Bates County Memorial Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 41865 Based on policy review, the hospital failed to follow its policies and procedures when they failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#3) of 22 Emergency Department (ED) records reviewed from 10/28/25 through 04/28/26. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s policy titled, “Medical Screening Exam (MSE),” effective 06/25/25 showed the ED would define the scope of the MSE to be tailored to the presenting complaint and the medical history of the patient. All MSE’s would include a physical examination, assessment and if applicable laboratory and imaging studies. Review of the hospital’s policy titled, “Patient Rights-EMTALA violation,” effective 06/25/25, showed all patients presenting to Bates County Memorial Hospital (BCMH) with an EMC were entitled to receive an appropriate MSE, necessary stabilizing treatment, and if necessary, an appropriate transfer to another health care facility. Please refer to A-2406 for further details.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 41865 Based on interview, record review, and policy review, the hospital failed to follow its policies and procedures when they failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#3) of 22 Emergency Department (ED) records reviewed from 10/28/25 through 04/28/26. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act Review of the hospital’s policy titled, “Medical Screening Exam (MSE),” effective 06/25/25 showed the ED would define the scope of the MSE to be tailored to the presenting complaint and the medical history of the patient. All MSE’s would include a physical examination, assessment and if applicable laboratory and imaging studies. Review of the hospital’s policy titled, “Patient Rights-EMTALA violation,” effective 06/25/25, showed all patients presenting to Bates County Memorial Hospital (BCMH) with an EMC were entitled to receive an appropriate MSE, necessary stabilizing treatment, and if necessary, an appropriate transfer to another health care facility. Review of the hospital’s recorded call titled, “CS call for Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) Service 01/28/26, 2320,” showed: - Sheriff’s Office: We have a medical call at (provided the address). I had gotten a call from, I believe it’s an uncle, that this male is schizophrenic (serious mental disorder that affects a person’s ability to think, feel, and behave clearly) and he was having some issues. The male then called 911 and said he’s in a lot of pain, so he’s requesting an ambulance. - EMS: Ok, do you know what kind of pain? - Sheriff’s Office: I don’t. The call came from another county and they said they couldn’t get a lot of information out of him. Review of the hospital’s recorded call titled, “CS call for EMS Service 01/28/26 Continued,” showed: - Sheriff’s Office: The uncle called me back and said that his nephew has taken medication and he thinks he’s going to be asleep soon, but it wouldn’t hurt to have him checked out I guess. - EMS: Ok, so you want me to just have someone come out there. - Sheriff’s Office: Yeah, just to check him out I suppose. - EMS: Ok, alrighty. Review of Patient #3’s ED medical record, dated 01/29/26, showed: - He was a 34-year-old male who presented to the ED, via EMS. Per EMS, the patient was at home when his family contacted law enforcement and reported that the patient had a history of schizophrenia and they wanted them to do a welfare check on the patient. When law enforcement arrived, they called EMS to see if the patient wanted to be seen at the hospital. EMS stated the patient refused to answer questions and stated he just needed a big shot of morphine (an opioid pain medication). - His chief complaint was psychiatric (relating to mental illness) disturbance. - He had history of schizophrenia, chronic low back pain, left knee pain, and nicotine dependence. - His vital signs (VS, measurements of the body’s most basic functions) were within normal limits (WNL). - A nursing triage assessment showed the patient refused to answer the nurse’s questions and just kept repeating, “I am not a doctor.” He started cussing and became increasingly agitated when the nurse asked questions. The patient’s airway, breathing and circulation were WNL. His behavior was noted as anxious, noncompliant, not responsive and yelling at staff and others. - A nursing assessment showed he had tape on his left hand, second and third digits, but would not say what happened. - An ED provider assessment showed the patient reported pain in his 3rd and 4th fingers. A nurse noted his fingers were taped up from a previous encounter and the patient was asking for morphine for pain. A physical head-to-toe assessment and review of body systems showed no concerning findings. - No assessment was completed related to any possible psychiatric complaints. - No re-assessment of the patient’s 3rd and 4th fingers was completed. - Morphine was listed as an allergy. - The patient refused Tylenol (medication that treats minor pains and fever) or Ibuprofen (medication used for treating pain, fever and inflammation) for pain. - His discharge education showed he was to keep his hand elevated, use ice, keep his fingers taped for support and to follow up with an orthopedist (medical specialty dealing with bones) if his fingers were not improving. - The patient was provided with verbal and written discharge instructions. He refused to verbalize understanding and refused to answer questions appropriately. No prescription was given. His VS were WNL, his respirations were even and unlabored. He was escorted out by a local law enforcement officer without incident and in no apparent stress. During a telephone interview on 05/04/26 at 2:00 PM, Staff E, Emergency Medical Technician (EMT), stated that he responded to the patient’s home after they received a call from the sheriff’s office stating the patient was asking for medical assistance due to pain. He was familiar with the patient and knew he had a psychiatric history and a history of drug use. That night he was being difficult and verbally aggressive, but he was not having delusions, suicidal ideations (SI, thoughts of causing one’s own death) or homicidal ideations (HI, thoughts or attempts to cause another’s death). The patient was demanding morphine before he got into the ambulance to go to the hospital. He refused to answer most questions and only continued to ask for morphine the entire ride. During a telephone interview on 05/01/26 at 4:45 PM, Staff G, RN, stated she took the incoming call from EMS while it was enroute to the ED. She stated that EMS told her that the county sheriff’s office got a call from the patient’s uncle who was concerned about him and wanted a welfare check. Police did a welfare check and nothing was concerning. They asked him if he needed medical assistance, and he stated he was in pain, so they called EMS. EMS stated that the patient had a psychiatric history and that he was in pain. She stated she wrote down his chief complaint as psychiatric disturbance as she was given very little information. When the patient arrived, he had his fingers buddy taped together but would not explain why. He refused to state where his pain was and just kept asking for morphine repeatedly, which was listed as one of his allergies. He was uncooperative and refused to answer most of the assessment questions so she could only do a visual assessment. He kept saying over and over that she wasn’t a doctor and became verbally loud and cussed at her but was not aggressive. He did not make any SI, HI or self-harm statements and from her assessment did not appear to be having any acute psychiatric concerns. Staff G assessed the patient, and he continued to ask for morphine. Staff G offered him Tylenol and Ibuprofen which he refused. After he was discharged, he refused to leave. He was in the lobby continuing to demand morphine and was disruptive, so police were called to assist him off the property. During a telephone interview on 05/01/26 at 1:42 PM, Staff H, ED Physician, stated he knew there was some sort of disturbance at the home, but he didn’t know what it was about or why the cops were called. The EMT explained that first the cops were called and then they were called. When he arrived at the ED he had his fingers taped up and he didn’t talk to the nurse much. He wanted some morphine for pain, “which I thought was overkill” so he offered him Ibuprofen or Tylenol. When he asked about his hand, he stated that he had already been to another ED, and he didn’t want another X-ray on his hand, he just wanted pain meds. He refused the medications offered so he was told to follow-up with orthopedics if it kept giving him issues. He had no mental health complaints, he wasn’t overtly psychotic (false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature), hallucinating (seeing or hearing things which are not there), delusional (false ideas about what is taking place or who one is) and had no SI or HI. Neither the ambulance, police, nor family filled out an affidavit, and he saw no reason for a tele-psych visit. He didn’t have anything; life, limb or site threatening, so he was discharged.”

