Adventhealth Littleton

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 47959 Based on interviews and documents reviewed, the facility failed to ensure a patient’s unresolved complaint received by a staff member was submitted to the patient advocate as a grievance by the next working day. Findings include: Facility policy: The Patient and Family Complaint/Grievances policy read, all staff will attempt to resolve complaints at the time of the complaint. If staff is unable to resolve the complaint at the time, the department leadership, administrative supervisor, or patient representative (or other designated individual) will be contacted to assist in resolving the complaint. If the complaint is unresolved, the complaint will become a grievance. Reference: The Hospital Patient Rights and Responsibilities document read, patients have the right to be given the name, business address, and telephone number of the person that will handle any complaints or questions about services being delivered. 1. The facility failed to ensure a patient’s unresolved complaint received by a staff member was submitted to the patient advocate as a grievance by the next working day. a. On 4/21/26 at 1:13 p.m., an interview was conducted with Officer #1. Officer #1 stated they received a phone call from a patient who wanted to speak with the patient advocate regarding a complaint about their missing property. Officer #1 stated they provided the patient advocate’s phone number to the patient and later learned the phone number was incorrect. Officer #1 stated they called the patient back to provide the correct phone number, however, the patient did not answer. Officer #1 stated they left a voicemail for the patient to call them back for the phone number and the patient did not call back. Officer #1 stated they escalated the patient’s complaint information to their shift supervisor. This was in contrast to the Patient and Family Complaint/Grievances policy which read, if staff were unable to resolve the complaint, the complaint became a grievance. b. A review of the facility’s grievances revealed no evidence of a grievance filed for the patient who called Officer #1 and requested the patient advocate’s contact information for a complaint about their missing property. This was in contrast to the Hospital Patient Rights and Responsibilities which read, patients had the right to be given the name, business address, and telephone number of the person who would handle any complaints or questions about services provided. Additionally, this was in contrast to the Patient and Family Complaint/Grievances policy which read, if staff were unable to resolve the complaint, the complaint became a grievance. c. On 4/21/26 at 2:45 p.m., an interview was conducted with security supervisor (Supervisor) #2. Supervisor #2 stated security officers were trained to report patient complaints to the supervisors and the patient advocate was notified when complaints were received. d. On 4/21/26 at 3:41 p.m., an interview was conducted with security program manager (Manager) #3. Manager #3 stated the patient’s complaint was escalated to them, as well as to the shift supervisor. Manager #3 stated they reviewed camera footage related to the patient’s complaint and determined the complaint was unfounded. Manager #3 confirmed the patient advocate had not been notified of the patient’s complaint. This was in contrast to the interview with Supervisor #2, who stated the patient advocate was notified when complaints were received. e. On 4/21/26 at 2:07 p.m., an interview was conducted with the patient experience manager (Manager) #4. Manager #4 stated staff notified the patient advocate when patients requested to file a complaint or grievance. Manager #4 stated once a patient was discharged, complaints were automatically considered to be a grievance. This was in contrast to the review of the facility’s grievances, which revealed the patient’s complaint regarding missing property had not been filed as a grievance. Manager #4 stated they were unaware of the patient’s request to file a grievance.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 47962 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.55 Emergency Services was out of compliance. Based on document review and interviews, the facility failed to ensure patients who presented to the emergency department (ED) for emergency medical care were assessed according to facility policy and protocol in two of ten medical records reviewed for patients seen in the ED (Patients #2 and 7). In addition, the facility failed to ensure patients with pain were being reassessed post-medication administration in four of thirteen medical records reviewed. (Patients #4, #5, #7 and #13) Findings include: Facility policies: According to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy, the purpose is to outline the standards of care for assessment and maintain an accurate record of patients’ assessments, progress, treatments, medications, and condition within the electronic health record. Patients screened as an ESI 1 and ESI 2 by the triage registered nurse (RN) were assessed by nursing staff within 30 minutes of arrival. Patients screened as an ESI 3 were assessed by nursing staff within one hour of arrival. According to the Emergency Medical Treatment and Active Labor Act (EMTALA) policy, the facility will provide an appropriate medical screening examination (MSE) within the capability of the ED to determine whether or not an emergency medical condition exists. The facility will not delay the provision of an MSE to inquire about the individual’s method of payment or insurance status. The facility may follow reasonable registration processes when examination or treatment is required, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage an individual from remaining for further evaluation. According to the facility’s pain management policy, a patient’s pain will be reassessed within one hour of administration of pain medication using an appropriate pain scale. Reference: According to the Trauma Team Activation guideline, the purpose is to ensure each trauma team member clearly understands the two top levels of trauma team activation (Full and Partial Teams). The full and partial consultation criteria for anatomic/mechanism included pulseless extremity. 1. The facility failed to ensure patients who presented to the ED for emergency medical care were assessed according to facility policy and protocol. A. Document review i. A review conducted of Patient #2’s medical record revealed Patient #2 presented to the ED on 10/27/24 at 5:38 p.m. with a laceration (skin wound) to their right arm. The record revealed RN #1 triaged Patient #2 at 5:46 p.m. (eight minutes after the patient presented to the ED). RN #1’s assessment of Patient #2 revealed Patient #2’s circulation was within defined limits (WDL) (normal). At 5:49 p.m., RN #1 designated Patient #2 as an ESI 3 (urgent) and placed the patient in a room. At 5:50 p.m. (12 minutes after arrival), a physician assistant (Provider) entered the room to evaluate Patient #2. At 5:52 p.m. (14 minutes after arrival) and while the patient was in the room, RN #1 documented Patient #2’s parent had applied a tourniquet at 5:05 p.m. (47 minutes earlier) after seeing pulsatile bleeding (indicating an arterial bleed). At this time, RN #1 changed Patient #2’s ESI from a 3 to a 2 (emergent) although this was then changed at 5:57 p.m. back to ESI 3 (urgent). At 5:57 p.m. (19 minutes after arrival), Patient #2 was transferred out of the room to a trauma room in the ED. The Provider’s note revealed the Provider entered the room at 5:50 p.m. and observed Patient #2’s hand was blue and there was a tourniquet on their right upper arm. The Provider documented that at this point, Patient #2 was made a partial trauma (indicating a team with a trauma surgeon, emergency physician, trauma ED nurse, ED technician, radiology technician, and laboratory technician) given the presence of a tourniquet. The Provider also documented a 1.5 centimeter laceration on the forearm, pulsatile bleeding when the tourniquet was removed, and a lack of movement or sensation in the blue right hand before the removal of the tourniquet. The ED physician’s note documented the Provider had recognized the presence of the tourniquet upon examination of Patient #2. This physician also documented that at this time, a partial trauma activation was called per facility protocol. This review of Patient #2’s medical record, which revealed an assessment of an extremity as WDL (although it was bound by a tourniquet and later described as pulseless and blue) was in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, the facility had standards of care for patient assessment and staff maintained an accurate record of the patients’ assessments and condition. This was also in contrast to the Trauma Team Activation guideline which read, the trauma team was activated for multiple conditions, including a pulseless extremity. The review of the record also revealed contradictory information in Patient #2’s ED Care Timeline which revealed a trauma activation was called at 5:38 p.m. (the time of Patient #2’s arrival) with a trauma team assuming care at this time. However, per the ED Care Timeline and the provider notes, Patient #2 was recorded to be in triage, roomed in a quickstart room, and moved to a trauma room before the trauma team assumed care. During an interview on 3/4/25 at 12:39 p.m. with RN #2, RN #2 stated the electronic medical record (EMR) was known to have issues that resulted in inaccurate timelines when inputting information after an event. They stated this compromised their ability to accurately