Munising Memorial Hospital

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment This Condition is not met as evidenced by: 36887 Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 485.623(c), 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, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include: C-0930 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code”

“QAPI CFR(s): Condition of Participation: Quality Assessment and Performance Improvement Program The CAH must develop, implement, and maintain an effective, ongoing, CAH-wide, data-driven quality assessment and performance improvement (QAPI) program. The CAH must maintain and demonstrate evidence of the effectiveness of its QAPI program. (a) Definitions. For the purposes of this section- Adverse event means an untoward, undesirable, and usually unanticipated event that causes death or serious injury or the risk thereof. Error means the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems; and Medical error means an error that occurs in the delivery of healthcare services. This Condition is not met as evidenced by: 36887 Based on record review and interview, the facility failed to implement and maintain an effective, ongoing, data-driven, facility wide quality assessment and performance improvement program resulting in the facility being potentially unaware of improvements in providing patient care services or in the environment effecting all patients served by the facility. Findings include: On 6/4/2024 at 1030, review of the provided quality assessment and performance improvement (QAPI) information from March 2024 revealed an agenda for discussion of benchmarks, patient experience reports/grievance, regulatory compliance, and education. Several unexplained pages of scores and graphs were present along with the “Michigan Critical Access Hospitals (MICAH) Qualtiy Network Organizational Chart 2022” and “Relevant Measures for MI (Michigan) Peer Group 5 CAHs” from May 2021. Current ED (emergency department) scoreboard information was present. On 6/4/2024 at 1045, CNO (chief nursing officer) Staff B, who was also the head of quality/risk management/compliance, was queried as to if there were other information or data including meeting minutes to review for the past 12 months. She provided the “Quailty Improvement Plan” policy. During the QAPI meeting on 6/4/2024 at 1126, CNO Staff B stated the facility “sometimes” has quarterly meetings for QAPI. When queried as to what was discussed in quality, she stated, “Pharmacy, patient issues and experience, complaints,and grievances.” She further stated there were no QAPI notes or meeting minutes as the person assigned to take the notes and minutes no longer worked for the facility. She indicated there was a separate meeting for infection control and policies. When queried as to if maintenance issues were discussed, she stated that the previous facilities director used to come to the meeting, and the current director was invited to come, but had not yet come to a meeting. Staff B was asked if there were any current performance improvement projects to which she stated, “Med scanning was identified as an issue.” When asked to show and discuss the issue involved, what was being done to correct the issue, time frame for monitoring and assessment, she stated all of the documentation was kept in (name of electronic medical record system) and reports could be run for needed data. If it was determined the project was not working, the plan was to educate the staff. She further stated the data was “not kept” nor was it tracked and/or trended. Staff B was then asked what quality information was presented to the governing body to which she stated that “pieces and parts of quality” were reported and included such information as Blue Cross, projects, and patient volumes. Review of facility policy #15160613 titled “Quality Improvement Plan” last revised 2/2023 states, “Each Clinical Department participates in a hospital wide Quality Improvement (QI) program desgned to monitor, evaluate and improve the quality, appropriateness and outcomes of clinical services by: Planning, designing, measusring, assessing, improving new or revised processes of patient care and service; Identifying opportunities through continuous assessment of systems and processes of care through a collaborative, interdisciplinary focus; Implementing solutions and actions which will bring about the desired change, to; Facilitate a positive patient outcome, while; Maintaining a safe environment for personnel, patients and visitors... The primary goals off the performance improvement plan are to continually and systematically plan, design, measure, assess, and improve performance of priority focus areas, imporve health care outcomes and reduce and prevent medical/health care errors... Information and the findings of discrete performance improvement activities and adverse patient events are used to detect trends, patterns and performance or potential problems that affect more than one department/service...Performance measures with relatd performance outcomes will be established as a means to systematically monitor the identified processes for review in an ongoing manner, and to provide operational linkages between the risk management functions related to the clinical aspects of patient care and safety and the performance improvement functions. Performance expectations will be established for any new or revised processes undertaken y the hospital. Performance measures will be specific and measurable. Performance measures will be structured and related to both the processes and outcomes of patient care. The following criteria will be utilized to assure that the indicator chosen for data collection is the most appropriate for monitoring the performance of a patient care or service process, system or function: The measure can identify the events it was intended to identify; The measure has a documented numerator and a denominator statement or description of the population to which the measure is applicable; The measure has defined data elements and allowable values; The measure can detect changes in performance over time; The measure allows for comparison over time winin the organization or between the organization and other entities; The data intended for collection is available and attainable; Results can be aggregated and reported in a way that is useful to the organization and other interested parties.””

