Hamilton Center Inc.

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 42622 Based on document review, observation and interview, the facility failed to ensure 1 of 1 battery powered emergency lights at the generator was maintained in accordance with LSC 7.9; failed to ensure monthly testing documentation of battery backup lights in the facility were complete and accurate; failed to ensure the automatic sprinkler piping systems was examined for internal obstructions where conditions exist that could cause obstructed piping as required by NFPA 25, 2011 Edition, the Standards for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, Section 14.2.1; failed to provide quarterly fire drill documentation for 1 of 3 shifts during 1 of 4 quarters; failed to provide complete fire drill documentation for 11 of 12 fire drills performed during the past 12 month period; failed to ensure annual inspection and testing of all fire door assemblies were completed in accordance of LSC 19.1.1.4.1.1; failed to document the transfer time to the alternate power source on the monthly load tests for 12 of the past 12 months to ensure the alternate power supply was capable of supplying service within 10 seconds; failed to ensure corrective action was taken after an annual fuel quality test was performed for the facility’s diesel powered generator; and failed to ensure a written record of weekly inspections for the generator was maintained for 7 of 52 weeks. Findings Include: The cumulative effect of these systemic problems resulted in the facility’s inability to ensure it had implemented a systemic plan of correction to prevent recurrence, therefore failing to ensure the provision of quality health care in a safe environment.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 44532 Based on document review and interview, it could not be determined that medical staff was accountable to the Governing Board for 4 of 4 Nurse Practitioners credential files reviewed. (NP1, NP2, NP3, and NP4). Findings include; 1. Medical Staff Bylaws indicated under Appendix A: Credentialing Policy and Process, a. Basic Responsibilities and Requirements: 1. As a condition of the Medical Staff or Allied Health Staff membership, every applicant and member specifically agree to the following as applicable: ii. To abide by the bylaws and policies of the Hospital and Medical Staff and any revisions or amendments. 2. a. Review of staff members NP1 credential files indicated on the reappointment dated 01/24/2023 lacked signed documentation of abide by Medical Staff Bylaws. b. Review of staff members NP2 credential files indicated on the reappointment dated 10/24/2023 lacked signed documentation of abide by Medical Staff Bylaws. c. Review of staff members NP3 credential files indicated on the reappointment dated 02/28/2023 lacked signed documentation of abide by Medical Staff Bylaws. d. Review of staff members NP4 credential files indicated on the reappointment dated 03/28/2024 lacked signed documentation of abide by Medical Staff Bylaws. 3. On 1/23/20 at approximately 1500 hours, staff A1 (Chief of Quality and Compliance) was interviewed and confirmed that NP1, NP2, NP3, and NP4 did not have a signed abide by rules for the reappointed dates.”

“CONTRACTED SERVICES CFR(s): 482.12(e)(2) The hospital must maintain a list of all contracted services, including the scope and nature of the services provided. This Standard is not met as evidenced by: 44532 Based on document review and interview, the facility failed to maintain a list of all contracted services. Findings include: 1. The facility lacked or failed to produce documentation of a list of contracted services. 2. On 11-07-2024 at 1350 hours, staff A1 (Chief of Quality and Compliance) confirmed that they did not have a list of contracted services and no documentation was provided by the end of survey.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 50584 Based on document review and interview facility failed to maintain documentation of providing Patient Rights to consumers seeking treatment in 14 of 30 Medical Records reviewed. (P5, P6, P7, P8, P13, P14, P15, P16, P17, P19, P20, P21, P25 and P28) Findings include: 1. Policy titled Rights of Service Recipients, Policy No.: CCBHC.04.04.00.00, Last R/R Date: 05/2024, indicated under Page 2, A. 6. A written statement delineating client rights shall be provided to all who seek services as well as a verbal explanation of his/her rights. 2. Review of Medical Records on 11/6/24 at 1430 hours and on 11/7/24 at 0800 hours with A2 (Chief of Crisis Services), indicated a lack of documentation of patient rights provided to P5, P6, P7, P8, P13, P14, P15, P16, P17, P19, P20, P21, P25 and P28. 3. In interview on 11/7/24 at approximately 1200 hours with A2, he/she confirmed medical records lacked documentation of providing patient rights to consumers upon admission to facility in 14 of 30 Medical Records reviewed.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 50584 Based on document review and interview facility failed to maintain documentation of notifying consumers of facility advanced directive policy at the time of admission for 14 of 30 Patient Medical Records reviewed. (P5, P6, P7, P8, P13, P14, P15, P16, P17, P19, P20, P21, P25 and P28) Findings include: 1. Facility policy titled Policy Rights of Service Recipients, Policy No.: CCBHC.04.04.00.00, Last R/R date 05/2024, indicated under Page 4, Under Policy Components B. The following guidelines are established for the protection of client rights: The right to make informed decisions regarding care. 2. Review of Medical Records on 11/6/24 at 1430 hours and on 11/7/24 at 0800 hours with A2 (Chief of Crisis Services), indicated a lack of documentation of advanced directive policy to make informed consent provided to P5, P6, P7, P8, P13, P14, P15, P16, P17, P19, P20, P21, P25 and P28. 