St Luke’s Jerome

“COMPLIANCE FED, ST, AND LOCAL LAWS AND REGS CFR(s): The CAH is in compliance with applicable Federal laws and regulations related to the health and safety of patients. This Standard is not met as evidenced by: 39430 Based on document review, medical record review, and staff interviews, the CAH failed to ensure compliance with state law governing the involuntary detention of individuals with suspected mental illness. Specifically, for 1 of 27 patients reviewed (Patient #6), the facility failed to document evidence of grave disability or imminent danger, failed to obtain a court order or initiate a legal mental health hold, and improperly detained and restrained Patient #6. This had the potential to put all patients at risk seeking treatment in the CAH emergency department. “IDAHO STATUTES TITLE 66 STATE CHARITABLE INSTITUTIONS 3 HOSPITALIZATION OF MENTALLY ILL,” updated 7/01/22, stated “66-326. Detention without hearing. (1) No person shall be taken into custody or detained as an alleged emergency patient for observation, diagnosis, evaluation, care or treatment of mental illness unless and until the court has ordered such apprehension and custody under the provisions outlined in section 66-329, Idaho Code; provided, however, that a person may be taken into custody by a peace officer and placed in a facility, or the person may be detained at a hospital at which the person presented or was brought to receive medical or mental health care, if the peace officer or a physician medical staff member of such hospital or a physician’s assistant or advanced practice registered nurse practicing in such hospital has reason to believe that the person is gravely disabled due to mental illness or the person’s continued liberty poses an imminent danger to that person or others, as evidenced by a threat of substantial physical harm; provided, under no circumstances shall the proposed patient be detained in a nonmedical unit used for the detention of individuals charged with or convicted of penal offenses. For purposes of this section, the term “peace officer” shall include state probation and parole officers exercising their authority to supervise probationers and parolees. Whenever a person is taken into custody or detained under this section without court order, the evidence supporting the claim of grave disability due to mental illness or imminent danger must be presented to a duly authorized court within twenty-four (24) hours from the time the individual was placed in custody or detained.” This Statute was not followed. An example includes: Patient #6 was a 41 year old female who was transported to the hospital via ambulance with chief complaint of altered mental status. She was transported after being approached by police officers in a parking lot and refusing to answer questions for police officers and EMS personnel. Patient #6’s medical record included the EMS report. The EMS report noted the following, “Upon arrival adult F is found standing in the parking lot of the carl jr’s [sic] with LE at patient side. Patient is noted to be breathing normally, refuses to answer questions. Patient refuses to be touched. Skin is noted to be cool and dry to the touch with feces noted to patients [sic] hands, down her legs and in her shoes.” In a section titled “Neurological Exam” the following is noted: “Level of Consciousness: Alert, Chemically Paralyzed: No, Neuro Comments: Patient is alert but refuses to answer questions. When willing to speak to EMS patient is alert but unable to recall current event’s [sic]. When attempted to [sic], Neurological Present: Speech Normal, Strength-Normal, Mental Present: Uncooperative.” Pupils are noted to both be normal and reactive. Sensory and motor is noted to be normal in all extremities. Glasgow coma scale is noted to be a total of 15. In a section titled “Airway” the following is noted: “Status: Patent, Comments: Patient airway is open and patent, breathing normally, able to speak in complete sentences when willing to answer questions.” On the EMS report there is a note timed, “01:55 Patient is transferred to hospital bed in room 6 using the slide method. SBAR report given to ED RN. SLJ assumes all patient care at this time.” The EMS report documented that Patient #6 was alert but chose not to answer questions. Patient #6’s medical record included an RN assessment note dated 11/17/24 with a time of 2:11 AM, “Patient in ed via found at the carls jr parking lot and will not answer questions. Patient on arrival keeps not answering. Patient with soiled pants myself and Maria RN attempted to clean patient up and patient remains not answering questions. Security and other RNs responded as patient started to get agitated and aggressive and wanted to leave. Patient was educated on we are there to help her and continually tried to deescalate verbally. Patient placed in restraints as she began to kick security guard multiple times, hit, scratch, and bite at other staff members ....” It was unclear through documentation why multiple persons were in the room with