record the course of a patient’s care in the medical record. ii. A review of Patient #7’s medical record revealed Patient #7 presented to the ED on 12/29/24 at 5:02 p.m. for back pain. The triage notes revealed RN #1 documented Patient #7 had pre-existing back pain and had also slipped two weeks ago when getting out of the car. At 5:17 p.m. (15 minutes after arrival), RN #1 documented an assessment of Patient #7 which included airway, breathing, circulation, and disability, scoring all WDL. At 6:09 p.m., after Patient #7 was roomed, another ED RN documented a neurological assessment and a Glasgow Coma Scale (to evaluate consciousness), both of which were WDL. This review of Patient #7’s record failed to reveal a nursing assessment of Patient #7’s musculoskeletal system, although the patient presented with back pain. This lack of nursing assessment was in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, the facility had standards of care for patient assessment and staff maintained an accurate record of the patients’ assessments and condition. This lack of assessment was also in contrast to an interview conducted on 3/5/25 at 12:41 p.m. with ED assistant nurse manager (Manager) #11 who stated the primary nursing assessment was important to document the patient’s baseline status and the focused nursing assessment was important for understanding the patient’s complaint and presentation. B. Interviews i. On 3/4/25 at 12:05 p.m., an interview was conducted with RN #1, who provided care to Patient #2 as the triage nurse. RN #1 stated registration relied on “buzz words” from patients to be able to alert triage staff of emergent complaints. They stated as a triage nurse, their responsibility was to take vital signs and determine acuity based on the number of resources required to care for the patients. RN #1 stated for patients with trauma, it was important that the triage RN alerted the charge nurse and provider as quickly as possible. They stated any patient with a tourniquet was automatically deemed a trauma patient per facility protocol. This statement was in contrast to a review of Patient #2’s record which revealed RN #1, the triage nurse for Patient #2, failed to recognize Patient #2 had on a tourniquet, scored Patient #2 as an ESI 3, and failed to call a trauma alert. RN #1 stated Patient #2 wore a jacket when they presented to the ED, which was why they did not recognize the patient had on a tourniquet. They stated the patient and their parent had not mentioned the tourniquet to registration or nursing staff. However, the medical record for Patient #2 revealed that although RN #1 had evaluated Patient #2 as having normal circulation at 5:46 p.m. with a tourniquet encircling their right arm, at 5:52 p.m. (six minutes later), Patient #2’s hand was blue and pulseless in the quickstart room. RN #1 stated they attributed the delay in Patient #2 receiving emergency care for an emergency medical condition to a lack of transparency by the patient and their parent, rather than RN #1’s inaccurate and incomplete nursing assessment. ii. On 3/4/25 at 12:29 p.m., an interview was conducted with RN #2. RN #2 stated acuity was determined by severity, with ESI 1 being used for stroke, trauma, and partial trauma, a compromised airway, breathing, and circulation, indicating the need for immediate evaluation and treatment. They stated ESI 2 was for unstable patients with concerns for airway, breathing, and circulation. RN #2 stated ESI 3 was used for most walk-in patients who were more stable than those with an ESI 1 or 2. RN #2 stated Patient #2’s tourniquet was not recognized in the ED immediately as the patient was wearing a jacket. They stated parents were expected to be forthcoming with details about their children’s medical history, and that without the parent informing staff, they had no way to know the tourniquet was present. RN #2 stated a patient with a tourniquet was always alerted as a trauma as this reflected a compromised circulatory system. They stated an arterial bleed, which Patient #2 had as a result of their laceration, could result in patient decompensation, and fast action was needed to save the patient and the limb. iii. On 1/14/25 at 9:07 a.m. and on 3/4/25 at 3:14 p.m., interviews were conducted with nurse manager (Manager) #8. Manager #8 stated staff were educated during shift change for two weeks after the incident with Patient #2. They stated staff were educated to evaluate the full extremity in the case of a laceration. This statement was in contrast to interviews with RN #1 and RN #2, both of whom stated Patient #2 and their parent were responsible for not disclosing the tourniquet and failed to recognize the lack of nursing assessment. iv. On 3/5/25 at 1:06 p.m., an interview was conducted with ED medical director (Director) #10. Director #10 stated they felt the care provided to Patient #2 was reasonable. They stated if the staff had been informed by the patient or their parent of the presence of the tourniquet, the staff would have acted with more urgency as tourniquets could cause tissue damage within 90 minutes to three hours after application. 52287 2. The facility failed to ensure pain was addressed in patients following pain medication administration. A. Medical Record Review i. A review of Patient #4’s medical record revealed the patient arrived in the emergency department (ED) on 12/25/24 at 6:15 a.m. with hip pain. According to the ambulance report, 50 micrograms (mcg) of Fentanyl (rapid-acting pain medication) were given in the ambulance before arrival in the ED. Upon arrival to the ED, Patient #4 rated their pain at a level of ten out of ten on the pain scale. Patient #4’s provider ordered Dilaudid (used to relieve severe pain) at 6:26 a.m., however, Patient #4 did not receive pain medication until 8:54 a.m. Patient #4 rated their pain at a level of seven out of ten at that time. A pain reassessment was not completed to determine if Patient #4 had pain relief. There was no further medication administration or assessments of pain completed in the ED before transferring the patient to the oncology floor at 12:39 p.m ii. A review of Patient #5’s revealed they arrived in the ED on 1/3/25 at 2:29 p.m. with flank pain that had started the previous night rating their pain a level of five out of ten. Patient #5’s provider ordered Toradol (used to relieve moderate to severe pain) for pain management at 2:40 p.m. Patient #5 received Toradol at 2:45 p.m. There was no reassessment completed to determine the effectiveness of the pain medication administered. Patient #5’s provider ordered oxycodone (used to treat severe pain) at 4:38 p.m. The pain medication was administered at 4:40 p.m. Patient #5’s pain was subsequently reassessed at 5:51 p.m. and rated at a level of two out of ten. Patient #5’s provider ordered oxycodone for pain control at 7:28 p.m. With a reported pain score of five out of 10, the patient was given oxycodone at 7:30 p.m. No further pain assessment was completed until after Patient #5 was transferred to the oncology unit at 9:06 p.m. iii. A review of medical records for Patient #7 revealed they arrived in the ED on 12/29/24 at 5:02 p.m. for back pain at a level of ten out of ten on the pain scale reported during the initial assessment. Patient #7 had a history of back pain and their provider ordered Ketamine at 11:30 p.m. and administered it to Patient #7 at 11:36 p.m. There was no reassessment of pain completed until 1:15 a.m. iv. A review of patient care records revealed Patient #13 arrived in the ED on 3/1/25 at 8:32 a.m. with intense abdomen pain rated a six out of 10. Patient #13’s provider ordered Dilaudid for pain at 11:07 a.m. The medication was given at 11:14 a.m. There was no reassessment of pain completed to determine the effectiveness of the medication until 1:33 p.m. The record reviews were in contrast to the Pain Management policy which read, that reassessing a patient’s pain was part of the scope of care in treating pain after receiving pain medications. B. Interviews i. On 3/5/25 at 12:41 p.m., an interview was conducted with the ED RN manager (Manager) #1. Manager #1 stated the facility conducted a recent audit regarding pain assessments, however, the audit was focused on the inpatient units and not the emergency department. Manager #1 stated even though their department was not part of the process, they would have liked to focus on it since it was an important topic. ii. On 1/14/25 at 2:07 p.m., an interview was conducted with RN #18. RN #18 stated they were previously used to assessing for pain every two hours and recently realized it was 60 minutes. RN #18 stated patients had increased risks of not wanting to participate in activities or therapies if pain was not addressed as well as there being a risk of extended hospital stays. iii. On 1/14/25 at 2:36 p.m., an interview was conducted with RN# 17. RN #17 stated education was provided for the assessment and reassessment of pain after the administration of scheduled medications. RN #17 stated some of the fallouts they were seeing were pain reassessment alerts not being generated by the electronic medical record documentation system, causing staff to not reassess pain on time. RN#17 emphasized that addressing pain promoted faster recovery and made patients feel valued and heard. iv. On 1/14/25 at 2:34 p.m., an interview was conducted with RN# 16. RN #16 stated they were provided with education on pain assessment and reassessment for scheduled and as-needed medications using the rule of thirty minutes after the administration of Dilaudid and oxycodone and an hour after the administration of Tylenol. They emphasized controlling pain promoted a faster healing process.”

