Aspirus Lake View Hospital

“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: 42587 Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital. Findings include: Please refer to the Life Safety Code inspection tags: K0223, K0225, K0281, K0291, K0324, K0353, L0361, K0372, K0712, K0781, K0914, K0918, K0920.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 47372 Based on observation, interview and document review, the facility failed to protect and secure the biohazard and sharps containers within the clinics. Findings include: During observation on 4/30/24 at 8:00 a.m., the Silver Bay clinic laboratory department, which contained a patient laboratory draw chair, contained opened and unsecured biohazard containers next to laboratory equipment and machines. Inside each biohazard container were multiple vials of vacuum tubes and used test stripes with visible dark tinged red liquid. During interview on 4/30/24 at 8:30 a.m., the technical consultant and lab manager (TCLM) stated that he does not expect staff to have the biohazard containers within the lab, with vacuum tubes containing reddish brown liquid and used test strips to be protected from spilling onto the counter or floor. TCLM stated he does not feel there is any potential harm if an opened biohazard bin with used biomedical waste were to fall onto the counter or floor. During observation and interview on 4/30/24 at 8:42 a.m., the Silver Bay clinic radiology room contained one sharps container with used needles. The sharps container had a locked lid, however, the opening to drop the sharps material was visible open and the container was not secured to prevent it from falling on the counter or floor. The CEO acknowledged the sharps container was not protected from falling and agreed that facility needs to assure all sharps and biohazard containers be covered and protected from tipping or falling over onto the ground. During observation on 4/30/24 at 9:03 a.m., the Silver Bay clinic medication room contained two sharps containers, each with a locked lid. However, the opening to drop sharps material was visible open and contained two lancets and one medication vial. The sharps container was not secured from falling on the counter or floor. During observation and interview on 4/30/24 at 1:34 p.m., the clinic within the hospital, med room, contained a sharps container with visible needles and vials 3/4 full. The sharps containers had a locked lid, however the opening to the lid had a visible opening. The sharps containers were on a counter next to a sink with a raised basin, making the sharps container visibly uneven with the surface of the counter. Additionally, the sharps container was not secured or protected from falling over on the counter or ground. The director of the medical clinic and outpatient services (DMCOS) stated that the sharps container should be secured from falling and tipping over and agrees that if the sharps container were to fall or spill, it could cause harm or exposure to infectious diseases. During interview on 5/2/24 at approximately 8:30 a.m., the director of environment services/ imaging, and materials (DESIM) stated she expected housekeeping to place biohazard bins and sharps containers in a secured location from tipping over and spilling onto the floor or counters. Additionally, she expected biohazard bins to have a lid. She stated that if a biohazard bin or sharps containers that was open and/or not secured from falling, that a patient or staff could be injured and potentially exposed to infectious diseases. During an interview on 5/2/24 at approximately 9:00 a.m., the director of nursing (DON) and infection prevention manager (IPM) stated that they would expect the biohazard bins and sharps containers should be covered and protected from falling and/ or spilling onto the ground. The DON and IPM agree, if uncovered and not secured, there is a potential for patients and staff harm from any sharps within the containers and infectious disease exposure. The pharmaceutical and waste stream pharmacy policy dated 2023 directed all pharmaceutical waste shall be disposed of according to state and federal regulations. This waste includes expired drugs, waste materials containing excess drug (syringes, IV bags, tubing, vials, etc.), and any other drugs that cannot be used or are intended to be discarded. All pharmaceutical waste is to be assumed hazardous and managed accordingly, unless evaluated and documented to be non-hazardous. For ease of determining waste streams and to protect the environment to the greatest extent possible, all pharmaceutical waste at Lake View Hospital will be deemed hazardous, with the exception of maintenance IV fluids (e.g. NS, D5W, LR, KCL).”

“EP Program Patient Population CFR(s): §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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 all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: 47372 Based on interview and document review, the facility failed to provide evidence it had created a policy and procedure that outlined the business continuity operations program. Findings include: During document review and interview, on 4/30/24 between 2:54 p.m. and 4:11 p.m., the emergency preparedness coordinator (EPC) and the director of nursing (DON) stated and acknowledged the facility had not created or implement a business continuity operation policy or procedure. The emergency incident/multiple casualty or over capacity policy and procedure last revised 12/21/23 indicated the facility under [the] emergency operations, Lake View will do its utmost to preserve its basic service and facilities for prompt and maximum use.”

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(b) Policies and procedures. The [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 at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 47372 Based on documentation review and interview, the facility failed to provide evidence it had completed an 1135 waiver policy and procedure as part of the emergency preparedness program. Findings include: During document review and interview, on 4/30/24 between 3:36 p.m. and 4:11 p.m., the EPC and DON stated and acknowledged the facility had not implemented or created an 1135 policy or procedure. The emergency incident/multiple casualty or over capacity policy and procedure last revised 12/21/23, indicated the facility under [the] emergency operations, Lake View will do its utmost to preserve its basic service and facilities for prompt and maximum use.”