Patient #6 while staff were trying to deescalate Patient #6. There was no documentation of attempted nonverbal de-escalation techniques utilized. It was unclear through documentation how Patient #6 refusing to answer questions put her in imminent danger or had grave disability. Patient #6’s medical record included the following ED provider note dated 11/17/24 with a time of 2:29 AM, “Patient is a 123 y.o. female presenting to the ED with altered mental status. Patient was apparently found in a parking lot by law enforcement. She was unresponsive. They called EMS and EMS brought the patient here to the ER. Once arrival here she went violent on staff and thus law enforcement was called and they put her in restraints. Patient is still not giving us meaningful responses. She told the story to the nursing staff that she was at a hotel with some unknown man. She is unsure if she was given something by this man. She has no complaints. Patient is in restraints. She has been incontinent of stool and urine. She does not give me any complaints. She does not really give me any history. Patient assaulted medical staff and thus will need to get lab work from her for HIV and hepatitis .....She was scratching and biting and grabbing and kicking and swinging and punching and trying to elope .....” There was no documentation of specific evidence of grave disability or imminent danger due to mental illness. Additionally, there was no documentation the Physician was seeking an evaluation for a mental health condition. The Nurse Manager was interviewed on 3/25/25 beginning at 12:35 PM and Patient #6’s medical record was reviewed in her presence. She stated that staff put the patient in restraints because patient was “getting agitated and aggressive and assaulted staff so she was not allowed to leave”. When asked why the patient was not allowed to leave, she stated, “Because she physically assaulted a healthcare worker.” The COO/CNO was interviewed on 3/26/25 beginning at 1:20 PM. He stated that patient was not allowed to leave the ED because the doctor had determined that she was not of sound mind as she was not willing to answer questions. He was asked if the patient had been placed on a mental health hold and he said she was not. He was asked if she had the capacity to make decisions for herself and he stated, “I do not think she had capacity to make decisions.” He was asked if there was any paperwork filed for the patient being detained and not allowed to leave the hospital and he stated there was not. The CAH failed to comply with Idaho Code §66-326 by detaining Patient #6 without obtaining a court order or documenting evidence of grave disability or imminent danger due to mental illness, as required by law for emergency mental health holds. Additionally, the facility failed to document that a physician was actively seeking or initiating a mental health evaluation or legal hold, resulting in the patient being improperly held and restrained against her will.”

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 39430 Based on hospital policy review, record review, EMS report review, and staff interview, it was determined the hospital failed to ensure restraints were utilized appropriately per hospital policy for 1of 1 patient (Patient #6) who’s record was reviewed and had restraints applied for violent behaviors. This had the potential for unsafe conditions for all patients receiving care at the hospital. Findings include: A hospital policy titled, “Restraints & Seclusion”, dated 05/23/24, stated: “II. LESS RESTRICTIVE MEASURES/ALTERNATIVES TO RESTRAINTS/SECLUSION A. Prior to the use of any restraint/seclusion, the patient care provider must attempt and/or consider less restrictive measures to protect the patient, staff members, or other from harm. B. Document the implementation of less restrictive measures or the reason less restrictive measures were not an option prior to restrain/seclusion application/use. C. The following are examples of less restrictive measures or the reason less restrictive alternatives to restraints/seclusion: 1. Address physical and medical needs (e.g., offer regular toileting, keep personal items within reach). 2. Treatment of symptoms of illness causing behaviors e.g., olanzapine for hallucinations due to delirium. 3. Provide patient with diversion activities (e.g., magazine, television, and music). 4. Move patient closer to the nurse’s station. 5. Use of medical equipment (e.g., splints, arm boards, positioning equipment). 6. Employ verbal de-escalation techniques. 7. Increase activity as tolerated. 8. Use Patient Safety Attendant/family member to stay with the patient. 