“SAFETY POLICY AND PROCEDURES CFR(s): 482.26(b) [§482.26 Condition of Participation: Radiologic Services §. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications.] §482.26(b) Standard: Safety for Patients and Personnel The radiologic services, particularly ionizing radiology procedures, must be free from hazards for patients and personnel. This Standard is not met as evidenced by: 47962 Based on interviews and document review, the facility failed to ensure radiological services were performed safely for a patient with an implanted device. Specifically, the facility failed to ensure all magnetic resonance imaging (MRI) parameters were met for a patient (Patient #8). Findings include: Facility policy: According to the MRI Quality, Safety, Emergency Procedure and Regulatory Compliance policy, implants could have a designation of magnetic resonance (MR) safe/MR conditional. The MRI technologist will utilize available resources to determine devices and implants as MR safe/MR conditional/MR unsafe. MRI produces thermal loads in the body and has the possibility to produce focal (localized) radiofrequency (RF)-related thermal injury. Each facility should have processes in place to monitor thermal loading (increased heat) and prevent focal thermal injury to patients. Education to patients about thermal considerations should occur prior to scanning. The MRI technologist should monitor the specific absorption rate (SAR) to minimize the potential for excessive thermal loading during scanning. References: According to the MRI Procedure Information Abbott Medical MR Conditional Deep Brain Stimulation (DBS) System for the Infinity 6660, before an MRI scan, determine the patient’s body temperature. If the patient has a fever, you should not perform an MRI scan. 1. The facility failed to ensure all magnetic resonance imaging (MRI) parameters were met for a patient. A. Document review i. A review conducted of Patient #8’s medical record revealed on 12/31/24, Patient #8 presented to the facility for MRIs of their cervical (upper) and lumbar (lower) spine due to back pain. The review revealed Patient #8 had a deep brain stimulator (DBS) Infinity 6660 to treat essential tremors. The review revealed the MRI technicians had determined Patient #8 was eligible to undergo MRI scanning as long as certain parameters (MRI conditions) were met before and during the scan. During an interview on 3/4/25 at 10:47 a.m. with lead MRI technician (Lead) #4 reviewing Patient #8’s record, Lead #4 stated the MRI technicians followed the DBS MRI conditions to ensure Patient #8’s safety. They stated determining Patient #8’s temperature before their MRI was a condition for this type of implant, although this information was not in their record. This lack of assessment was in contrast to the MRI Procedure Information Abbott Medical MR Conditional Deep Brain Stimulation System which read, before an MRI scan, staff were to assess a patient’s body temperature. If the patient had a fever, an MRI scan was not safe to be performed. This lack of assessment was also in contrast to the MRI Quality, Safety, Emergency Procedure and Regulatory Compliance policy which read, some implants were designated MR safe/MR conditional and the MRI technologist utilized resources to determine if implants were MR safe/MR conditional/MR unsafe. MRI produced thermal loads (increased heat) in the body and could produce focal RF-related thermal injury. ii. A review of the grievances revealed Patient #8 had submitted a grievance related to their MRI scan. They stated they felt they had experienced internal burns as a result of the procedure. The facility responded to the patient and stated all protocols were followed which was in contrast to a review of Patient #8’s medical record and MRI procedure information for this device. B. Interviews i. On 1/14/25 at 10:01 a.m. and on 3/4/25 at 10:47 a.m., interviews were conducted with Lead #4. Lead #4 stated staff screened patients for implants before medical imaging. They stated if the patient had an implant, staff investigated if the patients’ devices were able to be safely scanned by the MRI machines at their facility. Lead #4 stated some implants required certain conditions or parameters to be met before scanning to ensure patients’ safety. They stated implants created an increased risk of burns or movement of the implants (resulting in possible bleeds or ruptures) during an MRI, especially if the conditions were not met. Lead #4 stated determining Patient #8’s temperature before their MRI was a condition for this type of implant although their review of Patient #8’s record failed to reveal a record of their body temperature. They stated this condition was important to ensure patients did not have an elevated body temperature due to an elevated risk for thermal injury to the patient. ii. On 3/5/25 at 1:32 p.m., an interview was conducted with the director of radiology (Director) #5. Director #5 stated there were specific processes for safely imaging patients with implants. They stated the MRI technician was responsible for determining the conditions for safety and ensuring those conditions were met during the scanning. Director #5 stated the proper parameters were met for Patient #8. This was in contrast to a review of Patient #8’s medical record which failed to reveal an assessment of their body temperature. iii. On 3/5/25 at 1:32 p.m., an interview was conducted with radiologist (Radiologist) #6. Radiologist #6 stated if all of the MRI conditions were not met, including an assessment of a patient’s temperature if required, there was an increased risk of displacement, heating, and malfunction of the implant. Radiologist #6 stated thermal injuries due to overheating were unlikely to be visible externally and proving causation would be difficult. They stated staff would only be aware of patient injury if the patients’ actions revealed damage to an area of the brain.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 35629 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation, §482.41 Condition of Participation: Physical Environment was out of compliance. A-0700 - The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. Based on a life safety code complaint inspection completed on 12/18/2024, the facility failed to comply with the regulations set forth for Life Safety. Therefore, condition level deficiencies were cited under the Life Safety Code. See survey event ID MDYU21 for full details of the cited deficiencies.”

