Eastpointe 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: 49603 Based on observations and interviews during a hospital tour with hospital staff and the Life Safety Code surveyor, 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-0161, K-0222, K-0345, K-0353, K-0372, K-0511, K-0781, K-0914, K-0920”

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 53356 Based on the United States Food and Drug Administration (FDA) Food Code 2022, facility policies and procedures, Safety Data Sheets (SDS), observations, and interviews with staff, it was determined the hospital failed to ensure the following: a. Food was stored in a safe and sanitary manner. b. Trash bins remained covered per facility policy. c. Staff performed hand hygiene per facility policy. d. Chemicals were stored appropriately. e. Utensil handles in stored food remained above top of the food. f. Trays and plates were allowed to drain and air-dry before being stacked or stored. This deficient practice had the potential to negatively affect all patients, staff and visitors served by the facility. Findings include: United States Food and Drug Administration Food Code 2022 ...Chapter 3. Food... 3-305 Preventing contamination from the premises... 3-304. 12 In-Use Utensils, Between-Use Storage. During Pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored:... (B) In food that is not time/temperature control for safety food with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon;... 3-305.12 Food Storage, Prohibited Areas. Food may not be stored: ...(G) Under leaking water lines, including leaking automatic fire sprinkler heads, or under lines on which water has condensed... Chapter 4 Equipment, Utensils, and Linens... 4-901.11 Equipment and Utensils, Air-Drying Required. Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow... Chapter 7 Poisonous or Toxic Materials ...7-201 Storage 7-201.11 Separation. Poisonous or toxic materials shall be stored so they can not contaminate food, equipment, utensils, linens, and single-services and single-use articles by: (A) Separating the poisonous or toxic materials by spacing or partitioning; and (B) Locating the poisonous or toxic materials in an area that is not above food, equipment, utensils, linens, and single-service or single-use articles... Facility Policy: Disposal of Food Waste Policy Number: IC 3.21 Revised/Reviewed Date: 02/04/2025 ...Procedure:... 3. Rubbish and garbage items are kept in metal or plastic containers that do no leak. Containers must be covered with tight fitting covers except when in use in order to promote sanitary conditions and control rodents. Facility Standard Operating Procedure (SOP): Washing Hands SOP #: HACCP 126 Implementation Date: 8/24/15 Instructions: ...7. Wash hands:... Before putting on or changing gloves... After any clean up activity such as sweeping, mopping, or wiping counters... After handling trash... Facility Policy Name: Food Storage Policy Number IC 3.13 Revised/Reviewed Date: 01/31/2025 ...Procedure: ...Storage of Food Items... 25. Cleaning supplies are stored away from food and paper supplies. Safety Data Sheet Product Name: Solution QA Recommended Use: Sanitizer ...7. Handling and Storage ...Storage: Protect from freezing. Store locked up. Keep tightly closed in a dry, cool, and well ventilated place... Facility SOP: Storing and Using Poisonous or Toxic Chemicals SOP #: HACCP 120 Implementation Date: 8/24/15 Instructions: ...6. Store all chemicals in a designated secured area away from food and food contact surfaces using spacing or partitioning... 1. A tour of the kitchen was conducted on 6/16/26 at 10:15 AM with Employee Identifier (EI) # 3, General Manager. During the tour the following deficiencies were noted: a. Water was noted to be dripping from a blown light bulb in the dairy refrigerator. A small clear container was being used to catch the dripping water. Behind the clear container another container was noted to contain bread wrapped in clear plastic wrap. Several styrofoam containers were stored on a separate shelf to the left of the container with the dripping water. In the bottom of the refrigerator was a sealed container labeled hard cooked peeled eggs. b. Two trash containers were noted uncovered when not in use. c. A styrofoam cup was noted in the sealed container of flour. An interview was conducted at the time of the tour with EI # 3, who confirmed the styrofoam containers contained salads prepared to serve today to patients and a work order was placed for the light and leak last week. An interview was conducted on 6/18/26 at 1:22 PM with EI # 1, Chief Nursing Officer who confirmed the facility failed to store food in a safe and sanitary manner, ensure trash containers remained covered when not in use, and ensure proper utensils were used in stored food containers. 2. An observation of food prep was conducted on 6/17/26 at 10:30 AM with EI # 4, Cook. During the observation the following deficiencies were noted: a. EI # 4, was observed to use gloved hand to obtain a cloth and wipe down a cart within the kitchen area. The cloth was returned to sink, and gloves were changed without performing hand hygiene. b. EI # 4 was later observed to obtain a dirty cloth from the plating area and place it in a dirty laundry bag, after which he/she emptied food from fryer basket into metal serving dish without changing gloves and performing hand hygiene. An interview was conducted on 6/18/26 at 1:22 PM with EI # 1, who confirmed the facility staff failed to perform hand hygiene per facility policy. 