3. In interview on 11/7/24 at approximately 1200 hours with A2, he/she confirmed medical records lacked documentation of providing patients with advanced directive policy upon admission to facility in 14 of 30 Medical Records reviewed.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 50584 Based on document review and interview facility failed to maintain follow-up reports on 2 of 30 incident reports reviewed. (P6 and P7) Findings Include: 1. Facility policy titled Internal Event & Incident Reporting, Policy No.: EC.12.07.00.00, Last R/R Date: 07/2024, indicated under Policy, A. Facility staff complies with incident reporting requirements set forth by federal, state, and local regulatory agencies and accrediting bodies. 1. Staff reports all incidents and/or events involving employees, consumers and visitors including, but not limited to: a. Potentially injurious events; b. Accidents and injuries; c. Bloodborne exposures; d. Buildings, property and emergency responses; e. Equipment; and f. Medication. C. Staff completes the online facility Incident Report Form within 24 hours of and event or of becoming aware of an event. Follow-up reports are completed online for medication/treatment/procedures. Incident Reports are reviewed and as necessary, follow-up reports may be directed to the supervisor. 2. Review of Incident Report for P6 indicated the following: a. Incident Report on 1/18/2024 at 2030 hours indicated P6 was agitated and called the police. Staff had to turn the phone off because P6 was trying to call 911 and he/she became engraged, screaming and cursing, banging his/her fists on the walls and counters as he/she paced back and forth from his/her room to the dining area. Once P6 was at the medication room window banging his/her fists screaming at the medication nurse. Physician was notified and a decision was made to call Rapid Response when P6 refused to take as needed medications by mouth. b. Incident Report as well as MR lacked documentation of follow-up after Rapid Response was called. 3. Review of Incident Report for P7 indicated the following: a. Incident Report on 2/16/2024 at 1300 hours indicated P7 hit a wall in his/her room causing a dent in the wall, left hand resulting in an Abrasion/Scratch to left hand. b. Incident Report as well as MR lacked documentation of follow-up on P6 injury to left hand. 4. In interview on 1/6/24 at approximately 1200 hours with A2 (Chief of Crisis Services), he/she confirmed lack of follow-up documentation on Incident Reports for P6 and P7.”

“APPROVAL OF MEDICAL STAFF BYLAWS CFR(s): 482.22(c)(1) [The bylaws must:] (1) Be approved by the governing body. This Standard is not met as evidenced by: 44532 Based on document review and interview, the governing body had not approved current medical staff bylaws. Findings Include: 1. Review of the Medical Staff Bylaws indicated a lack of documentation of an approval date that the medical staff operates under current bylaws, rules and policies that have been approved by the governing board nor that any revisions or modifications in the medical staff bylaws, rules and policies had been approved by the medical staff and governing board, annotated with date of last review and initialed by persons responsible. 2. On 11-07-2024 at 1400 hours in interview with staff member A1 (Chief of Quality and Compliance), it was indicated that medical staff bylaws and rules and regulations had not been approved by the governing board.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50584 Based on document review and interview nursing services failed to complete documentation of consumer and/or staff debriefment following use of restraint/seclusion in 2 of 30 patient medical records reviewed. (P6 and P7) Findings include: 1. Facility policy titled Procedure: Use of Physical Restraints, Procedure No: IPU.08.03.01.00, Last R/R Date: 03/2024, indicated on Page 4, 3. RN documentation will include: g. The RN (Registered Nurse) will complete both IPU.08.03.01.06 consumer debriefing form and IPU.08.03.01.07 staff debriefing forms. Page 5, Under G. Debriefing, 1. Within two hours following the restraint episode, the RN will conduct a debriefing with the consumer. The debriefing will include exploration of alternatives that could be employed in response to future episodes of escalating emotions/behavior.Page 6, 2. A debriefing will also take place for the staff involved in the restraint procedure within two hours of the restraint episode. Discussion will include consideration of : a. What were the events leading up to the restraints?; b. What other strategies could have been used to handle the situation?; c. What alternative interventions might have been used?; d. Did the procedure go smoothly?; and e. Were there any injuries/ How could these have been prevented. 2. Review of P6 MR indicated the following: a. P6 was placed in restraints on 1/18/24. b. MR lacked documentation of patient and staff debriefing following use of restraints. 3. Review of P7 MR indicated the following: a. Patient was placed in restraints on 2/16/24. b. MR lacked documentation of patient debriefing following use of restraints. 4.In interview on 11/7/24 at approximately 1200 hours with A2, he/she confirmed medical records lacked documentation of consumer and staff debriefing following use of restraints for P6 and consumer debriefing following use of restraints for P7.”

