper credit and/or disposal. A tour of the surgical suite was conducted on 10/22/24 at 10:32 AM with Employee Identifier (EI) # 3, Registered Nurse, Outpatient Services Manager. An observation of the locked narcotic box revealed two vials of Fentanyl Citrate 100 micrograms (mcg) two milliliters (ml) with an expiration date of 9/1/24. EI # 3 confirmed, during the tour, the medication vials were expired, and available for patient use.”

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 50417 Based on observations, review of hospital policy and procedure, and interviews with staff it was determined the hospital failed to ensure expired foods were not available for use. This had the potential to affect all patients served by this hospital. Findings include: Hospital Policy: Expired Food Issued: 10/24/24 Policy: All food in the store room, refrigerator, deep freezers, walk in refrigerator, and walk in freezer will be thrown away on the expiration date or the “best if used by” date. Procedure: All food in the freezers will be thrown away on the expiration date or “best by” date. 1. A tour of the dietary department was conducted on 10/22/24 at 10:16 AM with Employee Identifier (EI) # 4, Cook, the following items were found in the dietary deep freezer. Eight egg and cheese omelets expired on 9/14/24. Three southern style chickens expired on 9/14/24. The staff failed to ensure foods were discarded when expired. An interview was conducted on 10/22/24 at 11:01 AM with EI # 4 who confirmed the egg and cheese omelets and southern style chickens were expired and available for patient use.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 46293 Based on observation, policies, and interviews, it was determined the hospital failed to ensure expired supplies were not available for patient use. This had the potential to negatively affect all patients served at this hospital. Findings include: Hospital policy: Shelf Life of Sterile Supplies/Non-sterile Supplies Policy number: PP 98 Date of review: 03/24 Purpose: To establish policy and provide standard procedure for determining the expiration date of sterilized/non-sterilized supplies. Policy: The following shelf life will be assigned as indicated to all medical and surgical supplies ... ...4. supplies are theoretically sterile until pack is opened or damaged or by manufacturer expiration date. 5. All other patient use supplies will be removed from stock and discarded appropriately according to the manufacture expiration date. Supplies are to be checked monthly in each department for expiration dates ... Hospital policy: Central Sterile Services Policy number: 101.012 Effective date: 03/30/2022 ...II. Policy: ...c. All supplies are to be checked for expiration on a monthly basis. When supplies have expired, they are immediately removed from circulation and turned in to the purchasing clerk. A tour of the Surgery unit was conducted on 10/22/2024 at 10:32 AM. with Employee Identifier (EI) # 3, Registered Nurse (RN), Outpatient Services Manager. In the Operating Room (OR) # 1: Two Medline intravenous (IV) Securement Sets with an expiration date of 1/31/23. One Rusch Sterile Slick Set with an expiration date of 12/28/21. One Scope Valet Trapit Dual Polyp Trap with an expiration date of 7/18/22. Eleven Precisor Hot Disposable Biopsy Forceps, 10 with an expiration date of 3/27/24, and one with an expiration date of 7/14/21. Four Scope Valet Trapit Single Chamber Polyp Trap with an expiration date of 7/24/22. Three Boston Scientific Resolution Clip, two with an expiration date of 1/7/21, and one with an expiration date 1/31/21. Six 3M Steri-Drapes with an expiration date of 8/20/23. Two 10 percent (%) 60 milliliter (ml) Neutral Buffered Formalin with an expiration date of 5/22. Three Scope Valet Endoscopic Bite Blocks with an expiration date of 4/10/23. In the OR hallway: Twenty Biological Indicators for the autoclave with an expiration date of 2/25/23. In the crash cart: Two IV Securement Sets with an expiration date of 9/30/21. Five Covidien Monoject 12 ml syringes with an expiration date of 5/31/23. In the Pre-Op area: One Braun 18 gauge (g) by (x) 1 ¼ inch needle with an expiration date of 9/1/21. Two Bectin Dickinson (BD) BBL Culture Swab with an expiration date of 5/31/21 and 7/31/24. Ninety Six BD 21 g x 1 inch Precision Glide Needle with an expiration date 9/20/19. One Hundred BD 18 g x 1 ½ inch needle with an expiration date of 1/31/22. An interview was conducted, during the tour, with EI # 3 who confirmed the supplies were expired and remained available for patient use.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 46293 Based on observations, hospital policies and procedures, Centers for Disease Control and Prevention (CDC) Guidelines for the Prevention of Intravenous (IV) Catheter-Related Infections, updated 2/28/24, CDC Hand Hygiene in Healthcare Setting, reviewed 1/8/21, and interviews, it was determined the hospital failed to ensure staff: 1. Performed hand hygiene per hospital policy. 2. Disinfected the rubber septum of a medication vial with alcohol per hospital policy. 