Wyandot Memorial Hospital

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 28999 Based on observation, interview and policy review, the facility failed to ensure staff checked emergency code carts and failed to ensure the integrity of the breakaway locks on emergency carts not in constant surveillance. This had the potential to affect all patients receiving emergency treatment. The hospital census was nine. Findings include: 1. The facility’s Emergency Department including a triage room, trauma bay, 11 treatment rooms, and four observation rooms, was toured on 07/23/24 at 12:50 PM. An emergency cart was observed in the two-bed trauma room. A red breakaway lock was threaded through only the first hole within the locking handle and then through itself. The breakaway lock was not threaded through the second hole which allowed the nine drawers of the emergency cart to be opened leaving emergency medication and equipment unsecured. Drawers one and two contained advanced cardiac life support drugs. Drawers three to eight contained basic airway equipment including bag valve masks, nasal cannulas, and oxygen masks. Drawer nine, a gray color, contained a tackle box with a label that read “Code Drugs.” Drawer nine also contained Diazepam 2.5 mg rectal gel (emergency medication used to stop cluster seizures). Staff B, present during the tour, confirmed that the breakaway lock should’ve been threaded through both holes of the locking handle in order for the drawers to remain locked, thereby securing emergency medication and equipment. Review of the policy titled “Standardized Medications on Crash Carts”, approved on 02/11/15, stated during a code the plastic lock is broken on the crash cart to make medication available. After the code, the nurse will remove medication trays and exchange them at the pharmacy for new trays. Nursing will then replace the plastic lock on the cart. 22432 2. Environmental tour conducted on 07/23/24 between 2:29 PM and 3:10 PM revealed the facility’s crash cart located in the main hallway between the medical surgery patient area and the ICU unit failed to document the daily monitoring of the crash cart as follows: Review of the months of April, May, June and July to date of 07/25/24 there were no daily crash cart checks as follows: Between 04/12/24 and 04/20/24 elapsed time of 8 days Between 04/21/24 /and 4/23/24 elapsed time of 2 days Between 04/26/24 and 4/30/24 elapsed time of 4 days Between 04/30/24 and 05/03/24 elapsed time of 2 days Between 05/03/10 and 05/10/24 elapsed time of 7 days Between 05/13/23 and 05/18/24 elapsed time of 5 days Between 05/23/24 and 05/25/24 elapsed time of 2 days Between 05/28/24 and 06/01/24 elapsed time of 4 days Between 06/06/24 and 06/09/24 elapsed time of 2 days Between 06/12/24 and 06/15/24 elapsed time of 2 days Between 06/17/24 and 06/22/24 elapsed time of 4 days Between 06/23/24 and 06/29/24 elapsed time of 5 days Between 07/03/24 and 07/09/24 elapse time of 5 days Between 07/09/24 and 07/13/24 elapsed time of 3 days Between 07/14/24 and 07/17/24 elapsed time of 2 days Between 07/20/24 and 07/22/24 elapsed time of 1 day During an interview on 07/25/24 at 3:23 PM, Staff A confirmed it was the expectation that facility nurses checked the emergency crash carts daily. Staff A stated it was usually night shift but it should be done and documented on the Crash Cart Check sheet daily. Nursing leadership collected the sheets at the end of the month. During an interview on 07/25/24 at 4:01 PM, Staff B stated the facility had inpatients during the times the facility failed to monitor the medical surgical unit crash carts. 3. During an observation on 07/23/24 at 1:47 PM, the emergency department (ED) front crash cart did not have the red plastic lock securely latched to the cart leaving the contents of the cart unsecured. The cart contained commonly used code medications such as first and second level Advanced Cardiac Life Support (ACLS) medications, endotracheal tubes used during insertion of breathing tubes, syringes, needles, and other commonly used supplies utilized during codes. Staff B was present during the observation and confirmed the findings. 21893 4. During an observation on 07/24/24 at 2:30 PM, the Radiology and Nuclear Medicine departments were toured. A crash cart in the Stress Lab was unlocked and unattended by staff. Staff G was present during the observation and confirmed the findings. Review of the policy titled “Standardized Medications on Crash Carts”, approved on 02/11/15, stated during a code the plastic lock is broken on the crash cart to make medication available. After the code, the nurse will remove medication trays and exchange them at the pharmacy for new trays. Nursing will then replace the plastic lock on the cart.”