“A survey was initiated following complaint investigation #CO38731 on 12/18/2024. Deficiencies were cited. The Initial Comments (ID Tag 0000) are informational only and are a representation of the facility’s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR Part 482.41(b). A full Life Safety Code recertification survey was conducted. The survey was conducted during the period of December 18, 2024, using the National Fire Protection Association (NFPA) Life Safety Code (20122) Chapter 19, Existing Health Care Occupancies. This facility is a off campus” location located in a Business Occupancies. The building classified as Fully Sprinklered, Type II(222) construction. The deficiencies cited were discussed with numerous facility staff, including the Safety Officer, Director of Plant Operations and Chief Executive Officer, during the course of the survey and during the exit conference conducted at the end of the onsite survey.”

“Interior Wall and Ceiling Finish CFR(s): NFPA 101 Interior Wall and Ceiling Finish 2012 EXISTING Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted. 10.2, 19.3.3.1, 19.3.3.2 Indicate flame spread rating(s). _____________________ This Standard is not met as evidenced by: 35629 STANDARD is not met as evidenced by: Through observation and staff interview the facility failed to install and maintain the Interior Wall and Ceiling Finishes per NFPA 101 Life Safety Code (2012 Edition), section 19.3.3.1 and 10.2. Failure to keep the flame spread rating of Class A or B could harm all occupants, staff, and visitors if a fire occurred. The CT storage room has missing ceiling tiles. Life Safety Code section 19.3.3.1 to comply with section 10.2. Section 10.2.3 requires, in part, the interior wall and ceiling finish that is required elsewhere in the Code to be Class A, Class B, or Class C shall be classified based on the test results from ASTM E 84. The deficient item was discussed with numerous facility staff during the exit conference.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 35629 STANDARD is not met as evidenced by: Through record review, observation and staff interview of the fire alarm system during the survey, the facility failed to maintain documentation and correct steps needed for Fire Alarm Installation in accordance with National Fire Protection Association (NFPA) 72. Failure to install the fire alarm system per the NFPA 72 requirements could have the potential to harm all occupants, staff, and visitors if the fire alarm system fails to operate as designed if a fire was to occur. Installation of an unapproved fire alarm panel without proper permitting, approval, and testing by the authority having jurisdiction. NFPA 72 10.18.1 Approval and Acceptance. 10.18.1.1 The authority having jurisdiction shall be notified prior to installation or alteration of equipment or wiring. 10.18.1.2* At the authority having jurisdiction’s request, complete information regarding the system or system alterations, including specifications, type of system or service, shop drawings, input/output matrix, battery calculations, and notification appliance circuit voltage drop calculations, shall be submitted for approval. 10.18.1.3 Before requesting final approval of the installation, if required by the authority having jurisdiction, the installing contractor shall furnish a written statement stating that the system has been installed in accordance with approved plans and tested in accordance with the manufacturer’s published instructions and the appropriate NFPA requirements. The deficient item was discussed with numerous facility staff during the exit conference.”

