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Based on a review of the facility's Emergency Plan, record review, and staff interview, it was determined, the facility failed to develop a facility-based and a community-based risk assessment prior to developing the facility's emergency plan. Failure to develop emergency plans based on community-based risk assessment poses a potential risk and may cause harm to the patients and staff during an emergency if the specific needs of both the patient and staff are not identified as part of the EP plan.

Findings include:


Observations made during document review made on June 14 and 15, 2023 revealed the facility failed to obtain a community-based risk assessment and use it to develop a facility-based risk assessment prior to developing the facility's emergency plan

Employees #1 and #2 confirmed during the exit conference that the facility did not obtain a community-based risk assessment and use it to create the facility's Emergency Plan.

Based on record review and staff interview, it was determined the facility failed to ensure within their Emergency Preparedness plan that they incorporated documentation to include the needs of the patient population they serve or a delegation of authority as part of the continuity of operations. Failure to develop a continuity plan involving the patient population which includes delegation of authority and succession plans may cause disruption of services to patients/clients during an emergency which could lead to harm.

Findings include:

Observation during review on June 14 and 15, 2023 revealed. The facility was unable to locate any documentation addressing the needs of the patient population within the current written plan.

Employees #1 and #2 confirmed during the document review that the facility was unable to locate any documentation addressing the needs of the patient population within the current written plan.
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Based on a review of the facility ' s Emergency Plan, record review, and staff interview, it was determined, the facility failed to develop a facility-based and a community-based risk assessment prior to developing the facility's emergency plan. and created policies that were not risk-based. The facility also failed to have policies for the required CMS hazards Failure to develop emergency plans based on a facility-based risk assessment may cause harm to the patients and staff during an emergency.

Findings include:

Observation during document review on June 14 and 15, 2023 revealed the policies provided, were not based on a current risk assessment. CFR 494.62 requires both facility and community hazard assessments but is used to develop the policy and procedures. The policies also are required to address extreme temperatures and emerging infectious diseases.

Employees #1 and #2 confirmed during the exit conference the facility did not have a copy of the community-based risk assessment to provide proof it was used to create the policies and procedures and did not contain policies for extreme temperatures or emerging infectious diseases.

Based on a review of the facility's Emergency plan, record review, and staff interview, it was determined, the facility failed to have policies and procedures for safe evacuation from the facility that contains all of the required elements. Failure to provide all of the required elements in the evacuation plan could lead to harm serious injury or death to both patients and staff.

Findings include:

Observation during document review on June 14 and 15, 2023, of the facility's emergency plan revealed, the evacuation policy did not contain instructions for how they would handle a situation in which a patient refused to evacuate the facility during an emergency.


Employees #1and #2 confirmed during the exit interview the evacuation plan did not have detailed instructions for how the facility would handle a situation in which a patient refused to evacuate.

Based on a review of the facility's Emergency Plan, record review, and staff interview, it was determined the facility failed to develop and implement a policy and procedure for the use of volunteers in an emergency. Failure to address the use of volunteers in an emergency could adversely impact patient care during an emergency and lead to potential harm.

Findings include:

During the document review on June 14 and 15, 2023, it was revealed the facility's Emergency Plan (EP) did not include policies and procedures to address the use of volunteers in an emergency.

Employees #1 and #2 confirmed during an interview that the facility EP did not include policies and procedures to address the use of volunteers in an emergency

Based on a review of the Emergency Plan (EP), facility record review, and interview, it was determined the facility failed to develop and implement emergency preparedness policies and procedures to describe its role in providing care at alternate care sites during an emergency. Failure to develop emergency policies and procedures at alternative care sites may cause harm to the residents during an emergency.

Findings include:

During the emergency plan document review on June 14 and 15, 2023 it was revealed the facility's Emergency Plan related to the section which addresses policies and procedures did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

Employees #1, and #2 confirmed or acknowledged during an interview that the facility EP plan did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

Based on a review of the facility's emergency plan and staff interview, it was determined the facility failed to have the new and existing staff review the emergency preparedness plan. Failure to have staff review the emergency preparedness plan consistent with their expected roles may cause harm to the residents and/or staff during an emergency.

Findings include:

Observations, interviews, and record reviews made on June 15, 2023, revealed the facility failed to provide documentation that new and existing staff reviewed the emergency preparedness policies and procedures during initial orientation. In addition, the staff was questioned nobody was able to find the emergency preparedness policies or phone numbers of required numbers. The staff was not familiar with the emergency Preparedness program and didn't recall receiving any training.

Employees #1 and #2 confirmed during the exit interview the facility failed to provide documentation that new and existing staff reviewed the emergency preparedness policies and procedures during initial orientation.

