Colorado River Medical Center

“EP Program Patient Population CFR(s): §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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 the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: 42003 Based on document review and interview, the facility failed to maintain the emergency preparedness plan (EPP). This was evidenced by the failure to provide a patient population profile including persons at risk. This could result in the facility being unprepared during an emergency. This affected two of two patients. Findings: During a review of records and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the EPP was reviewed. At 3:01 p.m., a patient population profile was not available for review. Upon interview, the CAO stated that she did not know if they had a patient population profile because they were not a long-term care facility, and thus their patient load was always changing.”

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 42003 Based on document review and interview, the facility failed to maintain the emergency preparedness plan (EPP). This was evidenced by the failure to provide an 1135 waiver policy. This could result in the facility being unprepared during an emergency. This affected two of two patients. Findings: During a review of records and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the EPP was reviewed. At 3:55 p.m., an 1135 waiver policy was missing. Upon interview, the CAO stated that she was not familiar with what an 1135 waiver was. The CAO stated that if they needed to obtain any waivers, they would ask California Department of Public Health (CDPH).”

“K3 BUILDING: 01 K6 PLAN APPROVAL: 1966 K7 SURVEY UNDER: 2012 EXISTING K12 TYPE OF STRUCTURE: ONE STORY, CONSTRUCTION TYPE II (111), FULLY SPRINKLERED. Resident Certified Beds: 25 Resident Census: 2 The following reflects the findings of the California Department of Public Health, during a Life Safety Code recertification Survey. The findings are in accordance with 42 Code of Federal Regulations (CFR) §485.623(c)(d)(e), National Fire Protection Association (NFPA) 101 - Life Safety Code, 2012 Edition, and NFPA 99 - Health Care Facilities Code, 2012 Edition. Representing the California Department of Public Health: 42003”

“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: 42003 Based on observation and interview, the facility failed to maintain the building’s construction. This was evidenced by drop ceiling tiles that were removed and exposed the attic plenum space, and for unsealed penetrations. This could result in the passage of smoke or toxic gases from one part of the building to another. This affected two of two patients and four of four smoke compartments. Findings: During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the building’s construction was observed. 1. At 10:09 a.m., a 24 x 48-inch ceiling tile in the Activities Storage Closet on the B-Wing Nurses Station had been removed and was left unattended. Upon interview, the DOM stated that someone for the maintenance staff must have forgotten to put the tile back in place after working in the attic space. 2. At 10:18 a.m., a sprinkler in the corridor by CEOs Office was observed falling out of place by approximately one inch, resulting in an approximately two-inch penetration in the ceiling tile around the pipe. Upon interview, the DOM stated that he did not know how this happened and stated that someone could have taken the escutcheon down and did not put it up all the way. 3. At 10:43 a.m., a telecom port was observed in the Medical Records Room on the northwest wall behind a desk. This port was yanked out of the wall, leaving behind an approximately two by three-inch hole with exposed wires. Upon interview, the DOM stated that the equipment connected to this port was taken offline and no longer in use. 4. At 10:55 a.m., an approximately one-quarter inch penetration a ceiling tile on the southeast side of the Emergency Room waiting room. Upon interview, the DOM stated that the penetrations probably came from the wiring for the security cameras. 5. At 11:05 a.m. an approximately 24 x 48-inch drop ceiling tile was removed in the Dirty Utility Room in the ER Ward resulting in a ceiling penetration. Upon interview, the DOM stated that someone must have been working in the attic space and forgot to put the ceiling tile back. 6. At 11:38 a.m., an approximately one-quarter inch penetration was observed around the escutcheon ring of a sprinkler in the Laboratory Storage Room and around the escutcheon of one sprinkler in the corridor in front of the Laboratory Storage Room. Upon interview, the DOM stated that it looked like the escutcheon rings had been offset from their original place. 7. At 11:41 a.m., an approximately one-quarter inch penetration was observed around the escutcheon ring of a sprinkler on the south side of the smoke barrier doors in the corridor near the Laboratory Storage Room. Upon interview, the DOM stated that some of the maintenance staff had been in the attic to check the smoke dampers and they could have bent the sprinklers out of place. 8. At 12:10 p.m., four penetrations were observed on the south wall of the IT/Telecom Room. From the east wall to the west wall, the penetrations measured approximately one-half inch, one inch, one-third inch, and one and a half inches in diameter. Upon interview, the DOM stated that the IT company had installed new wiring, and they did not seal up the penetrations. 9. At 12:10 p.m., an approximately one-half inch penetration was observed on the northwest wall of the EVS Storage Room across from the IT Room. An ethernet cable was coming through the penetration. Upon interview, the DOM stated that he did not know what the ethernet cable was for. 10. At 12:59 p.m., an approximately one-quarter inch penetration was observed around the edge of a sprinkler escutcheon ring in the Scrubs Room located in the Operating Room Nurses’ Station. The CAO observed this finding during the tour. 11. At 1:20 p.m., an approximately 24 x 48-inch drop ceiling tile was removed and left unattended in the Clean Utility Room of the Obstetrics and Labor ward resulting in a ceiling penetration. Upon interview, the DOM stated that one of his crew members was working in the attic space and forgot to put the tiles back. 12. At 1:29 p.m., two drop ceiling tiles were removed in the Laboratory Supply Room, which exposed the attic plenum space. The DOM and CAO observed this finding.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 42003 Based on observation and interview, the facility failed to maintain the doors with self-closing devices.. This was evidenced by an automatic closing door that was propped open with a floor wedge. This could result in a delay in preventing the spread of fire, smoke, or toxic gases. This affected staff and one of four smoke compartments. Findings: During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the doors with self-closing devices were observed. 1. At 1:27 p.m., the door to the Nursery Room was propped open with a floor wedge. This door had an automatic closing device installed. Staff in the room were interviewed and stated that the door was wedged because it would get hot in the room.”

“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: 42003 Based on observation, document review, and interview, the facility failed to maintain the cooking equipment. This was evidenced by the failure to provide any documentation of service for the ANSUL suppression system, for missing one of two kitchen hood cleaning reports, and for a missing annual inspection for the fuel-fed commercial cooking equipment. This could result in a malfunction of the cooking facilities. This affected two of two patients and one of four smoke compartments. NFPA 101: Life Safety Code, 2012 Edition 19.3.2.5 Cooking Facilities. 19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4. 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, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2014 Edition. 10.2.6 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer’s instructions, and the following standards where applicable: (4) NFPA 17A 11.2.1* 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 exhaust ducts shall be made by properly trained, qualified, and certified person (s) acceptable to the authority having jurisdiction at least every six months. 11.4* Inspection for Grease Buildup. The entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4. 11.5 Inspection, Testing, and Maintenance of Listed Hoods Containing Mechanical, Water Spray, or Ultraviolet Devices. Listed hoods containing mechanical or fire-actuated dampers, internal washing components, or other mechanically operated devices shall be inspected and tested by properly trained, qualified, and certified persons every 6 months or at frequencies recommended by the manufacturer in accordance with their listings. 11.7 Cooking Equipment Maintenance. 11.7.1 Inspection and servicing of the cooking equipment shall be made at least annually by properly trained and qualified persons. NFPA 17A, Standard for Wet Chemical Extinguishing Systems, 2009 Edition. 7.3.3* At least semiannually and after any system activation, maintenance shall be conducted in accordance with the manufacturer’s design, installation, and maintenance manual. 7.3.3.6.1 The owner or owner’s representative shall retain all maintenance reports for a period of 1 year after the next maintenance of that type required by the standard. 7.3.3.7* Each wet chemical system shall have a tag or label securely attached, indicating the month and year the maintenance is performed and identifying the person performing the service. Only the current tag or label shall remain in place. Findings: During a tour of the facility, review of documents, and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24 and 6/19/24, the cooking facilities were observed. 1. On 6/18/24 at 11:54 a.m., the pull station tag for the ANSUL suppression system in the kitchen indicated that an annual service was done in March of 2023. Upon interview, the DOM stated that the vendor should have come out to service the suppression system when they did the fire extinguishers. On 6/19/24 at 9:28 a.m., the facility was unable to provide documentation of the most recent service for the kitchen suppression system. Upon interview, the DOM stated that he went to the kitchen staff to obtain all of their maintenance documentation, and the suppression system was not included. 2. On 6/19/24 at 9:26 a.m., one of two kitchen hood cleaning reports was not available for review. Upon interview, the DOM stated that they clean the vent filters once per month as preventative maintenance, but the vendor only came out once to clean the ducts and exhaust vents for the previous year. 3. On 6/19/24 at 9:49 a.m., there was no annual kitchen equipment inspection available for review. Upon interview, the DOM stated that he went to the kitchen staff to obtain all of their maintenance documentation and they did not have this report. The DOM stated that he did not know this was a requirement.”

“Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This Standard is not met as evidenced by: 42003 Based on observation and interview, the facility failed to maintain the alcohol-based hand rub (ABHR) dispensers. This was evidenced by ABHRs that were installed directly above and within one horizontal inch of an ignition source. This could result in fire hazards from flammable liquids encountering electricity. This affected two of two patients and two of four smoke compartments. Findings: During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the ABHRs were observed. 1. At 10:35 a.m., an ABHR was observed on the south wall of the Admitting Office was less than one horizontal inch above an electrical outlet. The label on the liquid bladder stated that the solution contained 70% ethyl alcohol. 2. At 10:46 a.m., an ABHR was observed on the east wall of the Medical Records Room and was installed directly above four electrical outlets. Upon interview, the DOM stated that he did not know about this requirement and stated that it was the first time he had heard of this. 3. At 12:58 p.m., an ABHR on the south wall of the PACU Room in the Operating Room Nurses Station was installed directly above a light switch.”

“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: 42003 Based on document review and interview, the facility failed to maintain the fire alarm system (FAS). This was evidenced by the failure to replace Fire Alarm Control Panel (FACP) batteries, and for missing one of two load voltage tests for the FACP batteries. This could result in a malfunction of the FAS. This affected two of two patients and four of four smoke compartments. NFPA 101, life Safety Code, 2012 Edition 19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 9.6 Fire Detection, Alarm, and Communications Systems. 9.6.1 * General. 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. 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition Table 14.3.1 column 2 heading was revised by a tentative interim amendment (TIA). Table 14.3.1 Visual Inspection Frequencies 3. Batteries (d) Sealed lead-acid: Initial/Reacceptance; Semiannually 5. Fire alarm control unit trouble signals: Weekly; Semiannually 8. Remote annunciators: Initial/Reacceptance; Semiannually 9. Initiating devices (f) Heat Detectors: Initial/Reacceptance; Semiannually (h) Smoke detectors: Initial/Reacceptance; Semiannually (i) Supervisory signal devices: Initial/Reacceptance; Semiannually 14.4.2* Test Methods. 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. 5. Batteries-general tests: Prior to conducting any battery testing, the person conducting the test shall ensure that all system software stored in volatile memory is protected from loss. (a) Visual inspection: Batteries shall be inspected for corrosion or leakage. Tightness of connections shall be checked and ensured. If necessary, battery terminals or connections shall be cleaned and coated. Electrolyte level in lead-acid batteries shall be visually inspected. (e) Load voltage test: With the battery charger disconnected, the terminal voltage shall be measured while supplying the maximum load required by its application. The voltage level shall not fall below the levels specified for the specific type of battery. If the voltage falls below the level specified, corrective action shall be taken and the batteries shall be retested. 6. Battery tests (specific types) (d) Sealed lead-acid type (2) Load voltage test: Under load, the battery shall perform in accordance with the battery manufacturer ’ s specifications. 14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction. Table 14.4.5 Testing Frequencies 6. Batteries-fire alarm systems (d) Sealed lead-acid type 6. Batteries-fire alarm systems (d) Sealed lead-acid type Annually (3) Load voltage test - Initial/Reacceptance; Semiannually Findings: During a review of documents and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/19/24, records were requested and reviewed. 1. At 9:55 a.m., the Annual FAS Report dated 5/31/24 stated that the 1st floor electrical room required both Power Supply Panels to be replaced, the 1st floor FACP top power supply panel needed to be replaced, and the main FACP batteries needed to be replaced. This report also indicated that the sealed lead acid (SLA) batteries on the FACP were not tested for charging, discharging, and for load voltage. Upon interview, the DOM stated that the batteries had not been replaced yet because he had been too busy. He also stated that the batteries were not tested because of the vendors recommendations that they be replaced. 2. At 10:00 a.m., one of two semi-annual visual inspections for the duct detectors was missing. Upon interview, the DOM stated that they did monthly visual inspections to all the FAS components except for the duct detectors. He stated that he believed that the vendor came out on a semiannual basis to inspect the duct detectors, but he was not able to find the report.”

“Smoke Detection CFR(s): NFPA 101 Smoke Detection 2012 EXISTING Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1. 19.3.4.5.2 This Standard is not met as evidenced by: 42003 Based on document review and interview, the facility failed to maintain the smoke detectors. This was evidenced by the failure to perform sensitivity testing on the smoke detectors. This could result in a malfunction of the smoke detectors. This affected two of two patients and four of four smoke compartments. NFPA 101, life Safety Code, 2012 Edition 19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 9.6 Fire Detection, Alarm, and Communications Systems. 9.6.1 * General. 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. 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition 14.4.4* Testing Frequency. 14.4.4.3 * In other than one- and two-family dwellings, sensitivity of smoke detectors shall be tested in accordance with 14.4.4.3.1 through 14.4.4.3.7. 14.4.4.3.1 Sensitivity shall be checked within 1 year after installation. 14.4.4.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.4.3.3. 14.4.4.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. Findings: During a review of records and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/19/24, the smoke detectors were observed. At 10:02 a.m., a smoke detector sensitivity report was missing. Upon interview, the DOM stated that sensitivity testing was not done on the annual Fire Aalarm System report, and he did not know it was required.”

