Cobre Valley Regional Medical Center

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 48110 Based on record review and staff interviews, it was determined the hospital failed to ensure manufacturer’s instructions for three portable hemodialysis machines were followed and documented. This deficient practice poses a risk to the health and safety of patients if dialysis machines are not cleaned and maintained to accurately monitor and alert when there is a blood leak. Findings include: Policy titled, “Dialysis Program, Acute,” revealed: “ ...Purpose: ...Cobre Valley Regional Medical Center provides dialysis treatment, using the NxStage machine, for both acute renal failure patients and those end stage disease (ESRD) patients needing a hospital stay ....” Document titled, “NxStage System One User Guide ...For Cycler Models ...NX1000-5-A,” revealed: “ ...Chapter 6 Maintenance ...Monthly Maintenance ...1. Clean the Blood Leak Detector once a month, or more frequently if necessary. It is located inside the cycler ....” Documentation of the three portable hemodialysis machines blood leak detector monthly maintenance for the past three months was requested. None was provided. Employee #35 confirmed during an interview conducted on 03/06/2025 that the hospital has three NxStage cycler model NX1000-5-A portable hemodialysis machines. Employee #9 confirmed the dialysis staff cleans the blood leak detector once a week but does not document the cleaning. Employee #9 confirmed there was no documentation to indicate the monthly maintenance of the blood leak detector was performed on the three portable hemodialysis machines.”

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 46598 Based on review of policies and procedures, medical staff rules and regulations, medical record, and staff interviews, it was determined the Governing Body failed to ensure the physician documented a face-to-face assessment after the initial application of behavioral restraints for 3 out of 3 patients. The deficient practice of not assessing patients while in restraints poses a risk to the health and safety of patients by not identifying and preventing potential or actual injuries sustained while in restraints or the need to continue the restraint of the patient when it is not necessary. Findings Include: Policy titled “Restraint Policy” dated 02/2022 revealed: “ ...When restraints are used for the management of violent behavior or self-destructive behavior that jeopardizes the immediate physician safety of the patient, staff or others the patient must be seen face to face with in 1 hour after the initiation of the restraints by a physician, other LIP, Registered Nurse or Physician Assistant, for evaluation of the patients immediate situation, the patients reaction to the intervention, the patients’ medical and behavioral condition, and need to continue or terminate the restraint ....” Document titled “Medical Staff Rules and Regulations” revealed: “ ...5.6 RESTRAINTS AND SECLUSION. Cobre Valley Regional Medical Center Restraint Policy governs the use of restraints within the institution. Practitioners must abide by the restraint policy whenever restraints are to be used ....” A review of the patient’s medical records on 03/04/2025. Patient # 26’s medical record dated 04/15/2024 at 0850 revealed: “ ...Order Restraint-Violent Adult ....” No documentation of a face-to-face meeting was completed following the application of behavioral restraints. Patient # 27’s medical record dated: 09/12/2024, at 19:32 revealed: “ ...Order Restraint Violent Adult ....” No documentation of a face-to-face meeting was completed following the application of behavioral restraints. Patient # 28’s medical record dated 12/29/2024, 0845 revealed: .... Order Restraint Violent Adult ...” No documentation of a face-to-face meeting was completed following the application of behavioral restraints. Employee #10 confirmed during an interview conducted on 03/05/2025 that patient # 26, Patient # 27, and patient # 28’s medical records did not reveal documentation of a physician face to face following the application of Behavioral Restraints. 48110 Based on record reviews and staff interviews, it was determined the hospital failed to ensure medical staff member pronounced and documented time of death, and completed the death certificate for a patient (Patient #9). This deficient practice poses a potential risk of unclear time of death leading to delaying suitability of organs for transplantation. Findings include: Policy titled, “Determination of Cardiac Death: Role of the RN,” revealed: “ ...V. Additional Information: ...Certification of death: Physician documentation regarding patient details of death including but not limited to date, time and cause of death. This can only be filled out by the physician ....” Document titled, “Medical Staff Rules and Regulations,” revealed: “ ...4.7 Death in Hospital ...4.7.1 Pronouncing and Certifying the Cause of Death ...In the event of a hospital death, the deceased will be pronounced by the attending physician or his/her designee within a reasonable time. The body will not be released until an entry has been made and signed in the medical record of the deceased by the attending physician or another physician designated by the attending physician. The attending physician or his/her designee is responsible for certifying the cause of death, and completing the Death Certificate in a timely manner ....” Patient #9’s medical record dated 01/03/2025 identified a note titled, “ED - General Adult Hybrid,” and it revealed: “ ...terminally ill patient presenting to the ED with vomiting blood ....Physical Exam ...Patient is not responding to us ...appears to be very ill and is hypotensive bradycardic and appears to be passing away, patient is very pale and cachectic in appearance ...family wishes for comfort care. While examined (sic) the patient with ...family here the patient did pass away ....Patient Disposition: EXPIRED ....” Patient #9’s medical record dated 01/04/2025 identified a nursing note, and it revealed: “ ...Deceased picked up by ...funeral service chosen by family ....” Further review of Patient #9’s medical record revealed no documentation of time of death, or death certificate. Employee #3 and Employee #4 confirmed during an interview conducted on 03/04/2025 that there was no time of death documented in Patient #9’s medical record. Employee #3 and Employee #4 also confirmed there was no death certificate in Patient #9’s medical record.”