“Nelson, Christopher FIRE SAFETY An annual Life Safety recertification survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on 04/30/2024. At the time of this survey, Lake View Memorial Hospital and Silverbay Clinic was found not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR, Subpart 483.70(a), Life Safety from Fire, and the 2012 edition of National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care and the 2012 edition of NFPA 99, Health Care Facilities Code. THE FACILITY’S POC WILL SERVE AS YOUR ALLEGATION OF COMPLIANCE UPON THE DEPARTMENT’S ACCEPTANCE. YOUR SIGNATURE AT THE BOTTOM OF THE FIRST PAGE OF THE CMS-2567 FORM WILL BE USED AS VERIFICATION OF COMPLIANCE. UPON RECEIPT OF AN ACCEPTABLE POC, AN ONSITE REVISIT OF YOUR FACILITY MAY BE CONDUCTED TO VALIDATE THAT SUBSTANTIAL COMPLIANCE WITH THE REGULATIONS HAS BEEN ATTAINED IN ACCORDANCE WITH YOUR VERIFICATION. PLEASE RETURN THE PLAN OF CORRECTION FOR THE FIRE SAFETY DEFICIENCIES (K-TAGS) TO: IF PARTICIPATING IN THE E-POC PROCESS, A PAPER COPY OF THE PLAN OF CORRECTION IS NOT REQUIRED. Healthcare Fire Inspections State Fire Marshal Division 445 Minnesota St., Suite 145 St. Paul, MN 55101-5145, OR By email to: FM.HC.Inspections@state.mn.us THE PLAN OF CORRECTION FOR EACH DEFICIENCY MUST INCLUDE ALL OF THE FOLLOWING INFORMATION: 1. A detailed description of the corrective action taken or planned to correct the deficiency. 2. Address the measures that will be put in place to ensure the deficiency does not reoccur. 3. Indicate how the facility plans to monitor future performance to ensure solutions are sustained. 4. Identify who is responsible for the corrective actions and monitoring of compliance. 5. The actual or proposed date for completion of the remedy. Lake View Memorial Hospital is a 2-story building with no basement. The building was constructed in 1956 and is of type II(111) construction. The building is fully sprinkler protected and has a complete fire alarm system with smoke detection in the corridors and spaces open to the corridor, that is monitored for automatic fire department notification. The facility has a licensed capacity of 25 beds and had a census of 6 at the time of the survey. The requirements at 42 CFR, Subpart 483.70(a), are NOT MET as evidenced by:”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: *Required manual fire alarm system; and *Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and *Automatic sprinkler system, if installed; and *Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 45748 Based on observation and staff interview, the facility failed to install self-closing device per NFPA 101 (2012 edition), Life Safety Code, section 19.3.2.1.3 and 19.3.2.1.5. These deficient findings could have a widespread impact on the residents within the facility. Findings include: On 04/30/2024, between 7:30am and 12:30pm, it was revealed by observation that storage room doors in the following areas must be equipped with self-closing devises: 1) Hospital equipment storage room 2) Medical equipment storage room An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.”

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This Standard is not met as evidenced by: 45748 Based on observation and staff interview, the facility did not properly maintain enclose stairways used for exits and smoke proof enclosures in accordance with NFPA 101 (2012), Life Safety Code, section 7.1.3.2.1. These deficient findings could an isolated impact on the residents within the facility. Findings include: On 04/30/2024, between 7:30am and 12:30pm, it was revealed by observation that storage materials had been placed in the emergency exit stairwell in the following areas: 1) Stairwell that leads to Old Nursing Home 2) Stairwell leading from the Exp. Back Stairwell An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.”

“Illumination of Means of Egress CFR(s): NFPA 101 Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8 This Standard is not met as evidenced by: 45748 Based on observation and staff interview the facility failed to provide the level of lighting as required by the Life Safety Code, (NFPA 101) 2012 edition section 7.8.1.4. This deficient finding could have an isolated impact on the residents within the facility. Findings include: On 04/30/2024, between 7:30am and 12:30pm, it was revealed by observation that the exterior lights outside of the exit discharge from stairwell door 14 and outside back door from retail pharmacy each had only one bulb for illumination. Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2.2 lux) in any designated area. An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.”

“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: 45748 Based on observation the facility failed to maintain emergency lighting system per NFPA 101 (2012 edition), Life Safety Code sections 19.2.9.1 and 7.9.1.3. This deficient practice could have a patterned impact on the residents within the facility. Findings include: On 04/30/2024, between 7:30am and 12:30pm, it was revealed by observation that the facility failed to conduct the annual 90 minute required Emergency Lighting test. An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding 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: 45748 Based on documentation review and staff interview, the facility failed to test and inspect the kitchen hood ventilation and fire suppression system per NFPA 101 (2012 edition), Life Safety Code, section 9.2.3 and NFPA 96 (2011 edition), Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, section 11.2.1. This deficient finding could have an isolated impact on the residents within the facility. Findings Include: On 04/30/2024, between 7:30am and 12:30pm, it was revealed by a review of available documentation that inspection documentation for the kitchen hood ventilation and fire suppression system was not available. The facility could not provide completed test/inspection documentation for both of the semi-annual kitchen hood suppression system inspections for the last 12 months. An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding 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: 45748 Based on observation and staff interview, the facility failed to maintain spacing between storage and the sprinkler system per NFPA 101 (2012 edition), Life Safety Code, Section 9.7.5, NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 5.2.1.2, and NFPA 13 (2010 edition), Standard for the Installation of Sprinkler Systems, Sections 8.6.5.3.2 and 8.15.9. These deficient findings could a patterned impact on the residents within the facility. Findings include: On 04/30/2024, between 7:30am and 12:30pm, it was revealed by observation that storage materials had been placed on a storage rack, bringing the storage materials within the required 18 inch clearance area under the sprinkler heads. These obstructions were found in: 1) Clinic Storeroom 2) RQI Room 3) OR Supply Room 4) Disaster / Emergency Management Room 5) Material Storage Room An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.”