“Condition of Participation: Pharmaceutical Se CFR(s): 482.25 §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service. This Condition is not met as evidenced by: 36473 Based on observation, interview, hospital policy, and The United States Pharmacopeia (USP) for compound sterile preparations review, the hospital failed to: -Ensure the required life-saving medication was readily accessible when administering Malignant Hyperthermia triggering medications. - Ensure pharmacy staff followed the hospital’s policy and infection control standards for Sterile Compounding. (A-501) - Ensure pharmacy staff performed competencies for pharmacy staff responsible for Sterile Compounding. (A-501) - Ensure pharmacy staff removed all paper products (particle shedding) from the segregated compounding area (SCA). (A-501) - Ensure pharmacy staff maintained the quality of emergency medications in the crash carts. (A-505) Due to the potential risk and harm to all patients this resulted in the non-compliance with §42 CFR 482.25 Condition of Participation: Pharmaceutical Services. Please refer to A-501 and A-505 for further details 46554”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 18018 Based on policy review, record review, and interview, the facility failed to: - Complete a comprehensive quality of life activities assessment, which identified specific individualized, activity interest for four out of four discharged Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients (#25, #26, #27 and #28) reviewed for a complete comprehensive quality of life activities assessment. - Provide specific, individualized activity interests that stimulated the patient’s physical and mental well-being for four out of four discharged Swing Bed (#25, #26, #27 and #28) patients reviewed for specific individualized activity interests. - Develop a comprehensive activity care plan, which included activity interests and interventions for four out of four discharged Swing Bed (#25, #26, #27 and #28) patients reviewed for a comprehensive activity care plan. These failed practices had the potential to affect all Swing Bed patients by failing to stimulate their minds, body, and social interests. The facility census was five Acute Care patients, zero Swing Bed (Swing Beds - Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing Care at the same facility) patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or discharge the patient) patient for a total census of six. Findings included: 1. Review of the facility’s policy titled, “Multidisciplinary Team Plan of Care - Swing Bed Program,” dated 03/23/10, showed staff directives: - To provide a multidisciplinary individual plan of care for each Swing Bed resident. - The facility shall provide accurate assessments and care planning to address the resident’s needs through multidisciplinary interventions, accommodation of individual needs, and attention to the resident’s customary routine. - Utilizing collected data, the multidisciplinary team should identify and document resident problems with attention to individual needs and customary routine. This process shall be ongoing. - Upon admission to the Swing Bed Program, a care plan should be developed for each resident. The care plan should be a “blueprint” for action providing a list of identified problems, specific, realistic, and measurable goals, realistic deadlines for achievement, nursing actions, medical and other orders suggested to attain the goals. - Implementation of the plan of care shall be documented in the appropriate area of the medical record. - The Multidisciplinary Committee should perform an ongoing evaluation of the plan of care and care plan reviewed weekly to include: - The resident’s response to the interventions. - The effectiveness of the interventions in resolving the resident’s problems. - The degree to which the outcome criteria are met. 2. Review of Patients’ Electronic Medical Health Records (EMHR) showed: - Patient #25 was admitted to the facility’s Swing Bed program on 01/19/24, with complaints of status post fall with multiple fractured ribs and pneumothorax (collapsed lung); - Patient #26 was admitted to the facility’s Swing Bed program on 06/10/24, with complaints of urine retention (difficulty in emptying the bladder); - Patient #27 was admitted to the facility’s Swing Bed program on 11/08/23, with complaints of closed hip fracture; and - Patient #28 was admitted to the facility’s Swing Bed program on 10/09/23 with complaints of a fractured pelvic rami (bones that make up the pelvis). Patient #25’s, #26’s, #27’s, and #28’s EMHR showed staff failed to conduct a comprehensive quality of life activity assessment of the patients to assist in identifying the patients’ activity interests and staff failed to develop a comprehensive activity care plan for the patients during the patients stay in the facility’s Swing Bed program. 3. During an interview on 06/27/24 at 2:32 PM, Staff F, Swing Bed Coordinator, acknowledged Patient #25, #26, #27, and #28 EMHRs’ did not contain an activity assessment or an activity care plan. Staff F stated facility staff attended a webinar provided by the Hospital Association and information obtained from the webinar instructed hospitals with Swing Bed Programs that activity assessments and activity care plans were no longer required because the activity requirement was no longer a regulatory requirement for a facility’s Swing Bed Program. Staff F stated the facility stopped performing activity assessments and including activities in patients’ care plan after staff received information from the webinar that activities were no longer a regulatory requirement for patients admitted to the facility’s Swing Bed Program.”

“PHARMACIST SUPERVISION OF SERVICES CFR(s): 482.25(b)(1) §482.25(b)(1) - All compounding, packaging, and dispensing of drugs and biologicals must be under the supervision of a pharmacist and performed consistent with State and Federal laws. This Standard is not met as evidenced by: 18018 36473 Based on observation, interview, review of the Malignant Hyperthermia Association of the United States (MHAUS), review of the United States Pharmacopeia (USP) Chapter 797 and policy review, the hospital failed to: - Ensure the required life-saving medication was readily accessible when administering Succinylcholine (a muscle relaxant/paralytic) in the Emergency Department (ED) or the Operating Room (OR) or when administering Anesthesia gases such as Desflurane, Sevoflurane, Isoflurane (medications administered as a an inhaled gas by a qualified anesthesia professional during surgical procedures) in the OR. - Ensure pharmacy staff followed the hospital’s policy and infection control standards for Sterile Compounding. - Document education of pharmacy staff responsible for Sterile Compounding. - Remove all paper products (particle shedding) from the segregated compounding area (SCA). These failures had the potential to increase the risk of cross contamination with infection and increase the risk of harm to any patients who received compounded medications. The facility census was five Acute Care patients, zero Swing Bed patients, and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or discharge the patient) patient for a total census of six. Findings included: Emergency Department 1. Observation on 06/25/24 at 9:49 AM, in the Emergency Department (ED), showed the Rapid Sequence Intubation (RSI - potent anesthetic agent, muscle relaxant and/or paralytic agents) Kit was located in the ED’s automated medication dispensing system. The RSI Kit contained one 250 milligram (mg - unit of measurement) vial of Ryanodex (Dantrolene Sodium - antidote medication used to treat Malignant Hyperthermia). 2. During an interview on 06/25/24 at 10:00 AM, Staff E, ED Supervisor, stated the ED had enough Ryanodex medication to initiate treatment for Malignant Hyperthermia and if more of the medication was indicated, ED staff would retrieve addition Ryanodex from the pharmacy. Staff E stated the ED followed MHAUS guidelines. 3. Review of the facility document titled, “My Report: MED INVENTORY,” dated 06/25/24 at 10:03 AM, showed the facility had one Dantrolene Kit (Ryanodex Kit) in the ED and one Dantrolene Kit (Ryanodex Kit) in the Surgery Department. Pharmacy 4. Observation on 06/25/24 at 10:05 AM, of the showed the Pharmacy Department did not have any additional vials of Ryanodex located in the pharmacy. 5. During an interview on 06/25/24 at 10:09 AM, Staff A, Chief Nursing Officer, stated the facility followed MHAUS guidelines when Succinylcholine (muscle relaxant/paralytic) was used. Operating Room 6. Observation on 06/25/24 beginning at 10:00 AM, showed: - The OR automated medication dispensing system contained one Rynadex 250 mg vial. - The OR and ED failed to have a Malignant Hyperthermia box/cart with the recommended supplies centrally located and accessible in the event of an MH crisis. - The OR staff failed to obtain all recommened supplies in the 10 minutes needed per the MHAUS guidelines. 7. During an interview on 06/25/24 at 11:50 AM, Staff C, Certified Registered Nurse Anesthetist, stated all the recommended supplies was centrally located in the supply room for the OR. The Medications recommended were located in the anesthesia emergency kit except the insulin, that was in the OR automated medication dispensing system in the preoperative area. When asked to gather the supplies in a timely manner, Staff K was unable to locate the Charcoal filters. 