Essentia Health Fosston

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 43080 Based on observation, interview, and document review, the critical access hospital (CAH) failed to ensure signage pertaining to the Emergency Medical Treatment and Active Labor Act (EMTALA) was posted in all areas likely to be noticed by patients entering the Emergency Department (ED). This had the potential to affect all patients presenting to the ED seeking care and treatment via the ambulance/helipad patient entrance. Findings include: On 3/18/24, at 2:05 p.m., a tour of the emergency department (ED) was conducted with registered nurse house supervisor (RN)-A and a quality partner (QP)-A. During the tour, RN-A identified an entrance where most patients who arrived via ambulance, or helicopter, entered the facility. This area lacked posted EMTALA signage RN-A and QP-A acknowledged there was no signage posted in this area. On 3/20/24, at 5:42 p.m., a tour of the main ambulance/helipad patient entrance was conducted with the ED director of nursing (DON)-A. During the tour it was identified the area lacked EMTALA signage. She stated this entrance was utilized by patients who arrived via ambulance and/or helicopter. She acknowledged there was no signage posted in this area and she explained EMTALA signage was expected to be in any location patients entered the facility. An Emergency Medical Treatment and Labor Act policy, dated 2/14/23, identified its purpose was to ensure compliance with the provisions of EMTALA. The policy directed EMTALA signage was to be posted in locations likely to be noticed by all individuals entering the ED and other areas where individuals may present with emergency medical condition(s).”

“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 ensure emergency supplies and equipment had not expired and were available for use in 2 of 3 emergency equipment carts. Findings include: Observation of the Emergency Department (ED) on 3/18/24 at 2:05 p.m., revealed the pediatric crash cart (nine drawer color coded cart) with the contents included an endotracheal tube (ETT) (keep the airway open in order to give oxygen, medicine, or anesthesia), stylet (adjust the curve of an endotracheal tube in order to make insertion easier), suction catheter, laryngoscope (a thin tube with a light, lens and a video camera that helps providers look closely at your larynx), bag valve mask, oral airway, nasal airway, laryngeal mask airways (LMA) (temporary method to maintain an open airway during the administration of anesthesia or as an immediate life-saving measure), oxygen mask, urinary catheter, nasogastric tube, vascular access and blood pressure cuff. The gray drawer had an expiration date of 2/14/24, and was secured. The pink/red drawer had an expiration date of 2/11/24, and was secured. The purple drawer had an expiration date of 2/1/24, and was secured. The white drawer had an expiration date of 2/28/24, and was secured. The green drawer had an expiration date of 2/4/24, and was secured. An observation on 3/18/24 at 2:30 p.m., revealed the respiratory cart in the trauma room had a drawer with Miller blades (straight blade for the laryngoscope designed to obtain a view of the vocal cords) and Macintosh blades (curved blades for the laryngoscope) had an expiration date of 2/24. The drawer containing anesthesia masks, end tidal CO2 detectors (carbon dioxide detectors help verify endotracheal tube placement), CO2 colorimetric indicator (confirm proper ETT placement by assessing exhaled CO), suction, gastric tube had an expiration date of 2/24. An interview on 3/18/24 at 2:20 p.m., with registered nurse (RN)-A stated the nurse assigned to check the carts left last month and the cart checks had not been reassigned to any other nurse after she left. RN-A stated someone should have been checking the pediatric crash cart and respiratory cart for expiration dates. A facility policy was requested however was not received.”

