Vandalia Health Broaddus Hospital

“SNF SERVICES CFR(s): The CAH is substantially in compliance with the following SNF requirements contained in subpart B of part 483 of this chapter: §485.645(d)(1) Resident Rights (§483.10(b)(7), (c)(1), (c)(2)(iii), (c)(6), (d), (e)(2) and (4), (f)(4)(ii) and (iii), (g)(8) and (17), (g)(18) introductory text, (h) of this chapter). “ §483.10(b)(7) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident devolve to and are exercised by the resident representative appointed under State law to act on the resident’s behalf. The court-appointed resident representative exercises the resident’s rights to the extent judged necessary by a court of competent jurisdiction, in accordance with State law. “ §483.10(c) Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including: (1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. “ §483.10(c)(2)(iii) The right to be informed, in advance, of changes to the plan of care. “ §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. “ §483.10(d) Choice of attending physician. The resident has the right to choose his or her attending physician. (1) The physician must be licensed to practice, and (2) If the physician chosen by the resident refuses to or does not meet requirements specified in this part, the facility may seek alternate physician participation as specified in paragraphs (d)(4) and (5) of this section to assure provision of appropriate and adequate care and treatment. (3) The facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his or her care. (4) The facility must inform the resident if the facility determines that the physician chosen by the resident is unable or unwilling to meet requirements specified in this part and the facility seeks alternate physician participation to assure provision of appropriate and adequate care and treatment. The facility must discuss the alternative physician participation with the resident and honor the resident’s preferences, if any, among options. (5) If the resident subsequently selects another attending physician who meets the requirements specified in this part, the facility must honor that choice. “ §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. “ §483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement. “ §483.10(f)(4)(ii) The facility must provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident’s right to deny or withdraw consent at any time; “ §483.10(f)(4)(iii) The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident’s right to deny or withdraw consent at any time; “ §483.10(g)(8) The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to: (i) Privacy of such communications consistent with this section; and (ii) Access to stationery, postage, and writing implements at the resident’s own expense. “ §483.10(g)(17) The facility must- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section. “ §483.10(g)(18)[introductory text only] The facility must inform each resident before, or at the time of admission, and periodically during the resident’s stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility’s per diem rate. “ §483.10(h) Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. (1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. (2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. (3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident’s medical, social, and administrative records in accordance with State law. This Standard is not met as evidenced by: 50550 Based on medical record review, policy review, audio recording review and interviews, it was determined the facility failed to ensure the patient and patient representative to be part of the patient care in one (1) of ten (10) sampled patients (patient #1). This failure has the potential to negatively affect all patients receiving care at the facility. Findings include: A policy was reviewed titled “Patient Rights and Responsibilities”, last revised 03/25. The policy stated in part, “... K. A patient has the right to effective communication and full information in layman’s terms concerning diagnosis, treatment and prognosis including information about advantages/disadvantages, alternative treatments, and possible complications of proposed treatments. When it is not medically advisable to give such information to the patient, the information shall be given to the patient’s next of kin or other appropriate persons. Except in emergencies, a patient has the right to expect that his or her physician will obtain the necessary informed consent prior to the start of any procedure or treatment ... S. When medically permissible a patient may be transferred to another facility, only after the patient or next-of-kin or other legally responsible representative has received complete information and an explanation concerning the needs for and alternatives to such a transfer. The institution to which the patient is to be transferred must accept the patient for transfer in advance. The necessary medical information will be sent to the transfer facility ...” A medical record reviewed was conducted for Patient #1. A “General Notes” dated 06/29/26 at 21:53 (9:53 p.m.) states in part, “... Call placed to [other facility] MARS [Medical Access Referral Service] line. They notified me of extended delays in transfer to both [another facility] and [other facility]. They will contact providers at [other facility] to give me a call back about patient’s status and possible transfer back to their