8. The facility’s failure to ensure the required three vials of Ryanodex were maintained in the facility increased the risk for patient safety to all patients that required any Malignant Hyperthermia triggering medications during intubation. 9. Review of the Malignant Hyperthermia Association of the United States (MHAUS - to promote optimum care and scientific understanding of Malignant Hyperthermia and related disorders) guidelines, dated 2016, showed the following medications and supplies should be centrally located and accessible in the event of a MH crisis: -Drugs: Ryanodex, 3 vials of 250mg doses, sterile water for injection without bacteriostatic agent 5 ml of sterile water for injection, Sodium bicarbonate (8.4%) - 50 ml x 5, Dextrose 50% - 50 ml vials x 2, Calcium chloride (10%) - 10 ml vial x 2, Regular insulin - 100 units/ml x 1 (refrigerated), Lidocaine for injection (2%) - 100 mg/5 ml or 100 mg/10 ml in preloaded syringes, Amiodarone. - General Equipment: Refrigerated cold saline solution - A minimum of 3,000 ml for IV cooling, Charcoal Filters - Two pairs of activated charcoal, syringes - 60 ml x 5, intravenous catheters - 16G, 18G, 20G, 2-inch; 22G, 1-inch; 24G, 3/4-inch, 4 each, Nasogastric tubes, Toomey irrigation syringes 60 ml x 2, with adapter for NG irrigation. - Monitoring Equipment: Esophageal or other core temperature probes, central venous cannulation kits (sizes appropriate to your patient population), transducer kits for arterial and central venous cannulation. - Nursing Supplies: Large sterile drape, Urine meter x 1, irrigation tray with piston syringe, plastic bags for ice x 4, bucket for ice, and test strips for urine hemoglobin. - Laboratory Testing Supplies: Syringes (3 ml) for blood gas analysis or ABG kits x 6 or point of care monitor, blood specimen tubes, and urine collection container. 10. Review of the facility’s policy titled, “Malignant Hyperthermia, Management Of,” dated, 10/18/23, showed staff directives: PURPOSE AND STANDARD - Outline the proper procedure for the management of malignant hyperthermia. - Malignant Hyperthermia (MH), an event triggered in susceptible individuals by various anesthetics, is a rare, inherited paramagnetic syndrome. It strikes fast and without warning and is a sudden and life threatening condition. It is strongly recommended for providers of surgical services to have the requisite drugs and supplies available as defined by the Malignant Hyperthermia Association of the United States to prevent and treat MH. ACUTE PHASE TREATMENT - Notify Surgeon - Discontinue volatile agents and Succinylcholine - Hyperventilate with 100% oxygen - If available insert activated charcoal filters into the inspiratory and expiratory limbs of the breathing circuit - Change all rubber goods on the anesthesia machine - Get DANTROLENE: (one dose in Surgery Pyxis and one dose in ED Pyxis) NAME: RYANODEX - Give Dantrolene - Obtain blood gas (venous or arterial) to determine degree of metabolic acidosis - Cool patient if core temperature is >39 degrees C or less if rapidly rising SURGICAL SERVICES DEPARTMENT & PAR PERSONNEL SHALL BE AWARE OF THE FOLLOWING - Malignant Hyperthermia, although rare, does exist and prompt recognition and intervention is needed in this crisis situation. - Dantrolene sodium for injection is kept in the Pyxis in the Surgery Department as well as the Pyxis in the Emergency Department. Pharmacy 11. Observation on 6/26/24 at 8:07 AM, in the Pharmacy, showed Staff M, Pharmacy Technician, failed to clean under her fingernails and clean eyeglasses prior to entering the compounding area, wear sterile gloves during compounding, wipe off medications gathered for compounding prior to entering the SCA, remove glove cardboard box (particle shedding product) from the compounding area and remove single-use vial in the laminar hood used for a prior compounding medication. 12. Although requested, the hospital failed to provide proof for 12 out of 12 staff competencies for Sterile Compounding. 13. During an interview on 06/26/24 at 12:31 PM, Staff B, Director of Pharmacy Services, stated staff was expected to follow USP Chapter 797 and they have not had any staff competency training for Sterile Compounding since 03/2023. Staff B stated they did not have any competency training for Sterile Compounding for the Nurse Supervisors that had access to the SCA. There was a total of 12 staff untrained that performed Sterile Compounding. 14. Review of the USP, Chapter 797, dated 2013, showed that: - Staff were to clean hands with soap and water for 30 seconds and clean under fingernails with a nail pick. - If compounder wears eyeglasses, they were to clean them prior to entering the SCA. - Staff were to wipe down all products prior to bringing into the SCA. - Wear sterile gloves when compounding. - Particle shedding objects (pencils, corrugated cardboard, paper towels, and cotton items) were prohibited in the SCA. - Gloved fingertip sampling required for initial testing and retested every six months for all compounding personnel. - Media-fill testing required for initial testing and every six months. - Surface sampling required every six months and monitored for further action coordinated with the infection control officer. 15. Review of the hospital’s policy titled, “Sterile Compounding,” dated 02/23/24, showed the direction for staff: - To follow aseptic technique. - Place only clean products in the hood. - Clean glasses prior to entering the SCA. - Media-fill testing should be performed every six months. - Gloved fingertip and thumb sampling must be performed every 12 months. - Surface sampling every six months. 46554”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 36473 Based on policy and document review, observation and interview, the hospital failed to ensure expired medications were removed from the emergency crash carts (mobile cart which contains emergency medical supplies and medication) so the expired items were not available for staff use during an emergency and failed to ensure the appropriate supplies and medications were available in two of five emergency crash carts in the hospital. This deficient practice had the potential to affect all patients that received care, treatments, and services at the hospital. The hospital census was five Acute Care patients, zero Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of six. Findings included: 1. Review of the hospital’s policy titled, “Crash Cart: Daily Inventory,” dated 01/02/24, showed: - Pharmacy will check all medications and IV (intravenous) fluids (medications given directly in to the veins) for expiration dates monthly. - Nursing will remove the contents of all the drawers and clean he cart with an antimicrobial cleanser each month and replace any non-pharmaceutical supplies. - The nurse who uses the crash cart will check it after each use and reorder supplies used. - From 0700 to 1500: pharmacy will place a red tag after replacing medication after using carts. When pharmacy is closed, the Nursing Supervisor will restock the cart from pharmacy and get a “numbered” tag from the Pyxis (an automated medication dispensing cabinet), This numbered tag will indicate to pharmacy that nursing restocked and placed the lock. - Red locks are from pharmacy- cart will not be opened daily. Numbered lock is placed by nursing after use in a code. 2. Review of the hospital’s policy titled, “ Emergency Drugs and Antidotes,” dated 08/09/23, showed: - Emergency drugs, intended for the same purpose and stored in multiple locations, shall be uniformly arranged to facilitate rapid implementation of emergency care. - Emergency drugs shall be readily available to the staff but not accessible to patients, visitors, and unauthorized personnel. - The pharmacy shall responsible for maintaining the emergency drug contents at a predetermined level and for the inspection procedure to be used. Emergency drugs and emergency drug storage areas shall be checked by the pharmacy at least once a month and after each use to remove deteriorated and outdated drugs and assure completeness of content. The inspection shall assure that all items required for immediate availability are actually present and are in useable condition. - Seals shall be stored in the pharmacy and shall not be available to nursing service and others who use the drugs. - Users should check emergency drugs at least once each shift and notify pharmacy when drugs are missing, or other irregularities suspected. A determination that the seal is intact is a sufficient check for missing drugs. - The pharmacy shall replace missing, expired, and unusable drugs as soon as possible and seal the container. 3. Review of the hospital’s policy titled, “Outdated (Expired) Drugs and Unusable Drugs and Devices,” dated 10/26/23, showed: - The pharmacy shall identify outdated and other unusable drugs and devices and prevent their distribution and administration. - Pharmacy, nursing and other personnel, who discover outdated and other unusable drugs and devices, and containers with worn, illegible, or missing labels shall return them to pharmacy for proper disposition. 4. Review of hospital document titled “Crash Cart Restock Requisition”, undated, showed the medications, supplies, and inventory amounts for the crash cart. - Amiodarone (Pacerone, a medication used to slow the heart from a deadly high rate.) 150mg/100ml bag, inventory 1. - Atropine (a medication used to lower the heart rate.) 1mg, inventory 3. - Epinephrine 1:10,000 (a medication used to treat low heart rates or used to treat life threatening allergic reactions.) 1mg syringe, inventory 10. - Epinephrine 1:1,00 1mg vial, inventory 2. - Lidocaine (a medication used to correct deadly heart rhythms.) 