“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: 42003 Based on observation and interview, the facility failed to maintain the sprinkler system. This was evidenced by sprinkler pendants that did not have a minimum of 18 inches of clearance from the bottom of the deflector, and for a sprinkler that was obstructed by a light fixture. This could result in a malfunction of the sprinkler system. This affected two of two patients and two of four smoke compartments. NFPA 101: Life Safety Code, 2012 Edition 19.3.5.4* The sprinkler system required by 19.3.5.1 or 19.3.5.3 shall be installed in accordance with 9.7.1.1 9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems NFPA 13: Standard for the Installation of Sprinkler Systems, 2013 Edition 8.5.6 * Clearance to Storage. 8.5.6.1 * Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4, or 8.5.6.5 are met, the clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater. 8.10.6 Obstructions to Sprinkler Discharge (Residential Upright and Pendent Spray Sprinklers). 8.10.6.1 Performance Objective. 8.10.6.1.1 Sprinklers shall be located so as to minimize obstructions to discharge as defined in 8.10.6.2 and 8.10.6.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard. 8.10.6.1.2 Sprinklers shall be arranged to comply with one of the following arrangements: (1) Sprinklers shall be in accordance with 8.5.5.2, Table 8.10.6.1.2, and Figure 8.10.6.1.2(a). (2) Sprinklers shall be permitted to be spaced on opposite sides of obstructions not exceeding 4 ft (1.2 m) in width, provided the distance from the centerline of the obstruction to the sprinklers does not exceed one-half the allowable distance permitted between sprinklers. (3) Obstructions located against the wall and that are not over 30 in. (762 mm) in width shall be permitted to be protected in accordance with Figure 8.10.6.1.2(b). (4) Obstructions that are located against the wall and that are not over 24 in. (610 mm) in width shall be permitted to be protected in accordance with Figure 8.10.6.1.2(c). The maximum distance between the sprinkler and the wall shall be measured from the sprinkler to the wall behind the obstruction and not to the face of the obstruction. Findings: During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the sprinkler system was observed. 1. At 9:56 a.m., two sprinkler pendants in the Room 204 Storage area had approximately 15-inches of clearance between the bottom of the deflector and the top of some storage boxes. These sprinklers were located on the south side of the room. Upon interview, the DOM stated that the boxes were all PPE that the county sent them. 2. At 11:21 a.m., the X-Ray Film Room had a light fixture that was obstructing a sprinkler pendant. The bottom of the light fixture measured approximately seven and a half inches beneath the sprinkler deflector, and less than one horizontal inch away from sprinkler. Upon interview, the DOM stated that he could see how the light fixture would obstruct the sprinkler spray pattern.”

“Sprinkler System - Supervisory Signals CFR(s): NFPA 101 Sprinkler System - Supervisory Signals Automatic sprinkler system supervisory attachments are installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired. 9.7.2.1, NFPA 72 This Standard is not met as evidenced by: 42003 Based on observation and interview, the facility failed to maintain the sprinkler system. This was evidenced by a supervisory device that did not activate. This affected two of two patients and two of four smoke compartments. NFPA 101, life Safety Code, 2012 Edition 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 9.7.2 Supervision. 9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility. Findings: During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the sprinkler system was observed. At 2:05 p.m., the post indicator valve (PIV) was fully closed, and the exterior alarm bell nearby did not activate. The fire alarm control panel (FACP) annunciator in the IT/Telecom room had a supervisory LED flashing, but the LCD display was too dim to read what error it was giving. Upon interview, the DOM stated that the PIV had a tamper switch that was connected to an exterior alarm bell.”

“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: 42003 Based on observation and interview, the facility failed to maintain the sprinkler system. This was evidenced by sprinkler pendants that were corroded, or calcified, sprinkler heads that were intermingled, and for missing maintenance documentation. This could result in a malfunction of the sprinkler system. This affected two of two patients and four of four smoke compartments. NFPA 101, Life Safety Code, 2012 Edition 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7 19.3.5.4* The sprinkler system required by 19.3.5.1 or 19.3.5.3 shall be installed in accordance with 9.7.1.1 9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 13: Standard for the Installation of Sprinkler Systems, 2013 Edition 6.2.7 Escutcheons and Cover Plates. 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler. 8.3.3.2 Where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8.3.3.3. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition. 5.2* Inspection. 5.2.1 Sprinklers. 5.2.1.1* Sprinklers shall be inspected from the floor level annually. 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, pain, and physical damage; and shall be installed in the correct orientation (e.g., up-right, pendent, or sidewall). 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5) *Loading (6) Painting unless painted by the sprinkler manufacturer. 5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. 13.1.1.2 Table 13.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. 5.3.1.1.1 Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be tested. 5.3.3.2 * Vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually. Findings: During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the sprinkler system was observed. 1. At 10:12 a.m., a corroded sprinkler was observed in the bathroom of the physical therapy room on the B-Wing. The sprinkler had calcified water deposits on the red glass bulb and around the base of the pendant. Upon interview, the DOM stated that he did not know if the sprinkler was leaking and stated that the vendor was recently at the facility and did not comment on this sprinkler. 2. At 11:35 a.m., a green, corroded sprinkler was observed in the Bathroom of the Doctor’s Sleeping Room. The DOM and CAO observed this finding. 3. At 11:50 a.m., intermingled sprinkler heads were observed in the Kitchen storage area and consisted of one quick-response (QR) pendant and one standard sidewall mounted fusible link type sprinkler. Upon interview, the DOM stated that the sprinkler vendor recently came to the facility to collect expired sprinklers and send them to a lab for testing and it was possible that they installed the QR sprinklers in place of the ones they took. 4. At 11:52 a.m., a sidewall mounted fusible link sprinkler was observed in the bathroom in the kitchen and was painted over. Upon interview, the DOM stated that he did not know who painted in this area and did not know that the sprinkler was painted over. 5. At 11:59 a.m., a sprinkler in the laundry room near the entrance was missing an escutcheon. The DOM and CAO confirmed this finding. 6. At 1:45 p.m., two intermingled sprinklers were observed in Room 109 and consisted of one QR head and one sidewall mounted fusible link sprinkler. The DOM observed this finding and stated that the sprinkler vendor came to the facility to collect expired sprinklers to send to a lab for testing and they probably installed the QR sprinkler heads in place of the ones that they took. 7. At 1:51 p.m., intermingled heads were observed in the ICU ward. The ICU contained standard sprinkler heads throughout the suite, as well as one QR sprinkler in the nurse’s station area and one QR sprinkler in the room that used to be ICU Room 2. The DOM Stated that they did not have an ICU anymore and that the suite was mostly used for storage. He stated that he did not know about the intermingled sprinkler heads because people seldom went into this suite. 8. At 10:11 a.m., the annual sprinkler report was missing. Upon interview, the DOM stated that he thought the five-year sprinkler report and the annual fire alarm system report were enough to meet the requirements. The most recent five-year sprinkler service was performed on 4/12/2019, and the annual fire alarm system report did not include testing for all the sprinkler system components. 9. At 10:12 a.m., the facility was missing two of two semi-annual waterflow tests for the vane and pressure switches on the sprinkler system. Upon interview, the DOM stated that they were not testing the waterflow devices in house.”

