Cook Hospital

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 43080 Based on interview and record review, the facility failed to ensure the central emergency department (ED) log accurately tracked 3 of 21 patients (P1, P16, P21) who presented to the ED seeking care for an emergency medical condition. Findings include: During the entrance conference on 6/3/25, at 8:46 a.m., the previous six months of ED logs were requested. On 6/3/25, at 11:07 a.m., the requested ED logs were provided via email. The logs contained daily sheets labeled Daily Census Sheet and identified an Emergency Room Log section that indicated columns for patient name, time of presentation, chief complaint, time of discharge, disposition, and stability at discharge. These columns contained hand-written entries of patients and associated information. A Common Entry Point (CEP) report, submitted to the State agency (SA) on 3/31/25, identified an unknown female patient presented to the ED on 3/28/25, with left lower abdominal pain after a potential miscarriage two weeks prior. A Daily Census Sheet, dated 3/28/25, identified seven patients who presented to the ED that day; however, a patient representing the CEP report patient details was not listed. An Emergency Department Management Daily Summary report, requested from the facility to identify all patients who were registered in the ED on 3/28/25, verified a patient, not listed on the Daily Census Sheet, arrived on 3/28/25 at 8:29 a.m., for abdominal pain. She discharged home on 3/28/25 at 9:35 a.m. The CEP patient, based on review of this form and medical record review, was determined to be P1. During an observation on 6/3/25, at approximately 11:00 a.m., the 6/3/25 Daily Census sheet was observed in a three-ring binder located at the hospital’s nurses station. The ED log lacked entries. At that time, one patient was present in the ED who presented at approximately 9:57 a.m. During an abbreviated medical record review, on 6/4/25, the following two additional ED Log inconsistencies were identified: -P21’s medical record identified P21 presented to the ED on 4/21/25. -Daily Census sheets, dated 4/20/25 and 4/21/25, both identified, at 5:33 a.m., P21 presented to the ED for a throat lump. At 7:10 a.m., P21 discharged home in stable condition. P21 was incorrectly entered on the 4/20/25 ED log. -P16’s medical record verified P16 presented to the ED on 5/16/25. -The Daily Census sheet, dated 5/16/25, lacked information P16 presented that day, despite his presentation. -A Daily Census sheet, dated 5/17/25, identified P16 presented to the ED on 5/16/25 at 11:51 p.m. for intoxication. On 5/17/25, at 9:20 a.m., P16 discharged home in stable condition. When interviewed on 6/3/25, at 11:08 a.m., health unit coordinator (HUC)-A stated she or the nurse entered each patient onto the ED log the day they presented. The timeframe for this entry varied. During an interview on 6/3/25, at 11:42 a.m., registered nurse (RN)-A (the RN identified to be P1’s nurse based on chart review) stated all patients were expected to be entered onto the ED log when the patient presented to the ED. RN-A explained P1’s situation potentially sounded familiar; however, she lacked detailed remembrance. When interviewed on 6/3/25, at 12:55 p.m., RN-B stated generally when the patient was discharged all the paperwork from the ED encounter was brought to the main hospital’s nurses’ station and the patient was then added at that time to the ED log. She explained every patient that presented was expected to be entered onto the log for that day of presentation. On 6/3/25, at 1:35 p.m., both the assistant administrator (AA)-A and the administrator were interviewed together. They stated the ED log was a nursing process, and it was their understanding that each patient that presented to the ED was required to be entered onto this form the day they presented. Once completed, the forms were sent to admissions where they were audited to ensure accuracy. Both stated expectations that the logs should have accurate information. When interviewed on 6/3/25, at 1:52 p.m., patient registrar (PR)-A stated the ED logs were completed by the nurses. The day of the week determined when she received these sheets. If a patient presented on a Friday [the day P1 presented], or during the weekend, she typically was able to audit these sheets for accuracy the following Monday or Tuesday. She explained that during these audits, the information was not always accurate which prompted director of nursing (DON) collaboration to determine accuracy. PR-A denied any specific evidence for these audits as this was a standard workflow process. When P1 presented to the ED, PR-A was out on medical leave and PR-A did not return until 4/4/26. During this time, it was her understanding others in her department were expected to complete this job duty. PR-A explained she expected P1’s missed entry to have been caught at that time. During an interview on 6/3/25, at 2:33 p.m., the revenue cycle director (RCD)-A stated she covered for PR-A during PR-A’s medical leave. She explained, during that time, the department staffing was decreased by approximately half, and they underwent a financial audit. She acknowledged P1’s entry was missed, and this appeared to be an oversight during that time. RCD-A expected all patients who presented to the ED were accounted for on the appropriate ED log; however, she did question why handwritten ED logs were used when their computer system had the capacity to run reports with the required information. When interviewed on 6/4/25, at 1:41 p.m., P1’s ED medical doctor (MD)-A stated he was unfamiliar with the ED log processes and was not aware the nurses completed such a form. An EMTALA (Emergency Medical Treatment and Labor Act) policy, dated 2/10/25, directed all individuals who presented for evaluation and treatment must be entered into the Central Log. The policy lacked additional details related to the Central Log process.”