100mg, inventory 3. - Sodium Bicarbonate (a medication used to correct pH levels.) 50mEq, inventory 2. - Calcium Chloride (a medication used to correct the potassium level in the body.) 13.6mEq, Inventory 3. - Adenosine (Adenocard, a medication used to slow the heart from a deadly high rate.) 6mg, inventory 3. - Adenosine 12mg, inventory 1. - Digoxin (Digitalis, a medication used to slow and strengthen the heart.) 0.5 mg vial, inventory 2 - Lasix (Furosemide, a medication used to aid in fluid management of the cardiac system) 40mg, inventory 3. - Mag Sulfate (a medication used to treat low blood magnesium levels.) 1 gram vial and 10 cc sterile water, inventory 2. - Lopressor (Metoprolol, a medication used to lower blood pressure.) 5mg, inventory 3. - Pronestyl (a medication used to correct heartrate.) 1000mg vial and 20cc sterile water, inventory 2. - Verapamil (a medication used to treat high blood pressure.) 5 mg vial, inventory 3 - Narcan (a medication used to reverse the effects of narcotic overdose.) 2mg, inventory 2. - Amiodarone 150mg/100ml bag, inventory 2. - Dobutamine (Dobuterx, a medication used to help strengthen the heart.) 250mg, inventory 1. - Dopamine (Intropin, a medication used to raise blood pressure.) 400mg, inventory 1. - Epinephrine 1mg/ml and 250cc D5W (an IV fluid made containing sugar and sterile water.), inventory 1. - Normal Saline (NaCL Sodium Chloride, fluid used with the administration of intravenous (IV, in the vein) medication.) 1000ml, inventory 2. - Lidocaine 2gm premixed IV bag, inventory 1. - Mag Sulfate 1gm premixed IV bag, inventory 1. - Sodium Nitroprusside (Nipride, a medication used to lower blood pressure.) 50mg vial and 250cc D5W, inventory 1. - Normal Saline (NaCL Sodium Chloride, fluid used with the administration of intravenous (IV, in the vein) medication.) 1000ml, inventory 1. - Portable suction. - Additional non medication supplies and inventory amounts were listed separately. 5. Review of the hospital’s document titled, “Cardiac Stress Lab Crash Cart Restock Requisition,” undated, showed the following emergency medications to be stocked in the medication area of the emergency crash cart: - Amiodarone 150mg/100ml bag, inventory 1. - Atropine 1mg, inventory 1. - Epinephrine 1mg syringe, inventory 1. - Lidocaine 100mg, inventory 1. - Sodium Bicarbonate 50mEq, inventory 1. - Calcium Chloride 13.6mEq, Inventory 1. - Lasix 40mg, inventory 3. - Lopressor 5mg, inventory 2. - Adenosine 6mg, inventory 3. - Adenosine 12mg, inventory 1. - Dobutamine 250mg, inventory 1. - Dopamine 400mg, inventory 1. - Normal Saline 1000ml, inventory 2. - Portable suction. - Arterial blood gas (ABG) collection kits, inventory 4. 6. Observation on 06/25/24 at 3:32 PM, in the Nuclear Medicine/Cardiac Stress Lab, crash cart, showed: - The red lock out tag was un-numbered and intact at time of inspection. - Three vials of Lasix (Furosemide, a medication used to aid in fluid management of the cardiac system) 40mg/ml expiration date 11/2023. - The cart failed to have Epinephrine 1mg in the medication drawer. - The cart failed to have portable suction. - The cart failed to have ABG collection kits. - The red lock out tag used to resecure the cart was located in the top drawer. 7. Observation 06/27/24 at 10:00 AM, of the Medical/Surgical Crash carts on the second floor showed the cart contained: - 20 outdated lubricated jelly single use packets, expiration date 04/2024. - One vial of Procainamide with the vial lid removed. - Two outdated blue top blood collection tubes, expired 05/04/2024. - Two outdate Iodine swabs, one expired 08/2023 and one expired 10/2023. 8. During an interview on 06/25/24 at 3:53 PM, Staff O, Radiology Technician, stated there was no epinephrine, ABG kits or suction on the cart. they stated the procedure was when staff opened the cart, there was a new red tag in the cart so staff could secure it until pharmacy could be contacted to come and secure it. Staff O stated they do not have numbered lock out tags. 9. During an interview on 06/25/24 at 4:43 PM, Staff A, Registered Nurse, Chief Nursing Officer, stated the nuclear medicine cart would not be used in a code, Emergency room staff would come with their cart to any code on the first floor. Staff A stated the cart was used more as a reaction cart, but Staff A would expect to see the Epinephrine medication stocked in the cart. 10. During and interview on 06/27/24 at 1:06 PM, Staff B, Director of Pharmacy Services, stated the crash carts should not contain expired medication, and should be stocked according to the inventory sheets and checked monthly. Staff B state the Medications should be removed prior the the expiration dates during the pharmacy check. Staff B stated the pharmacy was not responisble for non medication supplies, and that was the responsiblility of the departments.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 18018 Based on observation, document/record review, interview, review of nationally recognized standards, and policy review, the facility failed to ensure staff followed infection control policies and infection prevention standards when staff failed to: - Follow and incorporate the Centers for Disease Control and Prevention (CDC) Core Elements of Hospital Antibiotic Stewardship Programs: 2019 into the facility’s Antibiotic Stewardship Program when the facility’s leadership failed to ensure Antibiotic Stewardship activities included an indication for use on orders located on patients’ Electronic Medication Administration Record (EMAR). This failure by the facility had the potential to affect the measurement of effectiveness of antibiotic medication as well as the transparency for staff to determine appropriateness for all patients presented to the facility that received antibiotic medication therapy. - Performed hand hygiene (washing hands with soap and water or use of appropriate hand sanitizer) and changed gloves when indicated during a Port-a-Catheter (Port - a small medical device installed beneath a person’s skin and connects the port to a vein, used to administer medications, fluids, and obtain blood samples used for long-term therapy) dressing change for one (#12) out of one dressing change observed. - Performed hand hygiene and changed gloves when indicated during medication administration for two out of two observations conducted of staff administrating medications to patients (#12 and #24). Staff’s failure to perform hand hygiene before gloving, after glove removal, and before re-gloving increased the risk of contaminating the gloves and all objects staff touched wearing the gloves. These failed practices had the potential to affect the measurement of antibiotic effectiveness of ordered antibiotic medication therapy, expose all patients, visitors, and staff to cross- contamination and increased the potential to spread infection. The facility census was five Acute Care patients, zero Swing Bed (Swing Beds - Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing Care at the same facility) patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or discharge the patient) patient for a total census of six. Findings included: Antibiotic Stewardship 1. Observation on 06/26/24 at 8:58 AM, showed Staff P, Registered Nurse (RN), prepared medication for Patient #4. Patient #4’s medication included Ciprofloxacin (antibiotic medication used to treat bacterial infections) intravenous (IV - in a vein), 500 milligrams (mg - unit of measurement), every 12 hours for seven days that failed to include an indication for use in the EMAR. 2. Review of patient #4’s medical record showed an additional medication order for Metronidazole (antibiotic medication used to treat bacterial infections) IV, 500 mg every eight hours for seven days that failed to have an indication for use in the EMAR. 3. During an interview on 06/26/24 at 1:22 PM, Staff B, Director of Pharmacy Services, stated “I would not expect to see an indication listed on the order for an antibiotic.” 4. Observation and concurrent interview on 06/27/24 at 9:10 AM, showed Staff J, RN, prepared medications for Patient #24. Patient #24’s medications included levofloxacin (antibiotic medication used to treat bacterial infections), IV, 750 milligrams every 48 hours for five days. When Staff J was asked what the indication for the ordered antibiotic medication was for, Staff J stated they were unsure because patients’ EMAR did not include the indication for the ordered antibiotic medication. Staff J stated staff would like for the indication to be included on patients’ EMAR so staff administering the medication would know the indication why antibiotic therapy was ordered for the patient. 5. Review of Patient #24’s EMAR and printed EMAR showed no indication for the ordered antibiotic medication was included to alert staff that administered the antibiotic medication the reason antibiotic therapy was ordered for the patient. 