North Baldwin Infirmary

“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: 41623 Based on observations and interviews with staff during a tour of the hospital by Life Safety Code 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-0226, K-0351, K-0363, K-0781, K-0211, K-0226, K-0353, K-0372, K-0345, and K-0712.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 50417 Based on medical record (MR) review, hospital policy, and interviews with staff, it was determined the hospital failed to ensure the hospital policy for skin assessment including wound measurements were followed. This deficient practice did affect three of nine MRs reviewed with wounds, including Patient Identifier (PI) # 18, PI # 3, and PI # 1, and had the potential to negatively affect all patients admitted to the hospital with wounds. Hospital Policy: Skin Assessment Policy Number: Not documented Revised: 3/25/25 Purpose: To establish guidelines for skin assessment and treatment options. Policy: Patient skin assessment should be completed ...upon admission and at a minimum of every shift ...or as indicated ...documentation in the electronic medical record...should be documented...upon admission ...flowsheet should be updated. ...5. The Wound Care Nurse or nurse who is specially trained and competent should measure wounds at the time of consult and within the next week or on subsequent visits as indicated by the patient condition... Findings include: 1. PI # 18 was admitted to the hospital on 3/12/25 with a diagnosis of Acute Hypoxic Respiratory Failure. Review of the primary nurse documentation dated 3/16/25 revealed a medial coccyx, unstageable pressure ulcer (PU). Review of the Physician’s Order dated 3/16/25 at 12:11 AM revealed orders for the Wound Care Nurse to assess coccyx wound. Review of Employee Identifier (EI) # 16, Wound Care Nurse, Televisit assessment, dated 3/16/25 at 5:19 AM revealed documentation of an unstageable PU. There was no documentation of wound measurements. An interview was conducted on 4/24/25 at 2:12 PM with EI # 3, Director of Nursing, who confirmed the agency failed to ensure wound measurements were completed per hospital policy. 30952 2. PI # 3 was admitted to the hospital on 6/29/24 with diagnoses including Acute Respiratory Failure, Severe Obesity, PU left (L) heel and sacrum, and Chronic wound right (R) lower extremity. Record review revealed wound care orders dated 6/29/24 for routine daily care, Mepilex dressing to a sacral stage 2 decubitus ulcer, saline wet-to-dry dressing R lower leg wound, and L heel wound, heel protectors if possible. Review of the nurse documentation dated 6/29/24 revealed a sacral PU, a perineum PU, and an arterial ulcer on the R posterior calf. There was no nursing assessment documentation of a L heel PU. There were no wound measurements documented for any wound. Review of the 6/30/24, 7/2/24, and 7/3/24 nurse documentation revealed no documentation of wound measurements. Review of the 7/1/24 nurse documentation revealed no wound assessments, no wound measurements, and no documentation wound care was provided. An interview was conducted on 4/24/25 at 2:34 PM with EI # 12, Medical Surgical /Intensive Care Manager, who confirmed there was no documentation wounds were measured, wounds were not assessed each shift per policy, and wound care was not provided daily as ordered. 3. PI # 1 was admitted to the hospital on 4/20/25 with diagnoses including Altered Mental Status, and recent Fall. Review of the 4/20/25 Emergency Department record documentation revealed the presence of a sutured laceration below the L eye, and bruising with skin tears to the L shoulder, and L knee. Further record review revealed wound orders dated 4/20/25, apply Bactroban 2 % to face, L knee, and L shoulder topically twice daily for seven days. Review of the nurse documentation dated 4/20/25 revealed no documentation the skin tears were measured. Review of the nurse documentation dated 4/21/25 revealed no documentation of wound assessments to the L shoulder or L knee skin tears. Review of the nurse documentation dated 4/22/25 at 6:00 AM revealed the presence of a R anterior knee skin tear. There was no wound assessment, and no wound measurements documented. Staff failed to conduct wound assessments every shift and document wound measurements at least every week per hospital policy. An interview was conducted on 4/24/25 at 2:08 PM with EI # 12, who confirmed staff failed to follow the hospital policy for wound assessment and measurements.”

