Centracare Health System - Sauk Centre

“FIRE SAFETY An annual Life Safety Code survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on 05/15/2024. At the time of this survey, Centracare Health System - Sauk Centre 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. CentraCare Health System Sauk Centre Hospital is a 2 story building with basement. The building was constructed at 3 different times. The original building was constructed in 1949 and was determined to be of Type II(222) construction. In 1993, an addition was added to the north that was determined to be of Type II(222) construction. In 2007, the main hospital addition and a 2nd floor mechanical room were added to the east of the 1949 building that were determined to be of Type II(222) construction. Because the original building and the additions does meet the construction type allowed for existing buildings, the facility was surveyed as one building. The building is fully sprinklered throughout. The facility has a fire alarm system with smoke detection in the corridors and spaces open to the corridors that is monitored for automatic fire department notification. The facility has a capacity of 14 beds and had a census of 8 at the time of the survey. The requirement at 42 CFR, Subpart 485.623(d) is NOT MET as evidenced by:”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 49715 Based on observation and staff interview, the facility failed to maintain smoke barrier doors per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.8 and 8.5.4.1. These deficient findings could have a patterned impact on the residents within the facility. Findings include: 1. On 05/15/2024 between 9:00 AM and 12:00 PM, it was revealed by observation that the smoke barrier doors going into the Shipping and Receiving area in the basement did not close when released from the magnetic hold-open device. 2. On 05/15/2024 between 9:00 AM and 12:00 PM, it was revealed by observation that the fire barrier door in the basement between the hospital and the clinic did not close and latch when released from the magnetic hold-open device. 3. On 05/15/2024 between 9:00 AM and 12:00 PM, it was revealed by observation that a fire door in the laundry area was being blocked in the open position with a plastic bottle. Violation was corrected at the time of discovery. 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: 49715 Based on a review of available documentation and staff interview, the facility failed to maintain the emergency generator per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.4.4.1.1.3, 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 8.4.9.7. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On 05/15/2024 between 9:00 AM and 12:00 PM, it was revealed by a review of available documentation that at the time of the survey the facility could not provide documentation showing a four (4) hour load bank test has been completed within the last 36 months. An interview with the Maintenance Director verified this deficient finding at the time of discovery.”