6. During an interview on 06/27/24 at 3:20 PM, Staff B, Director of Pharmacy Services, stated the pharmacy manager served as co-coordinator for the facility’s Antibiotic Stewardship Program. Staff B stated providers included the indication for antibiotic medication therapy in the patient’s History and Physical. Staff B stated antibiotic indication could be documented in progress notes or orders, but the indication was not included on patients’ EMAR. 7. Review of the facility’s document titled, “Antibiotic Stewardship Program,” dated 09/05/23, showed staff directives: - To achieve optimal clinical outcomes related to antimicrobial use while minimizing toxicity and other adverse events and the emergence of antimicrobial-resistant organisms. - REFERENCES and related documentation: CDC Antibiotic Stewardship - Definition: Antimicrobial Stewardship refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of the optimal antimicrobial regiment including dosing, duration of therapy, and route of administration. When used in conjunction with infection prevention and control, antimicrobial stewardship also prevents the development of antimicrobial-resistant pathogens. - Conduct prospective audits of select antimicrobial use based on established criteria with direct feedback to the prescriber. - Selection of target medications by the Antibiotic Stewardship Team to prompt review when ordered. - Recommend alternatives that maintain efficacy and safety while reducing resistance liability. - Evaluate target medications every 72 hours for de-escalation or discontinuation. - Communicate recommendations to the prescribing provider and, as appropriate, Pharmacy and Therapeutics Committee. 9. Review of the facility’s document titled, Antibiotic Stewardship Program failed to ensure the indication for antibiotic therapy was included in patients’ EMAR when the provider wrote an order for a patient to receive antibiotic medication therapy. 10. Review of the CDC document titled, “The Core Elements of Hospital Antibiotic Stewardship Programs: 2019,” showed: - Prompt initiation of antibiotics to treat infections reduces morbidity and save lives, however, about 30% of all antibiotics prescribed in the U.S. acute care hospitals are either unnecessary or suboptimal. - Patients who are unnecessarily exposed to antibiotics are placed at risk for adverse events with no benefit. The misuse of antibiotics has also contributed to antibiotic resistance, a serious threat to public health. - Optimizing the use of antibiotics is critical to affectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance. - Antibiotic Stewardship Programs can help clinicians improve clinical outcomes and minimize harm by improving antibiotic prescribing. The Core Elements of Hospital Antibiotic Stewardship Programs - Hospital Leadership Commitment; - Accountability; - Pharmacy Expertise; - Action; - Tracking; - Reporting; and - Education. Pharmacy-based Interventions - Documentation of indications for antibiotics. - Automatic changes from intravenous to oral antibiotic therapy. - Dose adjustments. - Dose optimization. - Duplicative therapy alerts. - Time-sensitive automatic stop orders. - Detection and prevention of antibiotic-related drug-drug interactions. Hand Hygiene - Gloving Port-A-Catheter Dressing Change 11. Observation on 06/26/24 at 8:55 AM, showed Staff I, RN: - Entered the room wearing gloves to perform a dressing change to Patient #12’s port. - Removed gloves, performed hand hygiene, and prepared Patient #12 for the dressing change to the patient’s Port. - Put on a face mask, handed the patient a face mask to wear during the dressing change, placed a barrier pad on the sink, and placed the supply packages onto the barrier pad, removed gloves, however, Staff I failed to perform hand hygiene after glove removal. - Picked up the sterile gloves from the barrier pad and put the sterile gloves on, however, Staff I failed to perform hand hygiene before putting the sterile gloves on. - Wearing the sterile gloves, Staff I opened the supply packages and removed the swab applicator and cleansed the port site and surrounding area with the antiseptic swab. - Wearing the same gloves worn to cleanse the port site and surrounding area, Staff I accessed the port, applied a dressing over the port, flushed the port line and capped the line. - At the completion of the dressing change, Staff I removed the sterile gloves, however, Staff I failed to perform hand hygiene after removal of gloves. - Placed a blood pressure cuff on the patient’s arm and placed a pulse oximeter on the patient’s finger and obtained the patient’s temperature. 12. Review of the facility’s policy titled, “Central Venous Catheter (CVC - a long, thin, flexible tube placed in a large vein for long-term use to administer medications, fluids, blood and to obtain blood samples) Management and Maintenance,” dated 11/22/23 showed staff directives: CVC Dressing Change - Perform hand hygiene. - Open supplies, apply mask. - Ask patient to either don a mask or cover patient’s head with drape during entire dressing change. - Don clean gloves and carefully remove old dressing without putting any tension on catheter or sutures. - Examine insertions site for signs of infection and external catheter to ensure that the sutures, catheter, and hub are intact. - Apply sterile gloves, activate the chloraprep (skin disinfectant and antiseptic) sponge pad, and clean the insertion site and surrounding skin with friction (back and forth motion) for 30 seconds. - Allow to air dry. - Apply transparent dressing. - Perform hand hygiene after the procedure. 13. During an interview on 06/27/24 at approximately 4:15 PM, Staff A, RN, Chief Nursing Officer (CNO), acknowledged the CVC Management and Maintenance policy was utilized for patients with a Port. Medication Preparation and Administration 13. Observation on 06/26/24 at 8:55 AM, showed Staff I, RN, prepared Patient #12 for an infusion of Cinrynze (medication used to treat a rare Hereditary Angioedema [a disorder that results in recurrent attacks of severe swelling] disorder) 1000 Units (U - unit of measurement) 10 milliliters (ml - unit of measurement) per port every other day. Staff I gloved, however, Staff I failed to perform hand hygiene before gloving. Staff I accessed the patient’s port and connected the IV line and placed the IV line into the IV pump, programmed the IV pump and started the infusion. At the completion of starting the infusion, Staff I removed gloves, however, Staff I failed to perform hand hygiene after removal of the gloves. 14. Observation on 06/26/24 at 8:59 AM, showed Staff O, RN, prepared and administered medications to Patient #4: - Staff O performed hand hygiene, gloved, checked the patient’s ID band, and began scanning patient’s medication. - Staff O removed gloves and re-gloved, however, Staff O failed to perform hand hygiene after glove removal and before re-gloving. - Staff O cleansed the patient’s saline lock (SL - a thin flexible tube placed into a vein used to administer fluids, medications and/or nutrition through the lock and into the vein) port, flushed the line, and connected the IV tubing to the SL port. - Wearing the same gloves, Staff O programmed the IV infusion pump and attempted to start the infusion. - Staff O removed gloves and re-gloved, however, Staff O failed to perform hand hygiene before re-gloving. - After the patient took the medications, Staff O removed gloves, performed hand hygiene, and left the room. 15. During an interview on 06/26/24 at 9:10 AM, Staff I, RN, stated: - Staff received yearly competency education related to hand hygiene. Hand Hygiene should be performed: - Before staff touch a patient; - Before accessing a patient’s port; - After staff completed procedures; and - Before staff put on gloves, after staff remove gloves and before re-gloving. Gloves should be worn: - Before an invasive procedure; - Before providing care, accessing medical devices, and dressing changes for CVC lines and ports; and - Anytime staff could have possible exposure to blood, body fluids, and when indicated. 16. Observation on 06/27/24 at 9:10 AM, showed Staff J, RN, prepared and administered medications to Patient #24: - Staff J performed hand hygiene, gloved, checked the patient’s ID band, and re-checked the patient’s finger stick blood sugar (FSBS) because the patient’s blood sugar was 88 when checked earlier that morning. - After Staff J re-checked the patient’s FSBS, wearing the same gloves, Staff J, typed on the workstation computer’s keyboard. - Staff J removed gloves and re-gloved, however, Staff J failed to perform hand hygiene after glove removal and before re-gloving. - Staff J removed the bar scanner from the workstation and scanned the patient’s identification (ID) band and wearing the same gloves worn to scan the patient’s ID band, Staff J cleansed the patient’s SL port, flushed the line, and connected the IV tubing to the SL port. - Wearing the same gloves, Staff J programmed the IV infusion pump and attempted to start the infusion, however, the IV pump would not program to infuse the medication, so Staff J removed the IV tubing from the IV pump, removed gloves and re-gloved, however, Staff J failed to perform hand hygiene after glove removal and before re-gloving. - Wearing the same gloves, Staff J removed the bar code scanner from the workstation and scanned each medication bar codes, removed each medication from the packages, and wearing the same gloves, Staff J removed the pills from the packaging, and placed each pill touched by the gloved hands into a plastic medication cup. - Staff J removed gloves and re-gloved, however, Staff J failed to perform hand hygiene before re-gloving to remove the nasal cannula worn to deliver oxygen therapy to the patient. - Wearing the same gloves worn to remove the nasal cannula from the patient, Staff J handed the plastic medication cup to the patient and the patient took the medications. - After the patient took the medications, Staff J removed gloves, performed hand hygiene, and left the room to retrieve another IV infusion pump. - Upon re-entry into the patient’s room, Staff J performed hand hygiene, gloved, placed the IV tubing into the IV infusion pump, programmed the IV infusion pump, scanned the bar code on the bag of IV antibiotic medication, and wearing the same gloves, Staff J cleansed the SL port, flushed the SL port, and connected the IV tubing into the SL, programmed the IV infusion pump and started the IV antibiotic medication. - At the completion of starting the IV antibiotic, Staff J removed gloves and performed hand hygiene. 