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 30952 Based on observation, hospital policy and procedure, Diversey J-512 Sanitizer, manufacturer directions for use (MDFU), and staff interviews, it was determined the facility failed to ensure staff followed the policy and the MDFU of the sanitizing solution. This had the potential to negatively affect patients, staff, and visitors. Findings include: Hospital Policy: Sanitizing Food Contact Surfaces Policy Number: F018 Date Reviewed: 3/24 Policies: ...Sanitizer solution must be at 200 ppm (parts per million) for J-512 Sanitizer. Procedures: ...Refer to the Diversey Product Guide for appropriate chemicals for...sanitization. ...Pot Sink: ...Immerse items in sanitizing solution for a minimum of 60 seconds... Diversey J-512 Sanitizer Use Instructions ...For Sanitization: To Sanitize Hard, Non-Porous Food Contact Surfaces and Equipment: ...3. Apply sanitizing solution by immersion...as appropriate to the equipment or surfaces to be treated. Allow a contact time of at least one minute... 1. An observation was conducted on 4/22/25 at 12:45 PM at the three compartment sink for sanitization of the cookware with Employee Identifier (EI) # 9, Cook. An interview was conducted on 4/22/25 at 12:50 PM, during the observation, with EI # 9. EI # 9 was asked how long the cookware should remain in the third bin sanitizer in the three compartment sink. EI # 9 reported, “10-15, maybe 20 seconds.” The surveyor observed EI # 9, wash, rinse, and sanitize three pans, three tong utensils, and a measuring cup, for a total of seven items. EI # 9 failed to allow each piece of cookware at least a one-minute immersion time in the sanitizer. An interview was conducted on 4/23/25 at 3:25 PM with EI # 11, Clinical Nutrition Manager. EI # 11 confirmed all cookware was not immersed in the Diversey sanitizing solution for the minimum 60 seconds per hospital policy and the Diversey J-512 MDFU.”

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 30952 Based on review of the hospital Emergency Preparedness Operations Plan (EOP) documentation, and interviews with staff, it was determined the hospital failed to ensure all off site locations were included in a comprehensive emergency preparedness program. This affected one of the six offsite locations, including North Baldwin Infirmary (NBI) Infusion Center, and had the potential to negatively affect all patients, staff, and visitors at the outpatient clinic. Findings include: Review of the hospital EOP documentation last reviewed 8/15/24, revealed the program scope was designed for NBI facilities. There was no documentation The Infusion Center, an offsite location, was included in the NBI EOP plan. An interview was conducted on 4/24/25 at 9:30 AM with Employee Identifier (EI) # 14, Manager, Protective Services, and EI # 15, Facility Compliance/Safety Manager, which confirmed the hospital had six offsite outpatient clinics under the facility provider number. EI # 14 reported there was an outpatient clinic, NBI Infusion Center, located greater than 20 miles away, in Daphne, Alabama. EI # 14 reported he/she recently learned the Infusion Center, was under the NBI provider number. An interview was conducted on 4/24/25 at 11:50 AM with EI # 15, who confirmed the Infusion Center, located in Daphne, was opened in 11/2023, and was not included in the NBI EOP.”

“EP Training Program CFR(s): §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: 30952 Based on review of contracted service personnel files, and interview with staff, it was determined the hospital failed to ensure contracted staff received training on Emergency Preparedness (EP) a minimum of every two years. This affected two of two contracted service employee files reviewed and had the potential to affect all persons served by the hospital. Findings include: Review of the dietary staff personnel files provided revealed no documentation Employee Identifier (EI) # 9, Cook, date of hire (DOH) 6/24/24, completed initial EP training. Review of EI # 10, Food Service Worker, DOH 11/4/16, personnel file documentation, revealed last EP training was 7/2020, which was greater than every two years. An interview was conducted on 4/25/25 at 10:40 AM with EI # 11, Clinical Nutrition Manager, Contracted Service, who confirmed there was no documentation the two employees had current EP training.”