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 48583 Based on observation, interview, and document review, the critical access hospital (CAH) failed to ensure the dish machine was properly fixed to maintain correct temperatures during the washing and rinsing cycles. This had the potential to affect all patients receiving meals from the kitchen. . Findings include: During an observation on 5/13/24 at 11:53 a.m., the digital monitor used to display the wash and rinse cycle temperatures read “Rinse Error Contact Ecolab, wash 162.2 degrees Fahrenheit”. During an interview on 5/13/24 at 11:53 a.m., dietary manager (DM) indicated the digital monitor was hooked up because the temperature gauges on the dish machine did not work properly all the time. DM further indicated it had been over a year since the digital monitor was installed and it continued to have an error reading for the rinse cycle. DM stated the representative from Ecolab continued to come to the facility and say he was going to fix it but it had not been fixed. DM explained staff could use thermal strips as verification if the temperature was adequately hot but the strips could not verify an actual temperature. On 5/13/24 at 3:28 p.m., contacted Ecolab to speak with facility representative regarding the dish machine. No return call was received. On 5/14/24 at 3:00 p.m., contacted Ecolab to speak with facility representative regarding the dish machine. No return call was received. During an interview on 5/14/24 at 4:10 p.m., dietary aid (DA)-A indicated the digital temperature monitor did not always work so the gauges attached to the dish machine would need to be read. DA stated the digital monitor read Contact Ecolab service representative (rinse error, wash 162.0). DA further indicated dietary staff could use a test strip to ensure the temperature got above 170 degrees Fahrenheit when dishes were being washed. DA identified the current test strips being used were called Ecolab Dishwasher Test Strips. The test strips were attached to a piece of silverware and put through the dish machine. If the tip of the strip paper turned bright orange, the dish machine’s rinse cycle was within temperature range. DA further indicated “we can use the chlorine test paper too”. DA found a bottle of test strips in the storage room and stated she would use the strips to check the concentration of the chlorine. DA dipped the test strip into the chlorine reservoir in the dish machine. DA read the strip by using the color coding on the bottle which identified the chlorine concentration was 100 parts per million (PPM). DA used Chlorine Test Paper lot #203222 and expiration date February 1, 2024. DA confirmed the test strips were expired and new ones would need to be used. DA contacted DM via phone and inquired about new Chlorine Test Paper that were not expired. DM indicated a bottle of Chlorine Test Strips had been given to the state surveyor for review and DA could request those test strips back. DM further indicated that bottle of Chlorine Test Strips were being used earlier in the day. State surveyor provided bottle of Chlorine Test Paper to DA to use during the supper dish machine run. The bottle of Chlorine test strips were labeled with code 4250-BJ and had an expiration date of 4/23, DA was informed and then DA confirmed the strips were expired. DA shared this information with the DM. DM and DA stated they were not aware that bottle of Chlorine Test Paper was also expired. DM indicated she would find new Chlorine Test Paper in the morning when she came into work. During an interview on 3/15/24 at 2:42 p.m., DM and dietician indicated staff were required to check and record the dishwasher temperatures after every meal. DM and dietician further indicated staff were to use the Ecolab Dishwasher Test Strips during the middle of washing dishes for testing the water temperature and Chlorine Test Paper prior to washing dishes to ensure the concentration was within an acceptable range. DM and dietician confirmed the digital monitor and dish machine gauges were not a reliable at this time. DM further confirmed the dish machine’s digital monitor was not working properly and the representative from Ecolab had not fixed the problem. DM stated she received regular service call reports from Ecolab but indicated nothing was reported about the digital monitor for temperature readings being serviced. DM indicated her expectations were staff were temping the dishmachine after every meal. If staff were unable to obtain the correct dishmachine temperature staff would use the Ecolab Dishwasher Test Strip/Chlorine Test Paper to ensure proper cleaning of the dishes. DM further indicated if staff did not know how to complete the process, staff was ask for help. Dietician stated her expectations were staff completed the dishmachine temperature the correct way to be sure sanitation guidelines were being met. During an interview on 5/15/24 at 4:39 p.m., the facilities president indicated he was not aware the dish machine’s temperature gauges and digital monitor were not working. The president further indicated his expectations were staff were to be following and meeting the compliance requirements. Review of Regular Service Call logs from Ecolab dated 1/24/23 to 1/22/24, on 1/24/23 and 1/22/24 a picture of the digital monitor error was included. Requested Ecolab’s response to the pictures however, one was not provided. Review of facility policy Cleaning Dishes - - Dish Machine and Manual effective date 1/24, dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitation. Prior to use, run the machine until verification of proper temperatures and machine function is made. Staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitation. Thermal strips may be used as verification that the temperature is adequately hot, but cannot verify actual temperatures.”

“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: 27955 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: K363 and K918 for additional information.”

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 34083 Based on observation, interview, and document review, the critical access hospital (CAH) failed to properly clean 1 of 1 Nova Statstrip Glucose monitor reviewed for blood glucose monitoring of patients. Findings include: On 5/13/24 at 4:39 p.m., registered nurse (RN)-A was observed using the Statstrip glucose monitor to check P24’s blood glucose. RN-A retrieved the monitor from the charging dock at the nursing station, gathered her supplies and went to P 24’s room. RN-A checked P24’s blood glucose and immediately returned to the nursing station. RN-A applied clean gloves, took a moistened wipe from a container labeled, “Sani-Cloth Prime”, with a symbol identifying “disinfects in 1 minute”. RN-A held the Statstrip monitor in her left hand and utilized the wipe to wipe over the surface of the meter for 10-15 seconds. She returned the meter to the wall mount charger and removed her gloves. RN-A failed to allow the meter to remain in contact with the sanitizing solution per the manufacturer’s recommendation of 1 minute. RN-A confirmed the solution was not in contact with the meter for the recommended time period and the monitor would have been used for the next patient without allowing any additional drying/decontamination time. Review of the manufacture’s written instructions located on the label of the Sani-Cloth Prime canister identified to Disinfect: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for (1) minute. Let air dry. Interview on 5/13/24 at 4:45 p.m. with RN-A, RN-B, and RN-C reported they also had been following the same procedure for wiping off the Statstrip monitor following use, and had not been aware of the manufacturer’s recommendation of allowing the surface to remain wet for 1 minute then allowing it to dry before use. Interview on 5/13/24 at 4:49 p.m. with the nurse manager voiced her expectation for the Statstip glucose meter to be cleaned/disinfected according to the manufactures recommendations. Interview on 5/15/24 at 3:00 p.m. with the infection practioner (IP) reported she was not aware staff were not following the manufacture’s recommendations for wet surface time using the Sani-Cloth Prime wipes. IP expected staff to use the product in accordance with the label. Review of the Standard Worksheet Process: Cleaning Glucose Meter (Nova Stat Strip) Desired Goal or Outcome to prevent cross contamination. Clean and disinfect both sides of meter ensuring good contact with the grip. Allow required wet contact time. Review of the June 2022 CentraCare Sauk Centre Bedside Glucose monitoring policy identified Quality Control, cleaning the meter: Clean the meter with a hospital approved disinfectant wipe. Immediately follow with a water-dampened cloth to remove all cleaning residue. Dry thoroughly with a soft cloth or lint-free tissue. The outside of the meter/tote must be cleaned between each patient, for infection control purposes, using a disinfectant wipe approved by the health system.”