“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: 42003 Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by doors that were obstructed or propped open with wedges. This could result in a delay in preventing fire or smoke from entering the corridor. This affected two of two patients and four of four smoke compartments. Findings: During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the corridor doors were observed. 1. At 9:54 a.m., a helipad patient gurney was left unattended in the door swinging path of Room 204 in the B-Wing obstructing the door from closing. Upon interview, the DOM stated that the room was used for storage and the gurney should have been pushed all the way in the room. 2. At 10:51 a.m., the door to the Respiratory Therapy Manager’s Office was wedged by a trash bin, preventing the door from closing. Upon interview, the DOM stated that sometimes the housekeeping staff would leave the trash bins in doorways like this. 3. At 11:03 a.m., in Room 3 in the Emergency Room Suite an automatic closing device was installed on the door, and the arm for the door closer was disconnected. Upon interview, the DOM stated that the arms for the automatic closers were disconnected on purpose because one of the old administrators asked that they be removed. The DOM stated that old administrator was no longer with the facility and that the automatic closing devices had been disconnected for a long time. 4. At 11:10 a.m., Room 4 in the Emergency Room Suite had an automatic closing device installed on the door, and the arm for the door closer was disconnected. 5. At 11:19 a.m., the door to the Personnel Lounge in the X-ray wing was wedged open with a floor wedge. This door was located on a corridor and had an automatic closing device installed. Upon interview, the DOM stated that sometimes the staff in this area would prop open the doors to promote air flow. 6. At 11:23 a.m., the east exit door of the X-ray room was wedged open with a floor wedge. This door was located on a corridor and had an automatic closing device installed. Upon interview, the DOM stated that sometimes the staff would prop open the doors with wedges because they had wheelchair bound patients and they did not want to have to keep opening the doors. 7. At 11:25 a.m., the east door of the Radiology Room was wedged open with a floor wedge. The door was located on a corridor and had an automatic closing device installed. Upon interview, the DOM stated that sometimes the staff in the area would prop open the doors with floor wedges so that they could easily move wheelchair bound to patients into the radiology room. 8. At 12:00 p.m., a sterilization cabinet was pressed against the corridor door with a self-closing device to the south Laundry Room Area obstructing the door from closing. Deep scrape marks were observed along the side of the sterilization cabinet. Upon interview, the CAO stated that the sterilization cabinet was supposed to be on the other side of the room, and she did not know why it was placed so close to the corridor door.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 42003 Based on observation and interview, the facility failed to maintain the heating, ventilation, and air conditioning (HVAC) system. This was evidenced by blocked off exhaust vents. This could result in a malfunction of the HVAC system. This affected two of two patients and two of four smoke compartments. 19.5 Building Services. 19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1. 19.5.2 Heating, Ventilating, and Air-Conditioning. 19.5.2.1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer ’ s specifications, unless otherwise modified by 19.5.2.2. 9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 90A: Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 Edition 4.3.8.3.2 9.2.2 Ventilating or Heat-Producing Equipment. Ventilating or heat-producing equipment shall be in accordance with NFPA 91, Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Noncombustible Particulate Solids; NFPA 211, Standard for Chimneys, Fireplaces, Vents, and Solid Fuel-Burning Appliances; NFPA 31, Standard for the Installation of Oil-Burning Equipment; NFPA 54, National Fuel Gas Code; or NFPA 70, National Electrical Code, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 91: Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Particulate Solids, 2010 Edition 10.2 General. Exhaust systems shall be tested, inspected, and maintained to ensure safe operating conditions. 10.2.1 The responsibility for maintenance shall be assigned to trained personnel who are capable of recognizing potential hazards. 10.2.2 Maintenance shall include the determination that special protection for duct systems is fully operable and that plant automatic sprinkler protection is in service. Findings: During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the HVAC system was observed. 1. At 12:10 p.m., an HVAC exhaust vent was observed in the EVS Storage Room and was sealed off with cardboard and duct tape. Upon interview, the DOM stated that he did not know what was going with the sealed off exhaust vent, and he did not know who would have taped it off. 2. At 1:36 p.m., an exhaust vent in the bathroom of Room 101 was stuffed with tissue paper. Upon interview, the DOM stated that he did not know why the vent was sealed off.”

“Smoking Regulations CFR(s): NFPA 101 Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4 This Standard is not met as evidenced by: 42003 Based on observation and interview, the facility failed to maintain the smoking regulations. This was evidenced by smoking materials that were not disposed of in approved ashtrays. This could result in fire hazards from smoking materials encountering combustible materials. This affected the smoking area.. Findings: During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the smoking areas were observed. At 10:57 a.m., the smoking area on the west patio of the Emergency Room waiting area had about 10 cigarette butts in the rocks, grass, and in the surrounding area. Upon interview, the DOM stated that most of the smoking materials came from visitors.”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This Standard is not met as evidenced by: 42003 Based on observation, document review, and interview, the facility failed to maintain the gas and vacuum systems. This was evidenced by a missing inspection/testing documentation for the piped in medical gas. This could result in a malfunction of the piped in medical gas system. This affected two of two patients and four of four smoke compartments. Findings: During a tour of the facility, review of documents, and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24 and 6/19/24, the piped in medical gas equipment was observed. 1. On 6/18/24 at 1:14 p.m., the Zone Valve #9 oxygen shutoff valve located in the Labor Room and Obstetrics Clinic had sticker on the zone valve window dated 4/2/20. The ball valve handle was also broken off. Upon interview, the DOM stated that the ball valve handle was removed because they do not use this area of the hospital anymore, and that they were not licensed for obstetrics or labor and delivery. He also stated that he thought the vendor had come out to the facility to service the medical gas more recently than 2020. 2. On 6/18/24 at 1:42 a.m., the main oxygen shutoff valve for the sub-acute and ICU zone valve had sticker on the window that was dated 4/2/20. Upon interview, the DOM stated that they no longer utilized the sub-acute and ICU wards, however, he thought that the medical gas had been serviced since 2020. 3. On 6/18/24 at 12:56 p.m., Zone Valve #5 oxygen shutoff in Operating Room Nurses Station had sticker on the window that stated the last inspection was done was done on 4/2/20. Upon interview, the DOM and CAO stated that they did not know inspections were required on zone valves. The DOM stated that since he took over, the system had not been inspected. 4. On 6/19/24 at 9:41 a.m., the inspection/testing documentation for the piped in medical gas was missing. Upon interview, the DOM stated that he was unable to find any maintenance documentation for the piped in medical gas, and that they would perform walkthroughs and visually checked for leaks on the oxygen lines on a quarterly basis, but they did not have a report from a vendor.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 42003 Based on document review and interview, the facility failed to maintain the essential electrical equipment (EES). This was evidenced by missing documentation for a 90-minute load bank test for the backup diesel generator, 4-hour load bank test for the diesel generator, and a missing annual fuel quality test. This could result in a malfunction of the EES. This affected two of two patients and four of four smoke compartments. NFPA 101, Life Safety Code, 2012 Edition. 19.5 Building Services. 19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1. 9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA99, Health Care Facilities Code, 2012 Edition 6.3.2.2.10 Essential Electrical Systems (EES) 6.3.2.2.10.2 General care rooms (Category 2 Room) Shall be served by a Type I or Type II EES. 6.4.1.1.6 General. Generator sets installed as an alternate source of power for essential electrical systems shall be designed to meet the requirements of such a device. 6.4.4.1.1.3 Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8. 6.4.4.2 Record Keeping. A written record of inspection, performance, exercise period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. 6.5.1 Sources (Type 2 EES). This requirement for sources for Type 2 essential electrical systems shall conform to those listed in 6.4.1. 8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards. 8.4.2.3 Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. 8.4.9.7 Where the test required in 8.4.9 is combined with the annual load bank test, the first 3 hours shall be at not less than the minimum loading required by 8.4.9.5 and the remaining hour shall be at not less than 75 percent of the nameplate kW rating of the EPS. 8.4.9* Level 1 EPSS shall be tested at least once within every 36 months. 8.4.9.1 Level 1 EPSS shall be tested continuously for the duration of its assigned class (see Section 4.2). 8.4.9.2 Where the assigned class is greater than 4 hours, it shall be permitted to terminate the test after 4 continuous hours. 8.4.9.5.3 For spark-ignited EPSs, loading shall be the available EPSS load. Findings: During a review of documents and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/19/24, the EES was observed, and maintenance documents were requested. 1. At 9:37 a.m., a 4-hour load bank test for the emergency diesel generator was missing. Upon interview, the DOM stated that he did not know a 4-hour load bank test was required. The DOM stated that he became the maintenance director about three years ago and was still learning the ropes. He stated that they had the capacity to perform a load bank test on site, he just did not know that one was required. 2. At 9:10 a.m., an annual fuel quality test was missing. Upon interview, the DOM stated that he did not know that was a requirement. Upon interview, the DOM stated that he inherited the position of maintenance lead about three years ago, right before the COVID-19 pandemic. He stated that he was still getting familiar with all of the requirements. This was a previous finding captured on the previous life safety code recertification survey from on 3/14/2018. 3. At 9:35 a.m. the 90-minute load bank test for the emergency diesel generator was missing. Upon interview, the DOM stated that he did not know this was required. He stated that he was told by the county that they could only run the generator for a certain number of hours in a year.”