care. [Spouse] has requested [other facility] for transfer, so will determine their status before calling anywhere else. [Spouse] has requested [different facility] as secondary transfer center if [other facility] does not have any bed availability. I plan to continue to treat [patient #1] as primary cardiac with likely fluid overload with daily lasix. Will continue to monitor respiratory status and oxygen saturations. Will be waiting to hear back from [other facility] MARS line for transfer status and capacity. If no bed, then will call [different facility] at that time.” A”General Notes” dated 06/30/26 at 18:29 (6:29 p.m.) states in part, “Progress note update. Call finalized with [other facility] Medicine. Initially told to send info to [another facility]. Information sent. Transfer refused as they did not see the need for transfer at this time. Case reviewed a second time by [other facility]. Decision is final that they do not believe [he/she] needs to be transferred. At this time, I still have concern that [he/she] has repeat pericardial effusion developing and that is causing [his/her] current respiratory worsening. Even though [he/she] remains vitally stable, [he/she] is now on oxygen when [he/she] did not require oxygen prior to admission to our swing bed. [He/she] may have shown slight improvement with IV [Intravenous] lasix and I plan to continue this. However, [spouse] is still requesting higher level of care for more complete workup as [he/she] had the same presentation last time before [he/she] was transferred to [other facility] and required pericardiocentesis and thoracentesis. Call will be placed to [different facility] transfer center to determine capacity for transfer to their facility.” An Audio Recording review was conducted for the “[Other facilities name] MARS” dated 06/30/26. The recordings events are described as follows: ... Time 17:25 (5:25) p.m. duration 7:20 minutes ... Staff #6 felt with current stable vital signs, there is not enough information to directly admit patient #1. Recommended that patient #1 be sent to a local ER for further evaluation of suspicion of possible pericardial effusion and would revisit transfer here. If preferred, patient #1 could wait for WVU ER to be off diversion and come to this ER, but may be better for patient #1 to be evaluated closer to the current location to expedite testing. Time 18:11 (6:11) p.m. duration 2:21 minutes. MARS called, notified staff #8 that patient #1 was declined by (other facility) since patient #1 appeared stable and looked as if the spouse had requested the transfer for a second opinion. Staff #8 stated that the spouse did not want a second opinion but since the patient was not doing well and was worsening while here, the spouse felt the patient needed to be seen by cardiology again. MARS staff made staff #8 aware patient was discussed with staff #6 at WVU Command Center after (other facility) declined patient, and with current information was declined for Direct Admission from Swing-Bed. It was recommended that patient go to ED for more chest films and labs, etc.. and based on those results, would reconsider for direct admission. Staff #8 verbalized that is the problem, it would require discharge from swing-bed and cannot necessarily do that as patient #1 was not stable enough to be discharged. Staff #8 to talk with the spouse, felt the spouse would be leaning toward sending the patient to (another facility) next. If there are no beds and if providers do not think it should happen, I will let the spouse know this as well.” An interview was conducted with staff #4 on 08/04/26 at 9:00 a.m. Regarding patient #1, staff #4 stated, “I stand by what I said before my last telephone interview a couple weeks ago.[It should be noted staff #4, was interviewed during another investigation into this complaint at another facility] The transfers from ER [Emergency Room] to ER in swing beds are not safe, the patient was vitally stable this is why it won’t be qualified to ER. If they are in diversion they didn’t put the patient in the list, They didn’t tell me to run more tests. I didn’t speak with the provider from another facility. I am sure that ER does not do ECHOs, only a fast exam. After the call with the [other facility] I called [different facility], and they accepted the patient ... I didn’t tell the [spouse] that the [other facility] is requesting more testing. I did not tell the [spouse] about the more testing or going from ER to ER. I didn’t feel that it was appropriate to tell [him/her]. After the refusal from both facilities. The patient was stable and continued with the diuretics, blood pressure was good.” An interview was conducted with patient #1 spouse on 08/04/26 at 10:16 a.m. Regarding patient #1, the spouse stated in part, “... States staff #4s name did not say anything about transfer from ER to another ER or additional testing request from the other facility...” An interview was conducted with staff #7 on 08/04/26 at 2:40 p.m. Regarding patient #1, staff #7 stated, “I am the Quality and Patient Advocate. I heard the audio recording, review the providers notes and concurred that the provider [staff #4] did not provide enough information to the patient’s [spouse]. [He/she] left out key pieces of information and caused the spouse to call the patient advocate from the other facility. It’s unfortunate what happened but it can be preventable . We do have an ECHO tech that comes to the facility, unsure about the schedule.””