“NURSING SERVICES CFR(s): A registered nurse or, where permitted by State law, a physician assistant, must supervise and evaluate the nursing care for each patient, including patients at a SNF level of care in a swing-bed CAH. This Standard is not met as evidenced by: 46598 Based on a review of Hospital records and staff interviews, it was determined that the Hospital failed to ensure that the assessment and re-assessment of patient status was documented at least every 15 minutes while one (1) patient while the patient was in behavioral restraints. The deficient practice of not assessing patients while in restraints poses a risk to the health and safety of patients by not identifying and preventing potential or actual injuries sustained while in restraints or possible death in a timely manner. Findings Include: Policy titled “Restraint Policy” dated 02/2022 revealed: “ ...II. DEFINITIONS: Restraint includes either a physical restraint or a drug that is being used as a restraint. Non-behavioral (Medical) Restraint is defined as temporary immobilization in relation to a medical condition or post-surgical procedure to ensure the patient does not compromise healing process ...Behavioral Restraints are those restraints used only in emergent situations when there is an imminent risk of a patient harming themselves, staff, others, or property; when non-physical interventions are not viable; and when safety issues require and immediate physical response ...V. APPLICATION OF BEHAVIORAL RESTRAINTS ...B. A written or verbal order is obtained and documented on the Behavioral Restraint Order. The ordering physician completes and electronically signs the order for restraint on the Behavioral Restraint Order ...D. Documentation: Every 15 minutes, the patient’s physical and behavioral status and needs for care are assessed and documented in the Electronic Medical Record by a competent, trained staff member. The patient’s condition and needs the type of restraint used, the staff’s clinical judgement will determine specific items will be assessed at any point in time ....” Patient # 27’s medical record dated: 09/12/2024, at 19:32 revealed: “ ...Order Restraint Violent Adult ....” No documentation of patient assessment every 15 minutes. Employee # 10 confirmed in an interview dated 03/04/2025 that patient # 27’s medical record revealed that the nurse assessed the patient every 2 hours and not the required every 15 minutes.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 46598 Based on observation, review of hospital records, Center for Disease Prevention and Control (CDC) guidelines, and staff interviews, the Department determined the Hospital failed to ensure single-use solutions and multi-dose solutions and ointments were utilized and stored as to be free from contamination. This deficient practice poses a health and safety risk to patients and staff by possibly exposing them to contaminated wound care products. Findings Include: Policy titled “Medication Storage Area Inspection” revealed: “I. POLICY: All drug storage areas will be inspected at least monthly by the pharmacist or pharmacy technician. The purpose is to ensure medications are stored properly and to remove outdated, adulterated, or otherwise unusable medications from stock ....” Policy titled “Expiration Dates for Multi Dose Vials” revealed: II. DEFINITIONS: Single Dose Vial: A vial that is free of preservatives and usually contains the labeling: “Single Dose.” ...Multidose Vial A vial that contains a preservative and contains the labeling such as “Multiple Dose” or “Multiple Dose Vial.” ....” Hospital Document titled “Infection Prevention and Control Plan, dated 12/2024, revealed: “ ...III.Procedure/Interventions (s) ...2. CVRMC’s IP&C program shall be conducted in accordance with applicable federal and state rules and regulations. Nationally recognized IP&C practices and guidelines are available as a reference, including but not limited to: a. Centers for Disease Control (CDC) b. Association for Professional in Infection Control and Epidemiology (APIC) c. Society for Healthcare Epidemiology of America (SHES) d. Association of perioperative Registered Nurses (AORN) e. Occupational Health and Safety Administration (OSHA) F. Centers for Medicare and Medicaid Services (CMS) g. Institute for Healthcare Improvement (IHI) ....” Document titled “CDC’s Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings” revealed: “ ...5. Standard Precautions Use Standard Precautions to care for all patients in all settings. Standard Precautions include: 5c. Injection and medication safety ...5c. Injection and Medication Safety References and resources: 7, 11, 16-20 ...Prepare medications in a designated clean medication preparation area that is separated from potential sources of contamination, including sinks or other water sources ...Ensure single-dose or single-use vials, ampules, and bags or bottles of parenteral solution are used for one patient only ...Dedicate multidose vials to a single patient whenever possible. If multidose vials are used for more than one patient, restrict the medication vials to a centralized medication area and do not bring them into the immediate patient treatment area (e.g., operating room, patient room/cubicle) ....” An observation of 3 patient cubicles located in the wound care unit on 03/04/2025 revealed: 2 open and dated 4-oz bottles of betadine solution labeled for single use 2 bottles of Medline READY PREP opened and dated 10/16/2024 and 12/20/2024, Hydrogen Peroxide Solution 3%, opened and dated 10/09/2023 Aquaphor ointment opened and dated 01/30/2024 and10/21/2024 Employees # 1 and Empoyee # 22 both confirmed during an interview conducted on 03/04/2025 that these items were being used on multiple patients after opening.”

