Ely - Bloomenson Community Hospital

“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: 27955 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 (a device used to create an electrical charge to stop an abnormal heart rhythm) for 3 of 3 defibrillator monitors reviewed for equipment and supplies. Findings include On 8/27/24 at 8:58 a..m., during a tour of the surgical services area registered nurse (RN)-D stated the surgery department Zoll monitor did a self-check during the night shift and gave a green check mark to indicate the Zoll monitor was working. RN-D stated the staff signed off on a clip board daily that the Zoll monitor did the self-check daily. RN-D confirmed they would only performed a manual test if there was a red “X” and the staff did not perform a manual test weekly. On 8/27/24 at 12:45 p.m., during a tour of the emergency department registered nurse (RN)-A stated the emergency department Zoll monitor did a self-check during the night shift and gave a green check mark to indicate the Zoll monitor was working. RN-A stated they signed off on a clip board daily that the Zoll monitor did the self-check daily. RN-A stated they would only performed a manual test if there was a red “X” and the staff had not performed a manual test weekly. On 8/27/24 at 2:43 p.m., during a tour of the medical surgical unit, registered nurse (RN)-A stated once a day at midnight they checked the Zoll monitor for a green check mark indicating the machine performed its self-checks successfully. If the machine showed a red “X” then they would need to run a manual check, but otherwise didn’t need to run a manual check. They recorded their initials on a paper calendar indicating they confirmed a green check mark. On 8/28/24 at 3:20 p.m., RN-C stated they did a nightly check of the Zoll monitor, if there was a green check mark it was good and meant it did its checks, and if the machine had a red “X” they would do a manual check of the machine. On 8/29/24 at 9:30 a.m., RN-B confirmed the facility had three Zoll defibrillators and they were checked every night by looking for the green check mark on the machine and recording that. RN-B confirmed he was not aware of the need for a weekly manual check of the system. RN-B stated checking the manufacturer instructions was important in case of an adverse event and for warranty purposes. On 8/29/24 at 10:18 a.m., the chief nursing officer (CNO) stated the Zoll machines were checked at midnight and the green check was affirmative for the things the machine self-checks, but if there was a red “X”, a manual test would need to be run. The CNO stated they didn’t routinely run manual checks and he was not aware of the need for that. After review of the Zoll Operator’s Guide, the CNO stated it was important to follow the manufacturer’s instructions to assure the equipment is working properly. The Zoll R Series Operator’s Guide dated 01/2018, 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 Ely Bloomenson Community Hospital policy, Crash Carts dated 7/18/24, did not address maintenance of defibrillators.”

“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: 47263 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: K0324, K0353, K0363 K0372, K0511, K0712, K0914, K0920, and K0923.”