“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: 37324 Based on record review and staff interview it was determined the facility failed to ensure all essential mechanical and electrical equipment followed manufacturer-recommended maintenance activities and schedules. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7. Findings include: Record review on 04/14/25 at approximately 2:07 p.m., revealed no documentation available for review during survey to show that all essential mechanical and electrical equipment was listed in an inventory, which includes a record of maintenance activities. Record review on 04/14/25 at approximately 2:15 p.m., revealed no documentation available for review during survey to show that preventative maintenance for all essential mechanical and electrical equipment followed manufacturer’s recommendations or an approved alternate equipment maintenance (AEM) program. Interview on 04/15/25 at approximately 2:16 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.”

“PROPER VENTILATION, LIGHTING, AND TEMPERATURE CFR(s): (5) There is proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas. This Standard is not met as evidenced by: 37324 Based on record review and staff interview it was determined the facility failed to ensure that appropriate air relationships, temperature, and humidity were maintained in patient care areas. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7. Findings include: Record review on 04/14/25 at approximately 3:18 p.m., revealed no documentation available for review during survey to show that all patient care areas were being monitored for appropriate temperature, humidity, or air relationships (positive/negative). Interview on 04/14/25 at approximately 3:26 p.m. with the Facilities Manager verified this finding. This finding was also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.”

“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: 37324 Based on observation, record review, and staff interview it was determined the facility failed to comply with the Health Care Occupancy chapter requirements of NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7. Findings include: In reference to Federal Life Safety Code (FLSC) citation K 271, the facility failed to ensure that exit discharge was properly maintained. In reference to FLSC citation K 321, the facility failed to ensure that hazardous areas were properly protected. In reference to FLSC citation K 324, the facility failed to ensure that cooking equipment was properly protected. In reference to FLSC citation K 353, the facility failed to ensure that the sprinkler system was properly tested and maintained. In reference to FLSC citation K 372, the facility failed to ensure that fire/smoke barriers were maintained to the proper fire resistance rating. In reference to FLSC citation K 511, the facility failed to ensure that electrical wiring and equipment was properly installed. In reference to FLSC citation K 781 the facility failed to ensure that portable space heaters were properly used and tested. In reference to FLSC citation K 918 the facility failed to ensure that the emergency generator was properly tested and maintained. In reference to FLSC citation K 923 the facility failed to ensure that oxygen cylinders were properly stored and maintained. Interview on 04/15/25 at approximately 2:08 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.”

“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: 37324 Based on observation and staff interview, the facility failed to ensure that exit discharge was maintained free of obstruction in accordance with NFPA (National Fire Protection Association) 96. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7. Findings include: Observation on 04/15/25 at approximately 1:51 p.m., revealed the exit discharge from the rear Laboratory area did not discharge to a refuge area or public way, as this exit discharged into a covered breezeway leading to a storage building. Interview on 04/15/25 at approximately 1:52 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.”

“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: 37324 Based on observation and staff interview, the facility failed to ensure that hazardous areas are protected and separated from other spaces in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7. Findings include: Observation on 04/15/25 at approximately 10:55 a.m., revealed missing ceiling tile and unsealed penetrations in the drop ceiling in the IT Server Room and the Maintenance Technician Office in the Mechanical/Boiler Room. Observation on 04/15/25 at approximately 1:54 p.m., revealed the Lab Storage Room near Respiratory Therapy, which was being used as a storage room with combustible storage and measured more than 50 square feet, did not have a door closure. Observation on 04/15/25 at approximately 2:06 p.m., revealed the Housekeeping Clean Utility Room near Speech Therapy, which was being used as a storage room with combustible storage and measured more than 50 square feet, did not have a door closure. Interview on 04/15/25 at approximately 2:07 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.”