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 36887 Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 485.623(c), 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, resulting in the potential for negative outcomes up to and including death in the event of a fire for all patients. Findings include: See the individually and below cited K-tags: K-291 K-321 K-324 K-345 K-346 K-351 K-353 K-354 K-511 K-712 K-753 K-761 K-908 K-918”

“Subsistence Needs for Staff and Patients CFR(s): §403.748(b)(1), §418.113(b)(6)(iii), §441.184(b)(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1), §483.475(b)(1), §485.542(b)(1), §485.625(b)(1) [(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal. This Standard is not met as evidenced by: 46638 Based on record review and interview, the facility failed to develop, at a minimum, policies and procedures that address; the provision of subsistence needs for staff and patients whether they evacuate or shelter in place, including, but not limited to: Food, water, medical and pharmaceutical supplies, alternate sources of energy to maintain temperatures to protect patient health and safety and for the safe and sanitary storage of provisions, emergency lighting, fire detection, extinguishing and alarm systems, and sewage and waste disposal. This deficient practice could affect all occupants in the event of an emergency. Findings Include: On June 3, 2024, at approximately 12:05 PM, during record review of the facility emergency preparedness plan, the facility failed to include a policy that addressed the provisions of food and water for staff and residents in the event of an emergency, as required by 82.15(b)(1). Interview with the Chief Executive Officer at this time confirmed this finding.”

“On June 3, 2024, a Life Safety Recertification Survey was conducted by the Michigan Department of Licensing and Regulatory Affairs, Bureau of Survey and Certification. At the survey, Munising Memorial Hospital was found not in substantial compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 482.41(b), Life Safety from Fire and the applicable provisions of the 2012 Edition of the National Fire Protection Agency (NFPA) 101, Life Safety Code and the 2012 Edition of NFPA 99, Health Care Facilities Code. The facility is a 1 story building of type Type II (111) construction, built in 2007. The building is fully sprinklered and has supervised smoke detection in the corridors and spaces open to the corridors. The facility has 11 certified beds. At the time of the survey the census was 5.”

“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: 46638 Based on record review and interview, the facility failed to ensure automatic emergency lighting of 1-1/2 hour duration is provided in accordance with 7.9, as required by 19.2.9.1. This deficient practice could affect all occupants in the event of a power failure. Findings Include: On June 3, 2024 at approximately 10:39 AM, record review revealed the facility failed to test their emergency lights monthly during the months of September, October, and November of 2023, as required by NFPA 101, 7.9.3.1.1 (1). This finding was confirmed by the Maintenance Director at the time of record review.”