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 42587 Based on observation, interview and document review, the critical access hospital (CAH) failed to complete manual weekly checks of the Zoll R series defibrillator monitors (used to create an electrical charge to stop an abnormal heart rhythm) for 2 of 2 defibrillator monitors reviewed equipment and supplies. Findings include: On 8/19/24 at 11:53 a.m., registered nurse (RN)-A stated there was a sign off sheet on the top of the crash cart, which staff had to sign off after they checked the lock was intact and the number on the lock matched the number recorded. In addition, the defibrillator (in the crash cart) would do a self-check, and as part of the crash cart check, staff would make sure the self-check light was green. If it wasn’t green, staff would need to do a manual defibrillator check to make sure the defibrillator was working. On 8/20/24 at 8:27 a.m., during the nursing tour, RN-B stated the nurses checked the defibrillator on each 12 hour shift to make sure the defibrillator passed the automatic defibrillator check that would run each night after midnight. They would look for a green check mark. Staff would record the lock number, date and time, and record an “A” for days and “P” for nights, record a check mark in the “Defib Check” column, and sign the “Crash Cart Lock Log.” If there was a red “X,” staff would then need to perform a manual defibrillator check. On 8/22/24 at 10:43 a.m., the chief nursing officer (CNO) stated the facility had two Zoll R series defibrillators. The CNO stated on each shift, the nurses were expected to check for the green check mark. If they saw a red “X,” they would be expected to perform a manual defibrillator check. They were not currently performing any manual defibrillator checks on any kind of schedule. The Defibrillator/Pacer Check (Emergency Room and Hospital) policy dated 12/14/23, did not address regular manual testing. The Zoll R Series Operator’s Guide dated 1/18, Chapter 12 Maintenance Frequency identified the following: Visual inspection - once per day, inspect Code Readiness indicator. Code Readiness test (automatic) - once per day, unless configured Off, in which case, perform manual defibrillator testing daily. Manual Defibrillator Testing - Once per week; daily if Code Readiness Test is configured Off.”

