Memorial Health Care Systems

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 44712 Based on observations, record review and staff interview the Critical Access Hospital (CAH) failed to maintain a complete inventory of all facility equipment used in the care of patients and failed to provide ongoing preventative maintenance in accordance with manufacturer specifications for 12 of 52 sampled pieces of medical equipment. This failed practice had the potential to affect all patients of the CAH. The CAH had 379 inpatient admissions, 207 observation admissions, 145 swing bed admissions, 4,105 emergency department visits and 7,176 outpatient specialty clinic visits for fiscal year 2023. Findings include: A. Tour of inpatient area (3/19/2024 at 9:00 AM) revealed the following equipment not listed on the Bio-Electronics equipment file listing or testing was documented: -IV pump with an equipment log sticker 1069. Equipment number 1069 on Bio-Electronics equipment file list revealed the columns “last test” and “test due” were blank. -Suction unit on the crash cart with an equipment log sticker 1108. Equipment number 1108 was not listed on Bio-Electronics equipment file list. -Baby warmer in the labor and delivery area with an equipment log sticker 1138. Equipment number 1138 was not listed on Bio-electronics equipment file list. -Kangaroo pump with an equipment log sticker 1144. Equipment number 1144 was not listed on Bio-Electronics equipment file list. -Kangaroo pump with an equipment log sticker 1145. Equipment number 1145 was not listed on Bio-Electronics equipment file list. B. Tour of radiology department (3/19/2024 at 3:30 PM) revealed vital sign machine in CT room with an equipment log sticker 861. Equipment number 861 was not listed on Bio-Electronics equipment file list. C. Tour of emergency department (3/20/2024 at 7:59 AM) revealed the following equipment not listed on the Bio-Electronics equipment file listing or testing was documented: - Cardiac monitor in exam room A with an equipment log sticker 1118. Equipment number 1118 on Bio-Electronics equipment file list revealed the columns “last test” and “test due” were blank. -Cardiac monitor in exam room A with an equipment log sticker 1119. Equipment number 1119 on Bio-Electronics equipment file list revealed the columns “last test” and “test due” were blank. D. Tour of outpatient specialty clinic (3/20/2024 at 3:00 PM) revealed the following equipment not listed on the Bio-Electronics equipment file listing or testing was documented: -Suction unit with an equipment log sticker 852. Equipment number 852 was not listed on Bio-Electronics equipment file list. - Electrocardiogram (EKG) machine (records heart’s electrical activity) with an equipment log sticker 942. Equipment number 942 was not listed on Bio-Electronics equipment file list. -Vital sign machine with an equipment log sticker 1103. Equipment number 1103 on Bio-Electronics equipment file list revealed the columns “last test” and “test due” were blank. E. Tour of respiratory therapy (3/21/2024 at 8:00 AM) revealed a bipap machine (machine used to help you breathe) with an equipment log sticker 930. Equipment number 930 was not listed on Bio-Electronics equipment file list. F. Review of facility policy titled Equipment & Electrical Safety Management (Reviewed August 2023) stated that “Department heads are responsible for identifying, evaluating and keeping an inventory list of all patient equipment in use in their departments” and, “The department heads keep a record of all inspections, maintenance or repair on file according to the record retention policy.” The policy also stated “Any new, under contract, leased or borrowed equipment should be tested prior to use by the operator to be sure it is operating within the parameters it is to be used.” -Review of facility policy titled Preventive Maintenance Program (Revised March 2024) stated “Each piece of equipment, responsible to the engineering department, is listed on a preventive maintenance form. Each unit is assigned an equipment number, along with the location and frequency of the duties to be performed. Each a month a printout is made of the equipment to be serviced that month. When the equipment is serviced, the date the work was completed, as well as the work performed, will be put on the printout. The printout will be used as the documentation of the work completed.” G. Interview with Director of Plant Operations (3/21/2024 at 9:20 AM) revealed new pieces of equipment goes to materials management and either Bio-electronics or facility puts equipment log sticker on equipment. Bio-Electronics are contacted by the facility when new equipment is received. -Interview with Director of Materials Management (3/21/24 at 9:22 AM) confirmed vital machines, IV pumps and kangaroo pumps are no longer under warranty. Facility acknowledged the need to contact Bio-Electronics to add patient care equipment to their list to do preventive maintenance on.”