17. During an interview on 06/27/24 at 9:26 AM, Staff J stated: - Staff received yearly competency education related to hand hygiene and gloving. Hand Hygiene and Gloving should be performed: - Before patient contact; - In-between patients; - When touching medications; - Upon entry and exit of patients’ rooms; and - Before gloving, after removal of gloves and before re-gloving. 18. Review of the facility’s policy titled, “Hand Hygiene,” dated 09/05/23, showed staff directives: - To promote and improve handwashing and hand antisepsis in health-care settings, thereby reducing the incidence of transmission of infectious disease and pathogenic microorganisms to patients and healthcare personnel. Hand Hygiene shall be performed: - Whenever hands are visibly soiled, dirty, or contaminated (with or without glove use). Before: - Putting on gloves; - Touching or having contact with patients; - Performing a procedure on a patient; - Inserting any invasive device; and - Manipulating an invasive device. After: - Removing gloves; - Touching or having contact with a patient or patient’s skin; - Having contact with bodily fluids or excretions, non-intact skin, wound dressings, or other contaminated items; - Performing a procedure on a patient; - Having contact with the patient’s environment; and - Having contact with inanimate objects, contaminated items, or surfaces near a patient. Glove Use: - Perform hand hygiene before donning gloves, after removing gloves, and between glove changes. Wearing gloves does not replace the need to perform hand hygiene. - Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin could occur. - Change gloves during patient care if moving from a contaminated body site to a clean body site and perform hand hygiene between glove changes. - Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash gloves between uses with different patients. 19. During an interview on 06/27/24 at 3:37 PM, Staff K, Infection Control Preventionist, stated staff was expected to: - Remove gloves after using the bar code scanner and perform hand hygiene. - Perform hand hygiene before staff removed medication from the packages, and before placing the medications in the plastic medication cup if staff wore gloves to scan the bar codes on the medication packaging. - Perform hand hygiene before flushing SL, IV lines and ports. - Remove gloves and perform hand hygiene if staff touched inanimate (non-living objects, for example, computer workstation, bar code scanner, computer keyboard) objects in the patient’s environment and before performing procedures, treatments, and services. - Perform hand hygiene before gloving, after glove removal and before re-gloving. - Follow the facility’s policy related to hand hygiene.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 46554 Based on observation, interview, record review, review of nationally-recognized standards and policy review, the hospital failed to ensure policies were in place to perform verbal fire-risk assessments prior to surgical procedures. This deficient practice had the potential to affect all patients that received surgical services and staff at an elevated fire risk. The hospital census was five Acute Care patients, zero Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patient and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of six. Findings included: 1. During an observation on 06/26/24 at 1:30 PM, of surgical Patient #18, in the Operating Room Suite, showed surgical staff failed to perform a verbal fire-risk assessment with all surgical staff involved in the case prior to a laparoscopic cholecystectomy (a closed surgical procedure to remove the gallbladder). 2. During an interview on 06/26/24 at 4:46 PM, Staff D, Director of Surgical Services, stated staff were expected to perform and document fire-risk assessments prior to surgical procedure. They do not do this verbally with the entire operative team currently. They stated they follow the current Association of PeriOperative Registered Nurses (AORN) national standards. 3. Review of Patient record #15’s medical record on 06/26/24, showed documentation of a fire-risk assessment prior to a laparoscopic cholecystectomy. 4. Review of the AORN “Guideline for Fire Prevention Practices,” dated 2023, showed the direction for staff to: - Perform a fire-risk assessment as part of the preprocedural briefing process, to include ignition, fuel, and oxidizer sources present in the OR. - Include cognitive aids (eg, algorithms, checklists). - Collaborate on and implement interventions based on the fire-risk assessment. 5. Review of the hospital’s policy titled, “Fire Safety In The Operating Room,” dated 10/17/23, failed to show any directive to staff to perform a fire risk assessment as part of the preprocedural briefing process. The policy addressed how to manage hazards associated with fire safety in the practice setting. 6. Review of the hospital’s policy titled, “Documentation Required for a Surgical Case,” dated 10/17/23, failed to show any directive to staff to document a fire risk assessment as part of the preprocedural medical record.”

“DELIVERY OF SERVICES CFR(s): 482.56(b)(2) The provision of care and the personnel qualifications must be in accordance with national acceptable standards of practice and must also meet the requirements of §409.17 of this chapter. This Standard is not met as evidenced by: 46554 Based on observation, interview, hospital policy review and review of equipment manufacturers recommendations, the hospital failed to ensure that the equipment used in the provision of care of patients was maintained to prevent potential hazard to patients in the outpatient therapy gym. This deficient practice has the potential to affect all patients that use specialized equipment provided by the hospital. The hospital census was five Acute Care patients, zero Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of six. Findings included: 1. Observation on 06/26/2024 at 4:27 PM showed a hydrocollator (a device that consists of a thermostatically controlled water bath for placing cloth heating pads. When the pads are removed from the bath, they are placed in covers and placed on the patient) and a paraffin wax bath (hot wax used to treat pain and swelling of hands and feet.) were being used in the treatment care area. 2. During an interview at time of observation, Staff O, Director of Rehabilitation Services, stated that the hydrocollator temperature was checked weekly. The paraffin bath temperature was checked monthly, and wax was replaced when needed. 3. Review of the paraffin bath manufacturers undated maintenance and use guide stated: - Test the temperature of the paraffin prior to use. - The usable operating temperature is from 126-134 degrees F. 4. Review of hospital document titled “Temperature Log- Paraffin” showed: - The temperature range for the paraffin bath should be between 125-135 degrees F. - The staff recorded a temperature readings within range for 07/2022-10/11/2022, 02/2023-03/2023 and 07/2023-01/2024. - The staff failed to record temperature readings for 11/2022-01/2022, 04/2023-06/2023, 02/2024-03/2024 and 06/2024. 5. Review of the hydrocollator manufacturers dated 2006 maintenance and use guide showed: - The hydrocollator should be cleaned and maintained every two weeks. - The recommended operating temperature is 160-166 degrees F. The temperature of the water should be checked with a thermometer after every adjustment, before using HotPacs. - Check the water level daily as it has a natural loss due to evaporation. 6. Review of hospital document titled “Temperature Log- Hydrocollator” showed: - Temperature range for the hydrocollator should be between 160-166 degrees F. - Staff recorded a temperature readings monthly for 02/2023-03/202, 07/2023-01/2024 and 04/2024-05/2024. - Staff failed to record temperature readings for 04/2023-06/2023 and 02/2024-03/2024. - Seven of the recorded temperatures recorded were below the temperature range indicated. 7. Review of the hospital Policy titled “Cleaning of Hydrocollator,” dated 10/11/2023, showed: - The hydrocollator unit will be cleaned quarterly, or more often if needed, to maintain cleanliness of hot packs. - Monthly temperature checks will be documented to ensure temperature is within manufacture’s range. 8. Review of the hydrocollator manufacturers undated maintenance and use guide said that the hydrocollator should be regularly drained, cleaned, and maintained, and recommended the interval of this process as every two (2) weeks.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 19172 Based on observation, interview and national standards, the facility staff failed to ensure corridor doors did not have kickdowns. The facility census was six. Findings included: 1.Observations on 6/24/24, during the facility tour, showed the following corridor doors had kickdowns attached to them: - Information Technology Storage room - Patients Accounts Leader room - Patients Benefit Advisor room - Extra Office - Tel Co Room 2.During an interview 6/24/24 the Facility Operations Manager confirmed the observations. NFPA 101, 2012 edition, section 19.2.2.2.7 states: 3.”19.2.2.2.7* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.””