“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: 42003 Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by two power strips that were connected to each other (Daisy-Chained). This could result in electrical shocks or fire hazards from connected electrical equipment. This affected two of two patients and one of four smoke compartments. NFPA 101, Life Safety Code, 2012 Edition. 19.5 Building Services. 19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 70, National Electrical Code, 2011 Edition 400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure. (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors. (3) Where run through doorways, windows, or similar openings. (4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B) (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings. (6) Where installed in raceways, except as otherwise permitted in this Code. (7) Where subject to physical damage 590.3 Time Constraints. (A) During the Period of Construction. Temporary electric power and lighting installations shall be permitted during the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities. (B) 90 Days. Temporary electric power and lighting installations shall be permitted for a period not to exceed 90 days for holiday decorative lighting and similar purposes. (C) Emergencies and Tests. Temporary electric power and lighting installations shall be permitted during emergencies and for tests, experiments, and developmental work. (D) Removal. Temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed. Findings: During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the electrical equipment was observed. At 10:27 a.m., two power strips were under a desk in the Business Offices in the B-wing that were daisy-chained together. Upon interview, the DOM stated that he did not know the power strips were connected this way.”

“Gas Equipment - Qualifications and Training CFR(s): NFPA 101 Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment. 11.5.2.1 (NFPA 99) This Standard is not met as evidenced by: 42003 Based on document review and interview, the facility failed to maintain the gas equipment. This was evidenced by the failure to provide continuing education for staff on oxygen tank handling. This could result in a delay in procuring oxygen tanks or damage from mishandling oxygen cylinders. This affected two of two patients and four of four smoke compartments. Findings: During a review of records and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the training policy for oxygen tank handling was requested. At 10:06 a.m., the facility was not able to provide a training policy or curriculum for how to handle oxygen tanks. Upon interview, the CAO stated that the facility had a generalized policy on handling and responding to an oxygen related issue, but this policy was not part of their continuing education curriculum.”

“ORGANIZATIONAL STRUCTURE CFR(s): Organizational Structure This Condition is not met as evidenced by: 47682 Based on interview and record review, the facility failed to ensure the Governing Body (GB- a committee that oversees the facility’s compliance and quality oversight efforts) provided adequate and effective oversight when: 1. the facility was unable to provide the documentation to show the quality assurance program was established, implemented and monitoring of expired food and patient care supplies, certification of infection preventionist, a clean and sanitary environment, and employee annual Tuberculosis (a highly contagious lung disease) skin testing to ensure the provision of quality health care for a universe of 25 patients admitted to the facility from May 1, 2024, through June 6, 2024. (Refer to C-962) The cumulative effect of these systemic problems resulted in the facility’s inability to deliver care in compliance with the Condition of Participation for GB which jeopardized the provision of quality patient care in a safe environment.”

“INFECTION PREVENT & CONTROL & ABT STEWAR PROG CFR(s): The CAH must have active facility-wide programs, for the surveillance, prevention, and control of HAIs and other infectious diseases and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic-resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in coordination with the facility-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 47682 Based on interview, and record review, the facility failed to ensure the infection prevention program demonstrate adherence to control the transmission of infectious disease and was coordinated and lead by a qualified Infection Control Preventionist (ICP), for a universe of 25 patients admitted to the facility from May 1, 2024, through June 6, 2024, when: 1. The facility did not ensure the appointed Infection Control Preventionist had the certification in infection prevention and control to create and sustain a safe health care environment (Refer to C-1204). 2. The facility did not ensure six (6) of eight (8) sampled employees Tuberculosis (TB - contagious infection spread through the air affecting the lungs) Skin Testing (Purified Protein Derivative - PPD- skin test used to determine if a person has been exposed to TB) were performed annually by employee health (Refer to C-1206). 3. Expired food items were found in the kitchen refrigerator, including five dozen (60) eggs, a container of leftover pasta salad and a packaged ham sandwich (Refer to C-1206). 4. The facility did not ensure to maintain a clean and sanitary environment in the facility’s kitchen when, severe corrosion of the kitchen washroom floor and rough mineral deposits on two of three stainless sinks prevented proper cleaning and sanitizing of these work surfaces, and a missing disposal drain cover seal left an exposed surface covered with slimy, dark colored deposits (Refer to C-1208). 5. The facility did not ensure a preventative infection control program was established and maintained when there was no process to identify and monitor infection control practices to minimize the risk of Hospital Acquired Infection (HAI--an infection acquired when receiving health care that was not present during the time of admission) (Refer to C-1225). The cumulative effects of these systemic problems resulted in the hospital’s inability to ensure a safe, sanitary environment and a quality infection control program.”

“QAPI CFR(s): Condition of Participation: Quality Assessment and Performance Improvement Program The CAH must develop, implement, and maintain an effective, ongoing, CAH-wide, data-driven quality assessment and performance improvement (QAPI) program. The CAH must maintain and demonstrate evidence of the effectiveness of its QAPI program. (a) Definitions. For the purposes of this section- Adverse event means an untoward, undesirable, and usually unanticipated event that causes death or serious injury or the risk thereof. Error means the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems; and Medical error means an error that occurs in the delivery of healthcare services. This Condition is not met as evidenced by: 47682 Based on interview and record review, the facility failed to develop and maintain an effective, ongoing, hospital wide, data driven Quality Assurance and Performance Improvement (QAPI) program for a universe of 25 patients admitted to the facility from May 1, 2024, through June 6, 2024, when: 1. The facility failed to identify, monitor and analyze the problem prone areas such as expired food and supplies, unclean and unsanitary environment, and safely maintain patient care supplies. (Refer to C-1306) 2. The facility failed to provide documented evidenced to show an ongoing effective QAPI program to monitor, analyze, and evaluate the provision of care. (Refer to C-1306) The cumulative effect of the facility’s failure to have a quality assurance system in place to ensure oversight of the hospital’s QA program resulted in the facility’s failure to deliver care in compliance with the Condition of Participation for QAPI and failure to provide care to their patients in a safe environment.”

