Lincoln Health Hospital

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment 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 §485.623 Physical Plant and Environment was out of compliance. C-0914 (b) The CAH has housekeeping and preventive maintenance programs to ensure that- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition. Based on observations, interviews, and document review, the facility failed to ensure the physical plant and environment was maintained in good working condition to ensure patient safety. Specifically, the facility failed to ensure equipment was maintained according to the manufacturer’s standards. (Cross-reference C-2523). In addition, based on a concurrent Life Safety Code survey completed on 10/3/24, the facility failed to comply with the regulations set forth for Life Safety. Numerous violations in regards to fire prevention and mitigation were identified, and four immediate jeopardies were called under Life Safety Code tags K161, K341, K353, and K920. See survey event ID 8D9821 for full details of the cited deficiencies.”

“ORGANIZATIONAL STRUCTURE CFR(s): Organizational Structure This Condition is not met as evidenced by: 50313 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.627 Organizational Structure, was out of compliance. C-0962 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. Based on document review and interviews, the facility failed to provide oversight of contracted services to ensure quality health care was provided 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: 47959 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.640 Infection Prevention and Control and Antibiotic Stewardship Programs was out of compliance. C-1208 (a)(3) 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. Based on observations and interviews, the facility failed to implement infection control prevention and surveillance measures to avoid possible sources of infection.”

“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: 50313 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.641, Quality Assessment and Performance Improvement Program, was out of compliance. C-1306 The CAH’s QAPI program must be ongoing and comprehensive. Involve all departments of the CAH and services (including those services furnished under contract or arrangement). Based on interviews and document review, the facility failed to ensure the quality assessment and performance improvement (QAPI) program identified and implemented performance improvement activities, including high-risk, problem-prone areas. This failure affected patient rights, infection control, and physical plant and environment. (Cross-reference C-1208, C-0914, and C-2523)”

“PATIENTS RIGHTS CFR(s): A CAH must protect and promote each patient’s rights. 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 §485.614 Patient Rights was out of compliance. C-2523 (c)(2) The patient has the right to receive care in a safe setting. Based on observations, document review, and interviews, the facility failed to protect the patient’s right to receive care in a safe setting. Specifically, the facility failed to have a functional fire suppression system and failed to implement a plan to mitigate the safety risk of fire throughout the entire facility. (Cross-reference C-0914)”

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 47959 Based on observations, interviews, and document review, the facility failed to ensure the physical plant and environment was maintained in good working condition to ensure patient safety. Specifically, the facility failed to ensure equipment was maintained according to the manufacturer’s standards. (Cross-reference C-2523). Findings include: Reference: The Anesthesia System instructions for use (IFU) read, the minimum frequency for periodic maintenance and gas bench calibration was annually. 1. The facility failed to maintain equipment to ensure a safe environment for patients. A. Observations i. Observations conducted on 9/26/24 in the operating room (OR) revealed the anesthesia cart performance maintenance (PM) tag to have expired in April of 2024. Facility staff used the anesthesia cart to administer anesthesia to surgical patients from 5/1/24 through 9/26/24 despite its expiration date. This was in contrast to the anesthesia system IFU which read, the minimum frequency for periodic maintenance and gas bench calibration was annually. B. Interviews i. On 10/1/24 at 3:25 p.m., an interview was conducted with the maintenance director (Director) #4. Director #4 stated a contracted company did the PMs for patient equipment. Director #4 stated the anesthesia cart had an expired PM because the facility planned to purchase a new machine. Director #4 stated the vendor delayed the delivery of the machine so the facility decided to not complete the PM and waited for the vendor to deliver the new machine. Director #4 stated the facility did not want to spend the money on preventative maintenance on a machine they wanted to replace. Director #4 stated they did not know of any specific risks to patients for using a machine that had an expired PM but agreed the facility should have performed the PM for patient safety.”

“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: 50313 Based on observations, document review, and interviews, the facility failed to provide direct oversight of contracted services to ensure quality health care was provided in a safe environment. Findings include: Facility policy: The Fire Protection Systems policy read, all facility fire protection systems shall be maintained in a serviceable state at all times through a proactive inspection, testing, and maintenance program that is designed to identify and repair any system deficiency or malfunction that could be a threat to the facility and its occupants. Inspection and testing tasks shall be performed by personnel who have developed competence through training and experience. Maintenance Staff shall complete the inspection on an annual basis and log the date on the Lincoln Health Fire Damper and heat tab Location and Functionality test log. Reference: The Bylaws of the Board of Trustees read, the term “Chief Executive Officer” or “CEO” shall mean the individual appointed by the Board to act in its behalf in the overall management and operation of the Hospital. The Board shall also have exclusive control of the construction or enlargement of any Hospital buildings; and the supervision, care and custody of the grounds, rooms or buildings purchased, constructed, leased or set apart for that purpose. The Board shall ensure the quality of care provided by the Hospital is consistent with the generally accepted standards of care and providers and staff are properly credentialed to provide such care. The CEO shall act as the duly authorized representative of the Board. In all matters in which the Board has not formally designated some other person to act. As such, they shall have the authority to sign appropriate contracts, including governmental and commercial payer contracts, on behalf of the Board, subject to any guidelines set forth by the Board. The CEO shall ensure that all departments are accountable for proper maintenance of all equipment and physical properties. The CEO shall be responsible for reviewing the Hospital’s policies and contracts to ensure that the foregoing comply with all applicable laws and regulations and that the objectives and purposes of the Hospital are being served by the requirements of such documents and policies. 1. The facility failed to provide direct oversight of contracted services to ensure quality health care was provided in a safe environment. A. Observations i. On-site observations conducted during the complaint survey completed on 10/3/24 revealed the facility failed to comply with the regulations set forth for Life Safety. Numerous violations in regards to fire prevention and mitigation were identified, and four immediate jeopardies were called under Life Safety Code tag K161, K341, K353, and K920. See survey event ID 8D9821 for full details of the cited deficiencies. This was in contrast to the Fire Protection Systems policy which read, all facility fire protection systems should be maintained in a serviceable state at all times through a proactive inspection, testing, and maintenance program that was designed to identify and repair any system deficiency or malfunction that was a threat to the facility and its occupants. B. Document Review i. Review of the contract between the external fire service company (Contractor) and the facility revealed the most recent contract for the fire sprinkler system inspection was entered into on 1/24/24. The contract was signed by the director of maintenance (Director #4). There was no evidence the contract was reviewed by the governing board or chief executive officer since its initiation. The contract read, the company shall visually inspect the fire sprinkler system one time per year. The inspection does not address the capability of the fire protection system to protect the building of its contents. It is not the role of the inspector to determine if changes have been made or the subsequent evaluation of the fire system. The responsibility for properly maintaining a water-based fire protection sprinkler system shall be that of the owner of the property. C. Interviews i. An interview was conducted on 10/2/24 at 9:02 a.m. with the director of maintenance (Director) #4. Director #4 stated they were not aware that the facility or the Contractor had installed a sprinkler head that was not connected to any water source. Director #4 stated the facility had been working with the Contractor for twelve years. Director #4 stated the Contractor was supposed to inspect the facility’s suppression systems, maintain the alarm panels, and inspect the sprinkler system. Director #4 stated the Contractor was supposed to ensure each sprinkler head was up to date, not corroded, and not painted, however, these services were not completed by the Contractor. Director #4 stated that they never checked the logs of work from the Contractor with the sprinkler system, and relied on the Contractor to do the work because the Contractor had been used by the facility for so long. Director #4 stated it was important to have a system that addressed safety issues because if patients at the facility were not safe, they would not receive good care. ii. An interview was conducted on 10/2/24 at 11:03 a.m. with the chief nursing officer (CNO) #5. CNO #5 stated the leadership team was responsible for overseeing contracts with external vendors and contractors and the facility. CNO #5 stated they were aware the facility had issues keeping a centralized list of contracts and had issues ensuring that contracted services were being performed according to agreements. CNO #5 stated the facility was implementing a system to centrally store contracts, but not all contracts were uploaded into the system at this time. iii. An interview was conducted on 9/30/24 at 4:40 p.m. with chief executive officer (CEO) #6. CEO #6 stated the facility did not properly supervise the Contractor. CEO stated the facility was not as vigilant because they trusted the fire service contractor. iv. An additional interview was conducted on 10/2/24 at 4:06 p.m. with CEO #6. CEO #6 stated their role was to oversee everything in the facility. CEO #6 stated the facility’s process regarding entering contracts and monitoring contracts was not formal. CEO #6 stated department managers would often enter into a contract with an outside contractor because they needed to get something done. CEO #6 stated the facility needed to have a process for regular evaluation of contracted services. CEO #6 stated the facility had been instructed by their certification authority in 2021 to ensure all contracts were readily available, but the facility was still working on this process.”