9. Offer medication for restlessness or anxiety if the medication and dose are currently part of the patient’s treatment plan. 10. Implement fall precautions. “ This policy was not followed. Patient #6 was a 41 year old female who was transported to the hospital via ambulance with chief complaint of altered mental status. She was transported after being approached by police officers in a parking lot and refusing to answer questions for police officers and EMS personnel. Patient #6’s medical record included the EMS report. The EMS report noted the following, “Upon arrival adult F is found standing in the parking lot of the carl jr’s [sic] with LE at patient side. Patient is noted to be breathing normally, refuses to answer questions. Patient refuses to be touched. Skin is noted to be cool and dry to the touch with feces noted to patients [sic] hands, down her legs and in her shoes.” In a section titled “Neurological Exam” the following is noted: “Level of Consciousness: Alert, Chemically Paralyzed: No, Neuro Comments: Patient is alert but refuses to answer questions. When willing to speak to EMS patient is alert but unable to recall current event’s [sic]. When attempted to [sic], Neurological Present: Speech Normal, Strength-Normal, Mental Present: Uncooperative.” Pupils are noted to both be normal and reactive. Sensory and motor is noted to be normal in all extremities. Glasgow coma scale is noted to be a total of 15. In a section titled “Airway” the following is noted: “Status: Patent, Comments: Patient airway is open and patent, breathing normally, able to speak in complete sentences when willing to answer questions.” On the EMS report there is a note timed, “01:55 Patient is transferred to hospital bed in room 6 using the slide method. SBAR report given to ED RN. SLJ assumes all patient care at this time.” The EMS report documented that Patient #6 was alert but chose not to answer questions. Patient #6’s medical record included an RN assessment note dated 11/17/24 with a time of 2:11 AM, “Patient in ed via found at the carls jr parking lot and will not answer questions. Patient on arrival keeps not answering. Patient with soiled pants myself and Maria RN attempted to clean patient up and patient remains not answering questions. Security and other RNs responded as patient started to get agitated and aggressive and wanted to leave. Patient was educated on we are there to help her and continually tried to deescalate verbally. Patient placed in restraints as she began to kick security guard multiple times, hit, scratch, and bite at other staff members ....” It was unclear through documentation why multiple persons were in the room with Patient #6 while staff were trying to deescalate Patient #6. There was no documentation of attempted nonverbal de-escalation techniques utilized. Patient #6’s medical record included the following ED provider note dated 11/17/24 with a time of 2:29 AM, “Patient is a 123 y.o. female presenting to the ED with altered mental status. Patient was apparently found in a parking lot by law enforcement. She was unresponsive. They called EMS and EMS brought the patient here to the ER. Once arrival here she went violent on staff and thus law enforcement was called and they put her in restraints. Patient is still not giving us meaningful responses. She told the story to the nursing staff that she was at a hotel with some unknown man. She is unsure if she was given something by this man. She has no complaints. Patient is in restraints. She has been incontinent of stool and urine. She does not give me any complaints. She does not really give me any history. Patient assaulted medical staff and thus will need to get lab work from her for HIV and hepatitis .....She was scratching and biting and grabbing and kicking and swinging and punching and trying to elope .....” It is unclear what less restrictive measures were implemented prior to the use of restraints. It is unclear how the hospital addressed her physical and medical needs prior to placing patient in restraints. It is unclear how the hospital treated any of Patient #6’s symptoms prior to placing her in restraints. It is unclear how the hospital provided diversion activities before placing her in restraints. It is unclear what verbal de-escalation techniques were used prior to placing Patient #6 in restraints. The Nurse Manager was interviewed on 3/25/25 beginning at 12:35 PM and Patient #6’s medical record was reviewed in her presence. She stated that staff put the patient in restraints because patient was “getting agitated and aggressive and assaulted staff so she was not allowed to leave”. When asked why the patient was not allowed to leave, she stated, “Because she physically assaulted a healthcare worker.” The COO/CNO was interviewed on 3/26/25 beginning at 1:20 PM and Patient #6’s medical record was reviewed in his presence. He stated that patient was not allowed to leave the ED because the doctor had determined that she was not of sound mind as she was not willing to answer questions. He was asked if the patient had been placed on a mental health hold and he said she was not. He was asked if she had the capacity to make decisions for herself and he stated, “I do not think she had capacity to make decisions.” He was asked if there was any paperwork filed for the patient being detained and not allowed to leave the hospital and he stated there was not. The hospital failed to ensure restraints were used appropriately.”