“DISCHARGE PLANNING CFR(s): (6) The CAH’s discharge planning process must require regular reevaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interview, it was determined the hospital failed to ensure the facility’s leaving against medical advice (AMA) policy was followed, and one of three patients (Patient #5) was encouraged to stay and risks of leaving AMA was explained. This deficient practice poses a risk to the health and safety of patients if all pertinent information was not presented to make an informed decision about leaving AMA. Findings include: Policy titled, “Leaving Against Medical Advice (AMA),” revealed: “ ...III. Procedure ...A. Every effort should be made to encourage the patient to remain under the care of the physician ....C. The physician should document in the chart that the patient has left against medical advice, noting the date and time, disclosure as to the risks of leaving, a determination that the patient understands and accepts the risks of leaving against medical advice, and documentation concerning the recommended treatment to which the patient refuses to consent ....” Patient #5’s medical record dated 01/31/2025 identified a section labeled “SBAR,” and it revealed: “ ...Fri Jan 31 16:14 ...This RN notified MD that the patient is requesting to leave the facility. MD advised that the patient can leave AMA ...Fri Jan 31 16:55 ...This RN notified MD that the patient is leaving AMA ....” Review of Patient #5’s medical record revealed they left AMA on 01/31/2025 at 1715. Review of Patient #5’s medical record revealed no documentation that Patient #5 was encouraged to remain in the hospital for medical evaluation and treatment. Further review of Patient #5’s medical record revealed no documentation in the physician notes that risks of leaving AMA were explained to the Patient #5. Employee #3 confirmed during an interview conducted on 03/04/2025 that Patient #5 left AMA. Employee #3 also confirmed there was no documentation Patient #5 was encouraged to stay for medical treatment or risks of leaving AMA were explained. Employee #3 confirmed the facility’s AMA policy was not followed.”