“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: 47959 Based on observations and interviews, the facility failed to implement infection control prevention and surveillance measures to avoid possible sources of infection. Findings include: Facility policies: The Infection Prevention Plan policy read, the infection prevention program addressed detection, prevention, and control of infections. Infection prevention included strategies to decrease risk and a surveillance plan. Infection prevention rounds are made to assess the level of quality provided and actions for improvement are taken as needed. Compliance with infection prevention practices is monitored and documented by staff evaluation and observation of practices. The infection preventionist and department managers review the compliance monitoring and initiate appropriate actions. The Surveillance Infection Control policy read, nursing staff were responsible for functions essential to the prevention, recognition, and management of infections. Prevention of infection was the main goal of the staff. This was accomplished by practicing good aseptic techniques, observing infection control policies and procedures, and recognizing the potential risks associated with invasive procedures. Adherence to the practice of standard precautions was expected of all nursing staff. Nursing staff served as a role model for all healthcare workers in the adherence of established guidelines. The Sink Storage policy read, there will be no supplies stored in cabinets underneath the sinks in patient care areas. Supplies will be stored meeting infection control guidelines in appropriate cabinets. The Physical Environment Pest Control Program policy read, all policies and procedures specific to pest and rodent control were the responsibility of the maintenance department and appropriate contract services. The Sanitation and Infection Control Pest Control policy read, if a pest situation was reported, the contractor was notified and requested to make an unscheduled visit to address concerns. 1. The facility failed to implement a process that identified areas of infection risk throughout the facility and mitigate possible sources of infection in the emergency department (ED), surgical services areas, procedural areas, magnetic resonance imaging (MRI) trailer, and inpatient care unit. A. Observations i. Observations were conducted on 9/26/24 at 9:00 a.m. in the ED. In the ED treatment room where staff cared for patients, observations revealed staff stored a bottle of sterile water and a bottle of normal saline, both used in patient care, under the sink in a plastic patient care bucket. This was in contrast to the facility’s sink storage policy which read, there will be no supplies stored in cabinets underneath the sinks in patient care areas and stored to meet infection control guidelines in appropriate cabinets. Further observations in the ED revealed an unknown soiled substance on the bottom shelf of the cupboard. Additional observations in the ED revealed an exposed cement floor in a patient supply storage room which produced dust and loose cement particles on the floor. ii. Observations conducted in the inpatient care unit nurses’ station revealed a large area of exposed, broken drywall under a window near medications and patient care items. Additional observations in patient care room #10 revealed a bottle of cleaning solution in disrepair with the instructions for use peeled and flaked off. iii. Observations conducted in the operating room (OR) revealed rust on top of a stand used to hold patient suction tubing during procedures. Further observations revealed staff had covered two sterile supply cabinets in the OR room with a thin sheet of plastic and used plastic tape to secure the plastic wrap in anticipation of construction in the OR. Observations revealed the tape did not secure or seal the plastic completely and left gaps for dust to reach the sterile supplies in both cabinets. iv. Observations conducted in the endoscopy and colonoscopy procedure room revealed a layer of dust on the air vent on the endoscopy computer tower. Further observations revealed the air return vent was also covered in dust. Additionally, there were crumbled cement and dust particles on the floor where staff stored supplies for scope procedures. These observations were in contrast to the facility’s Surveillance Infection Control policy which read, nursing staff were responsible for functions essential to the prevention, recognition, and management of infections. Staff accomplished this through the recognition of the potential risks associated with invasive procedures. v. Observations conducted in the OR supply room revealed a dead bug in the bottom of the cart used for patient supplies. Additional observations in the MRI trailer revealed dead moths in a plastic bin covered in dust used for storage of MRI equipment. vi. Observations in the magnetic resonance imaging (MRI) trailer revealed bottles of solution used for the MRI machine were stacked directly on the floor of the trailer. Multiple cardboard boxes and plastic air-filled bubble wraps stacked on top of the bottles of solution and leaned against an electrical panel. Further observations revealed a plastic tote filled with MRI equipment, dust, dirt, and dead moths. This was in contrast to the facility’s physical environment Pest Control Program policy which read, the maintenance department and appropriate contract services had the responsibility specific to pest and rodent control. B. Interviews i. On 10/1/24 at 1:49 p.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated staff completed infection prevention modules through online training. RN #1 stated the modules included hand hygiene, isolation precautions, and personal protective equipment. RN #1 stated she did not know the frequency of the modules. RN #1 stated they checked patient care rooms prior to patient placement because the building was old and bugs got into the rooms. RN#1 stated they did not know of any infection prevention surveillance conducted by any team or leadership. RN #1 stated it was important to keep the environment clean to decrease the risk of patient exposure to infectious matter. ii. On 10/1/24 at 2:33 p.m., an interview was conducted with the director of inpatient services and infection control (Director) #3. Director #3 stated their biggest priority for the infection prevention program was to keep the patients safe from hospital-associated infections (HAIs). Director #3 stated the infection control plan ensured that staff mitigated risks and provided a safe and clean environment for patients. Director #3 stated they followed the direction of their accreditation agency and tracked patient infections. Director #3 stated their primary focus was not the environmental areas, but instead, the bacterial and viral pathogens with which the patients entered the hospital. Director #3 stated they did not have a specific team that performed infection prevention surveillance nor utilized a formatted checklist. Director #3 stated instead, staff looked for imminent threats to patients while providing care. Director #3 stated they had a difficult time maintaining the environment of the building because the building was old, however, staff ensured each room they entered was as good as it could be. Director #3 stated it was important to have a clean hospital environment and risked patient contamination and infection if staff did not clean the environment. Director #3 stated CNO #5 and the director of maintenance (Director) #4 completed an infection control risk assessment (ICRA) which was reviewed and signed off by Director #3 when a larger construction project happened. Director #3 stated they directed staff to wrap the supply cabinets in the OR in anticipation of electrical work but had not been able to evaluate the wrapping done in the OR or sign off on it. iii. On 10/1/24 at 2:51 p.m., an interview was conducted with the director of housekeeping (Director) #2. Director #2 stated the housekeeping department cleaned all areas of the hospital daily except for the OR. Director #2 stated the OR was cleaned by OR staff. Director #2 stated the OR staff cleaned the OR because housekeeping did not have enough staff to clean that area. Director #2 stated they walked through the building daily, but not with a team of people as a formal surveillance. Director #2 stated staff encountered issues with multiple bugs due to the age of the building. Director #2 stated staff swept bugs away during the cleaning process and did not call pest control for additional pest control treatment. Director #2 stated staff had to do additional cleaning in the ED storage room with the broken cement floor due to the additional dust it produced. Director #2 stated patients deserved a clean environment to improve their health and risked infections when the environment was not clean. iv. On 10/2/24 at 9:02 a.m., an interview was conducted with the director of maintenance (Director) #4. Director #4 stated they did not have a current work order for the drywall in the inpatient unit nurses’ station and were unaware of the condition of disrepair of the wall. Director #4 stated the floor in the ED needed repair but they did not have an estimated time of completion. Director #4 stated they concentrated on direct patient care areas first for repairs. Director #4 agreed the drywall and cement deterioration posed a concern for infection control. Director #4 stated they did not participate in infection control surveillance and stated a plan needed to be in place for patient safety and good care so patients did not experience harm. v. On 10/2/24 at 12:59 p.m., an interview was conducted with chief nursing officer (CNO) #5. CNO #5 stated Director #3’s status as a medical doctor made them qualified as an infection preventionist. CNO #5 stated Director #3 brought infection prevention concerns to the quality meeting for review, but the facility did not have a formal surveillance process dedicated to infection control. CNO #5 stated if the facility did not practice a process for infection control issues throughout the facility environment, it placed the patients at risk for poor outcomes or complications of care. These interviews were in contrast to the facility’s infection prevention plan which read, infection prevention included strategies to decrease risk and a surveillance plan. Infection prevention rounds assessed the level of quality provided. The facility monitored compliance with infection prevention practices and documented staff evaluation and observation of practices. The infection preventionist and department managers then reviewed the compliance monitoring and initiated appropriate actions. Additionally, these interviews were in contrast to the facility’s sanitation and infection control pest control policy which read, when the facility reported a pest situation, the facility notified the contractor and requested an unscheduled visit to address concerns.”