“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: 40943 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: K0281, K293, K0353, K0712, K0761, K0918 and K0920 for additional information.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (vi) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. All patient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patients or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of § 483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care. This Standard is not met as evidenced by: 42587 Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to ensure the procedure to ensure food served to patients was cooked to a safe temperature to prevent food-borne illness. This had the potential to affect all patients being served food from the kitchen. Findings include: During a kitchen tour on 3/18/24 at 5:06 p.m., cook (C)-B stated the temperatures for foods had not been recorded for the evening meal and added the food temperatures had not been recorded on a regular basis for the month of March 2024. C-B indicated he had not recorded food temperatures for the evening meal. C-B reviewed the three ring binder with the food temperatures and stated that no food temperatures had been recorded since 3/10/24. Review of the Food Temperature logs from 2/25/24 to 3/18/24, revealed the following: 2/25/24, no temperatures recorded for the evening meal. 2/26/24, no temperatures recorded breakfast and evening meal. 3/2/24, no temperatures recorded for any meals. 3/3/24, no temperatures recorded for any meals. 3/5/24, no temperatures recorded for the evening meal. 3/6/24, no temperatures recorded for any meals. 3/7/24, no temperatures recorded for any meals. 3/8/24, no temperatures recorded for any meals. 3/10/24, no temperatures recorded for the evening meal. 3/11/24, no temperatures recorded for any meals. 3/12/24, no temperatures recorded for any meals. 3/13/24, no temperatures recorded for any meals. 3/14/24, no temperatures recorded for any meals. 3/15/24, no temperatures recorded for any meals. 3/16/24, no temperatures recorded for any meals. 3/17/24, no temperatures recorded for any meals. 3/18/24, no temperatures recorded for breakfast and lunch. During an interview on 3/19/24 at 1:33 p.m., registered dietician (RD)-D stated she would expect dietary staff to record the temperatures of food when they were removed from the stove or the oven to ensure they were at a safe temperature to serve to prevent any food borne illnesses. During an interview on 3/20/24 at 8:34 a.m., the director of nursing (DON) stated she would expect dietary staff to follow the procedure to ensure foods were cooked to a safe temperature. Taking/Recording Food Temperatures dated 11/5/21, identified the following “Nutritional Services staff will take and record temperatures of all food prior to serving”. The purpose as identified in the policy was to ensure food safety.”

“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: 34083 Based on observation, interview and document review, the critical access hospital (CAH) failed to ensure transmission based precautions (TBP) were followed which included the use of personal protective equipment (PPE) to prevent the potential spread of infection for 1 of 4 patients (P5) observed for TBP. Findings include: Observation on 3/19/24 at 11:30 a.m., P5’s room door was closed and a brightly colored sign posted at eye level was noted on the door. The sign was bright blue with a red stop sign that listed “check with nurse before entering”. The sign identified Droplet precautions (necessary when a patient has an infection that can be transmitted by talking, coughing, and/or sneezing). The sign identified a mask was required for staff and visitors and directed visitors to check with nursing for mask instructions. Observation on 3/19/24 at 12:18 p.m., family member (FM)-A walked past nursing station, down the hall, past the director of nursing (DON), walked to P5’s room, looked at the eye level sign, opened the door and entered without applying PPE. The DON was asked if FM-A was expected to apply a mask prior to entering P5’s room and she replied she thought she had spoken to FM on 3/18/24, about the required use of PPE. The DON donned PPE and entered P5’s room. Three visitors were present in the room with P5 and none of them were wearing a mask. All three visitors stated they were not aware of the need to use PPE and indicated they had been in and out of P5’s patient room multiple times over the past two days, spoken to unidentified nursing staff and had not received any education related to the need to use PPE. Interview on 3/19/24 at 12:20 p.m., FM-A stated she had not received any education on the need to wear a mask or perform hand hygiene upon entering and exiting patient rooms. In addition, FM-A indicated she had accompanied P5 when he was seen in the emergency department prior to admission and when P5 had first been seen in the clinic and stated no education had been provided to her regarding the use of PPE. FM-A stated the family had celebrated P5’s birthday and brought a cake on 3/18/24, which they had shared with another patient and nursing staff on duty. FM-A indicated she had also been in P5’s room on 3/19/24, when an unidentified staff member had entered P5’s room, without wearing a mask, gone to his bedside, worked with the computer, provided cares and exited the room. Interview on 3/19/24 at 12:20 p.m., the DON stated her expectation was for staff and visitors to follow the Essentia Infection Control policies and procedures and nursing staff should have provided education on transmission-based precautions (TBP’s) to any visitors prior to them entering P5’s room. DON indicated she needed to provide additional infection control education to staff due to the lack of providing education which could have resulted in potential infectious exposure to staff and other residents. Interview on 3/19/24 at 2:04 p.m., the physician assistant (PA)-A stated she had not been aware P5 was on droplet precautions until after she entered the room and accessed the electronic medical record (EMR). PA-A indicated she had exited the room and obtained a mask once she realized P5 was in precautions. PA-A stated the room door was open and she had not noticed the sign posted on the door prior to entering. PA-A indicated her expectation for both staff and visitors was to follow posted signage for precautions which included PPE use. PA-A confirmed the sign was posted on the outside of P5’s room door at eye level, however she had not noticed it and entered P5’s room without donning a mask. Interview on 3/20/24 at 10:31 a.m., the Fosston Infection Practioner (IP) identified when a patient required TBP, the physician documented an order for isolation precautions in the chart. IP stated it was then the responsibility of the nursing staff to implement precautions, place signage on the room door and provide education to the patient, visitors and staff. IP indicated the education provided should have been documented in the patient’s medical record and included in the care plan. Review of the facility policy titled Essentia Health Droplet Precautions dated 2/22/24, identified infectious particles were spread in the air during coughing, sneezing or during a respiratory procedure. The contaminated droplets could have been propelled through the air from two to 10 feet depending on the force of the cough or sneeze. Respiratory protection were required for staff or visitors when entering the patient room. Education to visitors was to include review of isolation procedures, limiting visitors, hand hygiene upon entry and exit of the room, and wearing of a mask while in the patient room.”