“EQUIPMENT, SUPPLIES, AND MEDICATION CFR(s): Equipment, supplies, and medication used in treating emergency cases are kept at the CAH and are readily available for treating emergency cases. The items available must include the following: This Standard is not met as evidenced by: 47682 Based on observation, interview, and record review, the facility failed to ensure patient care supplies were safely maintained and readily available for a universe of 14 patients presented to the Emergency Department (ED) from June 3, 2024, through June 4, 2024, when multiple expired medical supplies were found in the patient care areas. This failure had the potential for medical supplies not being readily available during an emergency situation and result in the use of an expired medical device which could compromise the integrity of the device and lead to delayed care, infection and patient harm. Findings: During a concurrent observation and interview on June 4, 2024, at 9:20 AM, with the Chief Nursing Officer (CNO), in the ED supply storage area, the following items were found to be expired: - Two [Name of manufacturer] size 7 sterile gloves with an expiration date of November 28, 2023 - Five Rapid RSV swabs (a nasal swab used to quickly test for [RSV] Respiratory Syncytial Virus - a serious respiratory infection) with expiration date of April 30, 2024 - One Multi lumen Central Line kit (kit with sterile supplies used by physician to put a device into a patients veins to deliver medications) with expiration date of March 31, 2023 - Two chlorhexidine (chemical used to disinfect the skin) applicators with expiration date of March 2024. The CNO confirmed the supplies were expired and stated, expired supplies should be removed from patient care areas and not available for patient use. During a continued concurrent observation and interview on June 4, 2024, at 9:35 AM, with the CNO, in the ED Crash Cart (a mobile cart that can be moved to the patient’s bedside and contains lifesaving medication and equipment), the following items were found to be expired: - One size 7 sterile gloves with expiration date of November 28, 2023 - Numerous alcohol preparation pads with the expiration date of October 26, 2021 - Two adult End Tidal Co2 (devices used to detect carbon dioxide at the end of a breathing tube to ensure placement) monitoring devices with expiration of February 15, 2024. The CNO confirmed the supplies were expired and stated, expired supplies should be removed from patient care areas and not available for patient use. During an interview with the Quality, Risk Case Manager (QRM) on June 6, 2024, at 9:10 AM, the QRM stated, the emergency department is responsible for identifying expired items proactively so that they will not be used for patient care. The QRM further stated, in the event of an emergency having an expired patient care supply or having to check an expiration date on a patient care supply means that supplies are not readily accessible for patient use. During a review of the facility’s policy and procedure titled, “Expiration Dates”, dated January 2023, the P&P indicated, “ ...Expiration dates shall be assigned according to this policy ...Expiration dates shall be assigned to all prepackaged products. Expiration dates shall be assigned in accordance with the laws and regulations of this state. In no case shall the assigned date exceed the manufacturer’s expiration date ...The expiration dates of all medical surgical care products and devices shall be checked upon receipt. Expired medical surgical care products and devices with 6 month short dating shall be returned to the supplier. Expiration dates shall be checked monthly.””

“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: 47682 Based on interview and record review, the facility failed to ensure the effective oversight of the Governing Body (GB) when the GB was unable to effectively implement and monitor operational policies to ensure provision of quality health care as evidenced by identified deficiencies including; storage and use of food and medical supplies, certification and qualifications of the Infection Control Preventionist (ICP), annual health screening of the employees and the maintenance of a clean and sanitary environment in the kitchen, inhibiting safe and appropriate health care for a universe of 25 patients admitted to the facility from May 1, 2024, through June 6, 2024. These failures resulted in the facility’s inability to ensure a safe care environment and impaired efforts to improve or sustain quality of care for patients. Findings: During a review of the facility’s “Quality / Patient Safety / Performance Improvement Plan 2024” (QPSPI), dated May 2024, the QPSPI indicated, “QI/IC/S/PR [Quality Improvement / Infection Control / Safety / Performance Review] Committee provides a quarterly summary report of trended data, as well as measurable improvement, to the GB.” During an interview on June 6, 2024, at 10:38 AM, in the conference room, with the Health Information Management Director (HIMD), the HIMD stated, “We do a quarterly meeting with QAPI [Quality Assurance and Performance Improvement] where they report their activities. The main ones they monitor are: medical documentation, Emergency Department patient turnaround times, lab blood contamination, nursing quality reports and approval of the minutes of the previous meeting.” . During a concurrent interview and record review on June 6, 2024, at 10:40 AM, with the HIMD, the “Board of Director’s Meeting Minutes” (MM), dated January 2023 to November 2023, were reviewed. The MM indicated, in May, the Quality Improvement Plan was approved with no changes. In November, the board reviewed and accepted the ‘Quality/Patient Safety Committee Report” (presented in Oct 2023). The GB MM made no other mention of QAPI reporting or their activities of data collection, analysis or reporting. activity. No evidence could be found to support a quarterly QAPI meeting with the GB. The HIMD stated, the QAPI report should be quarterly but there has been a lot of personnel changes recently, and the facility only recently hired a new Infection Preventionist. Many things have been delayed this year. During an interview on June 6, 2024, at 10:45 AM, in the conference room, with members of the Governing Board, the Chief Executive Officer (CEO) stated that the GB committee was unaware of the issues identified by the survey (storage and use of food and medical supplies, certification and qualifications of the infection preventionist, annual health screening of the employees and the maintenance of a clean and sanitary environment in the kitchen). The CEO stated, it would be better if the quality program monitor, track and report these issues so they are kept aware. The CEO further stated, “We could use more information about the issues throughout the hospital. More prompt, actual reports of QAPI activities will help us to be more effective as a board.” During a concurrent interview and record review on June 6, 2024, at 11:00 AM, with members of the board, the “QPSPI Plan 2024” dated May 2024, was reviewed. The QPSPI indicated, “X. Summary. The ultimate responsibility for Quality Management / Performance Improvement is the Governing Body.” The CEO stated, “Yes, we have to provide more oversight to ensure QAPI is effective. The Board is responsible.””

“INFECTION PREVENT & CONTROL ORG & POLICIES CFR(s): Infection prevention and control program organization and policies. The CAH must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body, or responsible individual, as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 47682 Based on interview and record review, the facility failed to ensure the appointed Infection Control Preventionist (ICP) had the certification in infection prevention and control to create and sustain a safe health care environment for a universe of 25 admitted patient between May 1, 2024, through June 6, 2024. This failure resulted in an Infection Prevention Program that did not meet regulatory standards and had the potential for increased patient risk of hospital acquired infection . Findings: During a phone interview with the ICP on June 5, 2024, at 8:30 AM, the ICP stated, she was appointed to the Infection control Nurse position approximately one month ago and does not have specific training or certification in infection prevention and control in an acute care hospital setting. During a concurrent phone interview and record review on June 5, 2024, at 4:40 PM, with the ICP, the ICP’s employee file was reviewed. There were no certificates or documentation related to higher education regarding infection control and prevention. The ICP, stated she did not have documentation of specific education regarding infection control and prevention. During an interview with the Chief Executive Officer (CEO) on June 6, 2024, at 10:35 AM, the CEO stated, he was not aware that the Infection Control Preventionist needed specific training and certification in infection prevention and control. The CEO further stated, the facility administrators should have been familiar with the regulations regarding the qualifications for infection preventionist position. During a review of the facility’s document, “Position Summary: Infection Control/Employee Health”, dated May 2024, the “Position Summary: Infection Control/Employee Health Nurse” indicated, “ ...The Infection Control/Employee Health Nurses’ focus is the delivery of health care in a clean, safe, protected environment. Position responsibilities include ...assuring compliance with established policies and procedures, ongoing surveillance and evaluation of infections in patients and personnel ...Updates the Infection Control plan annually to continually enhance the program ... Actively surveys all areas of the hospital for potential infectious/hazardous environments and takes steps for the immediate correction and resolution of any areas identified. Implements strategies designed to reduce the risk of nosocomial, epidemic infections, including initiating cultures on employees, patients or environment and may initiate or enforce isolation procedures to control infection or conduct outbreak investigations... Special Skills & Qualifications ...Must be able to assist in orientation and training for staff and must function as a resource for all hospital employees. Ability to demonstrate knowledge of the nursing process, as well as California Regulatory agencies ...”.”