“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: 50313 Based on interviews and document review, the facility failed to ensure the quality assessment and performance improvement (QAPI) program identified and implemented performance improvement activities, including high-risk, problem-prone areas. This failure affected patient rights, infection control, and physical plant and environment. (Cross-reference C-1208, C-0914, and C-2523) Findings include: Facility policies: The Fire Protection Systems policy read, all facility fire protection systems shall be maintained in a serviceable state at all times through a proactive inspection, testing, and maintenance program that is designed to identify and repair any system deficiency or malfunction that could be a threat to the facility and its occupants. Fire/smoke damper inspection to be completed at least every 6 years by technicians. Nebraska Safety & Fire has been asked to complete the inspection every 3 years. Maintenance staff will complete the inspection on an annual basis and log the date on the Lincoln Health Fire Damper and heat tab Location and Functionality test log. The Electrical Power Strips policy read, it is the policy that electrical power strips can be used as long as no electric extension cords are plugged into it before or after the power strip (piggy backing / daisy chaining). No electrical power strips can be used on medical equipment. No personal devices can be plugged into an electrical power strip. The Infection Prevention Plan policy read, the infection prevention program addressed detection, prevention and control of infections. Infection prevention included strategies to decrease risk and a surveillance plan. Infection prevention rounds are made to assess the level of quality provided and actions for improvement are taken as needed. Compliance with infection prevention practices is monitored and documented by staff evaluation and observation of practices. The infection preventionist and department managers review the compliance monitoring and initiate appropriate actions. The Infection Control-Maintenance policy read, the department will do on-going monitoring of the facility for areas needing repair. Leaks and areas of moisture shall be fixed promptly and drywall, ceiling tiles, and other materials shall be replaced. The Physical Environment Pest Control Program policy read, all policies and procedures specific to pest and rodent control were the responsibility of the maintenance department and appropriate contract services. Departments responsibilities were to report all pest problems to maintenance. Maintenance services receive all phone calls on pest problems and forward information to outside pest management contractor or corrective action. The Sanitation and Infection Control Pest Control policy read, if a pest situation was reported, the contractor was notified and requested to make an unscheduled visit to address concerns. The Incident-Variance Reporting policy read, this was mechanism for handling reportable incidents must be established in an effort to ensure proper management of incidents, and to enhance the quality of care to our patients by identifying problem areas in an effort to prevent the occurrence of future incidents. It is also done to document threatening incidents to staff so that potential safety hazards can be addressed. All reportable incidents associated with facility property, personnel, patients, or the public will be immediately documented and reported to the appropriate department manager. A written incident report will be submitted to the Compliance Office within twenty-four hours (forty-eight hours on weekends) following the actual occurrence. General incidents include any unusual or unexpected occurrence. Examples of incidents include: abuse, adverse cardiac or respiratory arrest, adverse reaction, complaints, complications, death, drug reactions, elopement, equipment or medical device malfunction, exposures, falls, injuries, and medication errors. References: The 2024 Quality Improvement Plan read, all services supported by the facility on a contracted basis will be evaluated on an as needed basis. The leadership team is responsible for: reporting to the management team on work plan results, selected outcome measures, program evaluation efforts, QI projects, patient satisfaction evaluation, state standard gaps, and QI Training needed by staff; assuring implementation of QI projects; and assuring continue identification and investigation of QI filters as they arise. The Bylaws of the Board of Trustees read, the CEO shall ensure that all departments are accountable for proper maintenance of all equipment and physical properties. The CEO shall be responsible for reviewing the Hospital’s policies and contracts to ensure that the foregoing comply with all applicable laws and regulations and that the objectives and purposes of the Hospital are being served by the requirements of such documents and policies. 1. The facility failed to ensure the QAPI program identified and implemented performance improvement activities, including in high-risk, problem-prone areas. A. Observations i. On-site observations conducted during the complaint survey completed on 10/3/24 revealed the facility failed to comply with the regulations set forth for Life Safety. Numerous violations in regards to fire prevention and mitigation were identified, and four immediate jeopardies were called under Life Safety Code tags K161, K341, K353, and K920. See survey event ID 8D9821 for full details of the cited deficiencies. ii. Observations conducted on 9/26/24 in the OR supply room revealed surgical supplies stacked on the top shelves of the storage area within the 18-inch sprinkler head clearance. This obstructed the sprinkler head from operation in the event of a fire. Additionally, observations also included surgical supplies on top of a radiator. iii. Observations conducted on 9/26/24 in the endoscopy procedure room revealed medical equipment plugged into extension cords and extension cords plugged into other power strips to increase the length of the extension cord. This was in contrast to the use of electrical power strips policy which read, staff should not use electrical extension cords when plugged into electrical power strips and should not use them for medical equipment. iv. Observations were conducted on 9/26/24 at 9:00 a.m. in the ED. In the ED treatment room where staff cared for patients, observations revealed staff stored a bottle of sterile water and a bottle of normal saline, both used in patient care, under the sink in a plastic patient care bucket. Further observations revealed an unknown soiled substance on the bottom shelf of the cupboard. Additional observations in the ED revealed an exposed cement floor in a patient supply storage room which produced dust and loose cement particles on the floor. This was in contrast to the facility’s sink storage policy which read, there will be no supplies stored in cabinets underneath the sinks in patient care areas and stored to meet infection control guidelines in appropriate cabinets. v. Observations conducted in the inpatient care unit nurses’ station revealed a large area of exposed, broken drywall under a window near medications and patient care items. Additional observations in patient care room #10 revealed a bottle of cleaning solution in disrepair with the instructions for use peeled and flaked off. vi. Observations conducted in the operating room (OR) revealed a stand with patient care suction tubing taped to the top of a metal plate with significant rust on the metal plate. Further observations revealed staff had covered the sterile supply cabinets in the OR room with a thin sheet of plastic and used plastic tape to secure the plastic wrap in anticipation of construction in the OR. Observations revealed the tape did not secure or seal the plastic completely and left gaps for dust to reach the sterile supplies in both cabinets. vii. Observations conducted in the endoscopy and colonoscopy procedure room revealed a thick layer of dust on the air vent on the endoscopy computer tower. Further observations revealed the air return vent also was covered in dust. Additionally, observations revealed the cement floor between the patient procedure room and the scope reprocessing room where staff stored scope supplies had crumbed cement which produced dust and cement particles. These observations were in contrast to the facility’s surveillance infection control policy which read, nursing staff were responsible for functions essential to the prevention, recognition, and management of infections. Staff accomplished this through the recognition of the potential risks associated with invasive procedures. viii. Observations conducted in the operating room (OR) supply room revealed a dead bug in the bottom of the carts used for patient supplies while in the OR. Additional observations in the MRI trailer revealed dead moths in a plastic bin used for storage of MRI equipment. This was in contrast to the facility’s physical environment pest control program policy which read, the maintenance department and appropriate contract services had the responsibility specific to pest and rodent control. Departments’ responsibilities were to report all pest problems to maintenance. Maintenance services were to receive all phone calls on pest problems and forward information to outside pest management contractor or corrective action. B. Interviews i. An interview was conducted with registered nurse (RN) #1. RN #1 stated they worked in the emergency department and the medical-surgical unit. RN #1 stated if there were an incident that needed to be reported they would fill out a paper sheet and give the sheet to the chief nursing officer. RN #1 stated that medication errors and falls should be reported as incidents. RN #1 stated it was important to practice good infection control to help keep patients safe. RN #1 stated patients preferred to be treated in a clean facility, and to not be exposed to anything. RN #1 stated the risk of not practicing infection control would be a patient acquiring a new infection. ii. An interview was conducted with the director of specialty services (Director) #7. Director #7 stated they helped oversee the operating room. Director #7 stated safety was their number one concern, and this was heightened due to the small size of the operating room. Director #7 stated they were not aware of any particular rounding process to identify infection control concerns. Director #7 stated their mindset around utilizing incident reports was to take care of any identified concerns and not file an incident report. Director #7 stated they did not provide education to their staff about filing reports, but thought someone from risk addressed this with staff. Director #7 stated the criteria to file a report was vague, but reports should have been filed for patient safety issues or injuries to patients. Director #7 stated it was important to have a process in place to identify patient safety issues so all staff were utilizing the same approach and standards to more easily identify issues. Director #7 stated the risk of not identifying or addressing safety issues would be patient harm or risk of harm. This was in contrast to the Incident-Variance Reporting policy which read, a mechanism for handling reportable incidents must be established in an effort to ensure proper management of incidents,, and to enhance the quality of care to patients by identifying problem areas in an effort to prevent the occurrence of future incidents. It was also done to document threatening incidents to staff so that potential safety hazards can be addressed. All reportable incidents associated with facility property, personnel, patients, or the public were to be immediately documented and reported to the appropriate department manager. A written incident report would be submitted to the Compliance Office within twenty-four hours (forty-eight hours on weekends) following the actual occurrence. iii. An interview was conducted with the director of maintenance (Director) #4. Director #4 stated areas of cement deterioration in the building and disintegration of floor tiles could have been an infection control concern. Director #4 stated the facility had been working with a fire service contractor (Contractor) for twelve years, but they were now aware that the Contractor was not completing the contracted work to maintain the facility’s fire suppression and alarm systems. Director #4 stated it was important to have a system for the facility to address safety issues to ensure that patients and staff were kept safe. Director #4 stated there was a risk of harm if the facility was not identifying safety issues and improving them. iv. An interview was conducted with the director of risk management (Director) #8. Director #8 stated they managed the facility’s incident reports. Director #8 stated the process to file an incident report was electronic, and staff could utilize the process from computers at the facility. Director #8 stated another team member would combine all the incident reports to provide quarterly reports for the board. Director #8 stated incident reports were to be filed by any staff at the facility if something occurred outside of the ordinary or was outside of policies or procedures. Director #8 stated many staff were not reporting incidents, and that the staff in the emergency department and inpatient unit did not use the facility’s electronic system and instead used paper forms. Director #8 stated these paper forms were kept with the department manager, and were not always received in a timely manner to ensure they were included in data for tracking and trending. Director #8 stated it was important to have a standardized system for monitoring incidents because the facility would not be aware of issues or be able to receive information from front line staff. Director #8 stated if the system used to identify issues was not used as intended there was a risk that the facility would miss large opportunities to correct issues and it could lead to something catastrophic. Director #8 stated there was a disconnect between the facility actively seeking out opportunities for safety improvement and a missing connection between the facility’s risk assessment team and quality improvement. Director #8 stated resources and staff were barriers to identifying issues, especially with respect to the physical environment of the facility. v. An interview was conducted with the director of inpatient services (Director) #3. Director #3 stated they oversaw the facility’s infection control program. Director #3 stated their biggest priority was to keep patients safe from hospital acquired infections. Director #3 stated this included mitigating risks for patients at the facility by maintaining a safe environment, and ensuring any construction on the building utilized methods that minimized risk of infection. Director #3 stated they would round on patients, and observe for any imminent environmental threats to patients during that time. Director #3 stated it was important to maintain a clean environment at the facility because patients may have a bacteria or virus, and these should not be transmitted to other patients seeking care at the facility. Director #3 stated there was a risk if certain areas were not cleaned at all or not cleaned appropriately. Director #3 stated they followed the direction of the facility’s accrediting agency to determine any infection control quality improvement projects. Director #3 stated they followed what the facility’s accrediting agency dictated rather than setting their own priorities for quality improvement. Director #3 stated they were focused on preventing the spread of catheter (a thin, flexible tube that’s inserted into the body to transfer liquids out) associated urinary tract infections and respiratory infections while patients were hospitalized. This interview was in contrast to the facility’s infection prevention plan which read, infection prevention included strategies to decrease risk and a surveillance plan. Infection prevention rounds assessed the level of quality provided. The facility monitored compliance with infection prevention practices and documented by staff evaluation and observation of practices. The infection preventionist and department managers then reviewed the compliance monitoring and initiated appropriate actions. This was also in contrast to the facility’s 2024 Quality Improvement Plan which read, quality improvement efforts included review and improvement of all programs and processes that had a direct influence on the quality of health services provided. Program managers were responsible for initiating problem solving processes and quality improvement projects. Leadership was responsible for assuring continual identification and investigation of quality improvement filters as they arose. vi. An interview was conducted on 10/2/24 at 11:03 a.m. with the chief nursing officer (CNO) #5. CNO #5 stated they were also the director of quality. CNO #5 stated it was important to help the facility and staff understand the impact of systems improvement. CNO #5 stated the QAPI plan should evaluate the facility from a 10,000 foot view. CNO #5 stated their responsibility for quality only covered the emergency department and the inpatient unit, with other managers responsible for monitoring and determining quality projects in their areas. CNO #5 stated they were instructed by their accrediting agency to use other departments to help evaluate the process in the emergency department. CNO #5 stated to ensure quality was not approached in a narrow manner, all quality issues were presented to the governing board. CNO #5 stated they were not involved with the infection control program but would listen to presentations to the board by the provider overseeing infection control. CNO #5 stated they were not aware of what different directors’ quality projects were. CNO #5 stated the leadership team oversaw contracts and was aware that a central list of contracts should have been kept in place to help monitor them. CNO #5 stated if the facility relied on the expertise of contractors, the facility needed to ensure the contracts were followed. CNO #5 stated they were aware of issues with the Contractor since 2020. CNO #5 stated it was important to have a comprehensive quality process that identified concerns because this allowed all staff to be successful with a proper system in place. CNO #5 stated the risk of not having a comprehensive approach to Quality would be a bad outcome, such as a bad patient outcome. This interview was in contrast to the 2024 Quality Improvement Plan which read, all services supported by the facility on a contracted basis would be evaluated on an as needed basis. The leadership team was responsible for: reporting to the management team on work plan results, selected outcome measures, program evaluation efforts, QI projects, patient satisfaction evaluation, state standard gaps, and QI Training needed by staff; assuring implementation of QI projects; and assuring continue identification and investigation of QI filters as they arose. vii. An interview was conducted on 10/2/24 at 4:06 p.m. with the chief executive officer (CEO) #6. CEO #6 stated their role was to oversee everything in the facility. CEO #6 stated it was key to have a QAPI program that worked on meaningful measures. CEO #6 stated they attended quality sub-committee meetings, and all departments had different improvement projects. CEO #6 stated it was important to oversee all departments with respect to quality, and to ensure systems issues were identified. CEO #6 stated there was not a formal process to enter contracts with vendors, and the facility needed to work on a more structured process to oversee contracted services.”

“PRIVACY AND SAFETY CFR(s): The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47959 Based on observations, document review, and interviews, the facility failed to protect the patient’s right to receive care in a safe setting. Specifically, the facility failed to have a functional fire suppression system and failed to implement a plan to mitigate the safety risk of fire throughout the entire facility. (Cross-reference C-0914) Findings include: Facility policies: The Fire Protection System Impairments policy read, to assure that unauthorized persons and/or outside contractors do not cause impairment to a fire protection system, the impairment process will occur prior to any outage. Inspection and testing tasks shall be performed by personnel who have developed competence through training and experience. System malfunctions shall receive immediate attention and repairs and if required, shall receive the highest priority to return the system(s) to full operation as quickly as possible. For shutdowns exceeding four hours within a 24-hour period, a fire watch will be implemented. The Fire Watch policy read, the fire protection system impairment policy will be implemented in the event the fire alarm system or sprinkler system must be shut down or is out of service. This was to provide a mechanism for monitoring a building or portions of a building for potential or actual fire smoke conditions during the fire protection system shutdown or operational failure. Upon notification of a system outage that is anticipated to last more than four hours in a 24-hour period, maintenance will initiate a fire watch. The Use of Electrical Power Strips policy read, electrical power strips can be used as long as no electric extension cords are plugged into it before or after the power strip. No electrical power strips can be used on medical equipment. No personal devices can be plugged into an electrical power strip. 1. The facility failed to implement a plan to mitigate the safety risk caused by a failed fire suppression system. A. Observations conducted during the complaint survey completed on 10/3/24 revealed the facility failed to comply with the regulations set forth for Life Safety. Numerous violations in regards to fire prevention and mitigation were identified, and four immediate jeopardies were called under Life Safety Code tags K161, K341, K353, and K920. See survey event ID 8D9821 for full details of the cited deficiencies. i. Observations conducted on 9/26/24 in the operating room (OR) supply room revealed surgical supplies stacked on the top shelves of the storage area within the 18-inch sprinkler head clearance. This obstructed the sprinkler head from operation in the event of a fire. Additionally, observations included surgical supplies on top of a radiator. ii. Observations in the endoscopy procedure room revealed medical equipment plugged into extension cords and extension cords plugged into other power strips to increase the length of the extension cord. This was in contrast to the Use of Electrical Power Strips policy which read, staff should not use electrical extension cords when plugged into electrical power strips and should not use them for medical equipment. iii. Observations in a hallway near the sterile processing department (SPD) revealed a closet door unable to shut due to the amount of patient care equipment (bedside commodes, walkers, oxygen concentrators) stacked to the ceiling of the closet. B. Interviews i. On 10/1/24 at 3:25 p.m., an interview was conducted with the maintenance director (Director) #4. Director #4 stated staff moved objects that obstructed sprinkler heads when staff identified issues. Director #4 stated maintenance staff rounded through the facility daily but the checklist did not include a check for supplies to be below 18 inches from the ceiling and stated staff likely did not do the checks for supplies around the sprinkler heads. Director #4 state supplies stacked within 18 inches of the ceiling created an obstruction for the sprinkler heads. This was in contrast to the document review of the rounding checklists kept by the facility which revealed maintenance staff completed the rounds three days each week, not daily, and primarily focused on mechanical equipment under the direction of the plant operations department. ii. An interview was conducted on 10/2/24 at 9:02 a.m. with Director #4. Director #4 stated a contracted vendor started in 2012 and inspected the fire suppression sprinkler system four times a year. Director #4 stated the contracted vendor’s responsibilities included suppression inspections, extinguisher inspections, maintenance on the kitchen hood, maintenance of alarm panels, strobes, horns, and ensured the sprinkler heads worked. Director #4 stated they accompanied and helped the contracted vendor with the water system. Director #4 stated they received reports of the deficiencies found with each quarterly inspection. Director #4 stated the reports all showed zero deficiencies except the report created after the inspection done in the presence of state life safety code surveyors. Director #4 stated that report had 17 deficiencies. Director #4 stated they did not check the contracted vendor’s logs against all the facility sprinkler system areas. Director #4 stated they assumed the contracted vendor did the work and showed the fire suppression system worked. Director #4 learned the system did not work properly at the time the state life safety code inspection started. The fire watch did not start until three days after they learned the fire suppression system did not work. This was in contrast to the fire protection system impairments policy which read, personnel who developed competence through training and experience would perform the inspection and testing of the fire protection system. For shutdowns which exceeded four hours within a 24-hour period, the facility implemented a fire watch. Additionally, it was in contrast to the fire watch policy which read, the facility implemented the fire protection impairment policy, which included the initiation of a fire watch in the event the fire alarm system or sprinkler system shut down or experienced operational failure. C. Document Review i. The fire sprinkler system inspection reports supplied to the facility by the contracted vendor were reviewed. The review included inspections performed by the contracted vendor on 12/5/22, 3/8/23, 6/22/23, 9/12/23, 12/13/23, 8/29/23, and 9/27/24. The review revealed all reports through 8/29/23 read, there were no reported deficiencies for the report submission to the facility. The review of two reports provided for the inspection on 9/27/24, completed at the request and in the presence of life safety surveyors, revealed a total of 17 deficiencies noted in the inspection reports. The deficiencies included critical severity levels of deficient findings. The inspection report read the main shutoff valve did not shut off completely and the sprinkler system did not have a necessary backflow assembly on the sprinkler system or the antifreeze system. The inspection report read the test valve in a stairwell was clogged with debris and there were improperly labeled forward flow test valves for the sprinkler system.”