“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: 46638 Based on observation and interview, the facility failed to separate Hazardous areas from other spaces by smoke resisting partitions and self-closing doors. This deficient practice could affect all occupants in the event of a fire emergency. Findings Include: 1) On June 3, 2024 at approximately 9:00 AM, observation revealed the door from the Maintenance Directors office going into the garage failed to have a self-closing device installed as required by NFPA 19.3.2.1.3. 2) On June 3, 2024 at approximately 9:30 AM, observation revealed two 1/2 inch round penetrations in Mechanical room 1. The void area around the penetrations failed to have approved, properly rated material capable of restricting the transfer of smoke as required by National Fire Protection Association (NFPA) 8.5.6.2. The Maintenance Director confirmed this finding at the time of discovery. 3) On June 3, 2024 at approximately 9:35 AM, observation revealed the hallway mechanical room door failed to close and latch completely when tested as required by NFPA 19.3.2.1.3. The Maintenance Director confirmed these findings at the time of discovery.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 46638 Based on record review and interview, the facility failed to ensure cooking facilities are protected in accordance with NFPA 96, unless meeting the requirements of 19.3.2.5.2, 19.3.2.5.3 or 19.3.2.4.4, as required by 19.3.2.5.1 through 19.3.2.5.5, 9.2.3 and TIA 12-2. This deficient practice could affect all occupants in the event of a fire. Findings Include: 1) On June 3, 2024 at approximately 11:30 AM, record review revealed the facility failed to produce documentation showing the required semi-annual inspection/cleaning of the installed kitchen hood ventilation system as required by NFPA 96, 11.4. 2) On June 3, 2024 at approximately 11:35 AM, record review revealed the facility failed to conduct and document the monthly owner’s hood inspection as required by NFPA 17A, 7.2.1 and 7.2.2. These findings were confirmed by the Maintenance Director at the time of discovery.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 46638 Based on record review and interview, the facility failed to ensure the fire alarm system was tested and maintained in accordance with an approved program complying with NFPA 70 and NFPA 72, and records are readily available as required by 19.6.1.3, 9.6.1.5, NFPA 70 and NFPA 72. This deficient practice could affect all occupants in the event of a fire. Findings Include: On June 3, 2024 at approximately 11:37 AM, no records were made available to review indicating they have completed annual fire alarm inspections as required. This finding was confirmed by the Maintnenac Director at the time of discovery.”

“Fire Alarm System - Out of Service CFR(s): NFPA 101 Fire Alarm - Out of Service Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.6 This Standard is not met as evidenced by: 46638 Based on record review and interview, the facility failed to ensure all of the required elements were included in their approved fire watch policy. This deficient practice could affect all occupants in the event of a fire. Findings Include: On June 3, 2024 at approximately 11:27 AM, record review revealed the facility failed to include the appropriate Authority Having Jurisdiction (AHJ) contact numbers were included in their established fire watch policy, as required by National Fire Protection Association 101, 9.6.1.6. This finding was confirmed by the Maintenance Director at the time of record review.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 46638 Based on observation and interview, the facility failed to ensure the automatic fire sprinkler system was maintained as designed and installed. This deficient practice could affect all occupants in the event of a fire. Findings Include: 1) On June 3, 2024 at approximately 9:35 AM, observation revealed a ceiling tile missing in the telephone closet, which violates National Fire Protection Association (NFPA) 19.3.5. 2) On June 3, 2024 at approximately 9: 37 AM, observation revealed a ceiling tile missing in the server room, which violates NFPA 19.3.5. These findings were confirmed by the Maintenance Director at the time of discovery.”

“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: 46638 Based on record review and interview, the facility failed to ensure the automatic sprinkler and standpipe systems are inspected, tested and maintained in accordance with NFPA 25, and records are readily available as required by 9.7.5, 9.7.7, 9.7.8 and NFPA 25. This deficient practice could affect all occupants in the event of a fire. Findings Include: On June 3, 2024 at approximately 11:29 AM, record review revealed the facility failed to provide documentation of the required 5 year internal inspection of piping and branch line conditions as required by NFPA 25, 14.2.1. This finding was confirmed by the Maintenance Director at the time of record review.”

“Sprinkler System - Out of Service CFR(s): NFPA 101 Sprinkler System - Out of Service Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service. 18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) This Standard is not met as evidenced by: 46638 Based on record review and interview, facility failed to ensure all of the required elements were included in their approved fire watch policy. This deficient practice could affect all occupants in the event of a fire. Findings Include: On June 3, 2024 at approximately 11:27 AM, record review revealed the facility failed to include the appropriate Authority Having Jurisdiction (AHJ) contact numbers were included in their established fire watch policy, as required by National Fire Protection Association 25, 15.5.2. This finding was confirmed by the Maintenance Director at the time of record review.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 46638 Based on observation and interview, the facility failed to ensure rooms containing electrical equipment are free from the storage of combustible items. This deficient practice could affect 3 occupants in the event of a fire. Findings Include: On June 3, 2024 at approximately 9:35 AM, observation revealed multiple combustible items stored within three feet of electrical equipment inside of the transfer switch room, which violates National Fire Protection Association 70, 110.26. This finding was confirmed by the Maintenance Director at the time of observation.”