“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: 35629 STANDARD not met as evidenced by: Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system per National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff, and visitors should the automatic sprinkler system fail to operate promptly and effectively due to non-code-compliant maintenance. Damaged, lost and missing escutcheon plate through-out the space. NFPA 101 2012 Edition Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating conditions and are installed, inspected, and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5 The deficient item was discussed with numerous facility staff during the exit conference.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 35629 STANDARD is not met as evidenced by: Based on observation and staff interviews during the survey, it was determined that the fire resistance rating of smoke barrier walls was not maintained in accordance with Life Safety Code Section 19.3.2.1. This deficient practice could affect all residents in all smoke compartments by allowing the spread of fire and smoke to the adjoining compartments. The fire barrier walls utilized for subdivisions must uphold a 1-hour fire rating; however, they were discovered to have penetrations in the fire riser and electrical room. Life Safety Code Section 19.3.2.1 requires that the smoke barrier wall be constructed in accordance with Section 8.3, and shall have a fire resistance rating of not less than 1 hour. Section 8.3.2 requires that the barrier be continuous through concealed spaces. Section 8-3.1.1 (3) requires, in part, that the space between piping penetrations. The deficient item was discussed with numerous facility staff during the exit conference.”

“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: 35629 STANDARD is not met as evidenced by: Based on observation, staff interview, during the course of the survey it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems 1999 edition Chapter 3 and 5 This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss. This was as evidenced by: The facility failed to maintain the emergency power system: Generator was not equipped with a manual stop station. 3-5.5.6 All Level I and Level 2 installation shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises were the prime mover is located outside the building. NFPA 110-2010 section 5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. The deficient item was discussed with numerous facility staff during the exit conference.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 35629 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation, §482.41 Condition of Participation: Physical Environment was out of compliance. A-0700 - The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. Based on a life safety code complaint inspection completed on 12/18/2024, the facility failed to comply with the regulations set forth for Life Safety. Therefore, deficiencies were cited under the Life Safety Code tags K-0211, K-0293, K-0311, K-0363, K-0372 and K-0541. See survey event ID 5VOH21 for full details of the cited deficiencies.”

“A survey was initiated following complaint investigation #CO38723 on 12/18/2024 with 15 deficiencies cited. Condition level tag cited on health survey. See event ID 8K8011. §482.41 PHYSICAL ENVIRONMENT The Initial Comments (ID Tag 0000) are informational only and are a representation of the facility’s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR Part 482.41(b). A full Life Safety Code recertification survey was conducted. The survey included the main campus, which consists of the original 1989 building and the 2003-2006 additions. The survey also included several on “on campus” and “off campus” location. The main hospital is a minimum of Type II (222) construction. The original 1989 building (north building) is eight stories (ground level through seventh floor) and an upper level mechanical penthouse. The 2003 addition (south building) was four levels (ground floor through third floor). In 2006, the fourth and fifth floors were constructed on top of the 2003 structure. Two-hour rated fire separation was not provided between the original 1989 addition and the 2003 addition. The central utility plant building (Type II (000) non-sprinklered) communicates with the original 1989 building via a tunnel at ground floor level. Two-hour fire rated separation was provided at the tunnel entrance. In 2024, a new fire alarm system was installed throughout the entire facility. The survey was conducted during the period, December 16 through December 18, 2024, using the National Fire Protection Association (NFPA) Life Safety Code (20122) Chapter 19, Existing Health Care Occupancies. The facility is classified as Partially Sprinklered, due to the lack of automatic sprinkler protection in several areas. The deficiencies cited were discussed with numerous facility staff, including the Safety Officer, Director of Plant Operations and Chief Executive Officer, during the course of the survey and during the exit conference conducted at the end of the onsite survey.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 35629 STANDARD not met, as evidenced by the observation and staff interview. It was determined that the facility failed to arrange and maintain the means of egress per Life Safety Code Section 19.2 and Chapter 7. This deficient practice could affect all residents, staff, and visitors throughout the facility if an exit discharge to the public way is not provided. A wall has been constructed across the corridor that served as the second exit from the temporary IT office, blocking the alternative accessible exit to the public way. This area also contains licensed bed space. 2012 Life Safety Code 101-7.5.4.3 Each required accessible means of egress shall be continuous from each accessible occupied area to a public way or area of refuge in accordance with 7.2.12.2.2. The deficient item was discussed with numerous facility staff during the exit conference.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 35629 STANDARD was not met, as evidenced by observation and staff interviews during the survey. It was determined that the facility failed to maintain the marking of means of egress per the 20212 Life Safety Code 101- Section 7.10. This deficient practice could affect all residents, staff, and visitors in the area if code-compliant exit signage is not provided for building egress. Missing exit signage, including directional arrows pointing in the wrong direction, was found throughout the facility on all floors. Life Safety Code 19.2.10.1. Means of egress shall have signs per section 7.10. The directional indicator shall be outside the Exit legend, not less than 3/8 in. (1cm) from any letter. The directional indicator shall be of a chevron type. The directional indicator shall be identifiable as a directional indicator at a distance of 40 ft. (12.2m). A directional indicator larger than the minimum established in this paragraph shall be proportionately increased in height, width, and stroke. The directional indicator shall be located at the end of the sign for the direction indicated. The deficient item was discussed with numerous facility staff during the exit conference.”