“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: 43814 Based on record review and interview with staff, it was determined the facility did not have documented evidence that the kitchen hood system was inspected semi-annually in accordance with NFPA 96. Failing to inspect the kitchen hood entire fire extinguishing system semi-annually could allow a build-up of grease and provide fuel for a fire. A fire in the kitchen has potential to harm the patients and staff. NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, “Cooking Facilities.” “Cooking facilities shall be protected in accordance with 9.2.3.” Section 9.2.3, “Commercial Cooking Equipment” “Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... “Chapter 11, Procedures for the use , Inspection, Testing, and Maintenance of Equipment. Section 11.2 “Maintenance of the fire extinguishing systems and listed exhaust hoods containing a constant or fire activated water system that is listed to extinguish a fire in the grease removal devices hood exhaust plenums and a exhaust ducts shall be made by properly trained, qualified, and certified persons acceptable to the authority having jurisdiction at least 6 months.” Findings Include: During the review of facility documentation, the fire suppression system for the kitchen hood system was requested on March 3-6, 2025. The facility was unable to provide documented evidence that the fire extinguishing system was inspected in accordance with NFPA 96 Edition. The last Simi annual test was conduted on December 27, 2023. Employees #2, and #4 confirmed during the exit conference on March 6, 2025, that there was no documentation that the fire extinguishing system was inspected in accordance with NFPA 96, 2011 Edition, semi-annually.”

“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: 43814 Based on Document review the facility failed to make repairs to a failed fire alarm panel. Failure tomaintain the fire alarm system could cause harm to staff and residents during an emergency. NFPA 101, Life Safety Code, 2012 Edition, Chapter 9, Section 9.6.1.3 “A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use”. NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition, Chapter 14, Section 14.2.2.1, “The property or building or system owner or the owner ’ s designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system”. Chapter 26, Section 26.3.5.2.2 “The subsidiary facility shall be inspected at least monthly by central station personnel for the purpose of verifying the operation of all supervised equipment, all telephones, all battery conditions, and all fluid levels of batteries and generators”. NFPA 72, National Fire Alarm and Signaling Code, Section14.6.2.1, Records shall be retained until the next test and fore 1 year thereafter. CMS requires 3 years. NFPA 72 Chapter 14, section 14.2.5 Releasing Systems. Requirements pertinent to testing the fire alarm systems initiating fire suppression system releasing functions shall be covered by 14.2.5.1 through 14.2.5.6. and must be inspected in accordance with section 14.3 Inspection which requires Monthly and Annual inspection amd service. Findings include: During review of the facility’s documentation on March 3-6, 2025, There was no documentation of a passing annual test of the following sysytems: 1.The fire alarm system had an annual test in August 2024 with ten failed batteries, two non-work horn/strobes and thirty eight mislabeled smoke detectors. The facility did placement to the batteries but no re-test was documented and non of the other repairs were completed. Employees #2, and #4 confirmed during the exit conferance that the facility failed to make repairs to fire alarm alarm system for over six months”

“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: 43814 Based on observation it was determined the facility failed to protect the entire facility with an automatic sprinkler system. This would result in the sprinkler system not being able to extinguish the fire and could result in injury or death to the building occupants. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1, “Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.” Chapter 9, Section 9.7.1.1, “ Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems.” NFPA 13, Chapter 8 Obstructions to Sprinkler Discharge Pattern Development. Section 8.6.5.2.1.1 Continuous or noncontiguous obstructions less than or equal to 18 in. below the sprinkler deflector that prevent the pattern from fully developing shall comply with 8.6.5.2. Findings include: A facility tour conducted on Mar 3-6, 2025, revealed that a sprinkler head was not appropriately installed during a recent building modification. The sprinkler head was lying directly above the drop ceiling tile with a danger tag attached. The ceiling tile would prevent the sprinkler from actuating in the event of a fire. This head was located just prior to the door of the kitchen back hallway Employees #2 and #4 confirmed during the exit conference that the sprinkler head in the kitchen back hallway was not installed correctly. The sprinkler head was installed directly above the drop ceiling tile during a recent building modification. The ceiling tile would prevent the sprinkler from actuating in a fire.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 43814 Based on observation the facility failed to provide a fire extinguisher near the generator. Failing to have an available fire extinguisher during an emergency could result in harm to the patients and/or staff. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 “Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1” Section 9.7.4.1 “Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers.” 9.7.4 Manual Extinguishing Equipment. 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 2010 Edition 6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, 6.3.1.2 Fire extinguishers shall be located so that the maximum travel distances do not exceed those specified in Table 6.3.1.1. NFPA 30 2012 edition 4.2.2 Combustible liquids Any liquid that has a closed cup flash point at or above 100 f as determined by the test procedures and apparatus set forth in section 4.4 NFPA 10 2012 edition 5.2.2 Class B fires are fires in flammable liquids, combustible liquids, petroleum greases, tars, oils, oil-based paints, solvents, lacquers, alcohols, and flammable gases. 6.3.1 Other Than for Fires in Flammable Liquids of Appreciable Depth. 6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, except as modified by 6.3.1.5. Table 6.3.1.1 Fire Extinguisher Size and Placement for Class B Hazards Type of Hazard Basic Minimum Extinguisher Rating Maximum Travel Distance to Extinguishers (moderate) 20-B 50 ft Findings include: Observations made while on tour on March 4, 2025, revealed there was not a fire extinguisher installed within 50 feet of the generator. Employees #2 and #4 confirmed on March 6th, 2025 that newer generator did not have an extinguisher within 50 feet from the generator.”