“COMP ASSESSMENT, CARE PLAN & DISCHARGE CFR(s): §485.645(d)(5) Comprehensive assessment, comprehensive care plan, and discharge planning (§483.20(b), and §483.21(b) and (c)(2) of this chapter), except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under §483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in §413.343(b) of this chapter). “ §483.20(b) Comprehensive assessments- (1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information. (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychosocial well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnoses and health conditions. (xi) Dental and nutritional status. (xii) Skin condition. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. (2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2) (i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. (For purposes of this section, “readmission” means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.) (ii) Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. (For purposes of this section, a “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both.) (iii) Not less often than once every 12 months. “ §483.21(b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25, or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25, or §483.40 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (i) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (ii) In consultation with the resident and the resident’s representative(s)- (A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident’s representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident’s needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident’s written plan of care. (iii) Be culturally-competent and trauma-informed. “ §483.21(c)(2) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident’s stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident’s status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative. (iii) Reconciliation of all pre-discharge medications with the resident’s post-discharge medications (both prescribed and over-the-counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services. This Standard is not met as evidenced by: 51906 Based on medical record review and staff interviews, it was determined that the hospital failed to ensure that patient care plans were complete for 5 of 5 swing bed patients (Patient #9, #10, #11, #12, #13) and assessments were comprehensive to ensure activity assessments were completed for 4 of 5 swing bed patients (Patient #9, #10, #11, #12) whose records were reviewed. This lack of comprehensive care plans and activity assessments created the potential for unmet patient needs. 1. Patient care plans were not complete to include necessary mental health interventions and goals. Patient #13 was a 76 year old female who was admitted to the hospital on 10/02/24. She was later transferred to swing bed admission on 10/17/24. Both her inpatient and swing bed records were reviewed. Patient #13’s medical record from her inpatient admission included a psychiatric consultation conducted on 10/08/24 by a psychiatrist. The assessment noted that she had experienced suicidal ideation within the last 48 hours. Additionally, the assessment indicated Patient #13 had adjustment disorder with depression and anxiety. Patient #13’s medical record included a history and physical admission note by her swing bed admitting provider on 10/17/24. The note stated that Patient #13 had “adjustment disorder with mixed anxiety and depressed mood.” Patient #13’s medical record included assessments of emotional well-being and mood. Patient #13 was assessed several times for mood as follows: · On 10/17/24, Patient #13 exhibited “flat affect” and “inappropriate/delusional-like conversation. · On 10/20/24, Patient #13 “avoids eye contact”, exhibited “flat affect”, and appeared “agitated.” · On 10/21/24, Patient #13 exhibited “flat affect”, declined care, and appeared “agitated”. Patient #13’s care plan for her swing bed admission was reviewed. The care plan lacked interventions and goals for her identified mental health needs. On 03/25/24, beginning at 10:00 AM, the hospital’s Assistant Nursing Manager was interviewed, and Patient #13’s record was reviewed in her presence. She confirmed that the care plan did not include goals and interventions for Patient #13’s assessed mental health issues. The CAH failed to ensure that swing bed admission care plans were complete, including necessary mental health interventions and goals. 2. Patient comprehensive assessments were not complete to include activities assessment, and patient care plans did not include activity’s integrated into their care plans. Pt # 9 was a 57 year old male who was admitted to swing bed on 3/13/25 for ambulatory dysfunction, his medical record was reviewed. Pt #9’s medical record included: “What Kind of Activities Do You Enjoy?” No activities were documented for this patient for his length of stay as a swing bed pt. Additionally, no documented activity preferences were included on patient #9’s care plan. Pt #10 was a 93 year old female who was admitted to swing bed on 3/26/25 for ambulatory dysfunction, her medical record was reviewed. Pt #10’s medical record included: “What Kind of Activities Do You Enjoy?” No activities were documented for this patient for her length of stay as a swing bed pt. Additionally, no documented activity preferences were included on patient #10’s care plan. Pt # 11 was a 68 year old female who was admitted to swing bed on 3/7/25 for ambulatory dysfunction, her medical record was reviewed. Pt #11’s medical record included: “What Kind of Activities Do You Enjoy?” No activities were documented for this patient for her length of stay as a swing bed pt. Additionally, no documented activity preferences were included on patient #11’s care plan. Pt # 12 was a 65 year old female who was admitted to swing bed on 3/20/25 for ambulatory dysfunction, her medical record was reviewed. Pt #12’s medical record included: “What Kind of Activities Do You Enjoy?” No activities were documented for this patient for her length of stay as a swing bed pt. Additionally, no documented activity preferences were included on patient #12’s care plan. The CAH’s Nursing Manager and Assistant Nursing Manager were interviewed on 3/26/25 beginning at 9:30 AM, and Pt’s #9, #10, #11, and #12’s records were reviewed in their presence. The Nursing Manager stated they assess activities for swing bed pt’s, but she confirmed there was no documentation for all 4 pt’s records. The hospital failed to ensure swing bed patients activity assessments were part of the patient comprehensive assessment, and that activities were integrated into their care plans.”

