Whittier Pavilion

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 27189 Based on document review, meeting minutes review, the Governing Board (GB) Bylaws review, and interview, the Hospitals Governing Body, which assumes full legal authority and responsibility for operations of the hospital, failed to ensure that an effective Quality Assessment and Performance Improvement Program (QAPI) was implemented and maintained. Findings include: The Hospital’s Governing Body, which assumes full legal authority and responsibility for operations of the hospital, failed to ensure that an effective Quality Assessment and Performance Improvement Program (QAPI) was implemented and maintained. Please refer to A-309.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 27189 Based on observation, document review, policy review and interview, the Hospital failed for 3 of 3 Units to protect and promote each patient’s rights by providing care in a safe setting. Findings include: 1. The Hospital failed for 3 of 3 Units (North, South and West) to provide care in a safe setting without ligature and self-harm risks when 1). 2 of 3 ice machines (West and South Units), located in the activity/kitchen area of the Units had electrical cords that were not secured and accessible by unattended psychiatric patients (ligature risk); 2). A metal radiator/base board heating cover (North Unit, sensory room) was observed to be bent and misshaped and with unsecured exposed sharp edges and accessible to unattended psychiatric patients (ability to harm self or others); and 3). 3 of 3 Nurses stations contained hazardous items that were close to the nursing station door (half door) such as BP cuffs, office supplies, pens and several boxes of latex gloves and could be reached by a patient and/or accessible to a patient if no staff were present. Refer to A-0144.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 27189 Based on policy review, document review, meeting minutes review, and interview, the hospital failed to ensure there was an effective, ongoing, hospital-wide quality assessment and performance improvement (QAPI) effort that was data-driven, that measured, analyzed, and tracked quality indicators and assessed processes of care, hospital service and operations and that all improvement actions were evaluated. Findings include: 1. The Hospital failed to ensure opportunities were identified for improvement and changes that were measured, analyzed, and that tracked quality indicators and assessed processes of care, hospital service, and operations. Please refer to A-0283. 2. The Hospital’s Governing Body, which assumes full legal authority and responsibility for operations of the hospital, failed to ensure that an effective Quality Assessment and Performance Improvement Program (QAPI) was implemented and maintained. Please refer to A-309.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 27189 Based on observation, document review, policy review, and interview, the Hospital failed for 3 of 3 Units (North, South, and West) to provide care in a safe setting without ligature and self-harm risks when 1). 2 of 3 ice machines (West and South Units), located in the activity/kitchen area of the Units had electrical cords that were not secured and accessible by unattended psychiatric patients (ligature risk); 2). A metal radiator/base board heating cover (North Unit, sensory room) was observed to be bent and misshaped and with unsecured exposed sharp edges and accessible to unattended psychiatric patients (ability to harm self or others); and 3). Nursing staff was not present at all times for 1 of 3 Nurse’s stations which contained hazardous items that were close to the nursing station door (half door) such as BP cuffs, office supplies, pens and several boxes of latex gloves and could be reached by a patient, thereby failing to protect and promote each patient’s rights by providing care in a safe setting. Findings include: Review of the Hospital’s Sharps and Potentially Dangerous Items Policy, effective 2/15/19, indicated the following: *To provide a safe environment for all patients, staff and visitors and to minimize access to items which have the potential for harm to self and others. 1). The Facility failed to ensure that 2 of 3 ice machines (West and South Units), located in the activity/kitchen area of the Units had electrical cords that were secured and not accessible by unattended psychiatric patients (ligature risk). On 4/10/25 at 9:30 A.M., the surveyors observed the West Unit activity/dining area which was observed to have an ice machine located on a counter top in the area. The surveyor observed the power cord of the ice machine to ensure it was secured and did not pose a ligature risk, The power cord had not been secured and the surveyor was able to extend the power cord to a length of approximately 10 to 12 feet long. The unsecured power cord posed a ligature risk as it had not been secured and is accessible by unattended psychiatric patients. On 4/10/25 at 9:45 A.M., the surveyors observed the South Unit activity/dining area which was observed to have an ice machine located on a counter top in the area. The surveyor observed the power cord of the ice machine to ensure it was secured and did not pose a ligature risk. The power cord had not been secured and the surveyor was able to extend the power cord to a length of approximately 10 to 12 feet long. The unsecured power cord posed a ligature risk as it had not been secured and is accessible by unattended psychiatric patients. During an interview on 4/10/25 at 11:45 A.M., the Director of Plant Operations said the ice machines had been installed by an outside contractor (not an employee of the Facility). He further said he believed the cords had been secured and was not aware that patients had the ability by to extend the cord to a length that posed a ligature risk. 2). The Facility failed to ensure a metal radiator/base board heating cover (North Unit, sensory room) that was observed to be bent and misshaped did not have unsecured exposed sharp edges and not accessible to unattended psychiatric patients (ability to harm self or others). On 4/7/25 at 11:30 A.M., during an environmental tour of the North Unit, the sensory room was observed to have a radiator cover, located on the baseboard of the wall. The radiator cover had an exposed, bent, sharp edge posing a risk for self-harm. During an environmental tour with the Director of Plant Operations on 4/7/25 at 11:30 A.M., he visualized the exposed bent sharp edge on the radiator cover and acknowledged the safety hazard posing a risk for self-harm and the need to be secured. During the environmental tour of the North unit on 4/7/25 at 11:45 A.M., the North Unit Charge Nurse was notified and observed the exposed bent sharp edge on the radiator cover. She said that she never noticed it before and acknowledged the safety hazard posing a risk for self-harm. During an interview on 4/8/25 at 4:45 P.M., the CEO and the DON were notified of the metal radiator/base board heating cover (North Unit, sensory room) that was observed to be bent and misshaped with unsecured exposed sharp edges. Neither the CEO or the DON had been notified of the concern. The DON and the surveyor proceeded to the sensory room on the North Unit and she agreed that it was a hazard posing a risk for self-harm and it needed to be secured more effectively. The DON further stated that she would notify the the current employee in plant operations on duty and if the risk could not be taken care of immediately she would have the room locked and the patients would not be able to access the room until there was no longer a risk for self injury by a patient. During an interview on 4/8/25 at 5:15 P.M., the DON said that the current plant operations employee could not address the risk correctly tonight, but she would have it taken care of in the morning. She said the room had been locked and no patient would have access. 