“Discharge from Exits CFR(s): NFPA 101 Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7 This Standard is not met as evidenced by: 19172 Based on observation, interview, record review and national standards, the facility staff failed to provide continuously maintained exit ways free of all obstructions or impediments continuous to a public way such as a parking lot. This deficient practice has the potential to affect all patients, staff and visitors in the facility. Failure to ensure exterior exit ways comply with LSC requirements could delay evacuation out of the building in the event of a fire or other emergency. This facility had a census of six. Findings included: 1. Observation on 6/24/25 and 6/25/24, during the facility tour, showed the following exit discharge areas required residents, staff, and visitors to traverse grass to reach a parking lot or sidewalk: - Exit by training room - Patient exit stairwell - Administrative Hallway exit - Stairwell B exit - Stairwell A exit 2.During interviews on 6/24/24 and 6/25/24 the Facility Operations Manager confirmed the observations. 3.Record review of the facility layout showed the exit discharge area designated for patient, staff and visitors use. 4. National Fire Protection Association 101, Life Safety Code 2012 Edition, section 7.7 state: 7.7 Discharge from Exits. 7.7.1* Exit Termination. Exits shall terminate directly, at a public way or at an exterior exit discharge, unless otherwiseprovided in 7.7.1.2 through 7.7.1.4.”

“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: 19172 Based on observation, interview and national standards, the facility failed to provide and maintain one of one kitchen range hood in accordance with NFPA 96, Standard for Ventilation Control and Fire Prevention of Commercial Cooking Operations, 2011 edition. The facility census was six. Findings included: 1. Observation on 6/25/24, during the facility tour, showed the range hood did not have an enclosed metal container to collect grease from the drip tray. 2. During an interview on 6/25/24 at 10:05 P.M., the Facility Operations Manager confirmed the observation. 3. NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, Section 6.2.4.1 states: “Grease filters shall be equipped with a grease drip tray beneath their lower edges””

“Interior Wall and Ceiling Finish CFR(s): NFPA 101 Interior Wall and Ceiling Finish 2012 EXISTING Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted. 10.2, 19.3.3.1, 19.3.3.2 Indicate flame spread rating(s). _____________________ This Standard is not met as evidenced by: 19172 Based on observation, interview and national standards, the facility failed to ensure an interior partition had a class A or B rating. The facility had a census of six. Findings included: 1.Observation on 6/24/24, during the facility tour showed an interior partition in the training room. Further observation showed the interior partition did not have a tag identify it as fire rated. 2.During an interview on 6/24/24 at 2:50 P.M., the Facility Operations Manager said that he did not know if the interior partition had a fire rating. 3.See NFPA 101, 2012 edition, section 10.2, 19.3.3.1, and 19.3.3.2”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 19172 Based on observation, interview and national standards, the facility failed to ensure that one of one fire alarm systems was installed per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The deficient practice has the potential to effect all facility patients, staff and visitors. The deficient practice could delay fire and emergency personnel response in the event of a fire. The census was six. Findings included: 1. Observation on 6/25/24, during the facility tour, showed the following areas did not have smoke detector coverage: - 2nd Floor Medication Room - 2nd Floor Dictation Room - 2nd Floor Coffee room 2.During an interview on 6/25/24 the Facility Operations Manager confirmed the observations. 3.National Fire Protection Association 101, 2012 edition, section 19.3.4.1 states: “19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.” Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 19172 Based on observation, interview and national standards, the facility failed to ensure the building sprinkler system met NFPA 13, Standard For The Installation Of Sprinkler Systems, 2010 edition installation requirements. This deficient practice could delay prompt fire extinguishment and evacuation in the event of a fire. The facility census was six. Findings included: 1. Observations on 6/24/24, during the facility tour, showed elevators 1 & 2, did not have sprinklers installed in the pit. Observation showed the elevators used combustible hydraulic fluid. 2.During an interview on 6/24/24 at 10:45 A.M., the Facility Operations Manager said the elevator pits did not have sprinkler coverage. 3. NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS, 2010 Edition section 8.15.5 states: “8.15.5 Elevator Hoistways and Machine Rooms. 8.15.5.1* Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit. 8.15.5.2 The sprinkler required at the bottom of the elevator hoistway by 8.15.5.1 shall not be required for enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids.”

“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: 19172 Based on record review, interview and national standards, the facility failed to inspect the sprinkler systems per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. The facility census was six. Findings included: 1.Record review on 6/25/24 showed the following inspections: - One quarterly waterflow alarm test in the last 12 months dated 6/13/23. - The last five year internal pipe inspection dated 5/19. 2.During an interview on 6/25/24 at 2:13 P.M., the Facility Operations Manager said that the last quarterly waterflow alarm test was conducted on 6/13/23. The Facility Operations Manager said that he did not have any other waterflow alarm tests. 3.During an interview on 6/24/24 the Facility Operations Manager said that the last five year internal pipe inspection was in May of 2019. The Facility Operations Manager said that a five year internal pipe inspection is not scheduled. 4.Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13 and 14 for additional information.”

“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: 19172 Based on observation and interview, the facility failed to ensure corridor doors were positive latching. This deficient practice had the potential to affect all patients, staff and visitors. Failure to ensure corridor doors positive latch had the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors in the event of a fire. The facility census was six. Findings included: 1.Observation on 6/24/24, during the building tour, showed the double doors to the training room did not latch. 2.During an interview on 6/24/24 at 2:46 P.M., the Director of Plant Operations confirmed the observation”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 19172 Based on observation and interview, the facility failed to ensure a hazardous waste room was adequately vented and kept under a relative negative pressure. This deficient practice has the potential to effect all residents, staff and visitors. Failure to provide adequate ventilation could increase the concentration of smoke, products of combustion and noxious fumes. The facility census was six. Findings included: 1.Observation on 6/25/24, during the facility tour, showed the hazardous area room did not have functioning exhaust ventilation. 2.During an interview on 6/25/24 at 9:50 A.M., the Facility Operations Manager said that the hazardous waste room did not have ventilation.”