3. Scrubbed the access port of the needless IV tubing prior to administration of IV medication per CDC Guidelines. 4. Donned gloves prior to IV medication administration. This did affect Patient Identifier (PI) # 25, one of one observation of an Endoscopy, PI # 2 and an unsampled patient, in two of four medication administration observations, and had the potential to negatively affect all patients served by the hospital. Findings include: Hospital policy: Hand Hygiene Policy number: 201.007 Effective date: 10/29/19 Purpose: To reduce the transmission of infectious pathogens Policy: All staff members involved with patient care shall practice proper hand hygiene... Procedure: Decontaminate hands before donning sterile gloves ... Decontaminate hands after contact with a patient’s intact skin (i.e. when taking a pulse or a blood pressure) ... Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. Decontaminate hands after removing gloves. CDC Hand Hygiene in Healthcare Settings reviewed 1/8/21. Glove Use ...perform hand hygiene prior to donning gloves... Perform hand hygiene immediately after removing gloves... ...Wearing gloves reduces the risk of healthcare workers acquiring infections from patients... Hospital policy: Safe Injection Practices Policy number: PP XXI 2b Date reviewed: 03/24 Policy: Safe Injection Practices are a set of recommendations within Standard Precautions, which are the foundation for preventing transmission infections during patient care in the hospital setting. Procedure: 1. Proper hand hygiene...is performed prior to preparing and administering medications 2. Injections are prepared using aseptic technique... 4. The rubber septum on a medication vial is disinfected with alcohol prior to needle insertion into the vial. This includes newly opened vials after the dust cap is removed... CDC Guidelines for the Prevention of IV Catheter-Related Infections, updated 2/28/24 Needleless IV Catheter Systems Recommendations: ...4. Minimize contamination risk by scrubbing the access port with an appropriate antiseptic (...70 % alcohol) and accessing the port only with sterile devices... 1. An observation was conducted on 10/22/24 at 12:05 PM of Employee Identifier (EI) # 5, Licensed Practical Nurse, administered IV antibiotics for PI # 2. EI # 5 removed the previously administered antibiotics bag, disinfected the patient’s IV access port using an alcohol pad, and connected the new antibiotic bag to the patient’s IV access port for administration of the IV medication. EI # 5 failed to don gloves prior to the disinfection of the IV access port and administration of the antibiotic, An interview was conducted on 10/24/24 at 12:00 PM with EI # 2, who confirmed the medication was given without following the hand hygiene policy. 2. An observation was conducted on 10/22/24 at 12:05 PM of EI # 7, Registered Nurse (RN), administered IV antibiotics to an unsampled patient. EI # 5 removed the previously administered antibiotics bag, disinfected the patient’s IV access port using an alcohol pad, and connected the new antibiotic bag to the patient’s IV access port for administration of the IV medication. EI # 5 failed to don gloves prior to the disinfection of the IV access port and administration of the antibiotic. An interview was conducted on 10/24/24 at 12:00 PM with EI # 2, who confirmed the medication was given without following the hand hygiene policy. 3. An observation was conducted on 10/24/24 at 7:24 AM of an Endoscopy for PI # 25. EI # 3, Outpatient Services Manager, donned gloves, without performing hand hygiene, started an IV catheter on PI # 25, then removed gloves. EI # 3 failed to perform hand hygiene prior to donning gloves and after removing gloves. EI # 8, Certified Registered Nurse Anesthetist (CRNA), and EI # 9, RN, donned gloves then transferred, per stretcher, PI # 25 into the Operating Room (OR) for the procedure. EI # 8 and EI # 9 failed to perform hand hygiene prior to donning gloves. EI # 10, scrub tech, donned gloves to assist with the non-sterile procedure. EI # 10 failed to perform hand hygiene prior to donning gloves. EI # 8 removed gloves, donned clean gloves, opened sterile syringe, withdrew Propofol and administered the Propofol IV to PI # 25. EI # 8 failed to perform hand hygiene after removing gloves, disinfect the rubber septum with alcohol prior to insertion of the needle, and disinfect the access port prior to administration of the Propofol. At the end of the procedure, EI # 9 and EI # 10 removed gloves and failed to perform hand hygiene. EI # 9 donned gloves, without performing hand hygiene, to assist in transfer of PI # 25 to the recovery room (RR). EI # 11, RN, donned gloves placed monitors on the patient, discontinued the IV, removed monitors from the patient, then assisted the patient with dressing. EI # 11 failed to perform hand hygiene prior to donning gloves and after contact with inanimate injects in the immediate vicinity of the patient. An interview was conducted on 10/24/24 at 11:55 AM with EI # 2, Director of Nursing, who confirmed staff did not follow hand hygiene per hospital policy, disinfect rubber septum of vial and access port of IV per CDC Guidelines. 49894”