3). The Hospital failed to ensure that nursing staff were present at all times on 1 of 3 Nurses stations (West Unit) which contained hazardous items that were close to the nursing station door (half door) such as BP cuffs, office supplies, pens and several boxes of latex gloves that could be reached by a patient and/or accessible to a patient. During an observation on 4/8/25 at 11:20 A.M., the West Unit nurse’s station was observed by the surveyor to be unattended by staff, for approximately 2 minutes. The nurse’s station was observed to have items, including but not limited to, computer and phone cords, a free-standing vital sign machine with a corded blood pressure cuff (BP), scissors, medical plastic gloves, pens and pencils. These items could be considered hazardous, if left unattended. During an interview on 4/10/25 at 9:30 A.M., the West Unit Charge Nurse said that although there is no policy, there should always be a staff member in the nurse’s station. During an interview on 4/10/2025 at 11:06 A.M., the DON said that there is no formal policy or procedure regarding that one staff member is to be present at the nurses station at all times. She further stated that she was aware of this practice by the Facility because she had been told of this practice when she was hired in 2016. The DON said that this practice is communicated to staff by word of mouth on orientation, but there is no formal policy addressing the practice. She said that staff are aware, she however could not provide a formal policy or any documentation that all staff were aware of this practice. 44223 38141 45980 10249”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 27189 Based on record review, policy review and interview, the Hospital failed to ensure opportunities were identified through their Quality Assessment and Performance Improvement program (QAPI) identified as the Process Improvement Program, for improvement and changes that were measured, analyzed, and that tracked quality indicators and assessed processes of care, hospital service, and operations. Findings include: Review of the facility policy titled, Process Improvement Program, last reviewed January 2023, indicated but was not limited to the following: Purpose: *The Process Improvement Program is designed to provide a coordinated objective and systematic approach to facility-wide quality assurance activities. The program is based upon and integrated and collaborative approach of measurement-based care to increase the probability of desired patient outcomes by assessing and improvement those governance, managerial, clinical and support processes that most affect patient outcomes. Scope: *The Program provides a system for the measurement and assessment of processes or outcomes related to patient care and organizational functions Data is collected and analyzed for improvement opportunities. Process improvement activities include utilization management, management of information, infection control, medication use, safety, risk management and quality control activities Quality assessment findings are communicated to the Medical staff and the Governing Board at least quarterly. Organization: *The Board has the ultimate responsibility and authority to establish, maintain and support an effective process improvement program. The Governing Board assures the necessary structures are established and processes are implemented to assess and continually improve the overall quality and efficiency of patient care. It receives and acts upon recommendations regarding quality assessment and improvement activities. *Management staff provide leadership for and actively participate in process improvement activities and establish criteria for assessing and improving Facility performance of both clinical and non-clinical processes and patient outcomes. They assure implementation of appropriate quality assessment and improvement activities and report the results to the Governing Board. *The Quality Council is the steering committee for the Program (QAPI) and will design, maintain, support and document evidence of an ongoing program to systematically measure, assess, and improve patient outcomes and Facility performance. *The Director of each department, service, and program is responsible for leading process improvement activities with in the individual department, service or program. Review of the Quality Council (QAPI) meeting minutes indicated that a meeting was held on 7/23/2024, with no further QAPI/Quality Council meetings held by the Facility after 7/23/2024. Review of the Department Directors meeting minutes, held on 10/24/2024, indicated the previous employee who was responsible for the Facility’s PI/QAPI had resigned his position in August 2024. The meeting minutes/discussion indicated the previous employee resigned in August 2024, and that the Facility was looking to restructure the position and ensure continuity. The meeting is structured so that each Department Director had an opportunity to bring forward concerns/issues/updates which are then open for discussion by the members. The meeting minutes indicated that Performance Improvement/HRO discussion did not take place due to the vacancy. There had been no action/follow-up documentation or discussion as to any/a remedial plan moving forward until the position had been filled. During an interview on 4/8/2025 at 9 A.M., the Director of Quality and PI said that she was recently hired in March 2025. She confirmed that there had been no Quality Council meeting since the last one on 7/23/2024. She said that she in the process of resuming the Quality Council/QAPI process and has scheduled her first meeting 4/28/2025. She further said that an email will be sent requesting data from each department director as they are responsible for leading process improvement activities with in their individual department. Review of the Governing Board (GB) meetings minutes, dated 12/3/2024 and 3/5/2025, indicated the GB did not address the PI position vacancy or indicate any/a remedial plan be put into effect until the position was filled, to ensure PI/QAPI would continue to function. During an interview on 4/8/25 at 11:50 A.M., the surveyor met with the following GB members, CEO, Chief Financial Officer (CFO), Chief Medical Officer (CMO), Director of Nursing (DON), and the Manager of Administrative Services who said that the PI position remained vacant for 8 months, resulting in no Quality Council/QAPI meeting since 7/23/2024 (9 months) and with no remedial plan put into effect by the GB.”