“EMERGENCY POWER AND LIGHTING CFR(s): 482.41(a)(1) There must be emergency power and lighting in at least the operating, recovery, intensive care, and emergency rooms, and stairwells. In all other areas not serviced by the emergency supply source, battery lamps and flashlights must be available. This Standard is not met as evidenced by: 42622 Based on document review, observation and interview, the facility failed to ensure 1 of 1 battery powered emergency lights at the generator was maintained in accordance with LSC 7.9. LSC 7.9.2.6 states battery operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70 National Electric Code. LSC 7.9.2.7 states the emergency lighting system shall be either be continuously in operation or shall be capable of repeated automatic operation without manual intervention; failed to ensure monthly testing documentation of battery backup lights in the facility were complete and accurate. Section 7.9.3.1.1 (1) requires 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, (3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered and (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction; failed to document the transfer time to the alternate power source on the monthly load tests for 12 of the past 12 months to ensure the alternate power supply was capable of supplying service within 10 seconds; failed to ensure corrective action was taken after an annual fuel quality test was performed for the facility’s diesel powered generator. NFPA 99, Health Care Facilities Code, 2012 Edition Section 6.5.4.1.1.2 states Type 2 EES (Essential Electrical System) generator sets shall be inspected and tested in accordance with Section 6.4.4.1.1.3. Section 6.4.4.1.1.3 states maintenance shall be performed in accordance with NFPA110, Standard for Emergency and Standby Power Systems, 2010 Edition, Chapter 8. NFPA 110, Section 8.3.8 states a fuel quality test shall be performed at least annually using tests approved by ASTM standards; and failed to ensure a written record of weekly inspections for the generator was maintained for 7 of 52 weeks. NFPA 99, 6.4.4.1.3 requires onsite generators shall be maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 8.4.1 requires an Emergency Power Supply System (EPSS) including all appurtenant components, shall be inspected weekly and exercised monthly. NFPA 99, 6.4.4.2 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. Findings Include: Based on observation with the Director of Operations at 3:25 p.m. on 11/06/24, the battery operated emergency light at the diesel generator failed to function when its respective test button was pushed five times. Based on interview at the time of the observation, the Director of Operations stated battery operated lights in the facility are tested monthly and confirmed the aforementioned battery operated emergency light failed to function when its respective test button was pushed. Based on record review on 11/06/24 at 1:10 p.m. with the Director of Operations, the Battery Operated Emergency Light monthly testing was incomplete. The monthly 30 second testing was documented as being complete, but were not identified and itemized by location in the facility. Based on an interview at the time of record review, the Director of Plant Operations indicated the facility has battery operated emergency exit lights throughout the facility that are tested monthly by the Security staff, but the testing documentation is not itemized by location. Based on record review on 11/06/24 at 1:55 p.m. with the Director of Operations, the Monthly Preventative Maintenance for Emergency Generator log sheets were reviewed over the past year and lacked the transfer time from normal power to emergency power. Based on interview at the time of record review, the Director of Operations confirmed the transfer time is not written on the Monthly Preventative Maintenance log sheets monthly when the load test is conducted. Based on record review with the Director of Operations on 11/06/24 at 12:20 p.m., documentation of an annual fuel quality test results for the diesel generator was dated 02/09/24. The result report stated ‘Action Required’ and that ‘iron corrosion is highly elevated. Sulfur level of this fuel is slightly above the ultra-low sulfur diesel range. We suggest to polish the fuel to restore the quality and reduce the existing particles. Resample in 3 months to monitor.’ Based on interview at the time of records review, the Director of Operations stated the facility does have a diesel generator and that additional documentation to show the fuel quality issues were addressed was not available for review at the time of the survey. Based on record review with the Director of Operations on 11/06/24 from 9:30 a.m. to 2:30 p.m., documentation for seven weeks of weekly generator testing was not available for review. Those weeks are 01/14/24, 05/19/24, 05/26/24, 06/23/24, 08/11/24, 09/01/24 and 10/06/24. Based on an interview at the time of record review, the Director of Operations confirmed additional weekly generator testing documentation for the above-mentioned weeks was not available for review at the time of the survey.