“PROPER VENTILATION, LIGHTING, AND TEMPERATURE CFR(s): (5) There is proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas. This Standard is not met as evidenced by: 42587 Based on observation, interview and document review, the critical access hospital (CAH) failed to complete monthly maintenance checks for the negative air flow rooms for 6 of 8 negative pressure rooms (used in airborne isolation - a room which had a ventilation system that generated a negative pressure to allow air flow into the isolation room, while preventing contaminated air from escaping the isolation room). Findings include: On 8/19/24 at 11:34 a.m., a bed count of the nursing unit was completed with registered nurse (RN)-A. RN-A stated room 8 was a negative air flow room, the door was closed, the display outside of the room read -0.0006 Inches of Water Guard (IWG). A tissue test (a test used to check if a room has negative air flow, or negative pressure. Hold a piece of tissue at the bottom of the door. If air pressure is appropriately negative the tissue will be sucked TOWARD the room.) was performed and failed. RN-A verified the tissue was not sucked into the room. RN-A stated they only recorded the pressure readings every hour if there was a patient in the room who needed airborne precautions. On 8/20/24 at 8:45 a.m., the chief nursing officer (CNO) stated all of the rooms (1-8) in the nursing department were negative air flow rooms. Plant Services (PS)-A verified room 8 was not working and stated it was likely a belt on the roof. PS-A stated maintenance checked all of the rooms monthly for pressure to make sure they were working and ready for use. On 8/21/24 at 10:50 a.m., CNO verified it was important to test negative air flow rooms on a regular basis to make sure they were ready for use. The CNO verified nursing only recorded readings when there were patient’s using the rooms for airborne precautions. On 8/22/24 at 11:30 a.m., PS-A reviewed the maintenance records and verified nursing rooms (1-6) were not being checked monthly for negative air pressure. Documents titled Pressure and Particulate Testing provided by the facility identified the following: 2/8/24, had hospital rooms 1-6 crossed off with no pressure readings 3/5/24, had hospital rooms 1-6 crossed off with no pressure readings 4/9/24, had hospital rooms 1-6 crossed off with no pressure readings 5/2/24, had hospital rooms 1-6 crossed off with no pressure readings 6/6/24, had hospital rooms 1-6 crossed off with no pressure readings 7/25/24, had hospital rooms 1-6 crossed off with no pressure readings The Precautions-Airborne Airborne + Contact dated 7/23 directed the IWG must remain greater than -0.001 Inches of Water Guard (IWG). If this reading is out of range, contact maintenance immediately!!”

“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: Building 1: K-0211, K-0226, K-0321, K-0345, K-0372, K-0511, K-0920, K-0923 Building 2: K-0353, K-0781, K-0920”

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 47263 Based on interview and document review, the critical access hospital (CAH) failed to ensure pharmacy and dietary department policies and procedures were reviewed biannually. Findings include: The following polices had not been reviewed biannually: Pharmacy Department -Patient’s Own Meds last reviewed6/15 -Medication Errors last reviewed 2/20 -Controlled Substance Records last reviewed 1/19 -Pharmacy Access: After Hours last reviewed 4/21 -Procedure for Adverse Drug Reactions last reviewed 219 -Director of Pharmacy last reviewed 6/18 -Pharmacy Technician Duties and Responsibilities last reviewed 5/19 -Pharmacy Monthly Unit Inspection last reviewed 6/18 -Medication Administration last reviewed 1/20 -Pharmacy Scope of Service last reviewed 10/20 Dietary Department -Patient/Residents at Nutritional Risk last reviewed 3/14 -Responsibility for Menus last reviewed 2/15 -Emergency Food Supply last reviewed 7/21 On 8/19/24 at 1:12 p.m., the pharmacist stated there had not been a comprehensive review of all the pharmacy polices since they had been employed (approximately 5 years). On 8/21/24 at 1:41 p.m., the certified dietary manager (CDM) stated per the hospital, policies should be reviewed yearly. The CDM opened the policy manager program and indicated they had 62 tasks listed in the program for policy reivew. The CDM confirmed they had not completed a comprehensive policy review biannually or yearly, instead they reviewed policies as they became pertinent. On 8/22/24 at 11:43 a.m., the administrator stated the facility required all policies be reviewed annually and indicated dietary and pharmacy policies were expected to be reviewed annually. For regulation compliance, the policies should at minimum be reviewed biannually. A policy on policy review was requested but not provided.”