“QAPI EXECUTIVE RESPONSIBILITIES CFR(s): 482.21(e)(1), (e)(2), (e)(5) 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: 1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained . (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: 27189 Based on document review, meeting minutes review, the Governing Board (GB) Bylaws review, and interview, the Hospital’s Governing Body, which assumes full legal authority and responsibility for operations of the hospital, failed to ensure that an effective Quality Assessment and Performance Improvement Program (QAPI) was implemented and maintained. Findings include: Review of the amended and restated Governing Board Bylaws, reviewed and signed into effect on March 5, 2025, indicated but was not limited to the following: *The Governing Board (GB) is ultimately accountable for the safety and quality of care, treatment and services provided by the Facility. The primary function of the Governing Board is to assure the Facility and its Medical Staff provide quality medical care that meets the needs of the community. For this purpose, the Managing Member has delegated to the Governing Board the authority to receive and evaluate periodic reports from the Medical staff and its officers, to decisions regarding Medical Staff appointment and Clinical Privileges, to oversee Quality assessment and improvement,(QAPI) utilization review, risk management and similar matters regarding the provision of quality patient care at the facility and to establish policies regarding these matter. *The Chief Executive Officer (CEO) is responsible for the overall management of the Facility. The CEO’s duties include but are not limited to the following: *Supporting the Facility’s QAPI and ensuring as necessary that new, modified and appropriate care, treatment and services processes are in place. Review of the Quality Council (QAPI) meeting minutes indicated that a meeting was held on 7/23/2025. There had been no other QAPI meeting minutes to review, as no further QAPI/Quality Council meetings had been held by the Facility after 7/23/2025. Review of the Governing Board (GB) meetings minutes on 12/3/2024 and 3/5/2025 indicated the GB did not address the PI position vacancy or indicate any/a remedial plan be put into effect until the position was filled, to ensure PI/QAPI would continue to function. During an interview on 4/8/25 at 11:50 A.M., the surveyor met with the following GB members, CEO, Chief Financial Officer (CFO), Chief Medical Officer (CMO), Director of Nursing (DON), and the Manager of Administrative Services who said that the PI position remained vacant for 8 months, resulting in no Quality Council/QAPI meeting since 7/23/2024 (9 months) and with no remedial plan put into effect by the GB. This resulted in the failure of the GB to implement and maintain the QAPI process/program as as required.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 10249 Based on clinical record review and interview, the Hospital failed to consistently provide entries into the medical record that were legible for 2 of 30 medical records reviewed (#2 and #27). Findings include: 1. The surveyor reviewed the clinical record of Patient #2 on 4/7/25. The surveyor was unable to decipher the hand writing on the Psychiatry progress notes dated 3/22/25, 3/29/25, and 3/30/25. Specifically, clinical status since last visit, Diagnosis/Assessment/Impression, medication adjustments (if any), and signature. The Provider was later identified by the Director of Medical Records as Physician #1. 2. The surveyor reviewed the closed clinical record of Patient #27 on 4/8/25. The surveyor was unable to decipher the hand writing on the Psychiatry progress note dated 1/27/25. Specifically, clinical status since last visit, diagnosis/Assessment/Impression, medication adjustments (if any), and signature. The Provider was later identified by the Director of Medical Records as Physician #2. During an interview on 4/9/25 at 2:30 P.M., the Director of Medical Records said this has been a long standing problem, and then she identified the signatures to the surveyor. During an interview on 4/10/25 at 10:00 A.M., The Medical Director said he was aware of the illegible hand writing by some staff.”