“A complaint survey prompted by CO#37676 was completed on 10/3/2024. 27 deficiencies were cited. Due to the nature of survey findings in K161, K341, K353, and K920 Immediate Jeopardy was initially declared on 9/25/2024 at 11:09 a.m. Based on observations, interviews, and record review the facility the facility failed to maintain building construction, fire alarm, fire sprinkler, electrical systems in a manner to detect, prevent, contain, and suppress fire and smoke in the event of a fire event within the facility. Failures included: failing to maintain the building structure resulting to the building’s inability to contain fire and smoke as planned during a fire event; failing to employ a fire alarm control panel consistent with code resulting in the potential to have undetected and reported fire events; failing to maintain the sprinkler system resulting in sprinkler system that would not function with the intended suppression during a fire event; and failure to use proper electrical equipment that presented risk for fire, power failure and spark during surgical procedures. According to the submitted facility plans, the facility would patch and repair all penetrations to original fire resistance ratings; initiate fire watch and have contractor complete fire suppression repairs; initiate fire watch and have a contractor bring the fire alarm control panel up to code; remove un-permitted electrical work and power strips; and have a qualified electrician inspect and verify electrical equipment integrity and safety. Based on the four submitted plans, the facility was notifed the Immediate Jeopardy was removed as of 9/26/2024 at 5:30 p.m. The facility is a single story, Type III (200), construction. The facility is protected throughout by automatic fire sprinkler systems and is classified as Fully Sprinklered. This facility was constructed in 1964 and is licensed for 22 beds. A new dining facility was constructed in 1996 of, Type II (000) construction with a partial basement housing a physical therapy office and rehab center, and is separated from the nursing home by two-hour construction. Based on the on-site life safety code recertification survey completed on October 03, 2024, the facility failed to comply with the regulations set forth for Life Safety. Please see Event ID X43711, for full details of the condition level tag cited under the Health Survey. §485.623 Physical Plant and Environment”

“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: 42961 Based on observations, interviews, and record review during the complaint survey completed on October 3, 2024, it was determined that the facility failed to maintain building construction standards in accordance with 2012 Life Safety Code 101 section 4.6.12 to comply with section 8. Specifically, the facility’s hazardous areas, floors, and rated walls were not maintained to provide the intended containment of smoke and fire for passive fire protection. These failures create the likelihood of serious adverse outcomes for all patients, staff, and visitors if a fire occurs within the facility. The findings include: I. Immediate Jeopardy A. Findings of Immediate Jeopardy Regulatory Requirement: 2012 Life Safety Code 101 section 19.3.7.3 to comply with section 8.5. Section 8.5.2.2, “Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.” 2012 Life Safety Code 101 section 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 2012 Life Safety Code 101 section 4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. 2012 Life Safety Code 101 section 19.1.6.1 Health care occupancies shall be limited to the building construction types specified in Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7. (See 8.2.1.) Observations: Cross-reference to K321 for observations of multiple penetrations in walls and ceilings of hazardous areas that would allow smoke and fire to travel within the facility’s maintenance area. Cross-reference to K371 for observations and interviews related to numerous penetrations that preclude the maintenance of intended fire/smoke barriers. Cross-reference to K223 for observations of numerous self-closing doors that would allow the travel of smoke and fire and void the fire resistance rating of the area. Cross-reference to K225 for observations of stairways and smokeproof enclosures that had been modified for storage, which would allow the travel of smoke and fire and void the fire resistance rating of the area. Cross-reference to K311 Vertical Opening enclosure that had been modified for storage would allow smoke and fire to travel and void the area’s fire resistance rating. Observations of the first floor, including the maintenance shop, boiler room, and maintenance room, revealed missing gypsum board from the ceiling throughout. Patients, staff, and visitors were observed throughout the facility during the survey. Interviews: On 09/25/2024, the facility maintenance director acknowledged that the penetrations in the walls, ceilings, and floors and the floor construction did not conform to the requirements. The maintenance director and the compliance coordinator stated that they were not allowed to spend money on repairs to save money to build a new hospital. On 09/25/2024, the maintenance director stated that the facility had been cited by its accrediting agency for the damages and modifications to the fire-rated door to the laundry room. However, the chief executive officer would not allow the door replacement because of the budget. On 09/27/2024, the chief executive officer acknowledged that the facility had some problems with its compliance. He stated that every dollar spent on the current facility pushes them further from their goal of building a new hospital. B. Notification of Immediate Jeopardy On September 25, 2024, at 1:36 p.m., the maintenance director and compliance coordinator were informed that the facility’s failures to maintain all rated assemblies, as designed, to prevent smoke and fire penetration created the likelihood of serious harm if the failures were not corrected immediately. C. Facility Plan to Remove Immediate Jeopardy On September 25, 2024, the facility submitted a plan to remove the immediate jeopardy. The removal plan read: 1) Plan: Patch and repair all penetrations to original fire resistance rating. May consult with design professional. 2) Procedure: Achieve compliance with NFPA 101 3) Monitering [sic]: Facility staff will monitor no less than weekly for ceiling penetrations 4. Person responsible: [staff proper name], Director of Maintenance 5. Completion: Will try to complete all repairs within 60 days bit may seek time-limited waiver if unable to get contractor in time. D. Removal of Immediate Jeopardy On September 25, 2024, at 4:30 p.m., the maintenance director and compliance coordinator were notified that the immediate jeopardy had been removed. Deficient practice will remain until all fire barriers and smoke barriers are restored to their rated assemblies per NFPA 101 2012.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 42961 Through observation during the survey, it was determined that the facility failed to meet the Egress Doors requirements in accordance with NFPA 101 19.2.2.2.4. This STANDARD is not met, as evidenced by: Based on observation, the door to the Operating Room has a hasp-style lock on the outside. Through an interview, it was determined that the Operating Room has the Hasp and Lock to maintain its cleanliness after cleaning it. Based on observation, the Gastroenterology (GI) Lab has a deadbolt-style lock on the door. This deadbolt is 60” above the finished floor. A deadbolt was added due to the field modifications to the door because of the roughness in the door and door frame, where it appears the door was cut in the field. Additionally, since the door was not manufactured for a deadbolt, the deadbolt latch is mounted on the surface of the door edge, creating a sticking point between the door and the door frame. This did not meet the requirement of LSC Sections 7.2.1.5.1 Door leaves shall be arranged to be opened readily from the egress side whenever the building is occupied. 7.2.1.5.10.1 The releasing mechanism for any latch shall be located as follows: (1) Not less than 34 in. (865 mm) above the finished floor for other than existing installations (2) Not more than 48 in. (1220 mm) above the finished floor 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one smoke compartment. Deficient items were discussed during the survey and at the exit conference.”

“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: 42961 Through observation during the survey, it was determined that the facility failed to meet the Doors with Self-Closing Devices requirements in accordance with NFPA 101, 19.2.2.2.7. This STANDARD is not met, as evidenced by: Based on observation, doors with self-closing devices were propped open throughout the facility or could not self-close and positively latch shut. Based on observation, the doors self-closing device between the Hugo Specialty Clinic and the hospital were disabled. Based on observation, the doors of the self-closing device between the Gordon Clinic and the hospital were disabled. Based on the door to the stairwell in the main building, there was a door at the bottom with a self-closure device on the door. However, the door handle had been removed. This prevented the door from positively latching shut. Based on observation, the door to the CT Scan trailer had been disabled by removing the closure arm of the door-closing device. Based on observation, the door to the laundry room ’ s self-closing device had been disabled by removing the closure arm. An interview with the Maintenance Director revealed that the facility’s Accreditation Agency had cited them for this door, but the facility had not fixed it due to its price. Additionally, the interview determined that this door had been cut and disabled because of the extreme temperature fluctuations in this area. This did not meet the requirement of LSC Sections 19.2.2.2.7* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.”

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This Standard is not met as evidenced by: 42961 Through observation during the survey, it was determined that the facility failed to meet the Stairways and Smokeproof Enclosures requirements in accordance with NFPA 101, 19.2.2.3. This STANDARD is not met, as evidenced by: Based on observation, the stairwell next to the second-floor lobby, the stairway, and the smokeproof closure fire resistance rating have been diminished. The stairwell consists of concrete masonry unit (CMU) block wall construction. On level one, on the north side of the stairwell, a portion of the CMU block has been removed from the stairwell. The CMU around the opening is broken and damaged. This area is being used for storage. While standing inside the storage area, looking up at the stairs, the stair’s construction is metal, and daylight comes in from the stringer and winders providing evidence that there is no fire-resistance rating between the storage and stairs. There is no sprinkler head in this area. This did not meet the requirements of LSC Sections. 19.3.1.7 A door in a stair enclosure shall be self-closing and shall normally be kept in the closed position, unless otherwise permitted by 19.3.1.8. 7.2.2.5.3* Usable Space. Enclosed, usable spaces within exit enclosures shall be prohibited, including under stairs, unless otherwise permitted by 7.2.2.5.3.2. 7.2.2.5.3.2 Enclosed, usable space shall be permitted under stairs, provided that both criteria are met: (1) The space shall be separated from the stair enclosure by the same fire resistance as the exit enclosure. (2) Entrance to the enclosed, usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.) 7.2.2.5.1.2 Inside stairs, other than those serving as an exit or exit component, shall be protected in accordance with Section 8.6. 8.6.5* Required Fire Resistance Rating. The minimum fire-resistance rating for the enclosure of floor openings shall be as follows (see 7.1.3.2.1 for enclosure of exits): (1) Enclosures connecting four or more stories in new construction — 2-hour fire barriers (2) Other enclosures in new construction — 1-hour fire barriers (3) Existing enclosures in existing buildings — 1/2-hour fire barriers (4) Enclosures for lodging and rooming houses — as specified in Chapter 26 (5) Enclosures for new hotels — as specified in Chapter 28 (6) Enclosures for new apartment buildings — as specified in Chapter 30 This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the two smoke compartments. Deficient items were discussed during the survey and at the exit conference.”