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 42622 Based on record review, observation, and interview, the facility failed to ensure the automatic sprinkler piping systems was examined for internal obstructions where conditions exist that could cause obstructed piping as required by NFPA 25, 2011 Edition, the Standards for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, Section 14.2.1. Section 14.2.1 states, “except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material; failed to provide quarterly fire drill documentation for 1 of 3 shifts during 1 of 4 quarters; failed to provide complete fire drill documentation for 11 of 12 fire drills performed during the past 12 month period; failed to ensure annual inspection and testing of all fire door assemblies were completed in accordance of LSC 19.1.1.4.1.1. Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.) LSC 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code. NFPA 80 5.2.1 states fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. NFPA 80, 5.2.3.1 states functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. NFPA 80, 5.2.4.1 states fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly. NFPA 80, 5.2.4.2 states as a minimum, the following items shall be verified: (1) No open holes or breaks exist in surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7. (6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. Findings include: Based on record review with the Director of Operations on 11/06/24 at 11:30 a.m., the annual sprinkler system inspection dated 08/21/24 indicated a 5 year internal pipe inspection was conducted 2023. Based on an interview with the Director of Operations at the time of record review, he stated inspection documentation for the most recent 5 year internal obstruction investigation was not available for review at the time of the survey. Based on review of the facility’s fire drill reports on 11/06/24 between 9:30 a.m. and 11:30 a.m. with the Director of Operations present, the facility lacked fire drill documentation for the first shift (day) of the second quarter (April, May, and June) of 2024. Based on interview at the time of record review, the Director of Operations said there was no other documentation available for missing fire drills during the previously mentioned shift and quarter of 2024. Based on review of the facility’s fire drill reports on 11/06/24 between 9:30 a.m. and 11:30 a.m. with the Director of Operations present, all 11 documented fire drills performed during the past 12 month period did not include the transmission of signal of the fire drills. Based on interview at the time of record review, the Director of Operations said there was no other documentation available to show the transmission of the fire alarm signal for each fire drill during the past 12 month period. Based on record review on 11/06/24 between 9:30 a.m. and 2:30 p.m. with the Director of Operations present, no annual inspection of the fire door assemblies were available for review. Based on observations during the tour of the facility between 2:30 p.m. and 3:35 p.m., there were labeled fire door assemblies noted throughout the building that were fire-rated and non-fire rated wall assemblies. Based on interview at the time of records review, the Director of Operations stated annual inspection documentation for the fire door assemblies during the past 12 month period was not available for review, and confirmed the doors in the facility were labeled 90-minute and 45-minute assemblies.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 42622 Based on record review and interview, the facility failed to provide complete emergency preparedness exercise documentation. The Hospital must do the following: (i) Participate in an annual full-scale exercise that is community-based; or a. When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. b. If the Hospital experiences an actual natural or man-made emergency that requires activation of the emergency plan, the Hospital is exempt from engaging its next required full-scale in a community-based or individual, facility-based full-scale functional exercise for 1 year following the onset of the actual event. (ii) Conduct an additional exercise that may include, but is not limited to the following: a. A second full-scale exercise that is community-based or an individual, facility-based functional exercise. b. A mock disaster drill; or c. A tabletop exercise or workshop that is led by a facilitator that includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the Hospital response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the Hospital emergency plan, as needed in accordance with 42 CFR 482.15(d)(2). This deficient practice could affect all occupants. Findings include: Based on record review on 11/06/24 between 9:30 a.m. and 2:30 p.m. with the Director of Operations and Chief of Quality and Compliance present, there was no documentation of Emergency Preparedness Exercises available for review. Based on interview at the time of record review, the Chief of Quality and Compliance stated there were no Emergency Preparedness exercises documentation available for review at the time of the survey. This finding was reviewed with the Director of Operations at the exit conference.”