3. An observation of food plating was conducted on 6/17/26 at 11:00 AM with EI # 4. During the observation the following deficiencies were noted: a. EI # 4, was observed to touch his/her face with gloved hand, after which he/she proceed to obtain utensils for plating and set out plates on counter for meal plating. EI # 4, failed to change gloves and perform hand hygiene after touching his/her face. b. EI # 4, was later observed to obtain cloth and wipe counter, after which he/she change gloves without hand hygiene, and began to uncover dishes to begin food plating. An interview was conducted on 6/18/26 at 1:22 PM with EI # 1, who confirmed the facility staff failed to perform hand hygiene per facility policy. 4. During a observation of the kitchen on 6/17/26 at 12:10 PM a green and a red bucket were noted to be beside stored cutting boards under the prep top table. An interview was conducted on 6/17/26 at 12:10 AM with EI # 3, who confirmed that one bucket contained water and the second bucket contained QA solution for cleaning. An interview was conducted on 6/18/26 at 1:28 PM with EI # 1, who confirmed the facility failed to ensure chemicals were properly stored away from food and food contact surfaces. 5. An observation of the dishwashing procedure was conducted on 6/17/26 at 12:03 PM with EI # 5, Food Service Worker. EI # 5 was observed to remove plates from washer, fan the plates two times and then proceed to stack them together. EI # 5 was later observed to remove three trays from dishwasher and immediately stack them on top of dry nested trays on shelf in kitchen. An interview was conducted on 6/18/26 at 1:22 PM with EI # 1, who confirmed that facility failed to allow equipment and utensils to air dry prior to stacking per the FDA Food Code.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 49603 Based on observations, review of hospital policy and procedure and staff interviews, it was determined the hospital failed to maintain a clean, sanitary, and safe environment. This deficient practice had the potential to affect all patients, visitors and staff served by this facility. Findings include: Facility Policy Name: Health and Safety (Environment of Care) Policy Number: HS 1.0 Revised Date: 2/3/2025 Policy: Altapointe Health Systems, Inc. (AHS) will maintain a Health and Safety (Environment of Care) program encouraging proper attention toward injury and illness prevention on the part of both supervisors and employees... Procedure: The Health and Safety/Environment of Care program will include: 1. Providing mechanical and physical safeguards to the maximum extent that is possible.... Facility Policy Name: Linens and Laundry Policy Number: IC 4.9 Revised Date: 3/25/2024 Policy: Altapointe Health protects patients and staff from exposure to potentially infectious materials during collection, handling, and sorting of contaminated linen... Procedure: ...3. Linens are changed per unit protocol. On the days that linens are changed, housekeeping wipes down the pillows and mattresses with appropriate disinfectant... 4. Laundry service is provided by in-house staff as needed... 1. A tour of Unit 400 was conducted with Employee Identifier (EI) # 2, Director of Nursing (DON), on 6/16/26 at 10:05 AM, the following was observed: Galley: 5 double cabinets, 2 single cabinets, and 9 drawers, unclean with coffee spills and coffee grounds, the floor unclean and sticky. Laundry Room with clean linens: An unclean floor, with dust, hair, and a T-shirt and undergarment lying on the floor. Rooms 402, 403, 407, 409, and 410: Black mold and pink mildew around edges of the shower floors. Room 402: A leaking showerhead created water on the bathroom floor. During the tour EI # 2 confirmed the hospital failed to maintain a clean, sanitary and safe environment of the rooms observed. 2. A tour of Unit 200 was conducted on 6/16/26 at 10:20 AM with EI # 7, Associate Clinical Director. The following was observed: Medication Room: The refrigerator was unclean and sticky with juice stains and spills on the shelving and on the door. Rooms 205, 206, 210, and 213: Mold/mildew in the floor of the shower with hair at the base of the shower in the corner round and baseboard flooring. Peeling plaster and grout at the base of walls, some with exposed metal L trim. Nightstand shelving, base of bed and surrounding floor dirty and dusty. Rust is evident around metal fixtures attached to the walls. Seclusion Room: The floor is dirty with dust noted. Smears of a dark maroon substance. are on the walls and splattered on the floor. A handprint is on the upper window of the door. Nursing Station: The outside wall of the nursing station with a smear of a dark maroon substance. During the tour, EI # 7 confirmed the hospital failed to maintain a clean, sanitary and safe environment per the hospital’s policy. 3. A tour of Unit 300 was conducted with Employee Identifier (EI) # 9, Nurse Coordinator, on 6/16/26 at 11:00 AM, the following was observed: Room 300: Peeling paint above the bedroom door. Room 302: Strong urine odor, floor around the base of the toilet soaked with urine, bottom side of mattresses on both beds soaked with urine, and clothing in basket wet with urine. Room 303: Strong urine odor, clothing in basket wet with urine, bottom side of mattress soiled with brown substance. During the tour EI # 9 confirmed the above findings were not per the hospital policy to maintain a clean, sanitary, and safe environment. 4. A tour of Unit 500 was conducted with EI # 2 on 6/16/26 at 11:10 AM, the following was observed: Rooms 502, 503, 504, 505, 507, and 508: Black mold and pink mildew around the edges of the shower floor. Room 503: A leaking showerhead collecting water inside the handicap rail creating black mold inside the rail. There was also a cover on top of the toilet tank that had a large amount of black mold on the right side of the cover. During the tour EI # 2 confirmed the observations, and confirmed the hospital failed to maintain a clean, sanitary and safe environment of the rooms observed.”