“NURSING SERVICES CFR(s): §485.635(d)(3) All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. This Standard is not met as evidenced by: 34083 Based on observation, interview and document review, the critical access hospital (CAH) failed to develop policies/procedure for self-administration of medication for 1 of 2 patients (P24) observed to self-administer a nebulized medication. Findings include: P24 had current physician orders for Brovana 15 micrograms (mcg)/ 2 milliliters ml) by nebulizer two times daily (BID) and Pulmacort 0.5 milligrams (mg)/2 ml BID. Observation on 5/14/24 at 9:06 a.m. with registered nurse (RN)-C as she prepared to administer P24’s morning medications. RN-C accessed the Omnicell patient medical record, identified the ordered medications and retrieved them from the unit. She referenced a pharmacy cheat sheet and determined the two nebulized medications were able to be combined in a single administration. RN-C went to P24’s room, confirmed the patient identification, administered her oral (PO) medications, and placed both nebulized medications into the mask vial for administration. She connected the mask to the tubing, handed the mask with medication to P24 and turned on the nebulizer unit. RN-C then told R24 she would come back and check on her in 10 minutes and left the room with P24 holding the mask to her face. There was no strap or method to hold the mask in place other than P24 holding it with her hand. Review of the current physician orders failed to contain an order that P24 was able to self-administer her medications. During an interview on 5/14/24 at 9:15 a.m. with RN-C reported P24 did not have an order to self-administer her medications and that she usually remained in attendance while P24 had her nebulizer treatment, but had not done so this morning. RN-C reported she should have remained in attendance in P24’s room to supervise as she finished her treatment. During an interview on 5/15/24 at 2:30 p.m. with the director of nursing (DON) reported her expectation for a patient to have an order on their current physician orders if they were able to self administer a medication/nebulizer treatment, otherwise the nurse was to remain in attendance during the treatment. Review of the November 2022 Medication Administration Policy identified were to be administered as ordered by the medical provider. The five rights of medication administration were listed and included medication name, dose, route, frequency, and rate. Nursing staff who administered a PO medication were to remain in attendance until the medication was taken. The policy failed to address nebulized medications and if a patient was able to self-administer the medication without the nurse remaining in attendance.”