“Hospital CAH and LTC Emergency Power CFR(s): §482.15(e) Condition for Participation: (e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section. §483.73(e), §485.625(e), §485.542(e) (e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section. §482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1) Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated. 482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2) Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code. 482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2) Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates. *[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):] The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes. (1) National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169, www.nfpa.org, 1.617.770.3000. (i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011. (ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011. (iii) TIA 12-3 to NFPA 99, issued August 9, 2012. (iv) TIA 12-4 to NFPA 99, issued March 7, 2013. (v) TIA 12-5 to NFPA 99, issued August 1, 2013. (vi) TIA 12-6 to NFPA 99, issued March 3, 2014. (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011. (viii) TIA 12-1 to NFPA 101, issued August 11, 2011. (ix) TIA 12-2 to NFPA 101, issued October 30, 2012. (x) TIA 12-3 to NFPA 101, issued October 22, 2013. (xi) TIA 12-4 to NFPA 101, issued October 22, 2013. (xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.. This Standard is not met as evidenced by: 42622 Based on record review and interview, the facility failed to implement the emergency power system inspection, testing, and maintenance requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code in accordance with 42 CFR 482.15(e)(2). This deficient practice could affect all occupants. Findings include: Based on record review on 11/06/24 at 10:19 a.m. of the generator load testing and maintenance documentation for the last twelve months with the Director of Operations, the following was noted: a) the transfer time for the diesel powered generator was not documented. b) weekly inspections were not available for seven of the last 52 weeks. c) fuel quality sample on 02/09/24 showed iron corrosion is highly elevated and sulfur level is slightly above range. Suggest to polish fuel to restore quality and resample in 3 months to monitor. Based on interview at the time of record review, the Director of Operations confirmed the transfer time was not documented on the monthly load testing, and the weekly inspections were not available. Additionally, the Director of Operations could not locate documents to show any action taken on the diesel fuel quality and that it was resampled three months to monitor. These findings were reviewed with the Director of Operations at the exit conference.”

“A Life Safety Code Recertification Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 482.41(b). Survey Date: 11/06/24 Facility Number: 005174 Provider Number: 154009 AIM Number: 100273170A At this Life Safety Code survey, Hamilton Center Inc. was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies. This facility was located on the second floor of a two story building and was determined to be of Type II (222) construction and was fully sprinklered. All consumer sleeping rooms were located on the second floor. The facility has a fire alarm system with hard wired smoke detectors in the corridors and spaces open to the corridors. The facility has a capacity of 16 and had a census of 15 at the time of this survey. The entire second floor of the facility was surveyed because there was no 2- hour separation between the health care unit and the business occupancies also located on the second floor. Quality Review completed on 11/12/24”

“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: 42622 1. Based on observation and interview, the facility failed to ensure 1 of 1 battery powered emergency lights at the generator was maintained in accordance with LSC 7.9. LSC 7.9.2.6 states battery operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70 National Electric Code. LSC 7.9.2.7 states the emergency lighting system shall be either be continuously in operation or shall be capable of repeated automatic operation without manual intervention. This deficient practice could affect all residents, staff and visitors in the facility. Findings include: Based on observation with the Director of Operations at 3:25 p.m. on 11/06/24, the battery operated emergency light at the diesel generator failed to function when its respective test button was pushed five times. Based on interview at the time of the observation, the Director of Operations stated battery operated lights in the facility are tested monthly and confirmed the aforementioned battery operated emergency light failed to function when its respective test button was pushed. 2. Based on observation and interview, the facility failed to ensure monthly testing documentation of battery backup lights in the facility were complete and accurate. Section 7.9.3.1.1 (1) requires 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, (3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered and (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all residents in the facility. Findings include: Based on record review on 11/06/24 at 1:10 p.m. with the Director of Operatons, the Battery Operated Emergency Light monthly testing was incomplete. The monthly 30 second testing was documented as being complete, but were not identified and itemized by location in the facility. Based on an interview at the time of record review, the Director of Plant Operations indicated the facility has battery operated emergency exit lights throughout the facility