“Draperies, Curtains, and Loosely Hanging Fabr CFR(s): NFPA 101 Draperies, Curtains, and Loosely Hanging Fabrics Draperies, curtains including cubicle curtains and loosely hanging fabric or films shall be in accordance with 10.3.1. Excluding curtains and draperies: at showers and baths; on windows in patient sleeping room located in sprinklered compartments; and in non-patient sleeping rooms in sprinklered compartments where individual drapery or curtain panels do not exceed 48 square feet or total area does not exceed 20 percent of the wall. 18.7.5.1, 18.3.5.11, 19.7.5.1, 19.3.5.11, 10.3.1 This Standard is not met as evidenced by: 19172 Based on observation, interview and national standards, the facility failed to provide window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. The facility census was six. Findings included: 1. Observations on 6/24/24 and 6/25/24, during the Life Safety Code tour, showed window blinds and curtains throughout the facility that did not have identification that showed them as being flame retardant. 2.During an interview on 6/24/24 at 2:50 P.M., the Facility Operations Manager said he did not know if the window covering had a rating. 3.NFPA Standard: Draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as /demonstrated by testing in accordance with NFPA 701. 2012 NFPA 101.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 19172 Based on observation, interview and national standards, the facility failed to ensure space heaters met the requirements of NFPA 101, 2012 edition. The facility census was six. Findings included: 1.Observations on 6/24/24 and 6/25/24, during the facility tour, showed the following areas contained space heaters built into the wall: - IT storage room - Patient Access stairwell exit - Elevator room (basement) 2.During an interview on 6/24/24 at 3:30 P.M., the Facility Operations Manager the space heaters have been in the walls since the building was constructed. 3.19.7.8 Portable Space-Heating Devices. Portable spaceheating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met: (1) Such devices are used only in nonsleeping staff and employee areas. (2) The heating elements of such devices do not exceed”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99) This Standard is not met as evidenced by: 19172 Based on observation, interview and national standards, the facility failed to provide a constantly attended remote annunciator panel (a panel providing information on the condition and problems with the emergency generator) for two of two emergency generators. The census was six. Findings included: 1. Observation on 6/24/24, during the facility tour, did not show a remote annunciator panel for the emergency generator in a constantly attended location. 2.During an interview on 6/24/24 at 4:00 P.M., the Facility Operations Manager said the remote annunciator panel is located in the basement area of the facility and not constantly attended. 3.NFPA 99, 2012 edition, section 6.4.1.1.17 states: “6.4.1.1.17 Alarm Annunciator. A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see 700.12 of NFPA 70, National Electrical Code). The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows: (1) Individual visual signals shall indicate the following: (a) When the emergency or auxiliary power source is operating to supply power to load (b) When the battery charger is malfunctioning (2) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following: (a) Low lubricating oil pressure (b) Low water temperature (below that required in 6.4.1.1.11) (c) Excessive water temperature (d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply (e) Overcrank (failed to start) (f) Overspeed 6.4.1.1.17.1* A remote, common audible alarm shall be provided as specified in 6.4.1.1.17.4 that is powered by the storage battery and located outside of the EPS service room at a work site observable by personnel. [110:5.6.6] 6.4.1.1.17.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm has been silenced, it reactivates after the fault condition has been cleared and has to be restored to its normal position to be silenced again. [110:5.6.6.1] 6.4.1.1.17.3 In lieu of the requirement of 5.6.6.1 of NFPA110, a manual alarm-silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action. [110:5.6.6.2] 6.4.1.1.17.4 Individual alarm indication to annunciate any of the conditions listed in Table 6.4.1.1.16.2 shall have the following characteristics: (1) It shall be battery powered. (2) It shall be visually indicated. (3) It shall have additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. (4) It shall have a lamp test switch(es) to test the operation of all alarm lamps. 6.4.1.1.17.5 Acentralized computer system (e.g., building automation system) shall not be permitted to be substituted for the alarm annunciator in 6.4.1.1.17 but shall be permitted to be used to supplement the alarm annunciator. 6.4.1.2 Battery. Battery systems shall meet all requirements of Article 700 of NFPA 70, National Electrical Code. Table 6.4.1.1.16.2 Safety Indications and Shutdowns Level 1 Indicator Function (at Battery Voltage) CV S RA (a) Overcrank (b) Low water temperature (c) High engine temperature pre-alarm (d) High engine temperature (e) Low lube oil pressure pre-alarm (f) Low lube oil pressure (g) Overspeed (h) Low fuel main tank (i) Low coolant level (j) EPS supplying load (k) Control switch not in automatic position (l) High battery voltage (m) Low cranking voltage (n) Low voltage in battery (o) Battery charger ac failure (p) Lamp test (q) Contacts for local and remote common alarm (r) Audible alarm-silencing switch (s) Low starting air pressure (t) Low starting hydraulic pressure (u) Air shutdown damper when used (v) Remote emergency stop CV: Control panel-mounted visual. S: Shutdown of EPS indication. RA: Remote audible. X: Required. O: Optional. Notes: (1) Item (p) shall be provided, but a separate remote audible signal shall not be required when the regular work site in 5.6.6 of NFPA110, Standard for Emergency and Standby Power Systems, is staffed 24 hours a day. (2) Item (b) is not required for combustion turbines. (3) Item (r) or (s) is required only where used as a starting method. (4) Item (j): EPS ac ammeter shall be permitted for this function. (5) All required CV functions shall be visually annunciated by a remote, common visual indicator. (6) All required functions indicated in the RAcolumn shall be annunciated by a remote, common audible alarm as required in 5.6.5.2(4) of NFPA 110. (7) Item (i) requires a low gas pressure alarm on gaseous systems. (8) Item (b) must be set at 11°C (20°F) below the regulated temperature determined by the EPS manufacturer, as re”

“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: 19172 Based on observation, interview and national standards, the facility failed to provide an emergency stop switch away from the generator set location. This facility had a census of six. Findings Included: 1. Observation 6/24/24, during the facility tour, showed the twos emergency generator’s emergency stop switches located on the generator. 2. During an interview on 6/24/24 at 4:02 P.M.,, the Facility Operations Manager confirmed the observation. The Facility Operations Manager said there are no emergency stop switches located away rom the generator set. 3. NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition states: 5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. 5.6.5.6.1 The remote manual stop station shall be labeled. 8.4.2* Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer (2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating 8.4.2.1 The date and time of day for required testing shall be decided by the owner, based on facility operations. 8.4.2.2 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source. 8.4.2.3 Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kWrating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. 8.3 Maintenance and Operational Testing. 8.3.1* The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class. 8.3.2 A routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the operational reliability of the system. 8.3.2.1 The operational test shall be initiated at an ATS and shall include testing of each EPSS component on which maintenance or repair has been performed, including the transfer of each automatic and manual transfer switch to the alternate power source, for a period of not less than 30 minutes under operating temperature. 8.3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established. 8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available. 8.3.4.1 The permanent record shall include the following: (1) The date of the maintenance report (2) Identification of the servicing personnel (3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced (4) Testing of any repair for the time as recommended by the manufacturer 8.3.5* Transfer switches shall be subjected to a maintenance and testing program that includes all of the following operations: (1) Checking of connections (2) Inspection or testing for evidence of overheating and excessive contact erosion (3) Removal of dust and dirt (4) Replacement of contacts when required 8.3.6 Paralleling gear shall be subject to an inspection, testing, and maintenance program that includes all of the following operations: (1) Checking of connections (2) Inspection or testing for evidence of overheating and excessive contact erosion (3) Removal of dust and dirt (4) Replacement of contacts when required 8.3.7* Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer ’ s specifications. 8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted. 8.3.7.2 Defective batteries shall be replaced immediately upon discovery of defects. 8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards. 8.4 Operational Inspection and Testing. 8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 8.4.6 Transfer switches shall be operated monthly. 8.4.6.1 The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position. 7.2.4* Minimizing the possibility of damage resulting from interruptions of the emergency source shall be a design consideration for EPSS equipment. A.7.2.4 When installing the EPSS equipment and related auxiliaries, environmental considerations should be given, particularly with regard to the installation of the fuel tanks and exhaust lines, or the EPS building, or both. To protect against disruption of power in the facility, it is recommended that the transfer switch be located as close to the load as possible. The following are examples of external influences: (1) Natural conditions (a) Storms (b) Floods (c) Earthquakes (d) Tornadoes (e) Hurricanes (f) Lightning (g) Ice storms (h) Wind (i) Fire (2) Human-caused conditions (a) Vandalism (b) Sabotage (c) Other similar occurrences (3) Material and equipment failures For natural conditions, EPSS design should consider the “100-year storm” flooding level or the flooding level predicted by the Sea, Lake, and Overland Surges from Hurricanes 918”