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 39257 Based on observations and interview, the hospital failed to appropriately secure controlled substances in a medication room, within a nursing unit, in accordance with applicable standards of practice and/or state law. Findings include: The Mass.gov’s guideline “General accountability guidelines for controlled substances in hospitals and clinics with pharmacies” under the section nursing units, states “All refrigerated controlled substances must be double locked and maintained in a dedicated medication refrigerator accessible only by licensed staff.” The surveyor conducted a tour of the South Unit on 4/7/25 at 1:15 P.M., and again on 04/08/25 at 11:00 A.M. The surveyor observed the refrigerated lorazepam (a schedule IV controlled substance medication) was located inside a lockbox that was attached to a refrigerator shelf in the refrigerator. However, the refrigerator shelf, along with the attached lockbox, was able to be fully removed from the refrigerator. During an interview on 4/8/2025 at 4:45 P.M., the DON said she had not been made aware of the ativan(lorazepam) not being double locked. She said that all controlled substances need to be doubled locked.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 27189 Based on observation, documentation review, and interview, the hospital failed to ensure that the condition of the physical plant was maintained in a manner to ensure the safety and well being of patients on 3 of 3 Units. Findings include: South Unit On 4/7/25 at 11:30 A.M., during an environmental tour of the South Unit, the dining room floor was observed to have large areas throughout the room where the top layer of laminate had been peeled off, leaving areas on the floor that were rough and uneven, causing concern for potential risk of safety for patients. Further observation of the dining room walls identified areas throughout the room where paint was chipped off and peeling. During an observation of room 109, the surveyor identified a strip of flooring missing the top layer of laminate, exposing a rough area, causing concern for potential risk of safety for patients. During an interview on 4/9/25 at 9:30 A.M., Registered Nurse #3 said the floor in the dining room had been replaced a few years back and said it had not worn well. She said the peeling areas of the floor really do need to be replaced because it could be a potential risk for patients. On 4/10/2025 at 9:20 A.M. the following observation of the kitchen area/activities on the South Unit included the following: The counter top/cabinet area had numerous areas where the laminate was no longer present. The counter top/cabinet area had a drawer facing that was no longer in place, however the tracks remained in place. The facing of the cabinets (not functional/not used) had screws/nails in place so that the cabinets/drawer could not be used that had begun to come loose. During an interview on 4/10/25 at 10:00 A.M., the Director of Plant Operation said that the area needed to be fixed. During an observation on 4/10/25 at 10:00 A.M., the sensory room on the South Unit was noted to have a 2 x 2 square foot area where the floor had been replaced. The uneven edges of the area caused a potential safety risk for patients. West Unit On 4/10/25 at 9:20 A.M., during an environmental tour of the West unit hallways, the surveyor observed multiple room identifier plaques that were missing letters, making it difficult to identify what the room is used for. Further observation of the West unit identified peeling paint on the medication room door, peeling paint on the doorframe of room 309, and peeling paint on the door where patient belongings were stored. The kitchen area/activities room walls identified areas throughout the room where paint was chipped off and peeling. There was peeling paint on the windowsills. On 4/10/2025 at 9:20 A.M. the following observation of the kitchen area/activities on the West Unit included the following: The counter top/cabinet area had numerous areas where the laminate was no longer present revealing the wood. The facing of the cabinets (not functional/not used) had screws/nails in place so that the cabinets/drawer could not be used that had begun to come loose. During an interview on 4/10/25 at 10:00 A.M., the Director of Plant Operation said that the area needed to be fixed. North Unit On 4/8/2025 at 2:00 P.M. the following observation of the kitchen area/activities on the North Unit included the following: The counter top/cabinet area had numerous areas where the white laminate was no longer present revealing the particle board. The facing of the cabinets (not functional/not used) had screws in place that had begun to come loose. The side of the counter top/cabinet area (that had the refrigerator located next to the area) was noted to be bulging, cracked, with multiple areas of particle board exposed and had a black discoloration to the particle board that was closest to the floor. The cabinets were in disrepair with areas of particle board lifting from the cabinet frame. The back splash was no longer attached to the wall, creating a large gap between the wall and the back splash. The window sill next to the refrigerator no longer had any paint, and the plaster was exposed. The walls throughout the room had areas of chipped paint and white spots where holes had been repaired and not repainted. During an interview on 4/10/25 at 10:00 A.M., the Director of Plant Operation said that the area needed to be fixed.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 31240 Based on record review, observation, interview, and policy review, the hospital failed to ensure its staff employed effective methods for preventing and controlling the transmission of infections within the hospital. Specifically, the hospital failed to 1.) ensure 9 (Activity Therapist #1, Behavioral Health Associates [BHA] #3 and #4, Licensed Practical Nurse [LPN] #14, Registered Nurses [RN] #19 and #20, Social Worker [SW] #21, and Nurse Supervisors #22 and #23) of 10 direct patient care staff, from a total of 23 employee files reviewed, completed the required N95 (a respiratory protective device worn to filter airborne particles) Fit Testing (a test conducted to assess the fit of the respirator and the wearer’s face); and 2.) ensure dietary staff wore appropriate facial hair restraints in a food service area. Findings include: 1. Review of the facility’s policy, entitled Employee Health Services, revised August 2024, indicated the following: * Employees in a job role that requires use of a N95 or higher respirator will be Fit Tested when hired, and when there are facial changes that impact the fit of the respirator. Review of 9 employee records indicated the required N95 Fit Testing had not been completed upon hire: * Activity Therapist #1 with a date of hire (DOH) of 9/3/19. * BHA #3 with a DOH of 2/3/25. * BHA #4 with a DOH of 1/30/24. * LPN #14 with DOH 5/31/2022. * RN #19 with a DOH 5/21/2018. * RN #20 with a DOH of 6/28/21. * SW #21 with a DOH of 7/10/23. * Nursing Supervisor #22 with a DOH of 8/23/22. * Nursing Supervisor #23 with a DOH of 1/4/21. During an interview on 4/10/24 at 11:25 A.M., the Director of Human Resources said that Fit Testing had not been completed for employees, as required by the facility’s policy. During an interview on 4/10/25 at 11:30 A.M., the Nurse Educator/Infection Control Nurse said she is responsible for the fit testing and completed training for Fit Testing in December 2024. She said the expectation of the facility is that all direct care staff be fit tested. 