“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, facility policy and procedure, Center for Disease Control (CDC) Hand Hygiene in Healthcare Settings - Glove Use, and interviews, it was determined the facility failed to ensure staff: 1. Performed hand hygiene per the facility’s policy. 2. Performed hand hygiene prior to donning gloves per CDC glove use policy. 3. Used a clean tourniquet for each patient. This deficient practice affected one of one observation of lab work drawn and had the potential to affect all patients served by the facility. Findings include: Facility Policy: Hand Hygiene Policy Number: IC 3.02 Revised/Reviewed Date: 01/31/2025 Policy: Altapointe Health System (AHS) utilizes CDC guidelines for hand hygiene. According to the CDC, practicing hand hygiene is a simple yet effective way to prevent infections in healthcare settings. Definition: Hand hygiene- cleaning of the hands by washing with soap and water or using an alcohol-based hand sanitizer, is one of the best ways to avoid getting sick and prevent spreading germs to others. Procedure: A. Indications for hand hygiene: 1. Before and after any patient procedure... 3. Before moving from a contaminated body site to a clean body site during care. 4. After contact with any blood, body fluids, or contaminated surfaces... 8. After hands have become obviously soiled. 9. After contact with inanimate objects or medical equipment close to the patient. 10. After removal of gloves. The use of gloves does not replace the need for hand hygiene. CDC Hand Hygiene in Healthcare Settings-Glove Use When and How to Wear Gloves Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. ... perform hand hygiene prior to donning gloves, before touching the patient or the patient environment... An observation of care was conducted on 6/18/2026 at 8:56 AM to observe Employee Identifier (EI) # 8, Phlebotomist, draw blood for lab work on two unsampled patients. EI # 8, without performing hand hygiene, donned gloves and drew Unsampled Patient (UP) # 1’s blood for lab work. EI # 8, removed his/her gloves, and did not perform hand hygiene. EI # 8, without performing hand hygiene, donned gloves, used the same disposable tourniquet on UP # 2 and drew blood for lab work. EI # 8 removed his/her gloves and did not perform hand hygiene EI # 8, failed to perform hand hygiene per the facility’s policy, follow the CDC guidelines for glove use, and use a clean tourniquet for each patient. An interview was conducted on 6/18/26 at 12:05 PM with EI # 1, Chief Nursing Officer, who confirmed staff failed to follow the facility’s policy for hand hygiene, the CDC’s guidelines for glove use, and to use a clean tourniquet for each patient.”

