Glenbeigh Health Sources

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 22432 Based on review of facility schematics, facility observation, review of preventative maintenance documentation and staff Interview and confirmation, the facility failed to ensure: There must be emergency power and lighting in at least the operating, recovery, intensive care, and emergency rooms, and stairwells. In all other areas not serviced by the emergency supply source, battery lamps and flashlights must be available; and the hospital must maintain written evidence of regular inspection and approval by State or local fire control agencies. The facility capacity was 114 with a census of 71. See Tags at A-0702 and A-0715.”

“EMERGENCY POWER AND LIGHTING CFR(s): 482.41(a)(1) There must be emergency power and lighting in at least the operating, recovery, intensive care, and emergency rooms, and stairwells. In all other areas not serviced by the emergency supply source, battery lamps and flashlights must be available. This Standard is not met as evidenced by: 22432 Based on observation and staff interview, the facility failed to maintain its generator in accordance with NFPA 101-2012 Edition section 7.9.2.4, NFPA 110-2010 Edition sections 5.6.5.6 and 5.6.5.6.1. This deficient practice had the potential to affect all 127 residents in the facility. Findings include: On 06/11/2024 at 1:45 P.M., observation during the facility tour with the Director of Maintenance revealed the facility’s generators were not equipped with remote manual stop stations. The Director of Maintenance verified the above finding at the time of observation. NFPA 101-2012 Edition, 7.9.2.4 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, other than battery systems for emergency luminaries in accordance with 7.9.2.5, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems. NFPA 110-2010 Edition, 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. A.5.6.5.6 For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.”

“REGULAR FIRE AND SAFETY INSPECTIONS CFR(s): 482.41(b)(8) (6) The hospital must maintain written evidence of regular inspection and approval by State or local fire control agencies. This Standard is not met as evidenced by: 22432 Based on observations, record review the facility failed to ensure receptacles in resident rooms were tested in accordance with the LSC, 2012 Edition 7.9.2.4, 6.3.3.2. This deficient practice had the potential to affect all 127 residents in the facility. Findings include: On 06/11/2024 at 1:13 P. M., during record review the facility was unable to provide documentation showing completion of the required annual receptacle testing in patient care rooms. The Director of Maintenance verified the above findings at the time of record review. NFPA 101-2012 Edition, 7.9.2.4 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, other than battery systems for emergency luminaries in accordance with 7.9.2.5, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems. 6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).”

“Amended 08/02/24 A Life Safety Code Recertification Survey was conducted by the Ohio Department of Health, between 06/11/2024 and 06/12/2024. Glenbeigh was found to not be in substantial compliance with the requirements for participation in Medicare/Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association 101, Life Safety Code Chapter 18, New Health Care Occupancies. Recovery Glen is a fully sprinkled 1 story facility with no basement was determined to be of construction Type V (000) construction and located at 2863 STATE ROUTE 45 ROCK CREEK, OH 44084. The facility has smoke alarm, and fire alarm systems in place. The facility has three additional buildings, Main Building, Hope Lodge and Serenity Bay all were single story with no basement, fully sprinklered, smoke and Fire alarms in place, and were surveyed as type V(000) construction.”

“Ammended 08/02/24 A Life Safety Code Recertification Survey was conducted by the Ohio Department of Health, between 06/11/2024 and 06/12/2024. Glenbeigh was found to not be in substantial compliance with the requirements for participation in Medicare/Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association 101, Life Safety Code Chapter 19, Existing Health Care Occupancies. This fully sprinkled 2 story facility with no basement was determined to be of construction Type II (000) construction. The facility has smoke alarm, and fire alarm systems in place. The facility has three additional buildings, Hope Lodge, Recovery Glen, and Serenity Bay all were single story with no basement, fully sprinklered, smoke and Fire alarms in place, and were surveyed as type V(000) construction.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 44541 Based on observations, record review the facility failed to ensure receptacles in resident rooms were tested in accordance with the LSC, 2012 Edition 7.9.2.4, 6.3.3.2. This deficient practice had the potential to affect all 127 residents in the facility. Findings include: On 06/11/2024 at 1:13 P.M., during record review the facility was unable to provide documentation showing completion of the required annual receptacle testing in patient care rooms. The Director of Maintenance verified the above findings at the time of record review. NFPA 101-2012 Edition, 7.9.2.4 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, other than battery systems for emergency luminaries in accordance with 7.9.2.5, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems. 6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to one month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 44541 Amended 08/02/24 Based on observations, record review the facility failed to ensure receptacles in resident rooms were tested in accordance with the LSC, 2012 Edition 7.9.2.4, 6.3.3.2. This deficient practice had the potential to affect all 127 residents in the facility. Findings include: On 06/11/2024 at 1:13 P.M., during record review the facility was unable to provide documentation showing completion of the required annual receptacle testing in patient care rooms. The Director of Maintenance verified the above findings at the time of record review. NFPA 101-2012 Edition, 7.9.2.4 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, other than battery systems for emergency luminaries in accordance with 7.9.2.5, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems. 6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).”

“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: 44541 Based on observation and staff interview, the facility failed to maintain its generator in accordance with NFPA 101-2012 Edition section 7.9.2.4, NFPA 110-2010 Edition sections 5.6.5.6 and 5.6.5.6.1. This deficient practice had the potential to affect all 127 residents in the facility. Findings include: On 06/11/2024 at 1:45 P.M., observation during the facility tour with the Director of Maintenance revealed the facility’s generators were not equipped with remote manual stop stations. The Director of Maintenance verified the above finding at the time of observation. NFPA 101-2012 Edition, 7.9.2.4 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, other than battery systems for emergency luminaries in accordance with 7.9.2.5, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems. NFPA 110-2010 Edition, 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. A.5.6.5.6 For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.”

“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: 44541 Amended 08/02/24 Based on observation and staff interview, the facility failed to maintain its generator in accordance with NFPA 101-2012 Edition section 7.9.2.4, NFPA 110-2010 Edition sections 5.6.5.6 and 5.6.5.6.1. This deficient practice had the potential to affect all 127 residents in the facility. Findings include: On 06/11/2024 at 1:45 P.M., observation during the facility tour with the Director of Maintenance revealed the facility’s generators were not equipped with remote manual stop stations. The Director of Maintenance verified the above finding at the time of observation. NFPA 101-2012 Edition, 7.9.2.4 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, other than battery systems for emergency luminaries in accordance with 7.9.2.5, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems. NFPA 110-2010 Edition, 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. A.5.6.5.6 For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.”