“Discharge from Exits CFR(s): NFPA 101 Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7 This Standard is not met as evidenced by: 42961 Through observation during the survey, it was determined that the facility failed to meet the Discharge from Exit requirements in accordance with NFPA 101, 19.2.7 . This STANDARD is not met, as evidenced by: Based on observation, the stairwell door on the southwest side of the building does not terminate at a public way. After exiting the building, there is a concrete landing. At the bottom of the landing, the ground surface is landscaped rock and a decorative paver. Then, around 20 feet of travel through turf grass is made before the public way is reached. Based on observation, the Exit from the west side does not terminate at a public way. After exiting the building, there is a concrete landing and four steps. At the bottom of the steps, the ground surface is landscaped rock and a decorative paver. Then, around 50 feet of travel through turf grass is made before the public way is reached. Based on observation, the path to the public way outside the 2nd-floor lobby is of concrete construction. On top of the concrete landings and stairs is a topping of pebbles around one inch thick and permanently held together. On the landing and stairs closest to the building, sections of this topping have come off. This can create potential trip hazards and variations in sizes of adjected tread depths. This did not meet the requirement of LSC Sections 7.7.1* Exit Termination. Exits shall terminate directly, at a public way, or an exterior exit discharge, unless otherwise provided in 7.7.1.2 through 7.7.1.4. 7.1.6.2 Changes in Elevation. Abrupt changes in elevation of walking surfaces shall not exceed 1/4 in. (6.3 mm). Changes in elevation exceeding 1/4 in. (6.3 mm), but not exceeding 1/2 in. (13 mm), shall be beveled with a slope of 1 in 2. Changes in elevation exceeding 1/2 in. (13 mm) shall be considered a change in level and shall be subject to the requirements of 7.1.7. 7.2.2.3.3.2* Stair treads and landings shall be free of projections or lips that could trip stair users. 7.2.2.3.6.1 Variation in excess of 3/16 in. (4.8 mm) in the sizes of adjacent tread depths or in the height of adjacent risers shall be prohibited unless otherwise permitted in 7.2.2.3.6.3. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 42961 Through observation, documentation review, and interview, it was determined that the facility failed to meet the Emergency Lighting requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: Through record review, not all of the emergency lights were listed on the emergency light documentation. Throughout observation, the emergency lighting in the operating room was not connected to the lighting circuit but to a receptacle circuit. Throughout observation, the emergency lighting in the Gastrointestinal room was not connected to the lighting circuit but to a receptacle circuit. This did not meet the requirement of LSC Sections 7.9.2.3* The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting due to any of the following: (1) Failure of a public utility or other outside electrical power supply (2) Opening of a circuit breaker or fuse (3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities 7.9.2.4 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3. 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1)Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2). (2)* The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. (3) Functional testing shall be conducted annually for a minimum of 11/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at 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: 42961 Through documentation, observation review, and interview, it was determined that the facility failed to meet the Exit Signage requirements in accordance with NFPA 101, 19.2.10. This STANDARD is not met, as evidenced by: 1) Based on observation, many exit signs throughout the facility were not illuminated. In an interview, the Maintenance Director acknowledged the low output from the exit lights but stated that if you open the sign, they are illuminated. This did not meet the requirement of LSC Sections 7.10.9.1 Inspection. Exit signs shall be visually inspected for the operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.1.3. 7.9.3.1.3 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Computer-based, self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided. (2) Not less than once every 30 days, emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine. (3) The emergency lighting equipment shall automatically perform annually a test for a minimum of 11/2 hours. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.3(2) and (3). (5) The computer-based system shall be capable of providing a report of the history of tests and failures at all times. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at 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: 42961 Through observation during the survey, it was determined that the facility failed to meet the Vertical Openings – Enclosure requirements in accordance with NFPA 101, 19.3.1. This STANDARD is not met, as evidenced by: 1) Based on observation, the stairwell next to the second-floor lobby, the stairway, and the smokeproof closure fire resistance rating have been diminished. The stairwell consists of concrete masonry unit (CMU) block wall construction. On level one, on the north side of the stairwell, a portion of the CMU block has been removed from the stairwell. The CMU around the opening is broken and damaged. This area is being used for storage. While standing inside the storage area, looking up at the stairs, the stair’s construction is metal, and daylight comes in from the stringer and winders providing evidence that there is no fire-resistance rating between the storage and stairs. There is no sprinkler head in this area. 2) Based on the door to the stairwell in the main building, there was a door at the bottom with a self-closure device on the door. However, the door handle had been removed. This prevented the door from positively latching shut. This did not meet the requirement of LSC Sections 19.3.1.1 Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. 19.3.1.7 A door in a stair enclosure shall be self-closing and shall normally be kept in the closed position, unless otherwise permitted by 19.3.1.8. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within two smoke compartments. Deficient items were discussed during the survey and at the exit conference.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 42961 Through observation during the survey, it was determined that the facility failed to meet the Hazardous Areas – Enclosure requirements in accordance with NFPA 101, 19.3.2.1. This STANDARD is not met, as evidenced by: 1) Based on observation, the door to the laundry room ’ s self-closing device had been disabled by removing the closure arm. Through an interview with the Maintenance Director, it was learned that the facility’s Accreditation Agency had cited them for this door, but the facility had not fixed it due to the price of the door. Additionally, through the interview, it was determined that this door had been cut and disabled because of the extreme temperature fluctuations in this area. 2) Based on observation, the storage room in the Emergency Room is considered hazardous because of its size and contents. The room has a hollow core door and no self-closing device separating it from the emergency room. 3) Based on observation, the maintenance shop had many penetrations on the walls and ceiling of this area. All these penetrations would allow smoke and fire to travel through in the event of a fire. 4) Based on observation, the Materials management door had no self-closing device. Upon further investigation and interview, it was determined that, at some point, this had been an operating room. When accessing this area from the corridor, you pass through a Dutch door, about 6 feet of a hallway, and then there is a door frame. This area must be assessed to ensure the added door will be in the proper door frame. This did not meet the requirement of LSC Sections 19.3.2.1 Hazardous Areas.Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 19.3.2.1.3 The doors shall be self-closing or automatic-closing. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at 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: 42961 Through documentation review, it was determined that the facility failed to meet the Cooking Facilities requirements in accordance with NFPA 101, 19.3.2.5. This STANDARD is not met, as evidenced by: 1) Through document review, it was determined that the kitchen hood fire extinguishing system is past due for a hydrostatic test. This did not meet the requirement of LSC Sections 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: 11.1.5 Listed exhaust hoods shall be operated in accordance with the terms of their listings and the manufacturer ’ s instructions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one smoke compartment. Deficient items were discussed during the survey and at 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: 42961 Through observation during the survey, it was determined that the facility failed to meet the Alcohol Based Hand Rub Dispenser (ABHR) requirements in accordance with NFPA 101, 19.3.2.6. This STANDARD is not met, as evidenced by: 1) Based on observation, there is an Alcohol Based Hand Rub dispenser located above a power receptacle in the radiology room. This did not meet the requirement of LSC Sections 19.3.2.6* Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, 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 This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one smoke compartment. Deficient items were discussed during the survey and at 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: 42961 Based on observations, interviews, and record review during the complaint survey completed on September 26, 2024, it was determined that the facility to install and maintain the fire alarm system in accordance with NFPA 101, section 19.1.1.4.4 and 43.5.1.3, including NFPA 72 National Fire Alarm Code. Specifically, the facility utilized a non-permitted fire alarm control panel, had missing smoke detection and had fire alarm devices in imaging trailer corridors, which created the possibility of undetected fire within the facility. These failures created the likelihood of serious adverse outcomes for all patients, staff, and visitors if a fire occurred within the facility. The findings include: I. Immediate Jeopardy A. Findings of Immediate Jeopardy Regulatory Requirement: 8 CCR 1507-31 Article 6.5.2 Shop (Installation) drawings for fire protection and life safety systems shall be submitted to the Fire and Life Safety Code Official(s) for review and approval prior to beginning installation of the system. A) Fire sprinkler and fire alarm shop drawings shall be submitted to the Fire and Life Safety Code Officials in accordance with the requirements of the adopted codes in the format as prescribed by the Division and the local fire department. NFPA 72 Section 10.14.2.1 All systems shall be installed in accordance with the specifications and standards approved by the authority having jurisdiction. NFPA 72 Section 10.18.1.1 The authority having jurisdiction shall be notified prior to installation or alteration of equipment or wiring. NFPA 72 Section 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. NFPA 72 Section 10.18.2.1.2.4 A final copy of the record of completion shall be provided after completion of the operational acceptance tests. NFPA 72 Section 10.18.2.3 Documentation Required. Every system shall include the following documentation, which shall be delivered to the owner or the owner’s representative upon final acceptance of the system: (1)* An owner’s manual and manufacturer’s published instructions covering all system equipment (2) Record drawings (3) For software-based systems, record copy of the site-specific software (4) A written sequence of operation. NFPA 72 Section 10.18.2.4* Verification of Compliant Installation. Where required, compliance of the completed installation with the requirements of this Code, as implemented via the referring code(s), specifications, and/or other criteria applicable to the specific installation, shall be certified by a qualified and impartial third-party organization acceptable to the authority having jurisdiction. NFPA 72 Section 10.18.2.4.1 Verification shall ensure that the installed system includes all components and functions, that those components and functions are installed and operate as required, that the system has been 100 percent acceptance tested in accordance with Chapter 14, and that all required documentation has been provided to the system owner. NFPA 72 Section 10.18.2.4.3 Verification shall include written confirmation that any required corrective actions have been completed. Observations: The fire alarm system had the following observed concerns: -The facility had installed a Potter PFC-5000 Series Fire Alarm Panel with a manufacturer date 2022. This was not the system of record. -A Public Emergency Alarm Reporting System had been installed. The manufacturer’s date was May 2022. -The corridor to the computerized tomography (CT) scanner had no smoke detection or notification devices. Patients, staff, and visitors were observed throughout the facility during the survey. Record Review: Requests were made for documentation related to the fire alarm control panel and public emergency alarm reporting. Documentation review revealed: -The new fire alarm control panel (FACP) did not receive initial acceptance testing. -The facility did not obtain a permit for the new FACP. -The facility had not obtained a permit for the public emergency alarm reporting. Interviews: On 9/26/2024, the facility maintenance director acknowledged that the FACP was changed; however, the change date was unknown. The facility maintenance director stated that the FACP was changed because the fire alarm contractor ruined the existing FACP while inspecting the system. The facility was not charged for the new FACP as the contractor made the mistake. The maintenance director acknowledged that the new FACP was a different make and model than the removed panel. On 9/26/2024, hospital leadership conducted a video conference meeting with the owner of the fire alarm contractor company. During the meeting/interview, the owner of the fire alarm contractor company acknowledged the following: -His company had shorted the previous FACP. The owner said the contractor replaced the damaged FACP with a new one. The owner gave a date of September 2022. -A permit was not pulled with any authorities having jurisdiction. -Initial acceptance testing was not performed on the replacement FACP. -His company had added a public emergency alarm reporting system. -His company did not pull permit with any authorities having jurisdiction for the public emergency alarm reporting system. -Initial acceptance testing was not performed on the public emergency alarm reporting system. B. Notification of Immediate Jeopardy On September 26, 2024, at 9:30 a.m., the maintenance director and compliance coordinator were informed of the facility’s failures to install and maintain the fire alarm system in accordance with NFPA 101 and NFPA 72, which created the likelihood of serious harm if the failures were not corrected immediately. C. Facility Plan to Remove Immediate Jeopardy On Sep 26, 2024, at 5:23?p.m., the facility submitted a plan to remove the immediate jeopardy. The removal plan read: “Re: IJ Removal Plan for 8D9821 9-26-2024 @ 0930 Fire Alarms 1. Plan: Facility will go on Fire Watch. Have Nebraska Safety and Fire return to the facility to assess the needs to bring the fire suppression [sic] system up to code. 2. Procedure: Facility began Fire Watch protocols at 1000 on 9/26/24. NE Safety and Fire has been contacted and will be asked to return to facility for assessment and bid of work to be done to get the fire suppression [sic] system up to code. 3. Monitoring: Fire watch protocol has been implemented with completion of log for the entire facility. 4. Person responsible: [staff proper name], Director of Maintenance 5. Completion: Fire watch protocol began at 1000 on 9/26/24. Local fire agency vice chief [proper name] was notified that Lincoln is on Fire Watch at 1057.” D. Removal of Immediate Jeopardy On September 26, 2024 at 5:30 p.m., the maintenance director and compliance coordinator, were notified the immediate jeopardy was removed. Deficient practice remains the facility installs and maintains a fire alarm system in accordance with NFPA 101, and NFPA 72.”