“DRUGS AND BIOLOGICALS ARE APPROPRIATELY STORE CFR(s): (3) Drugs and biologicals are appropriately stored; This Standard is not met as evidenced by: 28999 Based on observation and interview, the facility failed to ensure expired medications and medications were disposed of. This had the potential to affect all patients receiving care in the facility. The hospital census was nine. Findings include: 1. During an observation of 07/24/24 at 10:30 AM, the storage closet in Room 1 of the Sleep Lab contained a bottle of Gebauer Ethyl Chloride Topical Spray (topical medication used to prevent pain caused by injections and minor surgical procedures) with an expiration date of 02/23. The storage closet in Room 2 of the Sleep Lab contained two Nu prep Skin Prep Gel (lowers skin impedance to enhance performance of a monitoring electrode) with an expiration date of 01/01/24. The cabinet above sink in the respiratory department had a box containing 40 plastic vials of 0.9% Sodium Chloride inhalation solution (used to moisten airways and to loosen mucus or phlegm to help improve lung function) with an expiration date of 07/22. Staff F was present during the observation and confirmed the findings. 2. During an observation of the pharmacy on 07/24/24 at 1:40 PM, the storage shelf contained a bottle of Doxycycline for Patient #32 that had no expiration date. During an interview on 07/24/24 at 1:45 PM, Staff J stated he was uncertain of an expiration date for the medication and the medication should’ve been disposed of. 3. During an observation on 07/24/24 at 3:05 PM, the storage closet in infusion department contained two bags Lactated Ringer’s Electrolyte Injection Solution (replaces electrolyte loss in patients with low blood volume or low blood pressure) with an expiration date of 06/24 . Staff K was present during the observation and confirmed the findings. The freezer in the infusion department contained two frozen meals, one with an expiration date of 07/22 and the other 09/23. Staff A was present during the observation and confirmed the findings.”

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 42375 See Life Safety Code Report”

“PROTECTION OF RECORD INFORMATION CFR(s): The CAH maintains the confidentially of record information and provides safeguards against loss, destruction, or unauthorized use. This Standard is not met as evidenced by: 22432 Based on observation, interview and policy review, the facility failed to ensure medical records were protected from unauthorized access, fire or water damage. This had the potential to effect any patient whose paper charts were stored in the facility’s on site barn storage area. The current census was nine. Findings include: During an observation on 07/25/24 at 10:25 AM, the pole barn on the facility property housed vehicles, tractors, and environmental grounds machinery, equipment and supplies used in property management. The facility maintenance man unlocked the barn entry door, as well as a separate door that opened to a generalized storage area that contained a caged area which contained medical records. These locked areas were all unlocked by the facility maintenance staff. There were greater than six large metal shelving units filled with unboxed medical records and stored by medical record number dated between 2016 and 2022. There were no protective coverings of these medical records. There were were no sprinklers observed in the storage area of the barn. During an interview on 07/25/24 at 10:05 AM, Medical Record Staff N stated the facility medical records were primarily electronic since fall of 2020 however there were some hard paper medical records that the facility stored on site in the barn located behind the main hospital. Staff N stated she did not have keys to the barn but the facility’s maintenance department did. Staff N stated there were probably thousands of medical records in the barn that had recently been removed from a secured storage facility and placed in the barn on the hospital property. Staff N stated she estimated only three to five percent of the medical records stored in the barn had been scanned into the facility’s electronic medical record system. Staff N stated the building was not equipped with a sprinkler system in the event of fire nor were the records safe from non-authorized staff. Staff N confirmed the medical records contained protected health information. Review of the policy titled “Health Insurance portability Act (HIPPA)”, reviewed 05/02/23, listed the established minimum level of protection for patient information and administrative steps for compliance. The minimum necessary and the least