“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: 45748 Based on a review of available documentation and staff interview, the facility failed to inspect fire doors per NFPA 101 (2012 edition), Life Safety Code section 8.3.3.1, and NFPA 80 (2010 edition), Standard for Fire Doors and Other Opening Protectives, section 5.2.1. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On 04/30/2024, between 7:30am and 12:30pm, it was revealed by observation that the following fire doors and/or fire door frames were missing door rating tags. 1) Fire doors leading ER Trauma - Painted tags on door frame 2) Fire doors leading to Out-Patient area - Painted tags on door frame 3) Fire doors leading to In-Patient area - Painted tags on door frame An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 NEW Smoke barriers shall be constructed to provide at least a one hour fire resistance rating and constructed in accordance with 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations of fully ducted HVAC systems. 18.3.7.3, 18.3.7.4, 18.3.7.5, 8.3 Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 45748 Based on observation and staff interview, the facility failed to maintain their smoke barrier per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.1, 19.3.7.3, 8.5.2.2, and 8.5.6.5. These deficient findings could have a widespread impact on the residents within the facility. Findings include: On 04/30/2024, between 7:30am and 12:30pm, it was revealed by observation that there was a penetration running from one smoke compartment to another in the following locations: 1) HDC Area at entrance to Doctor On-Call area 2) Out Patient Exam Doors 3) Double door leading to In-Patient Care Doors 4) Hole in fire barrier wall in the Medical Storage Room An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.”

“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. 18.7.1.4 through 18.7.1.7 This Standard is not met as evidenced by: 45748 Based on a review of available documentation and staff interview, the facility failed to conduct fire drills under varied times and conditions per NFPA 101 (2012 edition), Life Safety Code, sections 19.7.1.6, 4.7.4, and 4.6.1.1. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On 04/30/2024, between 7:30am and 12:30pm, it was revealed by a review of available documentation that fire drills did not meet the varying time requirement: second shift 03/28/24 @ 1601, 06/29/23 @ 1603, 09/19/23 @ 1605 and 12/28/23 @ 1600. An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.”

“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: 45748 Based on observation and staff interview, the facility failed to implement its portable space heater policy per NFPA 101 (2012 edition), Life Safety Code, section 19.7.8. These deficient findings could have a patterned impact on the residents within the facility. Findings include: On 04/30/2024, between 7:30am and 12:30pm, it was revealed by observation of portable space heaters in ECO Examination Room. An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to one month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 45748 Based on a review of available documentation and staff interview, the facility failed to conduct the electrical testing and maintenance per NFPA 99 Standards for Health Care Facilities 2012 edition, section 6.3.3.2, 6.3.4.1.3, and 6.3.4.2.1.2. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On 04/30/2024, between 7:30am and 12:30pm, it was revealed by review of available documentation the acceptable required annual receptacle inspection documentation was not available at the time of the survey. An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.”

“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: 45748 Based on a review of available documentation and staff interview, the facility failed to install and maintain generators per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.4.4.1.1.3, 6.4.1.1.16.2 and 6.4.1.1.17, and NFPA 110 (2010 edition), Standard for Emergency and Standby Power Systems, sections 8.4.9, 8.4.9.1, 8.4.9.2 and 8.4.9.5.1. These deficient findings could have a widespread impact on the residents within the facility. Findings include: On 04/30/2024, between 7:30am and 12:30pm, it was revealed by a review of available documentation of the emergency generator maintenance and testing that the facility could not provide documentation that a 36 month four (4) hour load bank test had been performed. An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.”

“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: 45748 Based on observation and staff interview, the facility failed to maintain the usage of electrical adaptive devices per NFPA 99 (2012 edition), Health Care Facilities Code, sections 10.5.2.3.1 and 10.2.4.2.1, NFPA 70, (2011 edition), National Electrical Code, sections 400-8, and UL 1363. This deficient finding could have an isolated impact on the residents within the facility. Findings include: On 04/30/2024, between 7:30am and 12:30pm, it was revealed by observation that there were several electrical appliances plugged into a power strip and/or extension cords in the following areas: 1) Doctor-on-call rooms near HDC = multi-plug in all four (4) rooms 2) HDC Conference Room = extension cord 3) HDC Lunchroom = extension cord and power-strip. 4) Nurse Break Room = power-strip 5) Pharmacy Office = Power-strip An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.”