“QAPI CFR(s): (d) Standard: Program activities. For each of the areas listed in paragraph (b) of this section, the CAH must: (3) Set priorities for performance improvement, considering either high volume, high-risk services, or problem prone areas. This Standard is not met as evidenced by: 48583 Based on observation, interview, and document review, the critical access hospital (CAH) failed to identify the systematic dish machine sanitation gap and include it in the Quality Assessment and Performance Improvement (QAPI) plan (a creative problem solving to maintain and enhance quality). This had the potential to affect all the patients receiving meals from the kitchen. Findings include: Review of Dishmachine Temperature Log - CentraCare Health Sauk Centre dated May 2023 through May 2024 revealed the following: -5/23, 4 days of missing recorded temperatures and chlorine tests for 1-2 meals. -6/23, 18 days of missing recorded temperatures and chorine tests for 1-2 meals and 1 full day of missing recorded temperatures and chlorine tests for all meals. -7/23, 20 days of missing recorded temperatures and chorine tests for 1-2 meals. -8/23, 13 days of missing recorded temperatures and chorine tests for 1-2 meals and 1 full day of missing recorded temperatures and chlorine tests for all meals. -9/23, 10 days of missing recorded temperatures and chorine tests for 1-2 meals and 4 full days of missing recorded temperatures and chlorine tests for all meals-June 2023 18 days of missing recorded temperatures and chorine tests for 1-2 meals and 1 full day of missing recorded temperatures and chlorine tests for all meals. -10/23, no temperature log was provided. -11/23, 22 days of missing recorded temperatures and chorine tests for 1-2 meals and 7 full days of missing recorded temperatures and chlorine tests for all meals. -12/23, 9 days of missing recorded temperatures and chorine tests for 1-2 meals and 6 full days of missing recorded temperatures and chlorine tests for all meals. -1/24, 19 days of missing recorded temperatures and chorine tests for 1-2 meals and 9 full days of missing recorded temperatures and chlorine tests for all meals. -2/24, 16 days of missing recorded temperatures and chorine tests for 1-2 meals and 7 full days of missing recorded temperatures and chlorine tests for all meals. -3/24, 17 days of missing recorded temperatures and chorine tests for 1-2 meals and 11 full days of missing recorded temperatures and chlorine tests for all meals. -4/24, 11 days of missing recorded temperatures and chorine tests for 1-2 meals and 9 full days of missing recorded temperatures and chlorine tests for all meals. -5/1/24 to 5/12/24, 4 full days of missing recorded temperatures and chlorine tests for all meals. During an observation on 5/13/24 at 11:53 a.m., the digital monitor used to display the wash and rinse cycle temperatures read “Rinse Error Contact Ecolab, wash 162.2 degrees Fahrenheit”. During an interview on 5/13/24 at 11:53 a.m., dietary manager (DM) indicated the digital monitor was hooked up because the temperature gauges on the dish machine did not work properly all the time. DM further indicated it had been over a year since the digital monitor was installed and it continued to have an error reading for the rinse cycle. DM stated the representative from Ecolab continued to come to the facility and say he was going to fix it but it had not been fixed. DM explained staff could use thermal strips as verification if the temperature was adequately hot but the strips could not verify an actual temperature. During an interview on 5/15/24 at 2:42 p.m., DM and dietician confirmed the above findings and indicated they were aware of the the days that staff did not record temperatures or test strip readings following every meal. DM and dietician further indicated they were aware of the days staff did not record temperatures or test strips for the entire day. DM stated changes have taken place in the dietary services and different staff had been responsible for washing dishes in the dishmachine. DM further stated the new staff may not have been aware of the policy or how often temperatures and test strip readings needed to be completed. Dietician indicated the department was aware of the issue but was not/has not been a QAPI project, however, they were going to be working on the dishmachine gap going forward. Dietician further indicated the current QAPI projects were Press Ganey Scores (determining how hospitals are dedicated to enhancing a patient’s experience of food during their stay) food temps, and food quality. During an interview on 5/15/24 at 3:15 p.m., registered nurse infection preventionist (RNIP) indicated she was not aware of any sanitation concerns in the dietary department and nothing had been discussed during QAPI meetings. RNIP further indicated her expectations were staff must be following the temperature guidelines and policies on a daily basis for the safety of patients, family, and staff. During an interview on 5/15/24 at 4:39 p.m., the facilities president indicated he was not aware the dish machine’s temperature gauges and digital monitor were not working. The president further indicated his expectations were staff were to be following and meeting the compliance requirements. Review of manufactures documentation on Sodium Hypochlorite Solution/Dishmachine Sanitizer (current chlorine solution being used in the facilities dish machine) not dated, dishmachine sanitizer kills bacteria on contact in as little as 50 PPM. Can be used in high-temp machines when booster heater fails to reach 180 degree final rinse temperature. Review of the facility policy titled Kitchen/Food Service Observation dated 10/22, manual water temperature solution shall be maintained at no less than 110 degrees Fahrenheit. After washing and rinsing, dishes are sanitized by immersion in either: how water (at least 171 degrees Fahrenheit) for 30 seconds; or a chemical sanitizing solution. If explicit manufacture instructions are not provided, the recommended sanitation concentrations are as follows: chlorine: 50 - 100 parts per million (PPM) 10 second contact time. Review of facility policy titled Cleaning Dishes - - Dish Machine and Manual effective date 1/24, dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitation. Prior to use, run the machine until verification of proper temperatures and machine function is made. Staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitation. Thermal strips may be used as verification that the temperature is adequately hot, but cannot verify actual temperatures. Review of facility policy titled Quality Assurance/Performance Improvement - Nutrition Services effective date 1/24, each year, the food service and nutrition departments should set goals based upon desired outcomes or identified gaps. Steps will be taken to assure quality and safety of foods served, and adequacy of nutrition services and documentation. The QA/PI surveys may include sanitation audits. The sanitation audit form is intended to be open-ended. Use the guidelines in the infection control and sanitation section when evaluating the sanitation status of the food service department.”

“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 a review of available documentation and staff interview, the facility failed to maintain the emergency generator per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.4.4.1.1.3, 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 8.4.9.7. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On 05/15/2024 between 9:00 AM and 12:00 PM, it was revealed by a review of available documentation that at the time of the survey the facility could not provide documentation showing a four (4) hour load bank test has been completed within the last 36 months. An interview with the Maintenance Director verified this deficient finding at the time of discovery.”