“NUTRITION CFR(s): Nutrition (§483.25(g)(1) and (g)(2) of this chapter). “ §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident’s comprehensive assessment, the facility must ensure that a resident- (1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident’s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (2) Is offered sufficient fluid intake to maintain proper hydration and health. This Standard is not met as evidenced by: 47263 Based on interview and document review, the critical access hospital (CAH) failed to assure dietician consults were obtained for three swing bed patients (P44, P40, P41). Findings include: The facility policy Patient/Residents at Nutritional Risk dated 3/14, directed the certified dietary manager (CDM) was to put in a dietician referral after the interdisciplinary team discussed and identified a patient with nutritional risk. The policy listed the following as criteria for nutritional risk: -recent weight loss -intake less than 75 percent of determined need, or intake inconsistent with historical -increased nutrient need related to medical condition -many food dislikes/food choices outside scope of therapeutic diet -indicators of malnutrition -diagnosis with major nutritional impact -low body weight -mediations with major nutritional impact -alternations in swallowing or chewing process with nutritional impact -potential for skin breakdown -score of three or greater on the nurse assessment -risk for dehydration P44 P44 was admitted to the CAH on 6/5/24, for swing bed services with the diagnosis of chronic kidney disease, pneumonia, and generalized weakness. P44 had a consistent carbohydrate, low fat, low cholesterol, low sodium diet ordered. P44’s record lacked evidence of a referral to the dietician for policy identified nutritional risk factors. On 8/22/24 at 10:36 a.m., the CDM stated due to the complexity of P44’s diet, they should have had a dietician referral. P40 P40 was admitted to the CAH on 6/13/24, for swing bed services. P40’s chart contained a provider order for a dietary consult for anemia and a history of multiple bowel obstructions. P40’s record lacked evidence of a dietician consult being completed as ordered and as policy directed. P41 P41 was admitted to the facility on 6/7/24, for swing bed services. P41’s diagnoses included diabetes, acute kidney injury, chronic kidney disease with superimposed rhabdomyolysis [muscle tissue breakdown], likely dehydration, aspiration pneumonia, and traumatic contusion on the lower back and pelvis. P41’s record lacked evidence of a dietician consult being completed as directed by policy for nutritional risk factors. On 8/20/24 at 10:57 a.m., the CDM stated when there was a hospital dietary consult, they completed a review, and if they didn’t have enough expertise to address the patient’s needs, then they consulted the dietician. During an interview on 8/22/24 at 11:01 a.m., MD-A stated the dietary consult order in the electronic medical record (EMR) required a reason for consult, but it did not require the provider to indicate if the consult should be done by the dietary department or the dietician. MD-A stated they would expect a dietary consult order for a patient with complex nutritional needs, diets, or risk factors to be completed by the dietician. On 8/22/224 at 11:07 a.m., the director of nursing (DON) stated the care team held weekly meetings on all patients and nutrition was discussed. Registered nurse (RN)-C stated they were not clear what the CDM’s process was for a dietician consult, but indicated things like complex diets, anemia, kidney problems, and skin break down were all reasons for the dietician to be consulted. On 8/22/24 at 11:43 a.m., the administrator stated provider orders for dietary consult should clearly indicate if they wanted the patient seen by the dietician to avoid the possibility of the CDM only reviewing the patient when the provider intended for the dietician to see the patient. Polices should be followed. A policy on dietician consults were requested but not provided.”

“FIRE SAFETY An annual Life Safety recertification survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on 08/20/2024. At the time of this survey, Scenic Rivers Health Services 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. Scenic Rivers Health Services is a 1-story building with a partial basement. The original building was constructed in 1955 as the Tower-Soudan Elementary School with the clinic additions in 1979. The original school and the clinic additions are all Type III (200) construction with a 2 hour separation, therefore, the facility was inspected as two individual buildings. The lab area, the clinic, and dental office are not properly separated. The entire space was inspected a one building. The requirements at 42 CFR, Subpart 483.70(a), are NOT MET as evidenced by:”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 45748 Based on observation and staff interview, the facility failed to maintain a clear path of egress system per NFPA 101 (2012 edition), Life Safety Code, sections 19.2.1 and 7.1.10.1. This deficient finding could have a patterned impact on the residents within the facility. Findings include: On 08/20/2024, between 09:00am and 1:00pm, it was revealed by observation that there was rehabilitation equipment in the egress pathway leading into the rehabilitation area by exit door 815. this pathway must remain clear at all times for the safety of those in the area. An interview with the Plant Operation Director verified these deficient findings at the time of discovery.”

“Horizontal Exits CFR(s): NFPA 101 Horizontal Exits Horizontal exits, if used, are in accordance with 7.2.4 and the provisions of 18.2.2.5.1 through 18.2.2.5.7, or 19.2.2.5.1 through 19.2.2.5.4. 18.2.2.5, 19.2.2.5 This Standard is not met as evidenced by: 45748 Based on observation and staff interview, the facility failed to maintain a clear path of egress system per NFPA 101 (2012 edition), Life Safety Code, sections 19.2.1 and 7.1.10.1. This deficient finding could have a patterned impact on the residents within the facility. Findings include: On 08/20/2024, between 09:00am and 1:00pm, it was revealed by observation that there was medical equipment stored in the egress exit door 815. This exit was blocked with a patient walker and will need remain cleared at all times. An interview with the Plant Operation Director verified these deficient findings at the time of discovery.”