“Hospital CAH and LTC Emergency Power CFR(s): §482.15(e) Condition for Participation: (e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section. §483.73(e), §485.625(e), §485.542(e) (e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section. §482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1) Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated. 482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2) Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code. 482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2) Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates. *[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):] The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes. (1) National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169, www.nfpa.org, 1.617.770.3000. (i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011. (ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011. (iii) TIA 12-3 to NFPA 99, issued August 9, 2012. (iv) TIA 12-4 to NFPA 99, issued March 7, 2013. (v) TIA 12-5 to NFPA 99, issued August 1, 2013. (vi) TIA 12-6 to NFPA 99, issued March 3, 2014. (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011. (viii) TIA 12-1 to NFPA 101, issued August 11, 2011. (ix) TIA 12-2 to NFPA 101, issued October 30, 2012. (x) TIA 12-3 to NFPA 101, issued October 22, 2013. (xi) TIA 12-4 to NFPA 101, issued October 22, 2013. (xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.. This Standard is not met as evidenced by: 27955 Based on interview and document review, the critical access hospital (CAH) 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 3/19/24 between 12:00 p.m. and 4:00 p.m., 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 Maintenance Director verified these deficient findings at the time of discovery.”

“FIRE SAFETY An annual Life Safety recertification survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on 03/19/2024. At the time of this survey, Essentia Health Fosston Hospital and 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. Essentia Health Fosston Hospital building 01 Main Building is a 1-story building without a basement. The original building was constructed in 1960 and was determined to be of Type II(111) construction. In 1965 an addition to the south of the original building was constructed and determined to be Type II (111) construction. In 1972 an storage room was constructed to the north of the original building and the nursing home was constructed to the east of the original building and is separated by 2-hour fire barriers and not surveyed at this time. In 1993 clinic was constructed to the west of the original building is Type V (000) construction and separated by 2-hour fire barriers. In 2003 additions to the west and south were constructed and were determined to be Type II (000) construction. The building is divided into 4 smoke zones with a 30 minute and two 2-hour fire barriers. The building is protected with a complete automatic fire sprinkler system installed in accordance with NFPA 13 The Standard for the Installation of Automatic Sprinkler Systems. The facility has a fire alarm system with smoke detection in the corridor system, in all sleeping rooms and in common areas, installed in accordance with NFPA 72 “The National Fire Alarm Code”. The fire alarm system is monitored for automatic fire department notification. The requirements at 42 CFR, Subpart 483.70(a), are NOT MET as evidenced by:”