10249 2. The facility failed to ensure that 3 dietary staff wore appropriate beard covering in the kitchen during food preparation, meal service, and clean up. Review of the 2022 FDA Food Code, indicated the following: *2-402 Hair Restraints. *2-402.11 Effectiveness. *(A) Except as provided in ¶ (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. During the initial tour of the kitchen on 4/7/25, with follow up visits including observation of food preparation, meal service, and meal delivery, the following was observed: *Cook #1 was observed preparing the noon meal and although wearing a hairnet on his head, he was observed to have a full beard that was not covered with an appropriate hair restraint. Cook #1 was also observed without a beard restraint during the meal service, afternoon food prep, and clean up. *Dietary staff (aide) #1 was observed to have a full beard that was not covered. At the time of the observation, Diet Aide #1 was delivering food carts, from the kitchen to the units, during the noon meal observation. *Dietary staff (aide) #2 entered the kitchen during the noon meal observation to begin afternoon meal preparation. Diet Aide #2 was observed to have a beard that was not covered. During an interview on 4/7/25 at 3:30 P.M., the Director of Food Service (DFS) said that since his arrival to the facility in November 2024, staff have never used beard restraints in the kitchen. During a follow up interview on 4/8/25 at 8:30 A.M., The DFS said there is general information in the facility handbook for employees about appearance, but there was no policy to address dietary staff dress code, including hair and beard restraints. 44223”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 38141 Based on observations, interviews and hospital policies, the Hospital failed to maintain a clean patient care environment that avoided sources and transmission of infection. Findings include: Review of the Hospital 2025 Infection Prevention and Control Program Plan, indicated the following: *The purpose of the Infection Prevention and Control Program is to reduce transmission of pathogenic organisms for the safety of patients, staff, and visitors. *Surveillance: Infection prevention and control surveillance methodology is centered on the current risk assessment, the outcomes of the annual evaluation, and data collected from infection control environmental surveillance rounds, handwashing observations, outbreak investigations, and employee health data. *Surveillance monitoring will focus on: *Hand hygiene. *Healthcare associated infections. *Environmental cleaning and management of infectious waste. *Equipment cleaning and supply management. *Employee knowledge and infection prevention competency. *Patient screening and implementation of transmission-based precaution. *Employee TB screening and illness reporting. Review of the Hospital Infection Control Surveillance Rounds, dated 3/13/25, indicated that multiple vents had dust accumulation and that a work order was placed. On 4/10/25 at 10:45 A.M., the surveyor toured the inpatient floor with the Infection Control Nurse and observed the following: *West Unit Group room: -Three of 3 ceiling vents observed had a large buildup of dust, and spider webs, the metal heating element covers were rusty and dirty and in need of cleaning. *North Unit Group room: -Two of 3 ceiling vents observed with large buildup of dust. On 4/10/25 at 10:00 A.M., during an environmental tour of the South Unit, the surveyor observed the unit dining room. There was dust and debris on the window treatments and the metal heating element covers were rusty and dirty and in need of cleaning. During an interview on 4/10/25 at 10:55 A.M., the Infection Control Nurse said that air vents are part of her infection control surveillance. She said she does monthly environmental rounds with the Director of Plant Operation and Environmental Supervisor to check air vents. She said that during last months environmental rounds, multiple air vents were identified to have dust accumulation, but was not sure why they still have dust buildup. During an interview on 4/10/25 at 11:45 A.M., the Director of Plant Operation said they clean the air vents when they replace the air filters monthly. He said the air vents that were identified by the surveyor were dusty along with the window treatments. He also said that the heating element covers were dirty and rusty and needed to be either cleaned or replaced.”

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 51570 This Standard is not met as evidenced by: Based on a review of emergency preparedness documentation and staff interview, the facility failed to meet the requirements of CFR Section 42 CFR 482.15 (a)(1) & (2). Section 42 CFR 482.15 (a)(1) & (2) requires the facility develop and maintain an emergency preparedness plan that must be reviewed and updated at least bi-annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. Findings Include: A review of the facility’s Emergency Preparedness (EP) conducted on 04/08/25 indicates the facility did not produce a facility-based and community-based risk assessment at the time of survey. As a result of failing to provide an aligned EP program that utilized a facility-based and community-based risk assessment, the facility failed to ensure compliance with the requirements of CFR Section 42 CFR 482.15 (a)(1) & (2). This deficient practice could affect all patients, visitors and staff in the event of an actual emergency where the EP must be utilized. The finding was reviewed with and acknowledged by the facility’s Chief Executive Officer and Director of Plant Operations during the exit conference.”

“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: 51570 This Standard is not met as evidenced by: Based on a review of emergency preparedness documentation and staff interview, the facility failed to meet the requirements of 42 CFR Section 42 CFR 482.15 (d) (1) & (2). 42 CFR 482.15 (d) requires the facility to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The Hospital must do the following: 1) 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 a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. 2) 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. Findings Include: A review of the facility’s Emergency Preparedness (EP) conducted on 04/08/25 indicates the facility did not produce documentation of the requirements of (1) or (2). Therefore, the facility is not in compliance with the requirements of 42 CFR 482.15 (d) (1) & (2). This deficient practice could affect all patients, visitors and staff in the event of an actual emergency where the EP must be utilized. The finding was reviewed with and acknowledged by the facility’s Chief Executive Officer and Director of Plant Operations during the exit conference.”