“Vertical Openings - Enclosure CFR(s): NFPA 101 Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box. This Standard is not met as evidenced by: 35629 STANDARD not met: Through observation and discussion during the facility tour, it was determined that the facility failed to install and maintain fire resistance rating per NFPA 2012 Life Safety Code 101 Chapter 9. 19.3.1. Failure to maintain fire resistance rating has the potential to harm all occupants, staff, and visitors in the building if a fire was to occur. Stairwell 3 is missing fire stopping and evidence of drywall damage. 19.3.1 Protection of Vertical Openings. Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8. 19.3.1.1 Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. The deficient item was discussed with numerous facility staff during the exit conference.”

“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: 35629 STANDARD is not met, as evidenced by: During observation of the kitchen gas-fired cooking equipment, it did not meet the requirements of the 2012 Edition of NFPA 54 Fuel and Gas Code 9.6.1.2. This deficient practice could affect all residents and staff should a fire occur due to failure to operate safely due to non-code compliance. 1. One gas-fired cooking appliance in the main kitchen was not equipped with a restraining device or wheel chocks. 2. The kitchen fire-extinguishing system’s manual activation device lacks a proper placard. NFPA 54 -2012 Fuel and Gas Code 9.6.1.2 Restraints. Movement of the appliance with casters shall be limited by a restraining device installed per the connector and appliance manufacturer installation instructions. 13.5.5. The manual activation device for the fire-extinguishing system shall be clearly identified. The deficient item was discussed with numerous facility staff during the exit conference.”

“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: 35629 STANDARD not met, as evidenced by: Based on observation and staff interviews, it was determined that the facility needed to provide a safe location to install an Alcohol-Based Hand Rub dispenser per Life Safety Code Chapter 19, Section 19.3.2.6(8). This deficient practice could affect all patients, visitors, and staff should an electrical fault ignite the dispenser. Alcohol-based hand rub dispensers (ABHR) were positioned directly above an electrical outlet in the Radiology Office. Life Safety Code 101, Section 19.3.2.6 Alcohol-Based Hand-Rub Dispensers shall be protected per 8.7.3 unless all of the following conditions are met: (8) Dispensers shall not be installed in the following locations: (a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source. (b) To the side of an ignition source within a 1 in. (25 mm) horizontal distance from the ignition source. (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source The deficient item was discussed with numerous facility staff during the exit conference.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 35629 STANDARD is not met as evidenced by: Through observation and staff interview of the fire alarm system during the tour of the facility, the facility failed to install and maintain the fire alarm system with approved components, devices, or equipment per NFPA 101 Life Safety Code (2012 Edition), section 19.3.4.3.1 and NFPA 72, section 17.7.4.1. Failure to maintain the fire alarm system has the potential to harm all occupants, staff, and visitors if the fire alarm system fails to operate as designed if a fire was to occur. A smoke detector is installed 26 inches away from the HVAC diffuser in the North Tower elevator lobby. NFPA 72, 29.11.3.48) Smoke alarms and smoke detectors shall not be installed within a 36 in. (910 mm) horizontal path from the supply registers of a forced air heating or cooling system and shall be installed outside of the direct airflow from those registers. The deficient item was discussed with numerous facility staff during the exit conference.”

“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: 35629 STANDARD not met as evidenced by: Through record review and staff interview during the survey, the facility failed to inspect and test the fire alarm system per NFPA 72 and 2012 Life Safety Code 101. Failure to maintain and test the fire alarm system has the potential to harm all occupants, staff, and visitors within the facility if the fire alarm system fails to operate if a fire was to occur. 1. The fire alarm notification device 2A-01-07 is covered with plastic. 2. In the Equipment Room 4, combustible materials are obstructing the view of the strobe lights. 3. The alarm notification device in the soiled utility room is dangling by its wires. 2012 Life Safety Code 101 section 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. The deficient item was discussed with numerous facility staff during the exit conference.”

“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: 35629 STANDARD not met as evidenced by: Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system per National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff, and visitors should the automatic sprinkler system fail to operate promptly and effectively due to non-code-compliant maintenance. 1. The storage in the kitchen walk-in cooler is stacked to the ceiling, obstructing the sprinkler’s spray pattern. 2. GI Lab sprinkler head is missing an escutcheon plate. 3. Kitchen Dry Storage sprinkler head is missing an escutcheon plate. 4. The walk-in freezer in the kitchen sprinkler head broken escutcheon plate. 5. Throughout the kitchen pendent sprinkler shows signs of foreign materials around the working parts of the head. 6. Missing a list of the sprinklers installed in the property posted in the sprinkler cabinet. 7. Wires laying on sprinkler piping smoke compartment 5-4 south. 8. IT wires attached to fire sprinkler line in basement IT area. 9. Bed storage south shows signs of foreign materials around the working parts of the sprinkler head. NFPA 101 2012 Edition Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating conditions and are installed, inspected, and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5 The deficient item was discussed with numerous facility staff during the exit conference.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 35629 The standard has not been met, as indicated by observations and staff interviews. It was found that the facility did not properly maintain all portable fire extinguishers in accordance with NFPA 10, Chapter 4. This deficiency poses a risk to all residents, staff, and visitors, as the portable fire extinguishers may not function effectively if they are not maintained in compliance with the code. 1. Fifth-floor stairwell 4-5 fire extinguisher is not tagged. 2. Missing extinguisher near the Ultrasound Bone Density. 3. Extinguisher 1-20 missing tag. 4. Temporary IT office fire extinguisher not mounted. Life Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire Extinguishers. The deficient item was discussed with numerous facility staff during the exit conference.”