“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: 46638 Based on record review and interview, the facility failed to ensure fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions, are held at unexpected times under varying circumstances, conducted at least quarterly on each shift and responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership as required by 19.7.1.4 through 19.7.1.7. This deficient practice could affect all occupants in the event of a fire. Findings Include: On June 3, 2024 at approximately 9:22 AM, record review revealed the facility failed to ensure their fire alarm signal was received by the monitoring company while conducting fire drills. This finding was confirmed by the Maintenance Director at the time of discovery.”

“Combustible Decorations CFR(s): NFPA 101 Combustible Decorations Combustible decorations shall be prohibited unless one of the following is met: o Flame retardant or treated with approved fire-retardant coating that is listed and labeled for product. o Decorations meet NFPA 701. o Decorations exhibit heat release less than 100 kilowatts in accordance with NFPA 289. o Decorations, such as photographs, paintings and other art are attached to the walls, ceilings and non-fire-rated doors in accordance with 18.7.5.6(4) or 19.7.5.6(4). o The decorations in existing occupancies are in such limited quantities that a hazard of fire development or spread is not present. 19.7.5.6 This Standard is not met as evidenced by: 46638 Based on observation and interview, the facility failed to ensure combustible decorations were prohibited except as permitted by the requirements of 19.7.5.6. This deficient practice could affect all occupants in the event of a fire. Findings Include: On June 3, 2024 at approximately 9:15 AM, observation revealed combustible crepe paper hung from the ceiling throughout the corridor heading to the dining area. This finding was confirmed by the Maintenance Director at the time of discovery.”

“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: 46638 Based on record review and interview, the facility failed to inspect and test annually in accordance with NFPA 101, 19.7.6, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives 5.2, 5.2.3. 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. This deficient practice could affect all occupants in the event of a fire. Findings Include: On June 3, 2024 at approximately 9:32 AM, record review revealed the facility failed to conduct and document annual fire door inspections as required by NFPA 80, 5.2.1 for the installed fire doors at their facility. Of the records provided, the most recent inspection was conducted in March 2023. This finding was confirmed by the Maintenance Director at the time of record review.”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This Standard is not met as evidenced by: 46638 Based on record review and interview, the facility failed to ensure the gas and vacuum systems are inspected and tests and records are maintained as required by 5.1.14.2.3, 5.2.13, 5.3.13 and 5.3.13.4 of NFPA 99. This deficient practice could affect all occupants requiring oxygen in the event of system failure. Findings Include: On June 3, 2024, at approximately 2:26 PM, record review revealed the facility failed to ensure their medical gas system (piped in oxygen system) was tested annually as required by NFPA 99, 5.1.14.4.4. No records were made available by the exit of this survey. The Maintenance Director confirmed this finding at the time of record review.”

“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: 46638 Based on record review and interview, the facility failed to ensure generators or other alternative power sources and associated equipment is capable of supplying service within 10 seconds, is maintained, inspected, tested and exercised in accordance with NFPA 110, and records are readily available as required by 6.4.4, 6.5.4 and 6.6.4 of NFPA 99, NFPA 110, NFPA 111 and 700.10 of NFPA 70. This deficient practice could affect all occupants in the event of a power failure. Findings Include: 1) On June 3, 2024 at approximately 11:31 AM, record review revealed the facility failed to ensure the diesel fuel for their generator was tested annually as required by NFPA 110, 8.3.8. 2) On June 3, 2024 at approximately 11:32 AM, record review revealed the facility failed to conduct annual 90 minute load bank test as required by NFPA 110, 8.4.2.3. 3) On June 3, 2024 at approximately 11:33 AM, record review revealed the facility failed to conduct specific gravity testing or conductance testing of their generator batteries as required by NFPA 110, 8.3.7.1 These findings were confirmed by the Maintenance Director at the time of record review.”