“LIFE SAFETY CODE 42 CFR 482.41 The facility must meet the applicable provisions of the “National Fire Protection Association’s” (NFPA) 2012 edition of the “LIFE SAFETY CODE” (LSC) #101 for an existing building. The facility is determined to be a single-story building with a crawl space below the floor assembly, and a partial basement under the South Unit , Type III (200) construction. (c. 1963), equipped with a complete automatic wet-type sprinkler system. A second building, a single-story, with a full basement (c. 1971) of non-combustible, Type II (111) construction equipped with a complete automatic wet-type sprinkler system, per Massachusetts State Regulations. The facility has one elevator. There is no existing two-hour horizontal exit therefore the facility is surveyed as a Type lll (200) single-story construction classification. The exterior walls are of masonry brick, the remainder of the structural framing is of wood construction. with a flat roof, construction, It was built circa (c. 1963) with an addition (c. 1971) and is classified as “existing” and surveyed under Chapter 19 of the 2012 NFPA Life Safety Code. Emergency backup power to the building is supplied by a 130 kW generator operating on diesel fuel located inside of the facility. The facility’s generator provides emergency power to the building, including the following: electrical outlets identified as red in color, the fire alarm control panel, exterior door releases, emergency facility lighting, and life safety components utilized for preservation of life. The facility is less than three miles from a local paid fire department. There facility has three Units: West Unit 26 Beds, North Unit 24 Beds, and the South Unit 21 Beds. The total square footage 44,619 s.f. not including the partial basement in the 1963 building. The facility has a licensed capacity of 71 beds, with a census during survey of 61 residents. Form CMS-2786 R was completed. The requirement at 42 CFR Subpart 42 CFR 482.41 is NOT MET as evidenced by:”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 12268 Based on observations, the facility failed to ensure that hazardous areas were enclosed as required. Section 19.3.2.1.5 states that hazardous areas shall include, but shall not be restricted to the following: (1) Boiler and fuel-fired heater rooms (2) Central/bulk laundries larger than 100 ft2 (9.3 m2) (3) Paint shops (4) Repair shops (5) Rooms with soiled linen in volume exceeding 64 gal (242 L) (6) Rooms with collected trash in volume exceeding 64 gal (242 L) (7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction (8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard Hazardous areas are: 1. Protected by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated doors) or 2. An automatic fire extinguishing system in accordance with 8.7.1. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Section 8.4.3.4 states that door clearances shall be in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Section 8.4.3.5 states that doors shall be self-closing or automatic-closing in accordance with 7.2.1.8. NFPA 80, section 6.1.4.2.1, states that self-closing doors shall swing easily and freely and shall be equipped with a closing device to cause the door to close and latch each time it is opened. NFPA 80, section 7.1.4 Operation of Doors. Section 7.1.4.1 states that the doors shall swing easily and freely on their hinges. Section 7.1.4.2 states that the latches shall operate freely. NFPA 80, section 4.8.4 Clearance. Section 4.8.4.1 states the clearance under the bottom of a door shall be a maximum of 3.4 in. (19 mm). Findings Include: On 04/07/25, while touring the facility, it was noted that; 1. The basement level ceiling has several unsealed holes, located throughout the basement where access was cut in the gypsum wallboard (GWB) ceiling and left open, nullifying the smoke resisting partitions and doors in accordance with 8.4. 2. The Soiled Utility Closet, adjacent to room # 106 not equipped with function door closing device The finding was reviewed with and acknowledged by the facility’s Chief Executive Officer and Director of Plant Operations during the exit conference. .”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 51570 This Standard is not met as evidenced by: Based on observations and confirmed by staff, the facility failed to ensure that all required areas are protected by the automatic sprinkler system. NFPPA 101 section 19.3.5.1 states buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. NFPA 101 section 19.3.5.3 states where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. NFPA 101 section 19.3.5.4 states the sprinkler system required by 19.3.5.1 or 19.3.5.3 shall be installed in accordance with 9.7.1.1(1). NFPA 101 section 19.3.5.5 states in Type I and Type II construction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as non-sprinklered. NFPA 101 section 9.7.1.1 states each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems (2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes (3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height NFPA 101 section 9.7.5 states that all automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Findings Include: During the morning and afternoon hours of 04/07/25 while touring the facility, and based upon documentation from Johnson Controls dated 03/21/24, 06/06/24, and 09/06/24 and upon documentation provided by the facility, it was identified that the following was missing from the documentation for the sprinkler system: 1) The facility failed to produce any documentation of monthly psi checks of the sprinkler system. 2) No sprinkler maintenance records were produced at time of survey for Q1 2025 or Q4 2024. 3) Gauges in the sprinkler room were dated January 2020, so should have been replaced. This deficient practice could affect all residents, as well as an undetermined amount of staff and visitors in the event of an actual emergency situation if a fire were to occur and activation of the sprinkler system were necessary. As a result, the facility failed to maintain its sprinkler system in accordance with NFPA 13, NFPA 25 and NFPA 101 section 19.3.5.1. The finding was reviewed with and acknowledged by the facility’s Chief Executive Officer and Director of Plant Operations during the exit conference.”