“ANESTHETIC RISK AND EVALUATION CFR(s): (1) A qualified practitioner, as specified in paragraph (a) of this section, must examine the patient immediately before surgery to evaluate the risk of the procedure to be performed. (2) A qualified practitioner, as specified in paragraph (c) of this section, must examine each patient before surgery to evaluate the risk of anesthesia. (3) Before discharge from the CAH, each patient must be evaluated for proper anesthesia recovery by a qualified practitioner, as specified in paragraph (c) of this section. This Standard is not met as evidenced by: 15107 Based on medical record review and staff interview, the CAH (Critical Access Hospital) failed to ensure the physician examined the patient immediately before surgery to evaluate the risk of the procedure to be performed for 1 of 6 surgical medical records (Patient 30) reviewed. This failed practice had the potential to affect all surgical patients of the CAH. The CAH performs an average of 55 procedures a month. Findings are: A. Review of Patient 30’s surgical medical record (3/20/24 at 2:35 PM) revealed the patient had Electrocal cardioversion (procedure used to return an abnormal heartbeat to a normal rhythm) under MAC (Monitored Anesthesia Care- medications that help you relax during a minor procedure) on 12/20/23. Review of the entire medical record revealed the “Preprocedural Evaluation” signed, dated 12/20 (lacked year completed) and lacked documentation of time ensuring that the examination was completed before surgery. B. Interview (3/21/24 at 12:50 PM) with the Director of Nursing (DON) confirmed the pre-procedural evaluation lacked documentation of the year and time the assessment was completed. The DON also stated there was no policy and procedure in place for the pre-procedural examination.”

“Hospital CAH and LTC Emergency Power CFR(s): §482.15(e) Condition for Participation: (e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section. §483.73(e), §485.625(e), §485.542(e) (e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section. §482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1) Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated. 482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2) Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code. 482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2) Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates. *[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):] The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes. (1) National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169, www.nfpa.org, 1.617.770.3000. (i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011. (ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011. (iii) TIA 12-3 to NFPA 99, issued August 9, 2012. (iv) TIA 12-4 to NFPA 99, issued March 7, 2013. (v) TIA 12-5 to NFPA 99, issued August 1, 2013. (vi) TIA 12-6 to NFPA 99, issued March 3, 2014. (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011. (viii) TIA 12-1 to NFPA 101, issued August 11, 2011. (ix) TIA 12-2 to NFPA 101, issued October 30, 2012. (x) TIA 12-3 to NFPA 101, issued October 22, 2013. (xi) TIA 12-4 to NFPA 101, issued October 22, 2013. (xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.. This Standard is not met as evidenced by: 13879 Based on documentation review and interview, the facility failed to provide a mathematical formula to verify if the generator was run at 30 percent and did conduct a load bank test. This deficient practice would increase the probability that the generator would fail to run during an emergency loss of power and the emergency systems in the facility. The facility has the capacity for 25 beds with a census of 18 on the day of survey. Findings are: Documentation review on 3-21-24 at 12:08 pm revealed, the facility did not conduct an annual load bank for the generator. The facility failed to provide a mathematical formula to determine the required information for the 30 percent requirement for the generator. During an interview on 3-21-24 at 12:08 pm, Staff A confirmed the findings.”

“42 CFR 482.41 The facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code of the National Fire Protection Association. This facility is governed by Chapter 19, Existing Health Care Occupancies of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code. Memorial Hospital Health Care Systems is a 3 story building built in 1950 with additions in 2000 and 2015, Type II (III) construction and fully sprinkled with smoke detection in the corridors and spaces open to the corridors. Facility is licensed for 25 beds with a census of 18 at time of survey. This inspection includes an Assisted Living which is not seperated from the Hospital and Therapy Gym in the lower level used by inpatients and outpatients. Memorial Hospital Health Care Systems was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 482.41, Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition”