“. K3 Building: 0103 K6 Plan Approval: 1968/1991 K7 Survey Under: 2012 Existing K8 HOSP Generator: One Diesel, Cummins 750 kW (installed 2003) FACP: Simplex 4100U (installed 2005) Locking Devices: Magnetic full time for the Geri-Psych Unit only Fire Pump: One Electric Patterson LX 2100 (installed 2003) Smoke Detection: Complete Beds: 78 Census: 30 Type of Structure: 1968 two story unprotected noncombustible, Type II (000). 1991 two story protected noncombustible, Type II (111). This building has a complete automatic sprinkler system. During a routine recertification survey conducted on this date, the requirements of 42 CFR, Subpart 482.41 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. .”

“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 use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the means of egress per the requirements of: 2012 NFPA 101, 19.2.1, and 7.2.1.9.1.3 This deficiency affects 1 powered door leaf. Findings include: During a tour of the facility, the surveyor observed the powered door leaf, egress door between the Radiology and Surgery corridors did not have a sign on the egress side that reads: “IN EMERGENCY, PUSH TO OPEN”. A member of the maintenance staff was present when this deficiency was identified. .”

“Horizontal Exits CFR(s): NFPA 101 Horizontal Exits Horizontal exits, if used, are in accordance with 7.2.4 and the provisions of 18.2.2.5.1 through 18.2.2.5.7, or 19.2.2.5.1 through 19.2.2.5.4. 18.2.2.5, 19.2.2.5 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain a horizontal exit per the requirements of: 2012 NFPA 101, 19.2.2.5, 7.2.4.3.1, and 8.3.5.1 This deficiency affects 1 hoizontal exit. Findings include: During a tour of the facility, the surveyor observed an unsealed 3” conduit used as a chase for multiple black, red, blue and gray cables in the 2-hour fire barrier above the ceiling over the fire barrier cross-corridor doors between the Radiology and Administration corridors. A member of the 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 entire building. Findings include: During a tour of the facility, the facility failed to provide a smoke detector sensitivity test report conducted within the past two years. 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 a quick-response sprinkler 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 1 sprinkler compartment. Findings include: During a tour of the facility, the surveyor observed a quick-response sprinkler head installed in the same compartment (the Sitting/Waiting area outside the Chapel) with standard-response sprinkler heads. 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 observation and review of documentation, the facility failed to maintain the automatic sprinkler system per requirements of: 2012 NFPA 101, 19.3.5.1, and 9.7.5 2011 NFPA 25, 5.3.1.1.1.3 This deficiency affects the first floor and third floor of this building. Findings include: During a tour of the facility, the facility failed to provide documentation that the 2004 fast-response sprinkler heads found throughout the first and third floor of this building had been replaced or a representative sample tested within 20 years of installation. A member of the maintenance staff was 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: 41792 . Based on observation, the facility failed to maintain a corridor door per the requirements of: 2012 NFPA 101, 19.3.6.3.13 This deficiency affects 1 of 2 Pharmacy corridor doors. Findings include: During a tour of the facility, the surveyor observed the Pharmacy corridor door was a “Dutch” style door with the following deficiencies: 1. The upper leaf was not equipped with a latching device 2. The meeting edges of the upper and lower leaves were not equipped with an astragal, a rabbet, or a bevel A member of the maintenance staff was present when this deficiency was identified. .”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of: 2012 NFPA 101, 19.3.7.3, 8.5.1, 8.5.6.2, and 8.5.6.3 This deficiency affects 1 of 2 smoke barriers. Findings include: During a tour of the facility, the surveyor observed a 3/4” unsealed conduit used as a chase with multiple blue, white and black cables above the ceiling on both sides of the smoke barrier between the Main Hospital Lobby and the Radiology corridor. A member of the maintenance staff was present when this deficiency was identified.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 41792 . Based on review of documentation, the facility failed to conduct fire drills per the requirements of: 2012 NFPA 101, 39.7.2, 4.7.2, and 4.7.6 This deficiency affects all occupants of the facility. Findings include: During a review of documentation, the facility failed to provide documentation that fire drills were performed periodically, during the past year. 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 5 smoke barriers. Findings include: During a tour of the facility, the surveyor observed a portable space heating device that was off but plugged in to a receptacle, in the Medicaid Office. The device was sitting on the carpeted floor. The portable space heating device was not located in a patient sleeping smoke compartment. 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.”