“The facility is a single-story building with a partial basement, classified as protected non-combustible construction. The facility was originally constructed in 1951 and has undergone several renovations and a major addition to the Emergency Department (ED), Radiology and Main Entry. The building is provided with partial sprinkler coverage in portions of the basement and on the main level in the ED, Radiology and Main Entry addition only. There are two exits from each level to grade plus additional exits to the exterior from the main level at dietary service, radiology suite, and the ED suite. The Essential Electrical System is supplied by a diesel powered, on-site automatic generator. The facility is currently licensed for 25 hospital beds and had a census of 14 on the dates of the survey. The following deficiencies were cited during the annual fire/life safety survey conducted on March 12, 2025. The facility was surveyed under the LIFE SAFETY CODE, 2012 Edition, Existing Health Care Occupancy, in accordance with 42 CFR 482.41.”

“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: 34125 Based on record review, the facility failed to ensure fire alarm systems were maintained in accordance with NFPA 72. Failure to conduct sensitivity testing has the potential to hinder system performance as designed. This deficient practice affected patients, staff and visitors on the date of the survey. Findings include: During review of provided maintenance and inspection records conducted on 3/12/25 from 9:00 AM - 12:00 PM, no documentation was available demonstrating a sensitivity testing was conducted on the addressable fire alarm/smoke detection system. Actual NFPA standard: 14.4.5.3% In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7. 14.4.5.3.1 Sensitivity shall be checked within 1 year after installation. 14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3. 14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. 14.6 Records. 14.6.2.4% A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4: (1) Date (2) Test frequency (3) Name of property (4) Address (5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number (6) Name, address, and representati”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This Standard is not met as evidenced by: 34125 Based on record review and interview, the facility failed to ensure piped medical gas systems were maintained in accordance with NFPA 99. Failure to test all outlets and verify pressure, flow and concentration, along with valve conditions of gauge readings, labeling and leakage, has the potential to hinder system performance as designed. This deficient practice affected those patients, staff and visitors on the date of the survey. Findings include: During review of the provided annual piped medical gas inspection report conducted on 3/12/25 from 9:30 AM - 12:00 PM, records identified five (5) patient rooms that were not tested due to conditions preventing access at that time. Further review did not establish any further testing was performed at these locations when they became available. Interview of the Engineering Director at approximately 1:00 PM, established he was not aware that all outlets had to be tested at least annually, and that a revisit or other means was required to ensure these locations were included. Actual NFPA standard: NFPA 99 5.1.14.2.3 Inspection and Testing Operations. 5.1.14.2.3.1 General. The elements in 5.1.14.2.2.2 through 5.1.15 shall be inspected or tested as part of the maintenance program as follows: (1)%Medical air source, as follows: (a) Room temperature (b) Shaft seal condition (c) Filter condition (d) Presence of hydrocarbons (e) Room ventilation (f) Water quality, if so equipped (g) Intake location (h) Carbon monoxide monitor calibration (i) Air purity (j) Dew point (2)%Medical vacuum source - exhaust location (3) WAGD source - exhaust location (4)%Instrument air source - filter condition (5)%Manifold sources (including systems complying with 5.1.3.5.10, 5”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical 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 6 (NFPA 99) This Standard is not met as evidenced by: 34125 Based on record review and observation, the facility failed to ensure electrical installations were maintained and tested in accordance with NFPA 99. Failure to test those required cord and plug installations at required intervals and ensure maintenance of their installations, has the potential to hinder system performance as designed. This deficient practice affected staff and visitors on the date of the survey. Findings include: During review of provided maintenance and inspection records conducted on 3/12/25 from 9:30 AM - 12:00 PM, no documentation was available to establish a continual maintenance and testing procedure, biomed testing program, or verifying performance data for installation and usage of installed UL 1363A relocatable power taps (RPTs), . During the facility tour conducted on 3/12/25 from 1:00 - 3:00 PM, observation of the mobile monitoring equipment in the Emergency Department, identified a vitals monitoring unit with a UL 1363A RPT attached to the stand, with two (2) open outlets. Actual NFPA standard: NFPA 99 Chapter 6 Electrical Systems 6.3.2.2.8.5 In existing construction, the requirements of 6.3.2.2.8.1 shall not be required when a written inspection procedure, acceptable to the authority having jurisdiction, is continuously enforced by a designated individual at the hospital to indicate that equipment grounding conductors for 120-V, singlephase, 15-A and 20-A receptacles; equipment connected by cord and plug; and fixed electrical equipment are installed and maintained in accordance with NFPA 70, National Electrical Code, and the applicable performance requirements of this chapter. (A) The procedure shall include electrical continuity tests of all required equipment, grounding conductors, and their connections. (B) Fixed recep”