“PATIENT CARE POLICIES CFR(s): These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section and updated as necessary by the CAH. This Standard is not met as evidenced by: 42587 Based on interview and document review the facility failed to ensure dietary policies were reviewed and updated. This had the potential to affect patients who received food served by the kitchen. Findings include: During an interview on 8/27/24 at 1:30 p.m., food service director (FSD)-B verified the dietary policies had not been reviewed in the past year. Safe food handling procedures dated 2/2007 Identification system for patient trays dated 10/20/11 Procedures for accommodating non-routine occurrences such as admissions, changes in diets dated 10/20/11 Menu planning dated 1/1/11 Meeting the nutritional needs of patients 10/20/11 During an interview on 8/27/24 at 2:30 p.m., staff educator (SE)-C verified the dietary policies were not part of the policy review process for the hospital.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 42587 Based on observation and interview the facility failed to ensure proper cleaning for a shared glucometer. This failure had the potential to affect any patient who required glucometer checks. Additionally, based on observation, interview, and record review, the critical access hospital (CAH) failed to implement infection prevention measures to ensure medical equipment indented for patient care was stored in a manner that prevented exposure to cross-contamination of equipment stored in the dirty utility room. This deficient practice had the potential to impact all patients who required the use of a commode. Findings include: During an observation on 8/29/24 at 7:50 a.m., registered nurse (RN)-E performed a blood sugar check for P6. RN-E used a glucometer that was shared with other patients. RN-E brought supplies into the room- washed hands with soap and water at the sink- put on gloves- scanned self- scanned the strip bottle- scanned P6- cleansed P6’s finger with an alcohol wipe-placed the strip in the glucometer meter-poked P6’s finger with a device-wiped away the first drop of blood- touched blood to the strip - received a reading- disposed of sharp in sharps container- wiped machine all over with one bleach wipe walked back to the desk and placed the glucometer machine in the glucometer docking station. RN-E was asked about the dry time and RN-E responded “one minute” then looked at the container Sani-Cloth Bleach and stated the glucometer should remain wet for four minutes. RN-E then removed the glucometer from the docking station and wrapped it in a Sani-Cloth Bleach wipe. During an interview on 8/29/24 at 10:22 a.m., the chief nursing officer (CNO) verified glucometers were shared between patients. The CNO stated he would expect staff to clean glucometers based on the type of isolation, if any, the patient was in. The CNO stated he would expect staff to follow the directions for cleaning/disinfecting and dwell/dry time based on the product used. The CNO further stated the glucometer should not be placed in the docking station until it had finished the dry time. The Nova Statstip Glucose Meter no date, directed staff to clean and disinfect the machine after each patient use. The instructions directed staff to use a new, fresh, germicidal bleach wipe to thoroughly wipe the surface of the meter (top, bottom, left, and right sides) a minimum of three times horizontally followed by three times vertically avoiding the bar code scanner and electrical connector. To observe surface contact time to ensure the machine stayed wet for one minute and to allow machine to air dry for an additional minute. The Sani-Cloth Bleach wipe general guidelines for use dated 2024, directed staff to allow a surface to remain visibly wet for four minutes and to use additional wipes to keep the surface wet for continuous four minutes. Then to allow the surface to air dry. COMMODE STORAGE During an observation and interview on 8/27/24 at 9:31 a.m., two commodes, with a strip of white paper around the toilet seat indicating they were clean, were stacked in the dirty utility room of the medical-surgical unit. Registered nurse (RN)-A and RN-B confirmed these were clean commodes and should not be stored in the dirty utility room and should be stored in a clean area. During an interview on 8/29/24 at 9:27 a.m., RN-B stated it was important not to store clean equipment in the dirty utility room to prevent cross-contamination. During an interview on 8/29/24 at 10:18 a.m., the chief nursing officer (CNO) stated it would be his expectation to not have clean equipment stored in a dirty utility room because of the risk for transfer of germs and infection control. Policy summary.”

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 27955 Based on interview and document review the Critical Access Hospital (CAH) failed to ensure the Emergency Preparedness Plan (EPP) was reviewed every two years. This had the potential to affect all patients, visitors, and staff at the CAH. Findings include: During a review of the facility EPP on 8/29/24 at 8:20 a.m., indicated the last review date of 2016. During a review of the facility Emergency Operations Plan on 8/29/24 at 8:30 a.m., indicated the review date of 6/20. During an interview on 8/29/24 at 8:27 a.m., the chief nursing officer (CNO) stated there had not been a full review of the EPP.”

“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: 27955 Based interview and document review, the Critical Access Hospital (CAH) Emergency Preparedness Plan (EPP) failed to address the patient population including, but not limited to, patients most at-risk, the type of services the facility has the ability to provide in an emergency and continuity of operations that could be provided to those patients most at-risk. This had the potential to affect all patients residing in the CAH. Findings include: During an interview on on 8/29/24 at 8:45 a.m., the chief nursing officer (CNO) stated the EPP did not identify the patient population the CAH served. Review of the Emergency Operation Plan (EOP) undated and EPP dated 2016, lacked evidence of addressing the patient population at-risk.”

“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: 27955 Based on interview and document review, the Critical Access Hospital (CAH) failed to develop emergency preparedness policies and procedures which included provision of subsistence needs for patients and staff during an emergency. This had the potential to affect all patients and staff. Findings include: The CAH’s Emergency Operations Plan (EOP) 6/20, lacked evidence of policy and procedures for non-potable water and waste management. An interview on 8/29/24 at 8:40 a.m., the chief nursing officer (CNO) stated there was nothing in the EOP about non-potable water and waste management.”