“Corridors - Areas Open to Corridor CFR(s): NFPA 101 Corridors - Areas Open to Corridor Spaces (other than patient sleeping rooms, treatment rooms and hazardous areas), waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are in accordance with the criteria under 18.3.6.1 and 19.3.6.1. 18.3.6.1, 19.3.6.1 This Standard is not met as evidenced by: 12268 This Standard is not met as evidenced by: Based on observations and confirmed by staff the facility failed to ensure compliance with Chapter 19, Section 19.3.6.1 of the 2012 edition of NFPA 101 “Life Safety Code” and Chapter 17 Section 17.7.3.2.3.1 of the 2012 edition of NFPA 72 “National Fire Alarm and Signaling Code”. NFPA 101 Chapter 19, Section 19.3.6.1 “Corridor Separation” sub-section (7) states spaces, other than patient sleeping rooms, treatment rooms, and hazardous areas, shall be permitted to be open to the corridor and unlimited in area, provided that all of the following criteria are met: (a) The space and the corridors onto which it opens, where located in the same smoke compartment, are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4. (b)Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimum quantity and arrangement that a fully developed fire is unlikely to occur. (c) The space does not obstruct access to required exits. NFPA 72 Section 17.7.3.2.3.1 states that In the absence of specific performance-based design criteria, smooth ceiling smoke detector spacing shall be a nominal 30 ft (9.1 m). Findings Include: On 04/07/25, observations revealed that the open sitting area, adjacent to the South Wing’s nurses station, to be open to corridor and not equipped with electrically supervised automatic smoke detectors. As a result of the finding the facility is found to be non-compliant with criteria (1)(a) of NFPA 101 Chapter 19 Section 19.3.6.1 and Chapter 17 Section 17.7.3.2.3.1. of NFPA 72. Note: These particular spaces are not arranged and located so as to allow the whole room direct supervision by the facility staff from a nurses’ station or similar space. The finding was reviewed with and acknowledged by the facility’s Chief Executive Officer and Director of Plant Operations during the exit conference.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 12268 This Standard is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain smoke barriers in accordance with NFPA 101 Section 19.3.7.3, and section 8.5. NFPA 101 section 19.3.7.3 states any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1?2-hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c). (b) Not less than two separate smoke compartments shall be provided on each floor. (2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. NFPA 101 section 8.5.1 states where required by Chapters 11 through 43, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. NFPA 101 section 8.5.2.1 states smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. NFPA 101 section 8.5.2.2 states smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces. NFPA 101 section 8.5.2.1 states 8.5.6.1 the provisions of 8.5.6 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations of smoke barriers. NFPA 101 section 8.5.6.2 states penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke. Findings Include: On 04/07/25 while touring the facility, the following items were observed regarding smoke barriers: The Smoke Barrier wall separating the North Wing and the South Wing contained holes and unsealed voids around pipe, HVAC. duct, and electrical / communication wire penetrations above the in-lay ceiling tiles. These penetrations were noted above the in-lay tiles at the cross-corridor doors and adjacent domestic laundry rooms The Smoke Barrier wall separating the North Wing and the West Wing contained holes and unsealed voids around pipe and electrical / communication wire penetrations above the in-lay ceiling tiles at the cross-corridor doors. Due to the penetrations/openings listed above, the facility failed to ensure its smoke barriers are maintained as required. The finding was reviewed with and acknowledged by the facility’s Chief Executive Officer and Director of Plant Operations during the exit conference.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 12268 This Standard is not met as evidenced by: Based on record review and later observed during the building tour, the facility failed to ensure that smoke barrier doors are maintained as required. Section 19.3.7.8 states doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. Section 8.5.4.1 states doors in smoke barriers shall close the opening, leaving only the minimum clearance necessary for proper operation, and shall be without louvers or grilles. Findings Include: On 04/07/25 during facility tour, the smoke barrier door at the South Wing staff break room was not equipped with a door closing device. As a result, the facility failed to comply with section 19.3.7.8 and 8.5.4 requiring smoke barrier doors to self close and be smoke tight. The finding was reviewed with and acknowledged by the facility’s Chief Executive Officer and Director of Plant Operations during 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: 51570 This Standard is not met as evidenced by: Based on observations and confirmed by staff, the facility failed to ensure compliancy with Chapter 19 of the 2012 edition of NFPA 101 “Life Safety Code.” Chapter 19 “Existing Health Care Occupancies,” section 19.7.1 Evacuation and Relocation Plan and Fire Drills states the requirements for fire drills. NFPA 101 section 19.7.1.1 states the administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. NFPA 101 section 19.7.1.2 states all employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1. NFPA 101 section 19.7.1.3 states a copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator’s location or at the security center. NFPA 101 section 19.7.1.4* states fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. NFPA 101 section 19.7.1.5 states infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. NFPA 101 section 19.7.1.6 states drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. NFPA 101 section 19.7.1.7 states when drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. NFPA 101 section 19.7.1.8 states employees of health care occupancies shall be instructed in life safety procedures and devices. Findings Include: During the morning and afternoon hours of 04/07/25 and based upon the facility’s documentation, the following was observed concerning fire drills: 1) No fire drill conducted on 1st shift for Q1 2025. Staff indicated the drill was done in December 2024 to cover it, but code does not allow for that. 2) No alarm activation for fire drill conducted on 12/26/24 at 4:05pm on 2nd shift. Some of the records indicate it was sounded, others it was not. Cannot tell from documentation provided whether alarm was sounded or not. 3) Not enough variation in drill times. a. 1st shift: 10:51, 10:40, 9:13 b. 2nd shift: 3:50, 4:02, 4:05, 3:25 c. 3rd shift: 3:30, 1:45, 2:15, 3:20 This deficient practice could affect all residents, as well as an undetermined amount of staff and visitors in the event of an emergency where the fire safety plans are required to be utilized. As a result, the facility failed to comply with NFPA 101 section 19.7.1 and document fire drills as required. The finding was reviewed with and acknowledged by the facility’s Chief Executive Officer and Director of Plant Operations during the exit conference.