“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 03/19/2024 between 12:00pm and 4:00pm, it was revealed by observation that the exterior lights for A2 Exit (by room 158) of the exit discharges 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 Maintenance Director verified these deficient findings at the time of discovery.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 45748 The building is divide Based on observation and staff interview, the facility failed to maintain and/or install proper exit signage under NFPA 101 (2012 edition), Life Safety Code sections 19.2.10.1, 7.10.1.2.2, 7.10.8.3, 7.10.8.31 and 7.10.8.3.2. These deficient findings could have a widespread impact on the residents within the facility. Findings include: On 03/19/2024 between 12:00pm and 4:00pm, it was revealed by observation that the door leading to the Courtyard from the South corridor was missing a “NO EXIT” sign. The NO EXIT sign shall have the word NO in letters 2 in. (51 mm) high, with a stroke width of 3.8 in. (9.5 mm), and the word EXIT in letters 1 in. (25 mm) high, with the word EXIT below the An interview with the Maintenance 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, a review of available documentation, and staff interview, the facility failed to inspect and maintain the fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, section 9.7.5, and NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, sections 5.1.1.2, and 5.3.2.1. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On 03/19/2024 between 12:00pm 4:00pm, it was revealed by a review of available documentation the facility failed to provide documentation that the five (5) year sprinkler system testing was performed. An interview with the Maintenance Director verified these deficient findings at the time of discovery. 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 03/19/2024 between 12:00pm 4:00pm, it was revealed by observation that storage materials had been placed on a storage cabinet, bringing the storage materials within the required 18 inch clearance area under the sprinkler heads. These obstructions were found in storage closit in room 511 An interview with the Maintenance Director verified these deficient findings 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: On 03/19/2024 between 12:00pm and 4:00pm, it was revealed by a review of available documentation that fire drills were not completed: 1) Third Shift missing Forth Quarter (October - December) drill completely. 2) First Shift missing Second Quarter (July - September) drill completely. An interview with the Maintenance Director verified this deficient finding at the time of discovery.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 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 03/19/2024 between 12:00pm and 4:00pm, it was revealed by observation that the following fire doors and/or fire door frames had fire rating tags covered with paint and/or missing door rating tags. 1) Two (2) hour Fire doors leading to Administration - painted tags on door frame 2) Two (2) hour Fire doors off elevator lobby - painted tags on door frame An interview with the Maintenance Director verified these deficient findings 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 03/19/2024, between 12:00pm and 4:00pm, 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 Maintenance Director verified these deficient findings at the time of discovery. Based on a review of available documentation and staff interview, the facility failed to test and inspect the generator per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.4.4.1.1.4, and NFPA 110 (2010 edition), Standard for Emergency and Standby Power Systems, section 8.4.1 and 8.4.2. These deficient findings could have a widespread impact on the residents within the facility. Findings include: On 03/19/2024, between 12:00pm and 4:00pm, it was revealed by a review of available documentation of the emergency generator maintenance and testing, that the facility could not provide documentation of an annual generator inspection at the time of survey. An interview with the Maintenance 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 03/19/2024 between 12:00pm and 4:00pm, it was revealed by observation that there were several electrical appliances plugged into a power strip in the following areas: 1) Daisy chained appliances in the Ambulance Brake room 2) Daisy chained appliances in Office 502 An interview with the Maintenance Director verified these deficient findings at the time of discovery.”