amount of information necessary to accomplish the permitted task. The policy directed that protected health information included information on patients’ past, present and future physical and mental condition; provision of payment; identifying information including name, address, medical record number, telephone number, birthday, admission and discharge dates. Review of the policy titled “Retention of Secondary Records”, reviewed 03/23/22, directed that secondary records were those records that contained patient information or specific information regarding the operation of a department and were not maintained in a medical record. These records were kept separate from medical records and were secured in a secure location.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 22432 Based on observation, interview, policy review and manufacturer’s recommendations review, the facility failed to ensure staff properly reprocessed cystoscopy equipment. This had the potential to affect any patient who underwent cystoscopy at the facility. The facility performed eight cystoscopic procedures during the month of July 2024. The census was nine. Findings include: During an observation on 07/25/24 at 9:20 AM, the cystoscopy (equipment and procedure that allows the visualization the lining of the bladder and the ureter) area of the hospital had one cystoscopy procedure room as well as an associated high level disinfection re-processing room on the lower level of the facility. The facility employed two medical assistants (Staff L and Staff M) who reprocessed used cystoscopes. Observation of the reprocessing room revealed a room equipped with a twin compartment stainless steel sink. There was a one-gallon pump jug of Proslystica 2X Concentrate Enzymatic Presoak and Cleaner. There were no fill marks observed on the sink to indicate any liter or gallon fill points. During an interview on 07/25/24 at 8:35 AM, both Staff L and Staff M stated the scope reprocessing steps were to bring a used scope placed in a sealed container to the reprocessing room, prepare the left side of the sink (dirty side) with a solution of two pumps of Prolystica cleaner and to add warm water enough to cover the scope; remove the used cystoscope and place in the solution and proceed to clean the entire scope top to bottom, then rinse in clean water in the second compartment, and then place in the electronic cleaner for additional processing. Staff L and Staff M stated they were instructed to use two pumps of the enzymatic cleaner in the left side of the two-compartment sink and add warm water. Neither Staff L nor M could state the amount of water needed to reach the manufacturer’s dilution factor. Both stated they had been instructed on how to prepare the solution, but this was many years ago and had not been supervised, observed or competency checked since. Review of the personnel for Staff L revealed a hire date of 08/14/06 and Staff M had a date of hire of 09/04/11. The job description for both staff was Clinical Medical Office Assistant. The job descriptions failed to include duties outlined for the responsibility for high level disinfection of equipment. Neither personnel file contained documentation that Staff L or Staff M were trained, or competency checked to perform high level disinfection of cystoscope equipment. During an interview on 07/25/24 at 2:53 PM, Staff I confirmed neither staff’s personnel file contained any documentation they were educated or competency checked for high level disinfection of cystoscope equipment. Staff I stated there had been no infections associated with cystoscopy procedures in the preceding two quarters of 2024. Review of the policy titled “Surgery, Infection Prevention Surgery” reviewed 04/11/24, stated the policy was to provide guidelines for cleaning and disinfecting all endoscopes and prevent the spread of infections. The policy further directed that all endoscopes must be thoroughly cleaned and disinfected after each use following recommended manufacturer’s guidelines. High level disinfection of the endoscope and all channels must be performed after each use according to manufacturer instructions. The procedure directed staff to completely immerse all submersible parts of the scope in water and enzymatic detergent following manufacturer’s recommendations for dilution of the detergent. Review of the manufacturer’s directives for the Steris Prostylica 2X Enzymatic Presoak and Cleaner directed the dilution factor was 1-4 milliliters (mL) cleaner per liter of water. The directions further instructed staff to use the pump to deliver 15 mL of detergent per 5-8 liters of warm water.”