“. K3 Building: 0101 K6 Plan Approval: 2010 K7 Survey Under: 2012 Existing K8 HOSP Generator: One Diesel 250kW Kohler (installed 2014) (with remote manual stop station) FACP: EST 3 (Installed 2011) Smoke Detection: Complete Locking Devices: Full time magnetic - Front Lobby, Front Employee Entrance, Service Corridor at Kitchen, 2 sets of doors from Fish Bowl, cross-corridor doors in paths of egress All other exit doors are keyed Bed: 82 Census: 68 Type of Structure: 2010 Single story protected wood frame combustible, Type V(111). 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 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. .”

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the original building construction type per the requirements of: 2012 NFPA 101, 19.1.6.1, and Table 19.1.6.1 This deficiency affects one room. Findings include: During a tour of the facility, the surveyor observed multiple unsealed penetrations of cables and conduit through the 1-hour fire rated sheetrock ceiling of the IT Room. A member of the maintenance staff was present when this deficiency was identified. .”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to provide an emergency release switch for the full-time magnetic locks on the cross-corridor doors in the paths of egress per the requirements of: 2012 NFPA 101, 19.2.2.2.5.2 (2), and 19.2.2.2.6 This deficiency affects the magnetically locked cross-corridor doors. Findings include: During a tour of the facility, the surveyor observed the magnetically locked cross-corridor doors did not have an emergency release switch that automatically unlocked the full time magnetic locked doors in case of an emergency. 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: 41792 . Based on observation and documentation review, the facility failed to maintain the fire alarm system per the requirements of: 2012 NFPA 101, 19.3.4.1, and 9.6.1.3 2010 NFPA 72, 21.9, and Table 14.3.1(9)(h) This deficiency affects the fire alarm system. Findings include: During a tour of the facility, the surveyor observed the following: 1. All cross-corridor full time magnetically locked doors in the path of egress, failed to automatically unlock upon loss of power to the fire alarm system 2. The facility failed to provide documentation of conducting semi-annual visual inspections on the smoke detectors within the past 12 months 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: 41792 . Based on observation and review of documentation, the facility failed to maintain an automatic sprinkler head per the requirements of: 2012 NFPA 101, 19.3.5.1, and 9.7.5 2011 NFPA 25, 5.3.1.1.1.6 This deficiency affects one automatic sprinkler head. Findings include: During a tour of the facility, the facility failed to provide documentation that the 2009 dry sprinkler installed on the exterior side of the 200 Hall exit door had been replaced within 10 years of installation. A member of the maintenance staff and the administrator were 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 a smoke barrier 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 a smoke barrier. Findings include: During a tour of the facility, the surveyor observed an unsealed penetration of a 1” sprinkler pipe above the ceiling of the Staff Bathroom in the smoke barrier between Zones A & B. A member of the maintenance staff was present when this deficiency was identified. .”

“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: 41792 . Based on observation, the facility failed to maintain the electrical wiring and equipment per the requirements of: 2012 NFPA 101, 19.5.1.1, and 9.1.2 2011 NFPA 70, 314.27 (2) and 410.5 This deficiency affects the electrical wiring. Findings include: During a tour of the facility, the surveyor observed exposed wiring above the corridor ceiling in front of the Pharmacy (Room 116); a flexible conduit and conductors were disconnected from a light fixture and abandoned. 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 one room. Findings include: During a tour of the facility, the surveyor observed a portable space heating device on the floor, under a wood desk in the Security Office. This was located in a patient sleeping smoke compartment and the facility was unable to provide documentation that the heating element did not exceed 212 degrees. The heater was not on. A member of the maintenance staff was present when this deficiency was identified. .”

“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: 41792 . Based on review of documentation, the facility failed to maintain the receptacles not listed as hospital-grade at the residents’ bed locations per the requirements of: 2012 NFPA 99, 6.3.4.1.3, and 6.3.3.2 This deficiency affects all the receptacles at the residents’ bed locations. Findings include: During a tour of the facility, the facility failed to provide documentation of testing the receptacles not listed as hospital-grade at the residents’ bed locations within the past 12 months. A member of maintenance staff was present when this deficiency was identified. .”

“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: 41792 . Based on observation, the facility failed to maintain the electrical equipment per the requirements of: 2012 NFPA 99, 10.2.3.6, and 10.2.4 2011 NFPA 70, 400.8 S&C: 14-46-LCS This deficiency affects one office. Findings include: During a tour of the facility, the surveyor observed a cell phone charger, a fan and desk computer equipment plugged into 2 temporary electrical extension cords in Room 600. A member of the maintenance staff was present when this deficiency was identified.”