“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: 43814 Based on observation, it was determined the facility failed to fill penetrations in a smoke barrier in the entire main hospital. Failing to fill the penetrations, holes in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which could cause harm if a fire were to occur. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 “Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour.” Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall , floor or /ceiling assembly constructed as a smoke barrier , or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke. Findings include: Observations during a facility tour conducted on March 30-6, 2025, revealed a large hole in the drywall between rooms #1106 and #1118, the entire wall being a smoke barrier. (note) there were other areas with holes in the fire or smoke barriers, but these were corrected by the facility before the exit. During the exit conference, Employees, #2 and #4 confirmed knowledge of the holes in the smoke barriers between rooms #1106 and #1118.”

“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: 43814 Based on Observation, it was determined that the facility allowed the use of a power strip but did not mount it to the equipment in the operating rooms. There was also one non-rated power strip in the operating room. Failure to properly use power strips and outlets could lead to electrical overload or fire, harming the patients and staff. NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 “Mandatory References” NFPA 99 “Standard for Health Care Facilities, “ 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , “All Patient Care Areas,” Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)” Minimum Number of Receptacles.” “The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters. CMS S&C: 14-46-LSC- Life Safety Code surveyors assess the use of power strips in healthcare facilities. However, the following guidance is provided as a reference for healthcare surveyors as they survey the physical environment along with other CoP requirements. Any observed power strip deficiencies should be conveyed to the LSC surveyors for citation. If line-operated medical equipment is used in a patient care room/area inside the patient care vicinity: 1. UL power strips would have to be a permanent component of a rack-, table-, pedestal-, or cart-mounted & tested medical equipment assembly 2. Power strips providing power to medical equipment in a patient care room/area must be UL 1363A or UL 60601-1 3. Power strips cannot be used for non-medical equipment If line-operated medical equipment is used in a patient care room/area outside the patient care vicinity: UL power strips could be used for medical & non-medical equipment with precautions as described in the memo 1. Power strips providing power to medical equipment in a patient care room/area must be UL 1363A or UL 60601-1 2. Power strips providing power to non-medical equipment in a patient care room/area must be UL 1363 3. If line-operated medical equipment is not used in a patient care room/area, inside and outside the patient care vicinity: Findings include: Observations made during the tour from Mar 3-6, 2025, revealed that operating room #3 had the following: 1. a power strip that was not mounted to a rack, table, pedestal, or cart-mounted and tested medical equipment assembly 2. One power strip was not UL 1363A or UL 60601-1 rated being used”

“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: 43814 Based on Observation the facility failed to secure medical gas Helium and Oxygen cylinders in the med gas room, as well as untreated combustible items in the med gas room Failing to secure compressed medical gas cylinders could cause harm to the patients and staff. Storing combustibles item in the med gas room could result in a fire in the room NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 “Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.” NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart.” NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 “Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.” NFPA 99 2012 Edition Chapter 11 Section 11.3 Cylinder and Container Storage Requirements. 11.3.2 Storage for nonflammable gases greater than 8.5 m3 (300 ft3), but less than 85 m3 (3000 ft3), at STP shall comply with the requirements in 11.3.2.1 through 11.3.2.3.11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.11.3.2.2 Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1? 2 hour Findings include: Observations while on tour March 3-6, 2025 revealed the following: 1. Two (2) unsecured Helum cylinders in the storgare area of the med gas room and numerius small oxygen cylindars with the chain approx 2 in from the floor. 2. An untreated woodedn book case being used for storage in the med gas room Employees #2 and #4 conformed at the exit interview that the med gas room had unsecured cylindars and untreated wood storred inside the room”