“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: 37324 Based on record review and staff interview, the facility failed to properly install and maintain equipment protected by the kitchen hood extinguishing system in accordance with NFPA (National Fire Protection Association) 96. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7. Findings include: Record review on 04/14/24 at approximately 12:55 p.m., revealed no documentation available for review during survey to show that the kitchen suppression system had received hydrostatic testing in the previous twelve (12) years. Interview on 04/14/25 at approximately 12:56 p.m. with the Facilities Manager verified this finding. This finding was also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.”

“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: 37324 Based on observation and staff interview, the facility failed to ensure that the automatic sprinkler system was tested and maintained in accordance with NFPA (National Fire Protection Association) 25. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7. Findings include: Observation on 04/15/25 at approximately 10:06 a.m., revealed communication wiring laying on the sprinkler system in the interstitial space above the corridor near Physical Therapy. Observation on 04/15/25 at approximately 10:47 a.m., revealed communication wiring laying on the sprinkler system in the interstitial space above Speech Therapy and the Virtual Pharmacy Office. Observation on 04/15/25 at approximately 11:05 a.m., revealed communication wiring laying on the sprinkler system throughout the interstitial space above the X-Ray/Maintenance Corridor and near the DEXA Room area. Observation on 04/15/25 at approximately 11:20 a.m., revealed water supplies lines being supported by a wooden wedge, which was placed on the sprinkler system in the interstitial space above the Main Lobby area. Interview on 04/15/25 at approximately 11:21 a.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.”

“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: 37324 Based on observation and staff interview, the facility failed to ensure that fire barriers and smoke barriers were constructed and maintained in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7. Findings include: Observation on 04/15/25 at approximately 10:27 a.m., revealed an unsealed penetration in the 2-hour fire barrier, in the interstitial space above the ceiling near the Acute Care fire barrier doors. Observation on 04/15/25 at approximately 10:29 a.m., revealed an unsealed penetration in the 2-hour fire barrier, in the interstitial space above the ceiling near the Storage Room Wall in the Purchasing Corridor. Observation on 04/15/25 at approximately 10:38 a.m., revealed unsealed penetrations in the 2-hour fire barrier, in the interstitial space above the ceiling near the Virtual Pharmacy Office. Observation on 04/15/25 at approximately 10:57 a.m., revealed the Mechanical/Boiler Room (2-hour fire barrier) door was sagging and bowed at the top and exceeded the the 1/8-inch requirement at the meeting edges along the top and sides of the door. Observation on 04/15/25 at approximately 12:22 p.m., revealed a set of 2-hour rated fire barrier doors at the entrance to the Long Term Care Unit (2-hour fire barrier), which had the bottom rods and latches removed/missing and did not appear to have fire pins in the bottom of the doors. Observation on 04/15/25 at approximately 1:42 p.m., revealed the 2-hour rated fire barrier doors in the Maintenance Corridor near the Mechanical Room would not close and latch when released. Observation on 04/15/25 at approximately 1:45 p.m., revealed the 2-hour rated fire barrier doors in the X-Ray/Maintenance Corridor near the Financial Counselor Office would not close and latch when released. Interview on 04/15/25 at approximately 1:46 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.”

“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: 37324 Based on observation and staff interview, the facility failed to ensure that electrical wiring and equipment was in accordance with NFPA (National Fire Protection Association) 70. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7. Findings include: Observation on 04/15/25 at approximately 11:02 a.m., revealed a heating, ventilation, and air conditioning (HVAC) control box missing an appropriate cover in the interstitial space above the X-Ray/Maintenance Corridor near the DEXA Room. Observation on 04/15/25 at approximately 12:44 p.m., revealed a microwave plugged into an extension cord in the Doctor’s Sleep Room. Observation on 04/15/25 at approximately 1:22 p.m., revealed a power strip plugged into a second power strip in the Emergency Room Physician’s Office. Observation on 04/15/25 at approximately 1:24 p.m., revealed a refrigerator plugged into a power strip in the Emergency Room Nurse’s Station (hand sink area). Observation on 04/15/25 at approximately 1:29 p.m., revealed three (3) coffee pots plugged into a power strip in the Emergency Room Break Room. Interview on 04/15/25 at approximately 1:30 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.”