“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: 42961 Through documentation review, it was determined that the facility failed to meet the Fire Alarm System – Testing and Maintenance requirements in accordance with NFPA 101 and NFPA 72. This STANDARD is not met, as evidenced by: 1) Document review determined that the fire alarm system had an inspection on 03/14/2024 and 09/18/2024; however, both reports indicate semi-annual inspections. It was not clear which, if either, was an annual inspection. 2) A sensitivity testing report was not provided. This did not meet the requirement of LSC Sections 19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. NFPA 72: 14.2.2.1* The property or building or system owner or the owner ’ s designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system. NFPA 72: 14.2.2.3 Inspection, testing, or maintenance shall be permitted to be done by the building or system owner or a person or organization other than the building or system owner if conducted under a written contract. NFPA 72: 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. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.”

“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: 42961 Through observation, documentation review, and interview, it was determined that the facility failed to meet the Sprinkler System – Installation requirements in accordance with NFPA 101 and NFPA 13. This STANDARD is not met, as evidenced by: 1) Through observation during an above-ceiling inspection near Room 4, a sprinkler head that was not connected to the fire sprinkler system was found. The sprinkler head was in a 4-foot by 6-foot closet, and there was an access hatch through the ceiling in that same location. While looking above the ceiling for the sprinkler head nearest the access hatch, there was no sprinkler piping; some blown-in insulation was moved, and it revealed a 1-inch PVC “T.” When the surveyor touched the sprinkler below the ceiling, the PVC “T” moved. The Sprinkler head was unthreaded, and the assembly consisted of a brass-fusible link-style sprinkler head threaded into a PVC fitting(Slip by Female Pipe Thread). The PVC fitting was dry-fitted into a 1-inch PVC T. There was no water to this T. Email correspondence with the Compliance Coordinator determined that in 2015 the maintenance staff made some changes to the walls. The Colorado Division of Fire Prevention and Control has no records of permits being obtained for this work. 2) Through observation, it was determined that a sprinkler head was not in the room 4 closet. This area is related to K-Tag 351 evidence #1. Email correspondence with the Compliance Coordinator determined that in 2015, the maintenance staff made some changes to the walls. The Colorado Division of Fire Prevention and Control has no records of permits being obtained for this work. 3) Through observation and interview, it was determined that room 106 had been converted to a cardiac rehab area. The Compliance Coordinator confirmed that this conversion occurred around 2016-2017. In this area, a room was created within the Cardiac Rehab room; the addition of the walls created sprinkler head obstructions and distances that would not allow the sprinkler to cover all areas of the room in the event of a fire. The Colorado Division of Fire Prevention and Control has no records of permits being obtained for this work. 4) Through observation, it was determined that the Restroon between the GI lab and the Cardiac Rehab rooms had a sprinkler head too close to the wall. The distance between the sprinkler head and the wall was less than 4 inches. 5) Based on observation, the stairwell next to the second-floor lobby, the stairway, and the smokeproof closure fire resistance rating have been diminished. The stairwell consists of concrete masonry unit (CMU) block wall construction. On level one, on the north side of the stairwell, a portion of the CMU block has been removed from the stairwell. The CMU around the opening is broken and damaged. This area is being used for storage. There is no sprinkler head in this area because it was exempt from needing sprinkler protection, but if an area contains storage, it must be protected. This did not meet the requirement of LSC Sections 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(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 (2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes (3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height NFPA 13: 8.5.1.2 Sprinklers shall be positioned to provide protection of the area consistent with the overall objectives of this standard by controlling the positioning and allowable area of coverage for each sprinkler. NFPA 13: 8.6.3.3 Minimum Distances from Walls. Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at 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: 42961 Based on observations, interviews, and record review during the complaint survey completed on October 3, 2024, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, and NFPA 101, 19.3.5, and 4.6.12. Specifically, the facility’s failure to maintain its automatic sprinkler system created the potential for a failure to provide the intended sprinkler coverage during a fire. These failures created the likelihood of serious adverse outcomes for all patients, staff, and visitors if a fire occurs within the facility. The findings include: I. Immediate Jeopardy A. Findings of Immediate Jeopardy Regulatory Requirement: NFPA 25 Section 4.1.1.2 Inspection, testing, and maintenance shall be performed by personnel who have developed competence through training and experience. NFPA 25 Section 4.1.4.1 The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard. NFPA 25 Section 4.1.7 Valve Location. The location of shutoff valves shall be identified. NFPA 25 Section 4.1.8.1 A permanently marked metal or rigid plastic information sign shall be placed at the system control riser supplying an antifreeze loop, dry system, preaction system, or auxiliary system control valve. NFPA 25 Section 4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25 Section 4.5.1 All components and systems shall be tested to verify that they function as intended. NFPA 25 Section 5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). NFPA 25 Section 5.2.2.1 Pipe and fittings shall be in good condition and free of mechanical damage, leakage, and corrosion. NFPA 25 Section 5.2.2.2 Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe. NFPA 25 Section 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. NFPA 25 Section 5.3.1.1.1.6 Dry sprinklers that have been in service for 10 years shall be replaced or representative samples shall be tested and then retested at 10-year intervals. NFPA 25 Section 5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. NFPA 25 Section 5.3.4 Antifreeze Systems. Annually, before the onset of freezing weather, the antifreeze solution shall be tested using the following procedure: NFPA 25 Section 5.4.1.5 The stock of spare sprinklers shall include all types and ratings installed and shall be as follows:(1)For protected facilities having under 300 sprinklers - no fewer than 6 sprinklers(2)For protected facilities having 300 to 1000 sprinklers - no fewer than 12 sprinklers(3)For protected facilities having over 1000 sprinklers - no fewer than 24 sprinklers Observations: During the course of the survey, the following was observed: -Sprinkler heads had missing or broken sprinkler escutcheons (flanges) throughout the facility. -Sprinkler heads throughout the facility were loaded (dusty) or painted. -Ceilings had missing ceiling tiles or penetrations. -The IT room had a cardboard partition that obstructed the sprinkler head spray pattern. -The storage closet near the lobby server room had antifreeze system that was missing information to identify if it was active and evaluated. -The operating room adjacent storage closet antifreeze system was last inspected 6/15/2015. The pressure gauge for the antifreeze system was dated 2011. On 9/27/2024 the facility’s suppression system contractor conducting the annual inspection. The following concerns were identified: -The suppression contractor was not aware of where the valves were located. -An inspector’s test valve was opened, water started flowing and suddenly stopped with no human intervention. The valve was manipulated, and the blockage did not clear. -A main drain valve was connected to the inspector’s test valve section. The main drain valve could flow water. Patients, staff, and visitors were observed throughout the facility during the survey. Record Review: The following inspection dates contain zero deficiencies. 09/20/2022, 12/05/2022, 03/08/2023, 06/22/2023, 09/12/2023, 12/13/2023, 03/14/2023, 09/18/2024. The 6/26/2024 inspection had one deficiency. On 09/25/2024, the suppression contractor inspected the antifreeze system, which had not been inspected since 06/15/2015. The inspection report revealed three deficiencies. On 09/27/2024, the suppression contractor completed a full annual wet-based fire suppression system inspection, with a qualified contractor overseeing the inspection. This inspection resulted in 11 deficiencies, seven of which the report listed as “Critical.” The deficiencies and notes listed on the Wet Pipe Fire Sprinkler Report include: 1. Main shutoff valve does not shut off completely. No backflow assembly on fire sprinkler system, suggest installing one. No backflow assembly on antifreeze system, suggest installing one. Antifreeze tested at -5°F, suggest considering replacing antifreeze. Inspectors test valve in SW stairwell appears to be clogged with debris. 2. Multiple corroded heads throughout the facility. 3. Most mechanical rooms with obstructed heads 4. Multiple loaded heads throughout the facility 5. Multiple fast response heads throughout the facility due for sample testing/or replacement - will suggest to the customer that it would be most beneficial to replace all sprinkler heads in the facility. 6. Multiple heads throughout the facility over 50 years old or older - suggest replacing all heads in the facility 7. 2 dry pendants and 1 dry sidewall heads due to be replaced 8. The inspectors’ test valve was clogged with debris after briefly flowing water. Suggest obstruction investigation. 9. No vertical sidewall heads in the spare cabinet. 10. Signs of corrosion on sprinkler pipe outside maintenance office 11. Wire and tubing zip-tied to sprinkler pipe in maintenance and specialty clinic 12. Could not perform a 5-year inspection because the main shutoff did not shut off completely. The facility had no evidence that a five-year internal obstruction was completed as required. Interviews: On 09/25/2024, a representative from the fire suppression contractor stated that he was in the area of and his boss called and asked him to go to the facility to inspect one of the antifreeze systems. The representative stated that he does not typically do maintenance inspections on this facility. When asked if the antifreeze system had been tested after 06/15/2015, he responded that it did not appear it had been inspected since then. On 09/26/2024, the facility maintenance director stated that their fire suppression contractor had just been at the facility, and no issues were noted or brought to the facility’s attention. On 09/26/2024, the facility maintenance director acknowledged that at least one antifreeze system was in the facility, which was not listed on the inspection reports. On 09/27/2024, a representative from the fire suppression contractor could not find the inspector tests throughout the facility. When asked how the tests are performed monthly if the inspectors’ tests are not used, they responded that they probably just inspect the main drain test. On 09/27/2024, a representative from the fire suppression contractor was interviewed about why the dates of the sprinkler head were at or beyond 50 years, and the previous inspection report did not reflect that. The response was that the wording surrounding that section was confusing, and some authorities having jurisdiction did not like it to be checked, and some did. This section reads, “Standard response sprinklers 50 years old or more replaced or successfully sample tested in last 10 years?” The options to choose are Yes, No, or N/A. B. Notification of Immediate Jeopardy On September 26, 2024, at 9:30 a.m., the facility maintenance director and compliance coordinator were informed of the facility’s failures of the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, and NFPA 101, 4.6.12. created the likelihood of serious harm if the failures were not corrected immediately. C. Facility Plan to Remove Immediate Jeopardy On Sep 26, 2024, at 5:23?PM, the facility submitted a plan to remove the immediate jeopardy. The removal plan read: “IJ Removal Plan for 8D9821 9-26-2024 @ 0930 - Fire Suppression 1. Plan: Facility will go on Fire Watch. Have Nebraska Safety and Fire return to the facility to assess the needs to bring the fire suppression system up to code. 2. Procedure: Facility began Fire Watch protocols at 1000 on 9/26/24. NE Safety and Fire has been contacted and will be asked to return to facility for assessment and bid of work to be done to get the fire suppression system up to code. 3. Monitoring: Fire watch protocol has been implemented with completion of log for the entire facility. 4. Person responsible: [staff member name], Director of Maintenance 5. Completion: Fire watch protocol began at 1000 on 9/26/24. Local fire agency vice chief [proper name] was notified that Lincoln is on Fire Watch at 1057.” D. Removal of Immediate Jeopardy On September 26, 2024, at 5:30 PM, the maintenance director and compliance coordinator were notified that the immediate jeopardy had been removed. Deficient practice will remain until the automatic sprinkler system is maintained in accordance with National Fire Protection Association (NFPA) 25 and NFPA 101.”