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 12268 This standard is not met as evidenced by: Based on observations and confirmed by the facility’s Director of Maintenance during the building tour, the facility failed to ensure that portable space heaters are used in accordance with Section 19.7.8. of the 2012 edition of NFPA 101 Life Safety Code -NFPA 101 section 19.7.8 states portable space heating-devices shall be prohibited in all health care occupancies, unless both of the following criteria are met: (1) Such devices are used only in non-sleeping staff and employee areas. (2) The heating elements of such devices do not exceed 212 degrees F(100 degrees C). Findings Include: On 04/07/25 while conducting the facility tour, portable electric space heaters with a heating element capable of exceeding 212 degrees (100 degrees C) was located in the Lower Level office, adjacent to the elevator and exit discharge door. The finding was reviewed with and acknowledged by the facility’s Chief Executive Officer and Director of Plant 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: 51570 This standard is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain the automatic emergency generator system in accordance with LSC Section 19.5.1, NFPA 99 and NFPA 110. NFPA 101 section 19.5.1.1 states utilities shall comply with the provisions of Section 9.1. NFPA 101 section 9.1.3 states Emergency Generators and Standby Power Systems, where required for compliance with this Code, emergency generators and standby power systems shall comply with 9.1.3.1 and 9.1.3.2. NFPA 101 section 9.1.3.1 states emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 99 section 6.4.4.1.1.3 states maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8. NFPA 110 section 8.3.1 states that the EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class. NFPA 110 section 8.3.2 states a routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the operational reliability of the system. NFPA 110 section 8.3.2.1 states the operational test shall be initiated at an ATS and shall include testing of each EPSS component on which maintenance or repair has been performed, including the transfer of each automatic and manual transfer switch to the alternate power source, for a period of not less than 30 minutes under operating temperature. NFPA 110 section 8.3.3 states a written schedule for routine maintenance and operational testing of the EPSS shall be established. NFPA 110 section 8.3.4 states a permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available. NFPA 110 section 8.3.4.1 states the permanent record shall include the following: (1) The date of the maintenance report. (2) Identification of the servicing personnel. (3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced. (4) Testing of any repair for the time as recommended by the manufacturer. NFPA 110 section 8.3.8 states a fuel quality test shall be performed at least annually using tests approved by ASTM standards. Findings Include: During the morning and afternoon hours of 04/07/25 while touring the facility, and based upon the facility’s documentation, the following items were observed regarding the Emergency Power Supply Systems (EPSSs): 1) Monthly checks did not include either specific gravity or battery conductance as required. 2) Weekly checks missing in January 2025 as well as July 2025 3) Fuel sample not provided in 2024 or from 2025. This deficient practice could affect all residents, as well as an undetermined amount of staff and visitors in the event of an actual emergency where the use of emergency power is required. As a result of the missing documentation relating to the Emergency Power Supply Systems (EPSSs), the facility failed to maintain its EPSSs as required by LSC Section 19.5.1, NFPA 99 and NFPA 110. The finding was reviewed with and acknowledged by the facility’s Chief Executive Officer and Director of Plant Operations during 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: 12268 Based on observations and confirmed by staff interview the facility failed to ensure compliance with Article 400 and Article 590 of the 2011 edition of NFPA 70 National Electrical Code. -Article 400.8 prohibits the use of flexible cords as a substitute for the fixed wiring of a structure. -Article 590 states the following regarding the use of temporary wiring. -590.3 Time Constraints: (A) During the Period of Construction. Temporary electric power and lighting installations shall be permitted during the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities. (B) 90 Days. Temporary electric power and lighting installations shall be permitted for a period not to exceed 90 days for holiday decorative lighting and similar purposes. (C) Emergencies and Tests. Temporary electric power and lighting installations shall be permitted during emergencies and for tests, experiments, and developmental work. (D) Removal. Temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed. Findings Include: On 04/07/25 an extension cord was utilized to supplement power to the ceiling mounted television projector in the Lower level staff training room. The cord was plugged into an electrical receptacle and extended above the in-lay tiles into the projector. As a result of the finding the facility is found to be non-compliant with Article 400 and Article 590 of the 2011 edition of NFPA 70. Flexible cords may not be used as a substitute for fixed wiring or, if allowed, must be removed upon completion of the purpose intended. The finding was reviewed with and acknowledged by the facility’s Chief Executive Officer and Director of Plant Operations during the exit conference.”