“FIRE SAFETY SURVEY REPORT 2012 CODE EXISTING ADMINISTRATOR: Ty Shaul CENSUS: 9 BUILDING #1 OF #1 42 CFR 485.623 The facility must meet the applicable provisions of the 2012 Existing edition of the Life Safety Code (LSC) of the National Fire Protection Association. A Life Safety Code Survey was conducted by the Ohio Department of Health. At this survey, Wyandot Memorial Hospital was not found to be in substantial compliance with the requirements for participation in (Medicare/Medicaid) at 42 CFR Subpart 485.623, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19 Existing Health Care Chapter. This facility is divided up into 3 separate areas. Area #1 consists of the Main Hospital Building and separates by a two-hour firewall from Area #2 which is the Emergency Department. Area #3 is the Medical Offices Building which is separated by the hospital and the emergency department by a 3-hour firewall. Areas #1 and #2 were observed to have protected I-beams and were determined to be Type II (000) and area #3 was observed to be Type II (222) with protected structural elements throughout. The entire building was equipped with fire suppression, alarm, smoke detection systems, medical gases, and two generators. One generator is 750 kW and the other one is 420 kW. The building was surveyed as one building as a result of the noncombustible construction types and age of building in relation to the adoption of the Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19 Existing Health Care Chapter.”

“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: 42375 Based on record review, observation and interview the facility failed to ensure the was a fire alarm system was maintained in accordance with the LSC, 2012 Edition 9.6.1, 9.6.2 and 9.6.3. This deficient practice had the potential to affect all 9 residents. Findings include: During the record review with the Director of Maintenance (DM) on 07/24/24 at 10:30 A.M. revealed the fire alarm system not being maintained, as required. The documentation provided did not show a semi-annual visual inspection had been completed. No additional documentation was provided by the time of exit to validate the fire alarm system was tested and inspection every six months. Observation on 07/25/24 at 9:00 A.M. found the fire alarm panel had a trouble signal due to a ground fault. Interview with the DM verified the finding at the time of the review.”

“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: 42375 Based on record review, observations and interviews the facility failed to ensure that all sprinklers are properly maintained in accordance with the NFPA 101 19.3.5.3 and NFPA 25, 4.3, 4.3.1, 4.6.12, 4.6.12.1, 9.7.5, 9.7.6, 9.7.7, 9.7.8 and 13.4.4.2.9. This deficient practice had the potential to affect all nine residents. Findings include: Record review with the Director of Maintenance (DM) on 07/24/24 between 9:00 A. M and 1:00 P.M. noted the sprinkler inspection and test records. Further review revealed sprinkler testing was not completed as required in the following areas: “ Records provided did not document the three year air leak test requirement of all dry sprinkler systems as noted in the contractor quarterly inspection report. “ The fire department connection (FDC) five year hydrostatic test was not available for review. “ No records to indicate the weekly air pressure recordings or the monthly water pressure recordings were complete. Observations during the tour of the facility on 07/25/24 found the following deficiencies: “ At 9:30 A.M. wires and data cables were found attached to the sprinkler piping in the storage room across from the maintenance shop. “ At 11:51 P.M. the FDC by the Respiratory Entrance has bushes planted in front of it, which obstructed the access to the connection, in the event of a fire. Interview with the DM verified the finding at the time of discovery.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 42375 Based on observation and staff interview, the facility failed to ensure fire/smoke barriers were maintained in accordance with NFPA 101 - 2012 Edition, Section 8.3.5 . This deficient practice had the potential to affect all nine residents. Findings include: Observations during the tour with the Director of Maintenance (DM) on 07/29/24 revealed improperly sealed penetrations in the following locations: “ At 9:58 A.M. the smoke barrier wall for the oncology storage room was found to have unsealed penetrations around HVAC and conduits. “ At 10:27 A.M. the wall above the rolling fire door from the main lobby to the atrium was found to have unsealed penetrations along the top of the door frame, around the HVAC between the brick and the concrete wall and around the pipes and conduits. “ At 10:35 A.M. the wall between the ER and CAT scan had unsealed penetrations around conduit above the vending machines. “ At 10:44 A.M. the wall in the respiratory corridor had unsealed penetrations around conduits. “ At 10:53 A.M. the wall around the stairwell by the surgery lobby was not sealed to the roof deck. “ At 11:27 A.M. unsealed penetrations were found around conduits at the B level atrium wall. “ At 11:32 A.M. the wall above the door from the café to the atrium had unsealed penetrations around conduits. “ At 11:39 A.M. the wall above the door to the housekeeping ramp had unsealed penetration. “ At 11:48 A.M. unsealed penetrations were found above the stairwell door by the old boiler room. Interview with the DM verified the finding at the time of observation.