“Subdivision of Building Spaces - Smoke Compar CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Compartments 2012 EXISTING Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier. 19.3.7.1, 19.3.7.2 Detail in REMARKS zone dimensions including length of zones and dead-end corridors. This Standard is not met as evidenced by: 42961 Through observation, documentation review, and interview, it was determined that the facility failed to meet the Subdivision of Building Spaces – Smoke Compartments requirements in accordance with NFPA 101, 19.3.7. This STANDARD is not met, as evidenced by: Through interviews, it was determined that no life safety plans for the building exist; therefore, a thorough and comprehensive survey of the smoke compartments can not be conducted. Through observation, numerous penetrations above the ceilings do not maintain the suspected fire/smoke barriers. This did not meet the requirement of LSC Sections 19.1.1.3.2 Because the safety of health care occupants cannot be ensured adequately by dependence on evacuation of the building, their protection from fire shall be provided by appropriate arrangement of facilities; adequate, trained staff; and development of operating and maintenance procedures composed of the following: (1) Design, construction, and compartmentation (2) Provision for detection, alarm, and extinguishment (3) Fire prevention procedures and planning, training, and drilling programs for the isolation of fire, transfer of occupants to areas of refuge, or evacuation of the building This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 42961 Through observation, interview, and document review during the survey, it was determined that the facility failed to meet the Utilities – Gas and Electric requirements in accordance with NFPA 101, NFPA 99, and NFPA 70. This STANDARD is not met, as evidenced by: 1) On September 25th, 2024, at approximately 10:30 AM, the surveyors started investigating what was believed to be inappropriate wiring in the Operating Room. There were 4 receptacles on the room’s west wall and 2 receptacles on the east wall. All the receptacles in the room were in two gang boxes or double receptacles. On the west wall, the receptacles were in surface-mounted duplex boxes, which are common for adding receptacles to a circuit; however, they are uncommon in an operating room setting. One surface-mounted receptacle box was connected to another surface-mounted receptacle box by low profile plastic raceway- or surface-mounted conduit. The maintenance director was asked if the breaker tripped in this area where is the breaker to reset it, and he responded, “ I don’t know.” Through interviews, it was also determined that this operating room provides full sedation to the patients. A receptacle tester was inserted into all the receptacles in the room, and all contained an “open ground,” this was verified by a second receptacle tester. The Maintenance Director was asked to remove a receptacle from the raceway cover to check the wiring for compliance with NFPA 99. The wiring inside consisted of 14 gauge- 15 amp ROMEX brand wire, which is prohibited from operating rooms. Within the operating room, two electrical circuits were powering the 6 receptacles. The facility was notified that the operating room could not be used for operations until further assessments and corrective work had occurred. The ROMEX wire has a manufacture date of 11/13/2020. At 1213, a Colorado Department of Regulatory Agencies(DORA) Electrical Inspector Supervisor was contacted to discuss the site conditions. On 09/26/2024 around 11:30 AM, the Electrical Inspector Supervisor met the Life Safety Surveyors onsite to perform a safety inspection(DORA Permit # 1011354), and the report in part reads “Corrections: 517.19 Category 1 Spaces, (C)(1) Operating Room Receptacles. Minimum Number and Supply - Operating Room Comments: The safety inspection was for the Oprating Room and Maintenace Shop. Inside the Operating Room, I (Aaron Skubal) observed wiremold with 14-2 NM inside the wiremold. Per DFPC the receptacles had an “open ground” when they checkd it with their receptacle tester, please see the correction below.” 2) Through Observation, ROMEX wiring was observed throughout the maintenance shop in the basement. The DORA Electrical Inspector Supervisor confirmed this was not compliant. The DORA Permit #1011354 report in part reads “334.10(3) Uses Permitted, NM in Types III, IV, and V construction. Cables shall be concealed with a 15-minute finish rating - Maintenance area. Inside the Maintenance Shop there were several pieces of 12-2 NM exposed on the surface, please see the correction below. 3)Through observation, ROMEX wiring was observed to supply power to a refrigerator used for medicine storage in the basement near the maintenance shop. Through an interview, it was determined that this was non-compliant by the DORA Electrical Inspector Supervisor. 4) Through observation, wiring above the ceiling near room #4 appears to have a white wire running along sprinkler piping in the corridor. This did not meet the requirement of LSC Sections 19.5.1.1 Utilities shall comply with the provisions of Section 9.1. 19.5.1.2 Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life. NFPA 99: 6.3.2.2.6.1* Types of Receptacles. (A) Each power receptacle shall provide at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug, despite electrical and mechanical abuse. NFPA 99: 6.3.2.2.6.2 Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care rooms in accordance with 6.3.2.2.6.2(A) through 6.3.2.2.6.2(E).(C) Receptacles for Operating Rooms (Category 1). Operating rooms shall be provided with a minimum of 36 receptacles. NFPA 70: 517.61 Wiring and Equipment. (C) Other-Than-Hazardous (Classified) Anesthetizing Locations. (1) Wiring Methods. Wiring serving other-than-hazardous (classified) locations, as defined in 517.60, shall be installed in a metal raceway system or cable assembly. The metal raceway system or cable armor or sheath assembly shall qualify as an equipment grounding conductor in accordance with 250.118. Type MC and Type MI cable shall have an outer metal armor, sheath, or sheath assembly that is identified as an acceptable equipment grounding conductor. NFPA 70: 517.62 Grounding. In any anesthetizing area, all metal raceways and metal-sheathed cables and all normally non–current-carrying conductive portions of fixed electrical equipment shall be connected to an equipment grounding conductor. Grounding and bonding in Class I locations shall comply with 501.30. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.”

“Fundamentals - Building System Categories CFR(s): NFPA 101 Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99) This Standard is not met as evidenced by: 42961 Through interview and documentation review, it was determined that the facility failed to meet the Fundamentals – Building System Categories requirements in accordance with NFPA 101 and NFPA 99. This STANDARD is not met, as evidenced by: The surveyor requested a “Risk Assessment assessment with NFPA 99 categories. This shall be determined by following and documenting a defined risk assessment procedure for each room/area. See Chapter 4 of the 2012 NFPA 99.” The compliance coordinator responded, “This is something we will need to implement.” This did not meet the requirement of LSC Sections NFPA 99: 4.1* Building System Categories. Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code. NFPA 99: 4.2* Risk Assessment. Categories shall be determined by following and documenting a defined risk assessment procedure. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.”

“Gas and Vacuum Piped Systems - Other CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 5 (NFPA 99) This Standard is not met as evidenced by: 42961 Through interviews and observation during the survey, it was determined that the facility failed to meet the Gas and Vacuum Piped Systems – Other requirements in accordance with NFPA 101 and NFPA 99. This STANDARD is not met, as evidenced by: 1) There was a very old gas valve Across the hall from Human Resources and the Case Management office. When the Facilities Maintenance Director was asked if the gas valve was still in use, the maintenance Director stated, “I don’t know.” 2) While outside the operating room in the scrub room, the staff was asked if the gas valve was in use. The maintenance director stated he did not know. The facility’s Specialty Physician Outreach coordinator noted that it was in use. This did not meet the requirement of LSC Sections 4.5.5* Situation Awareness. Systems used to achieve the goals of Section 4.1 shall be effective in facilitating and enhancing situation awareness, as appropriate, by building management, other occupants and emergency responders of the functionality or state of critical building systems, the conditions that might warrant emergency response, and the appropriate nature and timing of such responses. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.”

“Electrical Systems - Receptacles CFR(s): NFPA 101 Electrical Systems - Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 42961 Through observation during the survey, it was determined that the facility failed to meet the Electrical Systems – Receptacles requirements in accordance with NFPA 101, NFPA 99, and NFPA 70. This STANDARD is not met, as evidenced by: Electrical receptacles in the Operating room are not grounded. Entrance to medication room broken outlet cover The outlet near the ambulance parking area has a cover coming apart. This area is subject to weather. This did not meet the requirement of LSC Sections NFPA 70- 314.15 Damp or Wet Locations. In damp or wet locations, boxes, conduit bodies, and fittings shall be placed or equipped so as to prevent moisture from entering or accumulating within the box, conduit body, or fitting. Boxes, conduit bodies, and fittings installed in wet locations shall be listed for use in wet locations. NFPA 70- 406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface. Receptacle faceplates mounted inside a box having a recess-mounted receptacle shall effectively close the opening and seat against the mounting surface. NFPA 70- 517.13 Grounding of Receptacles and Fixed Electrical Equipment in Patient Care Areas. Wiring in patient care areas shall comply with 517.13(A) and (B). (A) Wiring Methods.All branch circuits serving patient care areas shall be provided with an effective ground-fault current path by installation in a metal raceway system, or a cable having a metallic armor or sheath assembly. The metal raceway system, or metallic cable armor, or sheath assembly shall itself qualify as an equipment grounding conductor in accordance with 250.118. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.”