“Illumination of Means of Egress CFR(s): NFPA 101 Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8 This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to provide egress illumination that would provide illumination along the paths of egress. The lack of egress illumination along the path to safety would cause confusion and delay egress from the facility during an emergency. The facility has the capacity for 25 beds with a census of 18 on the day of survey. Findings are: Observation on 3-21-24 at 11:15 am revealed, the sidewalk from the new cafeteria addition failed to provide lighting to a public way. During an interview on 3-21-24 at 11:15 am, Staff A confirmed the lack of egress lighting along the egress path. NFPA Standard: NFPA 101, 2012, 7.8.1.1* Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 43. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to assure that hazardous areas were separated from the rest of the building. These deficient practices would not assure that fire smoke and gasses would remain within the hazardous area and not spread. The facility has the capacity for 25 beds with a census of 18 on the day of survey. Findings are: Observation on 3-21-24 between 12:08 pm and 2:12 pm revealed: 1. Vinyl base cove was used as a fire rated sweep to cover the large undercut on the 1 ½ hour rated door in the maintenance area leading into the unsprinkled crawl space. 2. The wall between the laundry linen storage and the maintenance shop failed to provide 1 hour fire rating. The wall consisted of glass and wood. 3. The OR supply room in Materials Management failed to provide a self-closing device on the door. 4. Accounting storage room in the Therapy Services area was over 50 square feet and the door failed to provide a self-closing device. During an interview on 3-21-24 between 12:08 pm and 2:12 pm, Staff A confirmed the observations.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 13879 Based on observation, documentation review and interview, the facility failed to assure that heat detectors were maintained and failed to assure that an audible and visual device was provided in sleeping areas. This deficient practice would not notify occupants in the areas of an emergency and that the heat detectors were operational. The facility has the capacity for 25 beds with a census of 18 on the day of survey. Findings are: Observation on 3-21-24 at 1:28 pm and 1:40 pm revealed: 1. The “Future MRI room” was used as a sleeping room and no audible visual device was provided. 2. No documentation of testing of the heat detector in the Assisted Living linen, housekeeping and electrical rooms. During an interview on 3-21-24 at 1:28 pm and 1:40 pm, Staff A confirmed the findings. Documentation review on 3-21-24 at 11:16 am revealed that no heat detectors had been tested. During an interview on 3-21-24 at 11:16 am, Staff A stated that all smoke detectors were removed.”

“Sprinkler System - Out of Service CFR(s): NFPA 101 Sprinkler System - Out of Service Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service. 18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) This Standard is not met as evidenced by: 13879 Based on record review and interview, the facility failed to provide a complete policy regarding the procedures to be taken in the event the fire sprinkler system was out of service for more than 10 hours in any 24-hour period. The lack of a complete written policy and procedure would result in staff failing to implement interim safety measures in the event of an emergency. The facility has the capacity for 25 beds with a census of 18 on the day of survey. Findings are: Record review on 3-21-24 at 11:12 am of the fire watch procedures revealed: 1. The policy lacked the required persons to contact including insurance carrier, the alarm company, property owner or designated representative, and supervisors. During an interview on 3-21-24 at 11:12 am, Staff A confirmed the lack of information in the fire watch policy. NFPA Standard: 2011, NFPA 25 15.5* Preplanned Impairment Programs. 15.5.1 All preplanned impairments shall be authorized by the impairment coordinator. 15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented: (1) The extent and expected duration of the impairment have been determined. (2) The areas or buildings involved have been inspected and the increased risks determined. (3) Recommendations have been submitted to management or the property owner or designated representative. (4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following: (a) Evacuation of the building or portion of the building affected by the system out of service (b)*An approved fire watch (c)*Establishment of a temporary water supply (d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire (5) The fire department has been notified. (6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified. (7) The supervisors in the areas to be affected have been notified. (8) A tag impairment system has been implemented. (See Section 15.3.) (9) All necessary tools and materials have been assembled on the impairment site. 15.6 Emergency Impairments. 15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure. 15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage. 15.6.3 The coordinator shall implement the steps outlined in Section 15.5.”