that are tested monthly by the Security staff, but the testing documentation is not itemized by location. These findings were reviewed with the Director of Operations 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: 42622 Based on record review and interview, the facility failed to ensure the automatic sprinkler piping systems was examined for internal obstructions where conditions exist that could cause obstructed piping as required by NFPA 25, 2011 Edition, the Standards for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, Section 14.2.1. Section 14.2.1 states, “except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. This deficient practice affects all residents, staff and visitors. Findings include: Based on record review with the Director of Operations on 11/06/24 at 11:30 a.m., the annual sprinkler system inspection dated 08/21/24 indicated a 5 year internal pipe inspection was conducted 2023. Based on an interview with the Director of Operations at the time of record review, he stated inspection documentation for the most recent 5 year internal obstruction investigation was not available for review at the time of the survey. This finding was reviewed with the Director of Operations at the exit conference.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 42622 Based on record review, observation and interview, the facility failed to inspect 1 of 30 portable fire extinguishers in the facility each month. NFPA 10, Standard for Portable Fire Extinguishers, Section 7.2.1.2 states fire extinguishers shall be inspected either manually or by means of an electronic device / system at a minimum of 30-day intervals. Section 7.2.2 states periodic inspection or electronic monitoring of fire extinguishers shall include a check of at least the following items: (1) Location in designated place (2) No obstruction to access or visibility (3) Pressure gauge reading or indicator in the operable range or position (4) Fullness determined by weighing or hefting for self expelling-type extinguishers, cartridge-operated extinguishers, and pump tanks (5) Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers (6) Indicator for nonrechargeable extinguishers using push-to-test pressure indicators. Section 7.2.4.1 states personnel making manual inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action. Section 7.2.4.3 requires where at least monthly manual inspections are conducted, the date the manual inspection was performed and the initials of the person performing the inspection shall be recorded. Section 7.2.4.4 requires where manual inspections are conducted, records for manual inspections shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or by an electronic method. Section 7.2.4.5 requires records shall be kept to demonstrate that at least the last 12 monthly inspections have been performed. This deficient practice could affect up to 16 residents, as well as staff. Findings include: Based on record review on 11/06/24 with the Director of Operations, the annual fire extinguisher inspections occurred 09/27/24. Based on observations with the Director of Operations 11/06/24 during a tour of the facility at 2:50 p.m., the monthly inspection tag on 1 of 2 fire extinguishers located in the second floor Mechanical room lacked documentation of monthly inspections for October 2024. This was confirmed by the Director of Operations at the time of observation. This finding was reviewed with the Director of Operations at the exit conference.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 42622 1. Based on record review and interview, the facility failed to provide quarterly fire drill documentation for 1 of 3 shifts during 1 of 4 quarters. This deficient practice could affect all consumers in the facility. Findings include: Based on review of the facility’s fire drill reports on 11/06/24 between 9:30 a.m. and 11:30 a.m. with the Director of Operations present, the facility lacked fire drill documentation for the first shift (day) of the second quarter (April, May, and June) of 2024. Based on interview at the time of record review, the Director of Operations said there was no other documentation available for missing fire drills during the previously mentioned shift and quarter of 2024. 2. Based on record review and interview, the facility failed to provide complete fire drill documentation for 11 of 12 fire drills performed during the past 12 month period. This deficient practice could affect all consumers in the facility. Findings include: Based on review of the facility’s fire drill reports on 11/06/24 between 9:30 a.m. and 11:30 a.m. with the Director of Operations present, all 11 documented fire drills performed during the past 12 month period did not include the transmission of signal of the fire drills. Based on interview at the time of record review, the Director of Operations said there was no other documentation available to show the transmission of the fire alarm signal for each fire drill during the past 12 month period. These findings were reviewed with the Director of Operations during the exit conference.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 42622 Based on observation, records review, and interview; the facility failed to ensure annual inspection and testing of all fire door assemblies were completed in accordance of LSC 19.1.1.4.1.1. Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.) LSC 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code. NFPA 80 5.2.1 states fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. NFPA 80, 5.2.3.1 states functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. NFPA 80, 5.2.4.1 states fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly. NFPA 80, 5.2.4.2 states as a minimum, the following items shall be verified: (1) No open holes or breaks exist in surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7. (6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. This deficient practice could affect all consumers and all other occupants in the facility. Findings include: Based on record review on 11/06/24 between 9:30 a.m. and 2:30 p.m. with the Director of Operations present, no annual inspection of the fire door assemblies were available for review. Based on observations during the tour of the facility between 2:30 p.m. and 3:35 p.m., there were labeled fire door assemblies noted throughout the building that were fire-rated and non-fire rated wall assemblies. Based on interview at the time of records review, the Director of Operations stated annual inspection documentation for the fire door assemblies during the past 12 month period was not available for review, and confirmed the doors in the facility were labeled 90-minute and 45-minute assemblies. This finding was reviewed with the Director of Operations during the exit conference.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 42622 1. Based on record review and interview, the facility failed to document the transfer time to the alternate power source on the monthly load tests for 12 of the past 12 months to ensure the alternate power supply was capable of supplying service within 10 seconds. This deficient practice could affect all consumers, staff and visitors. Findings include: Based on record review on 11/06/24 at 1:55 p.m. with the Director of Operations, the Monthly Preventative Maintenance for Emergency Generator log sheets were reviewed over the past year and lacked the transfer time from normal power to emergency power. Based on interview at the time of record review, the Director of Operations confirmed the transfer time is not written on the Monthly Preventative Maintenance log sheets monthly when the load test is conducted. 2. Based on record review and interview, the facility failed to ensure corrective action was taken after an annual fuel quality test was performed for the facility’s diesel powered generator. NFPA 99, Health Care Facilities Code, 2012 Edition Section 6.5.4.1.1.2 states Type 2 EES (Essential Electrical System) generator sets shall be inspected and tested in accordance with Section 6.4.4.1.1.3. Section 6.4.4.1.1.3 states maintenance shall be performed in accordance with NFPA110, Standard for Emergency and Standby Power Systems, 2010 Edition, Chapter 8. NFPA 110, Section 8.3.8 states a fuel quality test shall be performed at least annually using tests approved by ASTM standards. This deficient practice could affect all consumers and staff. Findings include: Based on record review with the Director of Operations on 11/06/24 at 12:20 p.m., documentation of an annual fuel quality test results for the diesel generator was dated 02/09/24. The result report stated ‘Action Required’ and that ‘iron corrosion is highly elevated. Sulfur level of this fuel is slightly above the ultra low sulfur diesel range. We suggest to polish the fuel to restore the quality and reduce the existing particles. Resample in 3 months to monitor.’ Based on interview at the time of records review, the Director of Operations stated the facility does have a diesel generator and that additional documentation to show the fuel quality issues were addressed was not available for review at the time of the survey. 3. Based on record review and interview, the facility failed to ensure a written record of weekly inspections for the generator was maintained for 7 of 52 weeks. NFPA 99, 6.4.4.1.3 requires onsite generators shall be maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 8.4.1 requires an Emergency Power Supply System (EPSS) including all appurtenant components, shall be inspected weekly and exercised monthly. NFPA 99, 6.4.4.2 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all consumers and staff. Findings include: Based on record review with the Director of Operations on 11/06/24 from 9:30 a.m. to 2:30 p.m., documentation for seven weeks of weekly generator testing was not available for review. Those weeks are 01/14/24, 05/19/24, 05/26/24, 06/23/24, 08/11/24, 09/01/24 and 10/06/24. Based on an interview at the time of record review, the Director of Operations confirmed additional weekly generator testing documentation for the above mentioned weeks was not available for review at the time of the survey. These findings were reviewed with the Director of Plant Operations 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: 42622 Based on observation and interview, the facility failed to ensure 2 of 2 power strips were not used as a substitute for fixed wiring to provide power equipment with a high current draw. NFPA-70/2011, 400.8 state unless specifically permitted in 400.7 flexible cords and cables shall not be used for (1) as a substitute for fixed wiring. This deficient practice could affect up to 2 staff. Findings include: Based on observations and interview during a tour of the facility with the Director of Plant Operations on 11/06/24 between 2:30 p.m. and 3:35 p.m., the following was noted: a) at 2:53 p.m. in the second floor exam room, a power strip was being used to power a refrigerator (high power draw equipment). The Director of Operations plugged the refrigerator into the wall upon observation. b) at 3:09 p.m. in the Recreational Therapist office on the second floor, a power strip was being used to power a refrigerator (high power draw equipment). These finding were confirmed by the Director of Operations at the time of discovery and again at the exit conference with the Director of Operations present.”