“. K3 Building: 0101 K6 Plan Approval: 1964/1977 K7 Survey Under: 2012 Existing K8 Hosp Generator: One Diesel, Cummins 210 kW (installed 1995) FACP: Fike Cyber Cat 254 (installed 2007) Locking Devices: Two magnetic full time in the E.R. Smoke Detection: Corridor Beds: 46 Census: 10 Type of Structure: 1964/1977 One story unprotected noncombustible, Type II(000). The facility has a complete automatic sprinkler system. During a routine recertification survey conducted on this date, the requirements of 42 CFR, Subpart 482.41 - HOSP were not met as evidenced by the following deficiencies of the 2012 NFPA 101 Life Safety Code (LSC), the 2012 NFPA 99 Health Care Facilities Code and the standards referenced by these codes, as observed by the LS Surveyor while accompanied by the facility maintenance personnel. .”

“Discharge from Exits CFR(s): NFPA 101 Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the exit discharge per the requirements of: 2012 NFPA 101, 19.2.1, and 7.7.3.2 This deficiency affects 1 of 7 exits. Findings include: During a tour of the facility, the surveyor observed the exit discharge to the public way at rooms 227 and 228 was not arranged and marked to make clear the direction of egress travel from the exit discharge to public way. This exit discharge passed through an outside covered sitting/smoking area. A member of the maintenance staff was present when this deficiency was identified. .”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain a hazardous room per the requirements of: 2012 NFPA 101, 19.3.2.1.2, and 8.4.2 (3) (a) This deficiency affects 2 of 4 smoke compartments. Findings include: During a tour of the facility, the surveyor observed Mechanical Room #4 had a gas boiler and an unsealed penetration around a 1 1/2” conduit through the South (2 hour fire barrier) wall. A member of maintenance staff was present when this deficiency was identified. .”

“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: 42853 . Based on observation, the facility failed to maintain the kitchen hood per the requirements of: 2012 NFPA 101, 19.3.2.5.1, and 9.2.3 2011 NFPA 96, 5.1.2, 12.1.2.2, 12.1.2.3, and 12.1.2.3.1 This deficiency affects the kitchen hood. Findings include: During a tour of the facility, the surveyors observed the facility failed to provide the following: 1. An approved method to ensure appliances that are protected under the hood, if they are moved, they are returned to the approved design location. 2. A liquidtight continuous external weld to the kitchen hood’s seams and/or joints, that direct and capture grease-laden vapors and exhaust gases. A member of maintenance staff was present when this deficiency was identified. .”