“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: 13879 Based on observation and interview, the facility failed to ensure corridor doors would resist the passage of smoke. This deficient practice would not prevent the spread of fire, smoke and gasses within the exit corridors. The facility has the capacity for 25 beds with a census of 18 on the day of survey. Findings are: Observation on 3-21-24 at 1:34 pm revealed, Trauma Room 1 sliding door failed to latch within the doorframe. During an interview on 3-21-24 at 1:34 pm, Staff A confirmed the door failed to latch within the frame and stated that the area was not a suite.”

“Evacuation and Relocation Plan CFR(s): NFPA 101 Evacuation and Relocation Plan There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2. 18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3 This Standard is not met as evidenced by: 13879 Based on interview and record review, the facility failed to provide a complete fire plan. This deficient practice would delay evacuation and affected all smoke compartments and all occupants. The facility has the capacity for 25 beds with a census of 18 on the day of survey. Findings are: Record review on 3-21-24 at 11:35 am revealed, the fire evacuation plan failed to include: 1. Removal of occupants in the immediate are of fire, those adjacent and across the hall and above or below the fire. 2. Smoke compartment evacuation. 3. Evacuation policy failed to detail that the room of fire origin shall not be crossed, before continuing to evacuate the remainder of the smoke compartment. 4. That items in the corridor shall be removed. 5. Staff required to call fire department/911. During an interview on 3-21-24 at 11:35 am, Staff A confirmed the lack of the of information in the fire plan. NFPA Standard: NFPA 101, 2012, 19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following: (1) Use of alarms (2) Transmission of alarms to fire department (3) Emergency phone call to fire department (4) Response to alarms (5) Isolation of fire (6) Evacuation of immediate area (7) Evacuation of smoke compartment (8) Preparation of floors and building for evacuation (9) Extinguishment of fire 18.7.2.3.1 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. 18.7.2.3.2 All health care occupancy personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under any of the following conditions: (1) When the individual who discovers a fire must immediately go to the aid of an endangered person (2) During a malfunction of the building fire alarm system 18.7.2.3.3 Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 13879 Based on documentation review and interview, the facility failed to conduct fire drills at random times and failed to activate the fire alarm 24 hours before or after the 3rd shift drills. This deficient practice failed to provide simulated training for staff to respond to a fire emergency during various activities and staffing levels. The facility has the capacity for 25 beds with a census of 18 on the day of survey. Findings are: Documentation review on 3-21-24 at 11:03 am revealed: 1. Numerous drills failed to be conducted more than 1 hour apart. 2. Fire alarm was not activated during 3rd shift, 24 hours before or after the drill was conducted. During an interview on 3-21-24 at 11:03 am, Staff A confirmed the findings.”

“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: 13879 Based on documentation review and interview, the facility failed to provide a mathematical formula to verify if the generator was run at 30 percent and did conduct a load bank test. This deficient practice would increase the probability that the generator would fail to run during an emergency loss of power and the emergency systems in the facility. The facility has the capacity for 25 beds with a census of 18 on the day of survey. Findings are: Documentation review on 3-21-24 at 12:08 pm revealed, the facility did not conduct an annual load bank for the generator. The facility failed to provide a mathematical formula to determine the required information for the 30 percent requirement for the generator. During an interview on 3-21-24 at 12:08 pm, Staff A confirmed the findings.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to prohibit the use of extension cords as a substitute for adequate wiring. This deficient practice would create an increased fire hazard. The facility has the capacity for 25 beds with a census of 18 on the day of survey. Findings are: Observation on 3-21-24 at 1:52 pm revealed, a refrigerator plugged into a power-strip in Respiratory Therapy office. During an interview on 3-21-24 at 1:52 pm, Staff A confirmed the findings.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to assure that excessive oxygen was not stored within a resident sleeping room. This deficient practice would allow the escape of oxygen which would cause an oxygen enriched atmosphere and increase the potential for a fire. The facility has the capacity for 25 beds with a census of 18 on the day of survey. Findings are: Observation on 3-21-24 at 1:21 pm revealed: 1. Resident in room 27 using an oxygen concentrator and nine additional oxygen cylinders in the room. During an interview on 3-21-24 at 1:21 pm, Staff A confirmed excessive oxygen within the resident room.”