“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: 47682 Based on observation, interview and record review, the facility failed to ensure infection control and prevention policies and procedures (P&P) were followed when: 1.Six of eight sampled employees Tuberculosis (TB - contagious infection spread through the air) Skin Testing (Purified Protein Derivative - PPD- skin test used to determine if a person has been exposed to TB) were performed annually by employee health. This failure had the potential to put all patients, visitors and staff in the medical center at increased risk of exposure to unsuspected cases of infectious tuberculosis which could jeopardize the health and safety of the vulnerable populations. 2. Expired food items were found in the kitchen refrigerator, including five dozen (60) eggs , a container of leftover pasta salad and a packaged ham sandwich. This failure had the potential to result in patients and staff being served food contaminated with harmful molds or bacteria that could severely compromise the health and safety of patients and staff in the facility. Findings: 1. During a concurrent interview and record review, on June 5, 2024, at 3:50 PM, with the Quality Assurance Performance Improvement Assistant (A-QAPI), eight sampled employee files (a confidential file that includes information about a specific employee) were reviewed. Six of eight sampled employee files sampled did not contain documentation of annual TB Skin Testing. A-QAPI confirmed there were no annual TB skin tests performed on current employees since 2021 and stated the previous ICP (Infection Control Preventionist) had told her that staff no longer needed to do an annual TB skin test. The A-QAPI further stated, a TB skin test would only be administered to a new employee upon hire, and she did not know if the policy and procedure had been changed or when a TB skin test would be indicated for an employee that was not newly hired. During a concurrent interview and record review, on June 5, 2024, at 4:46 PM, with the Infection Control Preventionist (ICP), the facility’s policy and procedure (P&P) titled, “Employee Health: TB Skin Testing”, dated August 2022, was reviewed. The P&P indicated, “ ...Purpose: To prevent the spread of Tuberculosis (TB) within the healthcare environment. Policy: Name of the hospital] Employee Health has established a mandatory TB skin testing for all Employees, to evaluate transmission, provide follow-up protocols and permit evaluation of the effectiveness of current Infection Control/Employee Health practices ...Periodic PPD Testing: All PPD negative employees will undergo mandatory annual PPD testing ...Documentation: Results of PPD tests will be recorded in the confidential employee health record for employees ...”. The ICP stated, the previous infection preventionist said employees did not require an annual TB skin test and only needed to do the TB Risk Assessment Questionnaire (RAQ - questions regarding common symptoms of TB) annually. The ICP further stated, she was told by the previous infection preventionist that annual TB skin testing was no longer necessary, The ICP stated, she assumed what she was told by the previous infection preventionist was in the policy. The ICP further stated, upon reviewing the policy now, all staff should be tested for TB annually. The ICP stated, the facility was not following their P&P and all staff needed to have a TB skin test performed immediately. During a review of the facility’s “Position Summary: Infection control/Employee Health Nurse”, dated May 2024, the “Position Summary: Infection Control/Employee Health Nurse”, indicated, “ ...The infection Control/Employee Health Nurses’ focus is the delivery of health care in a clean, safe, protected environment. Position responsibilities include ...assuring compliance with established policies and procedures, ongoing surveillance and evaluation of infections in patients and personnel ...Monitors and maintains compliance on all employee health files, immunizations, etc ...”. 2. During a concurrent observation and interview on June 4, 2024, at 8:20 AM, with the Dietary Manager (DM) in the kitchen walk-in refrigerator, there was a ready-to-eat ham and cheese sandwich found on the shelf dated May 30, 2024. The DM stated “Yes, this is expired. It should have been removed. I can’t serve this.” During an observation on June 4, 2024, at 8:22 AM, in the walk-in kitchen refrigerator, there were five full cartons of unpasteurized eggs (60 eggs), dated May 16, 2024, sitting on the shelf. The DM inspected the cartons and quickly gathered up the eggs and threw them in the trash. During a concurrent observation and interview on June 4, 2024, at 8:24 AM, with the DM, in the kitchen walk-in refrigerator, a container of left-over pasta salad was observed on the shelf dated May 25, 2024. The DM stated, “This is still good, it should be good for over a week. I may throw it away tomorrow.” During a concurrent interview and record review on June 5, 2024, at 9:00 AM, with the DM, the facility’s policy and procedure (P&P) titled “Storage and Use of Leftovers” dated May 2020, was reviewed. The P&P indicated, “Leftover items which are not frozen are held no longer than two days before they are used or disposed of.” The DM stated, “Yes, the policy states that leftovers should only be kept two days. The items you found were expired and should not be used. I threw them away already.” During an interview on June 5, 2024, at 9:05 AM, with the DM, in the kitchen walk-in refrigerator, the DM stated, there should not be any expired food in the fridge. It should be thrown away. The danger is that it could grow bacteria and cause illness if eaten. During a phone interview on June 5, 2024, at 10:45 AM, with the Registered Dietician (RD), the RD stated “All eggs should be pasteurized. When we order eggs from the company, my expectation is that they should be delivering pasteurized eggs. There should not be raw eggs in the fridge. Especially if they are over 2 weeks old.” During a follow up phone interview on June 5, 2024, at 10:50 AM, with the RD, the RD stated, pasta salad stored for a week was unsafe. It should never be kept in the fridge. The policy states leftover storage for only two days. The RD further stated, “Improper storage of foods can cause food-borne illnesses, they can result in diarrhea, nausea, dehydration.””

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 47682 Based on observation, interview and record review, the facility failed to ensure a clean and sanitary environment was maintained when; 1a. A missing disposal drain cover seal left an exposed surface covered with slimy, dark colored deposits, 1b. Severe corrosion and degradation was found over a large area of the kitchen washroom floor. 1c. Mineral deposits were noted on two stainless steel sinks, all of which prevented proper cleaning and sanitizing of these work surfaces. These failures had the potential to result in growth and transmission of bacteria which can contaminate food and spread diseases that can severely compromise the health and safety of patients and staff in the facility. FINDINGS: 1a. During a concurrent observation and interview on June 4, 2024, at 9:05 AM, with the Dietary Manager (DM) in the kitchen washroom, an in-sink macerator (food waste disposal) drain was observed to be missing the rubber splash guard with the bare opening covered in a thick, wet layer of moldy black slime. The DM stated, this drain cover has been gone for a long time. The DM stated, the rubber disintegrated and should be replaced. The DM further stated, “There are probably germs living there. It is not possible to clean that.” 1b. During a concurrent observation and interview on June 4, 2024, at 9:10 AM, with the DM, in the kitchen washroom, the cement floor under the dish sanitizer was found to be severely corroded, encrusted with mineral deposits over an uneven surface containing deep fissures. The DM stated, the cracks and bumps made it difficult to clean. It was not a cleanable surface. The DM stated, “We can’t really mop under that dishwasher, the floor is too corroded. It is not smooth enough to really clean.” The DM further stated “I would agree that the floor is not suitable for food service if it is not cleanable.” 1c. During a concurrent observation and interview on June 4, 2024, at 9:35 AM, with the DM, in the kitchen, two stainless steel sinks were observed with areas of crusted white colored mineral deposits that were rough to the touch. The DM stated, the facility’s water was very hard, it does leave deposits. The DM further stated, This would impede disinfecting. It should be a smooth surface. During a follow up interview on June 4, 2024, at 9:37 AM, with the DM, in the kitchen, the DM stated, kitchen surfaces should be without stains or deposits. The DM further stated, Surfaces that are not smooth can be hard to clean and could potentially harbor germs. The kitchen should have smooth, clean surfaces. During a phone interview on June 5, 2024, at 10:47 AM, with the Registered Dietician (RD), above survey findings in the kitchen were discussed. The RD stated, “Yes, I have seen the corrosion on the floor. I have mentioned to them it needs resurfacing. I would agree that this floor is not suitable for food service if it is not cleanable. It needs to be cleanable and sanitizable.” The RD stated, corrosion on sinks or stainless-steel surfaces can harbor germs and grow bacteria. A surface that cannot be properly cleaned can be a source of germs. This corrosion on surfaces prevents proper cleaning. The RD further stated, “A negative outcome would be illness. We try to prevent any negative outcomes through proper food storage, handling, and by disinfecting surfaces.” During a review of the facility’s policy and procedure (P&P) titled, “Food and Nutrition Services: Infection Control.” dated May 2020 , the P&P indicated, “To develop and maintain clean, sanitary work areas, storage areas and equipment for the handling of supplies in accordance with state and local health department standards.””

