Virginia Gay Hospital

“42 CFR 482.41(b) Virginia Gay Hospital was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 482.41(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition. Virginia Gay Hospital is a two story building that was built in 1950 with additions in 1976 and 2011. The building is composed of Type II (222) construction. The facility is fully sprinklered and there is supervised smoke detection located in the corridors, resident rooms, and the spaces open to the corridors. The facility has 25 certified beds. At the time of the survey, the census was 4. The requirement at 42 CFR 482.41(b) is NOT MET as evidenced by:”

“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: 49481 Based on observation and interview, the facility failed to maintain smoke detection in accordance with National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Section-17.7.4.1), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 4. Findings include: Observation and interview on 04/17/25 at 9:44 a.m., revealed a smoke detector located in the Main Entrance Lobby was within 36 inches of an air supply. The smoke detector will need to be moved at least 36 inches away from any air supply. The Maintenance Director verified this observation at the time of the survey process.”

“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: 49481 Based on observation and interview, the facility failed to maintain sprinklers in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems Section-5.2.1.1.1, 2011 Edition. This deficient practice affect all residents, staff, and visitors in the kitchen. This facility has a capacity of 25 and a census of 4. Findings include: Observation and interview on 04/17/25 at 12:02 p.m., revealed the Kitchen had multiple quick response sprinklers covered in lint and dust and required cleaning. The Maintenance Director verified this observation at the time of the survey process.”

“Evacuation and Relocation Plan CFR(s): NFPA 101 Evacuation and Relocation Plan There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2. 18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3 This Standard is not met as evidenced by: 49481 Based on record review and interview, the facility failed to provide a complete fire safety plan in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.2.2(9)), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 4. Findings include: Record review and interview on 04/17/25 at 11:46 a.m., revealed the provided Fire Safety Plan did not address the use of the different types of portable fire extinguishers in the facility. Nor did the plan address the use of the Ansul extinguishment system for the kitchen hood. The Maintenance Director verified this observation at the time of the survey process.”

“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: 49481 Based on record review and interview, the facility was not properly documenting all elements of testing for the emergency generator in accordance with National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems (Section-8.4.2), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 4. Findings include: Record review and interview on 04/17/25 at 9:55 a.m., revealed that during monthly load testing of the facility’s diesel powered Emergency Generator the facility failed to record meter start and stop time from 1/24/24 - 7/22/24, 1/16/25 & 3/3/25. The facility also failed to record the amperage for each leg of the testing. The Maintenance Director verified this observation at the time of the survey process.”

“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: 49481 Based on observation and interview, the facility is not assuring that extension cords are being used in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-10.2.4), 2012 Edition and National Fire Protection Association (NFPA) 70, National Electric Code (Section-400.8), 2011 Edition. This deficient practice affects all staff and residents throughout the facility. This facility has a capacity of 25 and a census of 4. Findings include: Observation and interview on 04/17/25 at 11:57 a.m., revealed on the first floor in the Corner Mechanical Room there was an extension cord providing power to a standing fan. The Maintenance Director verified this observation at the time of the survey process.”