“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: 45748 Based on observation and staff interview, the facility failed to maintain hazardous storage rooms per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.1.3 and 7.2.1.8.1. These deficient finding could have a patterned impact on the residents within the facility. Findings include: On 08/20/2024, between 09:00am and 1:00pm, it was revealed by observation that lower level maintenance storage room did not have a self-closing device. An interview with the Plant Operation Director verified these deficient findings 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: 45748 Based on a review of available documentation, staff interview, and observations, the facility failed to maintain the fire alarm system per NFPA 101 (2012 edition), Life Safety Code, sections 9.6.1.3, 9.6.7.5, and NFPA 72 (2010 edition), National Fire Alarm and Signaling Code, sections 10.12.4, 14.3.1, 14.4.5.3, and 14.6.2.4. These deficient findings could have a widespread impact on the residents within the facility. Findings include: On 08/20/2024, between 09:00am and 1:00pm, it was revealed by a review of available fire alarm test and inspection documentation and an interview with the Environmental Services Director that the facility could not provide current documentation verifying that a monthly inspection had been completed for the month of July for the battery operated initiating devices. An interview with the Plant Operation Director verified these deficient findings 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 08/20/2024, between 1:00pm and 3:00pm, it was revealed by observation that wooden wall type structure had been placed on a desk structure, bringing the combustible materials within the required 18 inch clearance area under the sprinkler heads. These obstructions were found in dental office waiting room. An interview with Plant Operation Directorverified these deficient findings at the time of discovery”

“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: 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 08/20/2024, between 09:00am and 1:00pm, it was revealed by observation that there was a penetration running from one smoke compartment to another above doors in the following areas: 1) Above Fire Doors leading into annex by the business office 2) Above Fire Doors leading into rehabilitation area 3) Above Fire Doors leading into surgical wing 4) Above Fire Doors leading into Lab/X-Ray 5) Above Fire Doors in P.D. Doctors Sleeping Lounge 6) Above Fore Doors to Link An interview with the Plant Operation Director verified these deficient findings at the time of discovery.”

“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: 45748 Based on observation and staff interview, the facility failed to secure electrical panels per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.3.2.2.1.3 and failed to maintain the Gas and Utility System per NFPA 101 (2012 edition), Life Safety Code section 9.2.2 and NFPA 54 (2012 edition), National Fuel Gas Code, sections 9.2.2 and 10.3.2.2. These deficient findings could have a widespread impact on the residents within the facility. Findings include: On 08/20/2024, between 09:00am and 1:00pm, it was revealed by observation that the electrical panel LP - N102 was not locked. An interview with the Plant Operation Director verified these deficient findings 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 08/20/2024, between 1:00pm and 3:00pm, it was revealed by observation of portable space heaters in the following areas; 1) In dental office employee room / office area near patient care area 2) in patient care area by dental chair 3) in oxygen storage area “space heaters in or near patient care areas are prohibited”. An interview with Plant Operation Director verified these deficient findings 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 08/20/2024, between 09:00am and 1:00pm, it was revealed by observation that there were several electrical appliances plugged into a power strip in the following areas: 1) Surgery refrigerator plugged into power-strip 2) Outpatient managers Office - refrigerator and microwave plugged into power-strip 3) Office 267D power-strip pugged into power-strip An interview with the Plant Operation Director verified these deficient findings at the time of discovery.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 45748 Based on observation and staff interview, the facility failed to store oxygen cylinders per Health Care Facilities Code NFPA 99 (2012 Edition), sections 11.3.2.3, 11.6.5.2 and 11.6.5.3. These deficient findings could have a widespread impact on the residents within the facility. Findings include: On 08/20/2024, between 09:00am and 1:00pm, it was revealed by observation that oxygen is being stored in X-Ray corridor was not secured while not in use. An interview with the Plant Operation Director verified these deficient findings at the time of discovery.”