“LEADERSHIP RESPONSIBILITIES CFR(s): (1) The governing body, or responsible individual, must ensure all of the following: (i) Systems are in place and operational for the tracking of all infection surveillance, prevention and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities. This Standard is not met as evidenced by: 47682 Based on interview, and record review, the facility failed to ensure a preventative infection control program was established and maintained for a universe of 25 patients admitted to the facility from May 1,2024, through June 6, 2024, when there was no process to identify and monitor infection control practices to minimize the risk of Hospital Acquired Infection (HAI--an infection acquired when receiving health care that was not present during the time of admission.) This failure resulted in the facility’s inability to track and evaluate the infection control program within the hospital and had the potential to compromise the quality of health care provided, which may result in a life-threatening infection and prolong the hospitalization of vulnerable patients. Findings: During an interview on June 5, 2024, at 8:30 AM, with the Infection control Preventionist (ICP), the ICP stated, there are no tools being used to monitor if staff are adhering to infection control policies and procedures or audits taking place regarding infection control, as in hand washing opportunities here at the facility. The ICP further stated, she does not know if the previous ICP was conducting infection control audits prior to her leaving the position one month ago. During an interview on June 5, 2024, at 10:40 AM, with the Quality, Risk Case Manager (QRM), the QRM stated, there was no tracking for monitoring infection control practices in the facility. The QRM further stated, infection control surveillance and monitoring regarding staff following infection control standards and facility policies and procedures was not discussed in QRM and no data was collected by the prior infection control nurse . During a concurrent interview and record review on January 5, 2024, at 4:46 PM, with the ICP, the “Position Summary” for “Infection Control/Employee Health Nurse”, revised May 2024, was reviewed. The Job Description indicated, “ ...The Infection Control/Employee Health Nurses’ focus is the delivery of health care in a clean, safe, protected environment. Position responsibilities include ...assuring compliance with established policies and procedures, ongoing surveillance and evaluation of infections in patients and personnel ...Updates the Infection Control plan annually to continually enhance the program ... Actively surveys all areas of the hospital for potential infectious/hazardous environments, and takes steps for the immediate correction and resolution of any areas identified. Implements strategies designed to reduce the risk of nosocomial, epidemic infections, including initiating cultures on employees, patients or environment and may initiate or enforce isolation procedures to control infection or conduct outbreak investigations...”. The ICP stated there was no system in place for monitoring staff performing patient care to ensure the facility infection control P&Ps are being followed. The ICP further stated, identifying infection control problem areas would provide an opportunity to implement safer practices which could decrease the risk of hospital acquired infection.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (2) Be ongoing and comprehensive. (3) Involve all departments of the CAH and services (including those services furnished under contract or arrangement). This Standard is not met as evidenced by: 47682 Based on interview and record review, the facility failed to establish and maintain an effective, ongoing, hospital-wide, data driven Quality Assurance and Performance Improvement (QAPI) program when the facility was unable to ensure the Infection Control Preventionist (ICP) nurse was trained and qualified, an effective infection control program, a clean and sanitary environment, accurate monitoring of inventory and the collection and analysis of hospital-wide clinical data and risk assessment issues used to evaluate the quality and appropriateness of the treatment and services provided for a universe of 25 patients admitted to the facility from May 1, 2024,through June 6, 2024. These failures resulted in the facility’s inability to identify and address important focus areas and proactively implement interventions that would ensure the provision of quality patient care in a safe environment for all patients who received services within the facility. Findings: During an interview on June 4, 2024, at 9:40 AM, with the Dietary Manager (DM) the DM stated, The Infection Control Preventionist (ICP) nurse does not look at the kitchen at all. The DM stated there was nobody else from the hospital to really check and monitor the kitchen. The DM stated, the Registered Dietician (RD) does come in every other month and audit with notes on what she finds. The DM further stated, a copy of RD’s findings goes to QAPI, but the kitchen was responsible for addressing the issues ourselves. The RD findings are not included in the QAPI program at all. During an interview on June 4, 2024, at 10:18 AM, with the Quality /Risk case Manager (QRM) the QRM stated, the ICP should be more integrated into QAPI, collecting data to monitor infection-control related issues. The QRM stated, It would be good if they also monitored the kitchen to ensure compliance with Infection Control standards and kitchen hygiene policies. During an interview on June 5, 2024, at 8:30 AM, with the ICP, the ICP stated, there are no tools being used to monitor if staff are adhering to infection control policies and procedures or audits taking place regarding infection control, as in hand washing opportunities here at the facility. The ICP further stated, she does not know if the previous ICP was conducting infection control audits prior to her leaving the position one month ago. During an interview on June 5, 2024, at 10:40 AM, with the QRM, the QRM stated, there was no tracking for monitoring infection control practices in the facility. The QRM further stated, infection control surveillance and monitoring regarding staff following infection control standards and facility policies and procedures was not discussed in the Quality Management meetings and no data was collected by the prior infection control nurse. During a concurrent phone interview and record review on June 5, 2024, at 4:40 PM, with the ICP, the ICP’s employee file was reviewed. There were no certificates or documentation related to higher education regarding infection control and prevention. The ICP, stated she did not have documentation of specific education regarding infection control and prevention. During a concurrent interview and record review on June 5, 2024, at 4:46 PM, with the ICP, the “Position Summary” for “Infection Control/Employee Health Nurse”, revised on May 2024, was reviewed. The Job Description indicated, “ ...The Infection Control/Employee Health Nurses’ focus is the delivery of health care in a clean, safe, protected environment. Position responsibilities include ...assuring compliance with established policies and procedures, ongoing surveillance and evaluation of infections in patients and personnel ...Updates the Infection Control plan annually to continually enhance the program ... Actively surveys all areas of the hospital for potential infectious/hazardous environments and takes steps for the immediate correction and resolution of any areas identified. Implements strategies designed to reduce the risk of nosocomial, epidemic infections, including initiating cultures on employees, patients or environment and may initiate or enforce isolation procedures to control infection or conduct outbreak investigations...”. The ICP stated there was no system in place for monitoring staff performing patient care to ensure the facility infection control P&Ps are being followed. The ICP further stated, identifying infection control problem areas would provide an opportunity to implement safer practices which could decrease the risk of hospital acquired infection. During an interview with the Chief Executive Officer (CEO) on June 6, 2024, at 10:35 AM, the CEO stated, he was not aware that the Infection Control Preventionist needed specific training and certification in infection prevention and control. The CEO further stated, the facility administrators should have been familiar with the regulations regarding the qualifications for infection preventionist position. During a follow up interview on June 6, 2024, at 10:14 AM, with the QRM, the QRM stated, bi-monthly kitchen audit reports were submitted by the Registered Dietician (RD), but they were not included in any quality data or interventions. The QRM further stated the DM was expected to handle it internally in the dietary department. During an interview on June 6, 2023, at 10: 22 AM in the conference room, with the Chief Nursing Officer (CNO) the CNO stated, the facility did not have any specific person assigned to check for expired supplies. During a follow up interview on June 6, 2024, at 10:23 AM, with the QRM, the QRM stated, “We did not identify the issues you found in the survey. There are a lot of things that we are not really monitoring as we should.” The QRM further stated, she was not fully aware that the scope of QA should be more comprehensive, monitoring all areas facility wide, including all departments and services. The survey revealed that there are some important areas like the kitchen that have not been included. The QAPI did not work closely enough with the ICP and incorporate all the data that they monitor.”