“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: 35629 STANDARD is not met, as evidenced by the observation and staff interview during the survey. It was determined that the facility failed to maintain corridor doors per the Life Safety Code Section 19.3.6.3. This deficient practice could affect all residents within the smoke compartments should the egress become untenable due to smoke and heat transfer via the non-latching corridor doors, as evidenced by the following: Corridor doors were not maintained to close and positively latch, as required. 1. G4 smoke does do not seal into the frame. 2. Doors throughout the facility being propped open with wooden wedges. 3. North Tower 4-3, 4-2, 2-3 and 2-4 doors do not latch into the doorframes. 4. Stairwell 3 GF doors do not latch into the doorframes. 5. Physicians lounge door dose not latch into the doorframes. 6. Elevator 2 smoke/fire doors do not latch into the doorframes. 7. 4th floor stairwell 1-G7 excessive gap around doors. 8. 4th floor stairwell 3-G8 excessive gap around doors. The Life Safety Code, Section 19.3.6.3.2, requires that corridor doors be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. Doors must be unobstructed from closing and positively latch into the door frame. Section 19.3.6.3.1, Exception #2, requires that corridor doors installed within sprinkler-protected smoke compartments be constructed to resist the passage of smoke. The deficient item was discussed with numerous facility staff during the exit conference.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 35629 STANDARD is not met as evidenced by: Based on observation and staff interviews during the survey, it was determined that the fire resistance rating of smoke barrier walls was not maintained in accordance with Life Safety Code Section 19.3.2.1. This deficient practice could affect all residents in all smoke compartments by allowing the spread of fire and smoke to the adjoining compartments. 1. The fire/smoke barrier walls utilized for subdivisions must uphold a 1-hour fire rating; however, they were discovered to have penetrations throughout the building on all floors. 2. Ceiling tiles throughout the building on all floors are broken, missing, or damaged. Life Safety Code Section 19.3.2.1 requires that the smoke barrier wall be constructed in accordance with Section 8.3, and shall have a fire resistance rating of not less than 1 hour. Section 8.3.2 requires that the barrier be continuous through concealed spaces. Section 8-3.1.1 (3) requires, in part, that the space between piping penetrations. The deficient item was discussed with numerous facility staff during the exit conference.”

“Rubbish Chutes, Incinerators, and Laundry Chu CFR(s): NFPA 101 Rubbish Chutes, Incinerators, and Laundry Chutes 2012 EXISTING (1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5. (2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7. (3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.) (4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use. 19.5.4, 9.5, 8.4, NFPA 82 This Standard is not met as evidenced by: 35629 STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain sprinkler protected hazardous areas in accordance with Life Safety Section 19.3.2.1. and 9.5 This deficient practice could affect all residents and staff in all the main smoke compartment should there be smoke and heat transfer between the hazardous area and other portions of the building. 1. The door of the linen chute on the third floor south is not latching properly. 2. All the fusible links on the laundry chute doors have expired since 2006. Life Safety Code 101-2012 edition. 9.5.2 Installation and Maintenance. Rubbish chutes, laundry chutes, and incinerators shall be installed and maintained in accordance with NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment, unless such installations are approved existing installations, which shall be permitted to be continued in service. The deficient item was discussed with numerous facility staff during the exit conference.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 35629 STANDARD is not met as evidenced by: Based on observation and staff interview it was determined that the facility failed to maintain fire safe environment within the facility. This deficient practice could affect all patients, staff and visitors should a fire occur by the non-rated space heaters. 1. Surgical services non-rated space heater. 2. Housekeeping supervisor office non-rated space heater. 3. Administrative office first floor 4X non-rated space heater. Life Safety Code, Section 19.7.8. Portable space-heating devices shall be prohibited in all heath care occupancies. Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee’s areas where the heating elements of such devices do not exceed 212? F (100? C). The Administrator and Maintenance Director acknowledge the deficiency of the prohibited space heaters during the facility tour.”