“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: 37324 Based on observation, record review, and staff interview, the facility failed to ensure that portable space heaters were used in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7. Findings include: Observation on 04/15/25 at approximately 12:29 p.m., revealed a portable space heater in use in the Risk Management Office. No documentation was provided during survey to show that the elements in this space heater did not exceed 212 degrees Fahrenheit. Observation on 04/15/25 at approximately 12:33 p.m., revealed a portable space heater in use in the Director of Nursing Office. No documentation was provided during survey to show that the elements in this space heater did not exceed 212 degrees Fahrenheit. Observation on 04/15/25 at approximately 12:43 p.m., revealed a portable space heater in use in the Doctor’s Sleep Room. No documentation was provided during survey to show that the elements in this space heater did not exceed 212 degrees Fahrenheit. Observation on 04/15/25 at approximately 1:06 p.m., revealed a portable space heater in use in the Patient Access Coordinator’s Office. No documentation was provided during survey to show that the elements in this space heater did not exceed 212 degrees Fahrenheit. Observation on 04/15/25 at approximately 1:21 p.m., revealed two (2) portable space heaters in use in the Emergency Room Physician’s Office. No documentation was provided during survey to show that the elements in these space heaters did not exceed 212 degrees Fahrenheit. Observation on 04/15/25 at approximately 1:25 p.m., revealed a portable space heater in use in the Emergency Room Nurse’s Station area. No documentation was provided during survey to show that the elements in this space heater did not exceed 212 degrees Fahrenheit. Interview on 04/15/25 at approximately 1:26 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.”

“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: 37324 Based on observation, record review, and staff interview, the facility failed to ensure that the emergency generator was tested and maintained in accordance with NFPA (National Fire Protection Association) 110. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7. Findings include: Record review on 04/14/25 at approximately 12:51 p.m., revealed no documentation available for review during survey to show that an annual fuel quality test for the emergency generator had been completed in the previous twelve (12) months. Record review on 04/14/25 at approximately 1:13 p.m., revealed no documentation available for review during survey to show that emergency generator had been exercised with the available load monthly during March 2025, January 2025, August 2024, June 2024, or May 2024. A load bank test had not been completed in the previous twelve (12) months. Interview on 04/15/25 at approximately 1:14 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.”

“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: 37324 Based on observation and staff interview, the facility failed to ensure that oxygen cylinders were stored and maintained in accordance with NFPA (National Fire Protection Association) 99. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7. Findings include: Observation on 04/15/25 at approximately 12:47 p.m., revealed empty and full oxygen E-cylinders, which were not properly segregated in the Acute Care Storage Room, near Purchasing. Observation on 04/15/25 at approximately 12:48 p.m., revealed oxygen E-cylinders, which were stored less than five (5) feet from combustibles in the Acute Care Storage Room, near Purchasing. Observation on 04/15/25 at approximately 1:32 p.m., revealed the Emergency Room Utility Room, which was being used to store oxygen E-cylinders, did not have a precautionary sign readable from five (5) feet of the door, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING”. Observation on 04/15/25 at approximately 1:59 p.m., revealed an unsecured gas cylinder (therapy treatment gas) in the Pulmonary Function Room in Respiratory Therapy. Observation on 04/15/25 at approximately 2:00 p.m., revealed the Pulmonary Function Room in Respiratory Therapy, which was being used to stored oxygen E-cylinders, did not have a precautionary sign readable from five (5) feet of the door, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING”. Interview on 04/15/25 at approximately 2:01 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.”