“Electrical Systems - Wet Procedure Locations CFR(s): NFPA 101 Electrical Systems - Wet Procedure Locations Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment conducted by the facility governing body. Operating rooms defined as wet locations are protected by either isolated power or ground-fault circuit interrupters. A written record of the risk assessment is maintained and available for inspection. 6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2 This Standard is not met as evidenced by: 42961 Through documentation review, it was determined that the facility failed to meet the Electrical Systems – Wet Procedure Locations requirements in accordance with NFPA 101 and NFPA 99. This STANDARD is not met, as evidenced by: 1) A written record of the risk assessment is not maintained and available for inspection. This did not meet the requirement of LSC Sections NFPA 99- 6.3.2.2.8.4 Operating rooms shall be considered to be a wet procedure location, unless a risk assessment conducted by the health care governing body determines otherwise. NFPA 99- 6.3.2.2.8.7 Operating rooms defined as wet procedure locations shall be protected by either isolated power or ground-fault circuit interrupters. NFPA 99- 6.4.4.2 Record Keeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within two smoke compartment. Deficient items were discussed during the survey and at the exit conference.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 42961 Through documentation review, it was determined that the facility failed to meet the Electrical Systems – Maintenance and Testing requirements in accordance with NFPA 101 and NFPA 99. This STANDARD is not met, as evidenced by: 1) A written record of the maintenance and testing is not maintained and is not available for inspection. This did not meet the requirement of LSC Sections NFPA 99- 6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. NFPA 99- 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. NFPA 99- 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. NFPA 99- 6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. NFPA 99- 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification. NFPA 99- 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Receptacles Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking. 6.4.2.2.6, 6.5.2.2.4.2, 6.6.2.2.3.2 (NFPA 99) This Standard is not met as evidenced by: 42961 Through observation during the survey, it was determined that the facility failed to meet the Electrical Systems – Essential Electric System Receptacles requirements in accordance with NFPA 101, NFPA 99, and NFPA 70. This STANDARD is not met, as evidenced by: Electrical receptacles or cover plates supplied from the life safety and critical branches do not have a distinctive color or marking This did not meet the requirement of LSC Sections NFPA 99- 6.4.2.2.6.2(C)* The electrical receptacles or the cover plates for the electrical receptacles supplied from the life safety and critical branches shall have a distinctive color or marking so as to be readily identifiable. A.6.4.2.2.6.2(C) If color is used to identify these receptacles, the same color should be used throughout the facility. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at 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: 42961 Through documentation review, it was determined that the facility failed to meet the Electrical Systems – Essential Electric System Maintenance and Testing requirements in accordance with NFPA 101, NFPA 110 and NFPA 99. This STANDARD is not met, as evidenced by: Generator Batteries are not tested monthly. Transfer switches are not operated monthly. This did not meet the requirement of LSC Sections NFPA 110- 8.3.7* Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer ’ s specifications. NFPA 110- 8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted. NFPA 110- 8.4.6 Transfer switches shall be operated monthly. NFPA 110- 8.4.6.1 The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.”

“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: 42961 Based on observations, interviews, and record review during the complaint survey completed on October 3, 2024, it was determined that the facility failed to it was determined that the facility failed to maintain electrical power cords in accordance with NFPA 99 and Life Safety Code Section. Specifically, the facility’s use of non-permitted, non-listed power cords, particularly in the operating room, created the potential for sparks in the presence of medical gasses, fire, and power failure. These failures created the likelihood of serious adverse outcomes for all patients undergoing procedures in the operating room and gastrointestinal room due to potential power loss from overloading power equipment. The findings include: I. Immediate Jeopardy A. Findings of Immediate Jeopardy Regulatory Requirement: 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. NFPA 99 Section 10.2.3.4.1 Power cords, regardless of whether intended for use on grounded or isolated power systems, shall be connected in accordance with the conventions of a grounded system. NFPA 99 Section 10.2.4.2.2 Attachment plugs and fittings shall be listed for the purpose. NFPA 99 Section 10.5.2.3.1 Adapters and extension cords meeting the requirements of 10.2.4 shall be permitted to be used. NFPA 99 Section 10.5.2.5 System Demonstration. Any system consisting of several electric appliances shall be demonstrated to comply with this code as a complete system. NFPA 99 Section 10.5.6.1.1 A permanent file of instruction and maintenance manuals shall be maintained and be accessible. Observations: Cross-reference to K511 for observations of multiple Utilities-electrical issues that could result in fire. Cross-reference to K912 for observations of multiple Electrical Systems- Receptacles issues that could result in fire. Observation of the operating room revealed a non-listed extension-type cord that created another electrical outlet. This outlet was used to plug operating room equipment into the power strip. Medical gas jets and anesthesia equipment were in close proximity to the outlet. The extension cord in the operating room consisted of a twist-style electrical plug and, from there, a 33’ whip or 16/3 cord(maximum current rating of 13 amps). This was run into a junction box intended for use in the wall, but it was surface-mounted onto the gypsum board and connected to a 15A-125V receptacle. The following equipment was near the non-permissible wiring and is used from this wiring when needed. Warming Cabinet- 15 amps- Always in use Stryker Neptune 3 Rover- 12 amps Electrocurgical Generator- 3 amps Anesthesia System- 12 amps Electrocurgical Generator- 3 amps Endoscopy Machine- 4 amp Monitor- 4.8 amps. The gastrointestinal (GI) room had a Non-medical grade extension cord used on patient-use equipment. The GI room had a daisy chain consisting of a non-medical grade power strip powering a medical grade power strip present. The facility used extension cords and power strips to power refrigerators and cooking appliances. The electrical configurations in the Operating Room and the GI Room do not meet the NFPA 99 Building System Category Requirements. These rooms are considered a Category 1 Building System Category: “Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code.” Patients, staff, and visitors were observed throughout the facility during the survey. Record Review: Throughout the document review of Work Order: 901-81634, it was discovered that a “Warming Unit” Model#: T/PUMP Serial#: TP700J317 11 MFG: STRYKER CORPORATION Location: SAL CH 3.1.2024 stated “Note: “I went to unplug this device from the outlet and sparks flew and the device power chord melted.” The Lincoln Health Clinical Incident Report Form dated 12/23/2023 states, “Device was received from staff w/ ? (with complaints of) sparks + smoke when being plugged in the device was not being utilized on a pt (patient) @ the time of the incident.” Interviews: On 09/25/2024, the facility’s Specialty Physician Outreach stated that operations had increased from 25 to 40 cases a month in the last three years. These cases include all spectrums of surgeries, with patients undergoing up to full sedation. The Specialty Physician Outreach Coordinator could not estimate when the extension cord was added. The Specialty Physician Outreach Coordinator stated that the extension cord had been there for the duration of their tenure. On 09/25/2024, the facility maintenance director could not estimate when the extension cord was added. The maintenance director stated that it had been there for the duration of his tenure. On 09/25/2024, the Facility Compliance Coordinator could not estimate when the extension cord was added, stating it had been there for the duration of their tenure. On 09/25/2024, the facility director or nursing could not estimate when the extension cord was added, stating it had been there for their whole tenure. On 09/25/2024, the facility director or nursing could not remember any details about Work Order: 901-81634. In pertinent part the work order read, “Warming Unit” Model#: T/PUMP Serial#: TP700J317 11 MFG: STRYKER CORPORATION Location: SAL CH 3.1.2024 ... Note: I went to unplug this device from the outlet and sparks flew and the device power chord melted.” The incident report was requested. The facility provider the incident report, which was reviewed. B. Notification of Immediate Jeopardy On September 09/25/2024, 2024, at 11:09 a.m., the Compliance Coordinator, Maintenance Director, and Specialty Physician Outreach were informed that the facility’s failures to maintain electrical power cords in accordance with NFPA 99 and Life Safety Code Section 10.2.3.6 created the likelihood of serious harm if the failures were not corrected immediately. C. Facility Plan to Remove Immediate Jeopardy On September 25, 2024, the facility submitted a plan to remove the immediate jeopardy. The removal plan read: 1) Plan: The junction box, receptacle, 32 feet of cord, and power strip will be removed from OR. Will have a qualified electrician to inspect and verify integrity, safety and compliance. 2) Procedure: The junction box, receptacle, 32 feet of cord, and powerstrip [sic] was removed from OR on 09/25/2024 at 1145. Will have a qualified electrician to inspect and verify integrity, safety and compliance. 3) Monitering [sic]: Will monitor the OR for noncompliant electrical equipment and will only use equipment permitted by all adopted codes and standards of NFPA 13, 70, 99, and 101. After electrical work is complete, surgery stadd [sic] will complete logs no less an 2x.wk to ensure no noncompliant equipment is used. 4. Person responsible: [proper staff name], Director of Maintenance 5. Completion: 09-25-2024 at 11:45 a.m. Electrician to be here by 9-28-2024. D. Removal of Immediate Jeopardy On September 25, 2024, at 4:30 p.m., the Maintenance Director and Compliance Coordinator were notified that the immediate jeopardy had been removed. Deficient practice remains until the facility maintains all electrical power cords per NFPA 101 and NFPA 99.”

“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: 42961 Through observation during the survey, it was determined that the facility failed to meet the Gas Equipment – Cylinder and Container Storage requirements in accordance with NFPA 101 and NFPA 99. This STANDARD is not met, as evidenced by: 1) On the north side of the building, next to the oxygen farm, there is debris, such as leaves and branches that are too close to the tanks. 2) In the RT area, whether the oxygen tanks are empty or full is undetermined. This did not meet the requirement of LSC Sections NFPA 99- 11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. NFPA 99- 11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems (3)Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour NFPA 99- 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. NFPA 99- 11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.”

“Gas Equipment - Testing and Maintenance Requi CFR(s): NFPA 101 Gas Equipment - Testing and Maintenance Requirements Anesthesia apparatus are tested at the final path to patient after any adjustment, modification or repair. Before the apparatus is returned to service, each connection is checked to verify proper gas and an oxygen analyzer is used to verify oxygen concentration. Defective equipment is immediately removed from service. Areas designated for servicing of oxygen equipment are clean and free of oil, grease, or other flammables. Manufacturer service manuals are used to maintain equipment and a scheduled maintenance program is followed. 11.4.1.3, 11.5.1.3, 11.6.2.5, 11.6.2.6 (NFPA 99) This Standard is not met as evidenced by: 42961 Through documentation review, it was determined that the facility failed to meet the Gas Equipment – Testing and Maintenance Requirements requirements in accordance with NFPA 101 NFPA 99. This STANDARD is not met, as evidenced by: The survey team asked for the maintenance documentation for the Anesthesia. The facility’s Specialty Physician Outreach stated that maintenance was past due by a few months because the facility was purchasing a new anesthesia unit. The date for the PM Gas Module by Mindray DF USA, Inc. for the maintenance inspection is 04/18/2023. According to the Operating Instructions for the unit, maintenance is due annually. The Anesthesia machine is a Mindtay Model A5. This did not meet the requirement of LSC Sections A5/A4 Operating Instructions Maintenance Schedule The schedules listed in TABLE 7-1 are the minimum frequency based on 2000 hours of usage per year. The equipment should be serviced more frequently if used more than this yearly usage. Maintenance should be performed by a trained technician. Daily - Clean the external surfaces. Every 72 hours- Perform 21% O2 calibration (O2 sensor in breathing system). The A5/A4 will prompt the user for 21% O2 calibration (only for units with an galvanic O2 cell). Monthly– Water trap on AG module. Annually- Periodic maintenance due, to be performed by a trained technician. Gas Bench calibration. Contact Mindray Technical Support for details. Every three years- Periodic maintenance due, to be performed by a trained technician. Contact Mindray Technical Support for details. As necessary · Perform 100% O2 calibration after replacing the O2 sensor. · Replace the O2 sensor if it cannot be calibrated. · Before installing the cylinder, use a new cylinder gasket on the cylinder yoke. · Empty the water trap if there is water buildup. · Replace the soda lime in the canister if soda lime color change is detected. Follow the manufacturer ’ s instructions. · Replace the flow sensor if the seal for the flow sensor is damaged, the membrane inside the flow sensor is cracked or distorted, or the flow sensor is cracked or distorted. · Calibrate the flow sensor after re-installing the cleaned or disinfected flow sensor, after replacing with a new flow sensor, or when tidal volume measurement is inaccurate. · Replace the waste gas transfer tube if it is damaged. · Inspect the O2 flush button for normal movement. If not , refer to the service manual for the disassembling and cleaning. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one smoke compartment. Deficient items were discussed during the survey and at the exit conference.”