“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: 35629 STANDARD not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to install electrical equipment according to National Fire Protection Association 70, National Electrical Code. This deficient practice could affect all residents throughout the smoke compartments due to increased potential electrical fire hazards. The facility utilizes power strips and extension cords rated for 15 amps to supply electricity to refrigerators and microwaves in the following locations. 1. PET CT portable cooler plugged into extension cord. 2. PET CT lobby refrigerator plugged into a power strip. 3. Consultant room near IR refrigerator plugged into a power strip. 4. Women newborn breakroom extension cord plugged into a power strip routing through the ceiling to power pipe heater on sprinkler line. 5. Pathology refrigerator plugged into a power strip. 6. Physicians sleep room refrigerator plugged into a power strip. 7. HIM refrigerator plugged into a power strip. NFPA 99 Section 10.2.3.1.1 The flexible cord, including the grounding conductor, shall be of a type suitable for the particular application; shall be listed for use at a voltage equal to or greater than the rated power line voltage of the appliance; and shall have an ampacity, as given in Table 400.5(A) of NFPA 70, National Electrical Code, equal to or greater than the current rating of the device. The deficient item was discussed with numerous facility staff during the exit conference.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 35629 STANDARD not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to maintain all oxygen cylinders in storage as required by 2012 NFPA 99 Section 11.6.2.3. This deficient practice could affect all residents, staff and visitors should the facility fail to provide safe operation and management of cylinders. Freestanding cylinders needed to be properly chained or supported in a cylinder stand or cart in the Supply chain oxygen storage room. NFPA 99- 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures. (11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. The Maintenance Director acknowledged the lack of properly store cylinders during the tour of the facility.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 47959 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES was out of compliance. A-0395 §482.23 (b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and document review, the facility failed to provide nursing services in accordance with facility protocol and policy. Specifically, the facility failed to provide pain interventions and reassess the effectiveness of pain management interventions implemented for patients in pain in three of four medical records reviewed.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 47959 Based on interviews and document review, the facility failed to provide nursing services in accordance with facility protocol and policy. Specifically, the facility failed to provide pain interventions and reassess the effectiveness of pain management interventions implemented for patients in pain in three of four medical records reviewed. (Patients #1, #3, and #4) Findings include: Facility policy: The Pain Management policy read, documentation of pain assessment is completed on admission, during and after any known pain-producing event, with each new report of pain, and at least once a shift. Pain reassessment timeframe and/or interval is based on patient assessment and knowledge of the onset and peak effect of the intervention provided. Documentation of reassessment will be within one hour of as needed (PRN) pain medication. Reassessment of pain includes the pain level using an appropriate pain scale. 1. The facility failed to ensure staff provided pain interventions and reassessed after pain management interventions according to facility protocol and policy. A. A review of medical records revealed gaps in the pain management policy being followed for patient’s pain management. i. On 8/2/24, Patient #1 arrived at the emergency department (ED) with leg pain and was admitted for sepsis (a condition caused by severe infection). Patient #1 had a history of a left below the knee amputation (BKA) and peripheral neuropathy (a condition where the nerves become damaged and cause pain, usually in the hands and feet). Patient #1’s provider ordered Tylenol, oxycodone, Dilaudid, and Robaxin for their pain management. On 8/2/24 at 11:57 a.m., Patient #1 received oxycodone for leg pain at a level 8 out of ten pain scale (8/10). There was no reassessment completed to determine if Patient #1 had relief. At 7:33 p.m., Patient #1 stated their leg pain was 10/10, however, Patient #1 did not receive pain medications again until 8/3/24 at 6:39 a.m. Patient #1 received oxycodone at that time for leg pain 7/10. There was no reassessment completed to determine if Patient #1 had relief. On 8/3/24 at 8:45 a.m., Patient #1 stated they had generalized pain 8/10, however, Patient #1 did not receive pain medications (Robaxin) again until 11:33 a.m. for pain 8/10. Further examples of no pain reassessment to determine the effectiveness of the pain medication were identified on 8/4/24, 8/5/24, 8/6/24, and 8/7/24. ii. On 9/8/24, Patient #2 arrived at the ED with symptoms of lethargy (feeling exhausted and without mental alertness) and chills. Patient #2 was admitted for sepsis of a right BKA. Patient #2 fell on 9/18/24 and fractured their left leg and required pain medication. Patient #2’s provider ordered oxycodone, Dilaudid, Tylenol, and Robaxin for pain management. On 9/18/24, Patient #2 received Robaxin at 3:21 p.m. for leg pain 8/10 but staff did not reassess to determine the effectiveness of the pain medication. On 9/19/24, Patient #2 received Tylenol for left leg pain 6/10 at 10:39 a.m. but staff did not reassess to determine the effectiveness of the pain medication. Further examples of no reassessment which determined the effectiveness of the pain medication were identified on 9/18/24, 9/19/24, 9/22/24, and 9/26/24. Additionally, on 9/23/24 at 9:03 p.m., Patient #2 had leg pain 5/10 but did not receive pain medication until 9/24/24 at 9:15 a.m. Similarly, on 9/24/24 at 9:27 p.m., Patient #2 had leg pain 5/10 with no pain management interventions performed. iii. On 9/20/24, Patient #4 arrived at the ED with chills and concerns of a right BKA infection. Patient #4 was admitted to treat the confirmed infection in the right BKA. Patient #4 had a history of chronic back pain and their provider ordered Tylenol and Tramadol for pain management. On 9/21/24 at 8:30 a.m., Patient #4 received Tylenol for 6/10 back pain, but staff did not reassess to determine the effectiveness of the pain medication. On 9/22/24 at 8:27 a.m., Patient #4 had 8/10 left sided back pain. Record review revealed Patient #4 had medication administered, however, no documentation of pain medication administration was found during this time. Patient #4 did not have a reassessment until 11:43 a.m., when the patient reported a pain score of 7/10. On 9/22/24 at 9:57 p.m., Patient #4 had 5/10 left sided back pain, but had no pain management intervention until 12:09 a.m. when they received Tylenol. Further examples of no pain reassessment to determine the effectiveness of the pain medication were identified on 9/20/24, 9/23/24, 9/25/24, and 9/26/24. The record reviews were in contrast to the Pain Management policy which read, staff based pain reassessment on patient assessment and the peak effect of the intervention provided. Reassessments included documentation within one hour of the PRN pain medication. B. Interviews i. On 11/20/24 at 10:36 a.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated they assessed patients for pain every shift and each time they took vital signs. RN #1 stated they assessed patients to ensure patients did not have any new pain which required provider notification. RN #1 stated they completed a reassessment within an hour of the pain management intervention to determine if the pain medication worked to treat the patient’s pain. If the pain medication did not work, RN #1 stated they called the provider to determine other possible interventions for the patient. RN #1 stated pain management and reassessment was important to ensure poor outcomes did not occur, such as pain crisis, immobility which resulted in skin breakdown, pneumonia, blood clots, or longer hospitalizations. RN #1 stated reassessment ensured good pain management for patient mobility and decreased adverse event outcomes. ii. On 11/20/24 at 11:52 a.m., an interview was conducted with clinical nurse manager (Manger) #2. Manager #2 stated the expectations for pain management and reassessment included frequent interventions, reassessments, and provider notification if a pain medication did not effectively treat the patient’s pain. Manager #2 stated staff completed reassessments within the hour of the intervention. Manager #2 stated the electronic medical record automatically reminded staff when the reassessment was due so staff should not have missed the reassessment. Manager #2 stated they trained staff upon hire as well as during inpatient unit education when their audits showed an increase in outliers in reassessment documentation. Manager #2 stated it was necessary for RNs to reassess a patient’s pain because it ensured pain was managed and patients did not experience complications related to poor pain control. iii. On 11/20/24 at 9:47 an interview was conducted with medical provider (Provider) #3. Provider #3 stated a pain level of 8/10 was significant and needed treatment. Provider #2 stated RNs made providers aware of patient pain management issues and providers wrote pain medication orders which included patient safety from adverse events caused by pain medication. Provider #3 stated it was important to keep patients comfortable without creating an oversedation situation from too much pain medication that would make the situation worse. The interviews were in contrast to the medical record reviews which revealed patients experienced pain but did not receive pain management interventions and reassessments which determined the effectiveness of the interventions.”