“Policies/Procedures-Volunteers and Staffing CFR(s): §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(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:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: 27955 Based on interview and document review the Critical Access Hospital (CAH) failed to ensure their emergency operations plan (EOP) addressed the use of volunteers in an emergency. This had the potential to affect all patients and staff. Findings include: On 8/29/24 at 8:48 a.m., a review of the EOP with the chief nursing officer (CNO), lacked evidence of the use of volunteers in an emergency or other emergency staffing strategy that utilized volunteers to address surge needs in an emergency. During an interview on 8/29/24 at 8:48 a.m., with the CNO verified the EOP lacked a policy or procedure that addressed the training of and use of volunteers during an emergency.”

“FIRE SAFETY An annual Life Safety recertification survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on 08/27/2024. At the time of this survey, Ely Bloomenson Community Hospital / Babbitt Rehab Services was found 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, the Health Care Facilities Code. Babbitt rehab room 142 is located in a mixed occupancy building of type II (000) construction and is used for out-patient services only. The building is in a former school, now owned by the city and has a complete automatic fire sprinkler system. The facility has a capacity of 0 beds at time of the survey. The requirements at 42 CFR, Subpart 483.70(a), are MET.”

“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 observation, a review of available documentation, and staff interview, the facility failed to install the required safety features for cooking equipment per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.5.3 (9) and 19.3.2.5.4. This deficient finding could have an isolated impact on the residents within the facility. Findings include: On 08/27/2024, between 9:00am and 1:30pm, it was revealed by observation that the residential stove located in physical therapy was not equipped with a lock-out switch and was not on a timer, not exceeding a 120-minute capacity, that automatically deactivates the cook-top or range, independent of staff action. An interview with the Maintenance Director 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 08/27/2024, between 9:00am and 1:30pm, 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) Information Technology (IT) Office 2) Data Room 3) Dish Washing Area in Kitchen An interview with the Maintenance Director verified this deficient finding at the time of discovery.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 45748 Based on observation and staff interview, the facility failed to maintain corridor doors per NFPA 101 (2012 edition), Life Safety Code, section 19.3.6.3.5. This deficient finding could have an isolated impact on the residents within the facility. Findings include: On 08/27/2024, between 9:00am and 1:30pm, it was revealed by observation that the room door B121 does not latch. An interview with the Maintenance Director 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 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 08/27/2024, between 9:00am and 1:30pm, it was revealed by observation that there was a penetration running from one smoke compartment to another above doors in the following areas; 1) A145 Doors 2) A201 2 Hour Fire Wall 3) A229 2 Hour Fire Wall An interview with the Maintenance Director verified this deficient finding 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 08/27/2024, between 9:00am and 1:30pm, it was revealed by observation that the electrical panels located in the following areas were not locked. 1) Panel D 2) Panel C 3) Panel CR101 4) Panel L101 An interview with the Maintenance Director 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. 19.7.1.4 through 19.7.1.7 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: 1. On 08/27/2024, between 9:00am and 1:30pm, it was revealed by a review of available documentation that fire drills did not meet the varying time requirement: second shift 02/08/2024 at 4:00 PM, 05/08/2024 at 4:33 PM, and 08/09/2024 at 3:05 PM. 2. On 08/27/2024, between 9:00am and 1:30pm, it was revealed by a review of available documentation that fire drills were not completed: first shift missing, third quarter (July - September) and first quarter (July - September) drills completely. An interview with the Maintenance Director 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 1 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 08/27/2024, between 9:00am and 1:30pm, it was revealed by review of available documentation the required annual receptacle inspection documentation was not available at the time of the survey. An interview with the Maintenance Director 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 08/27/2024, between 9:00am and 1:30pm, it was revealed by observation that there were several electrical appliances plugged into a power strip in in the following areas 1) Human Resourses Office 2) Laundry Room 3) Culanary Office An interview with the Maintenance Director verified this deficient finding 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 5.1.3.2, 5.1.3.3.4, 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 08/27/2024, between 9:00am and 1:30pm, it was revealed by observation that the facility oxygen storage room does not have a vent system. An interview with the Environmental Services Director verified these deficient findings at the time of discovery.”