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 42375 Based on observation and interviews the facility failed to ensure smoke barriers were maintained in accordance with NFPA 101 - 2012 Edition, Section 19.3.7.6, section 8.5.4, and NFPA 80 2010 Edition Section 4.2. This deficient practice had the potential to affect all nine residents. Findings include: Observations during the tour of the facility with the Director of Maintenance (DM) on 07/24/24 2 revealed the fire doors were not maintained properly in the following locations: “ At 2:56 P.M. elevator equipment Room C did not latch to the frame. “ At 3:46 P.M. the double door by the café did not latch to the frame “ At 3:50 P.M. the smoke doors from the atrium to the café had a gap in excess of 1/8” between the doors, “ At 4:04 P.M. the double corridor doors by the kitchen did not latch to the frame. Interview with the DM verified the finding at the time of observation.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 42375 Based on observations and staff interview, the facility failed to ensure the electrical panels were readily and safely accessible in accordance with NFPA 101-2012 Edition, Section 19.5.1.1, 9.1, and NFPA 70-2011 Edition, Section 110.26. This deficient practice had the potential to affect all nine residents. Findings include: Observations during tour of the facility with the Director of Maintenance (DM) on 07/25/24 at revealed electrical panels not being maintained properly in the following locations: “ At 9:30 A.M. the main storage room had boxes stored within three feet of the electrical panels. “ At 9:44 A.M. the dietary storage room had boxes stored within three feet of the electrical panels. “ At 9:50 A.M. the electrical panels behind the laundry was blocked by storage. Interview with the DM verified the finding at the time of 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: 42375 Based on observations, record review, and staff interview the facility failed to ensure fire dampers were maintained in accordance with NFPA 101 2012 Edition section 19.5.2, NFPA 90 A-2012 Edition, Section 5.4.8, and NFPA 80-2010 Edition, Section 19.4. This deficient practice had the potential to affect all nine residents. Findings include: Record review on 07/24/24 at 11:00 A.M. noted the facility inspection and test records from the previous 24 months. Further review revealed the documentation lacked a fire damper inspection within the past six years. The last report fire damper inspection was completed in 2016. No additional documentation was provided to validate the dampers were inspected. Interview with the Director of Maintenance verified the finding at the time of review.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 42375 Based on record review, observation, and staff interview the facility failed to ensure fire door assemblies were annually inspected, tested, and maintained in accordance with NFPA 101 - 2012 edition Section 7.2.1.15, 8.5.4, NFPA 80 5.2.4, and NFPA 105 - 2010 Edition Section 4.1.1 and 5.2.1. This deficient practice had the potential to affect all nine residents. Findings include: Record review on 07/24/24 between 9:00 A.M. to 1:00 P.M. noted the facility inspection and test records from the previous 12 months. Further review revealed no record of fire doors being inspected and tested. No additional documentation was provided at the time of survey to validate the inspections were completed. Interview with the Director of Maintenance verified the finding at the time of review.”

“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: 42375 Based on record review and interview the facility failed to ensure the emergency generator is exercised monthly under load for 30 minutes in accordance with the LSC, 2012 Edition 8.3.1 through 8.3.4 and 8.4.1 through 8.4.2.3. This deficient practice had the potential to affect all nine residents. Findings include: Record review on 07/24/24 at 12:30 P.M. during the generator record review with the Director of Maintenance (DM) revealed the diesel generator monthly operational testing was not done properly. The monthly run test of the generator did indicate what the load was. The facility had no record of the 36 month load bank test had been performed. Interview with the DM verified the finding at the time of observation.”