“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: 42853 . Based on review of documentation, the facility failed to maintain the smoke detectors per the requirements of: 2012 NFPA 101, 19.3.4.1, and 9.6.1.3 2010 NFPA 72, 14.4.5.3.2 This deficiency affects the entire facility. Findings include: During a tour of the facility, the facility failed to provide a smoke detector sensitivity test report completed within the past two years. The facility failed to provide the last documented smoke detector sensitivity test. A member of the maintenance staff was present when this deficiency was identified. .”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to install quick-response sprinklers per the requirements of: 2012 NFPA 101, 19.3.5.1, and 9.7.1.1(1) 2010 NFPA 13, 8.3.3.2, and 8.3.3.4 This deficiency affects the Emergency Department Waiting Room. Findings include: During a tour of the facility, the surveyor observed one quick-response sprinkler had been installed in the same compartment (the Emergency Department Waiting Room) with 5 standard-response sprinklers. A member of the maintenance staff was present when this deficiency was identified. .”

“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: 42853 . Based on review of documentation, the facility failed to maintain the automatic sprinkler system per the requirements of: 2012 NFPA 101, 19.3.5.1, 9.7.5, and 9.7.8 2011 NFPA 25, 14.2.1 This deficiency affects the automatic sprinkler system. Findings include: During the review of the documentation, the facility failed to provide documentation of conducting the automatic sprinkler internal pipe inspection during the past 5 years. A member of the maintenance staff and the administrator were present when this deficiency was identified. .”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 42853 . Based on observation, the facility failed to maintain the corridor doors per the requirements of: 2012 NFPA 101, 19.3.6.3.4 This deficiency affects two residents’ rooms corridor doors. Findings include: During a tour of the facility, the surveyor observed residents’ rooms 217 and 218 corridor doors had an approximately 3/4 in. gap between the door and door frame when door was fully closed; prohibiting the door from being smoke resistive. A member of the maintenance staff was present when this deficiency was identified. .”

“Smoking Regulations CFR(s): NFPA 101 Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4 This Standard is not met as evidenced by: 42853 . Based on observation, the facility failed to maintain the permitted smoking area per the requirements of: 2012 NFPA 101, 19.7.4 (6) This deficiency affects 1 of 1 smoking areas. Findings include: During a tour of the facility, the surveyor observed the residents’ medical detox unit permitted smoking area was without a metal container with self-closing cover device: A member of the maintenance staff was present when this deficiency was identified. .”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to prohibit a portable space heating device per the requirements of: 2012 NFPA 101, 19.7.8 This deficiency affects 1 of 4 smoke compartments. Findings include: During a tour of the facility, the surveyor observed a portable space heating device on a night stand next to a bed in the Doctors Lounge, this device was not on. This was located in a patient sleeping smoke compartment and the facility was unable to provide documentation that the heating element did not exceeding 212 degrees. A member of the maintenance staff was present when this deficiency was identified. .”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This Standard is not met as evidenced by: 42853 . Based on review of documentation, the facility failed to maintain the piped medical gas and vacuum systems per the requirements of: 2012 NFPA 99, 5.1.14.2.3 This deficiency affects all of the piped medical gas and vacuum systems. During a tour of the facility, the facility failed to provide documentation of the annual inspection for the piped medical gas and vacuum systems for the past 12 months. A member of the maintenance staff was present when this deficiency was identified. .”

“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 4 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, readily identifiable, and separate from normal power circuits. 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: 41792 . Based on review of documentation, the facility failed to provide a remote manual stop station for the emergency generator per the requirements of: 2012 NFPA 101, 19.2.9.1, and 7.9.2.4 2010 NFPA 110, 5.6.5.6, and 5.6.5.6.1 This deficiency affects 1 of 1 emergency generator. Findings include: During a tour of the facility, the facility failed to provide a labeled, remote manual stop station (of a type to prevent inadvertent or unintentional operation) located outside the room housing the generator, for the 210 kW emergency generator. A member of the maintenance staff was present when this deficiency was identified. .”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 42853 . Based on observation, the facility failed to maintain the oxygen manifold cylinder storage area per the requirements of: 2012 NFPA 99, 11.6.2.3 (11), 11.3.2.3 and 11.6.5.4 This deficiency affects 1 of 1 outside oxygen manifold cylinder storage areas. Findings include: During a tour of the facility, the facility failed to protect the outside oxygen manifold cylinder storage area against continuous exposure to direct rays of the sun where extreme temperatures prevail. A member of the maintenance staff was present when this deficiency was identified.”