Based on record review and interview staff it was determined the facility failed to provide documentation of a local fire inspection. An annual local fire inspection ensures the building remains within the building codes and fire safety codes. Failure to have an annual fire inspection could bring harm to patients and staff during an emergency.

CMS State Operations Manuel Appendix A- Interpretive Guidelines §482.11 The hospital must ensure that all applicable Federal, State and local law requirements are met.. The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. NFPA 101 2012 Life Safety Code Section 4.6.12. Maintenance, Inspection, and Testing. 4.6.12 Maintenance, inspection and testing shall be performed under supervision of a responsible person who shall ensure that testing, inspection, and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

485.625 42 CFR Ch. IV (10-1-16 Edition) adversely affect the health and safety of patients.
(4) The CAH maintains written evidence of regular inspection and approval by State or local fire control
agencies.

Findings include:

Records review on June 15, 2023 revealed the facility failed to provide required documentation of an annual local fire inspection since before 2020.

Employees #1, #2, confirmedduring the exit conferance that the facility failed to provide required documentation of an annual local fire inspection.

Based on the requirement to minimum NFPA 101-chapter 19 fire protection features such as 2-hour separation, sprinkler, and alarm function for the hospital. The facility failed to meet this requirement for the construction shell on the West side of the building in the adjoining building. Failure to provide the minimum fire protection features could cause serious injury or death in the event of a fire. This is a conditional finding this area does not meet the requirements of NFPA 101 2012 edition. This is a conditional finding

NFPA 101: Life Safety Code, 2012 Edition - Chapter 19 Existing Health Care Occupancies
19.1.2 Classification of Occupancy.
6.1.5.1 * Definition - Health Care Occupancy.
An occupancy used to provide medical or other treatment or care simultaneously to four or more patients on an inpatient basis, where such patients are mostly incapable of self-preservation due to age, physical or mental disability, or because of security measures not under the occupants' control.
19.1.3.4 Contiguous Non-Health Care Occupancies.
19.1.3.4.1 *
Ambulatory care facilities, medical clinics, and similar facilities that are contiguous to health care occupancies, but are primarily intended to provide outpatient services, shall be permitted to be classified as business occupancies or ambulatory health care facilities, provided that the facilities are separated from the health care occupancy by not less than 2-hour fire resistance-rated construction, and the facility is not intended to provide services simultaneously for four or more in patients who are litter borne.
19.1.3 Multiple Occupancies.
19.1.3.3 *
Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
1. They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self-preservation.
2. They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8.
3. For other than previously approved occupancy separation arrangements, the entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

NFPA 101 2012 Edition, Section 8.2 Construction and Compartmentation.

8.2.1.1 Buildings or structures occupied or used in accordance with the individual occupancy chapters, Chapters 11 through 43, shall meet the minimum construction requirements of those chapters.
8.2.1.2 * NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification.
8.2.1.3 Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on one of the following:
(1) Separate buildings, if a 2-hour or greater vertically aligned fire barrier wall in accordance with NFPA 221, Standard for High Challenge Fire Walls, Fire Walls, and Fire Barrier Walls, exists between the portions of the building.
(2) Separate buildings, if provided with previously approved separations.
(3) Least fire-resistive construction type of the connected portions, if separation as specified in 8.2.1.3(1) or (2) is not provided.

Findings:

Observations made while on tour on June 14 and 15, 2023 revealed the facility's unoccupied construction shell is not a licensed area of the hospital and is not separated from the hospital with a 2-hour fire barrier. The missing barrier is located between the new hospital entrance and the unoccupied area. This shell area is under construction and has small amounts of hospital storage.

Employees #1 and #2 confirmed during the exit conference conducted on June 15, 2023, that the facility's shell area is not located within the hospital proper and the adjoining building does meet the requirements of NFPA 101 Chapter 19 Existing Health Care Occupancies. .

Based on observations during Life Safety Survey the facility failed to remove combustible material from the emergency evacuation stairwells. Failure to remove combustible materials from the stairwell could result in a fire spreading to the stairwell and could result in the death of staff or patients

NFPA 101: Life Safety Code, 2012 Edition - Chapter 7 Means of Egress
7.1.4 Interior Finish in Exit Enclosures.
7.1.4.1 * Interior Wall and Ceiling Finish in Exit Enclosures.
Interior wall and ceiling finish shall be in accordance with Section 10.2. In exit enclosures, interior wall and ceiling finish materials complying with Section 10.2 shall be Class A or Class B.
7.1.4.2 * Interior Floor Finish in Exit Enclosures.
New interior floor finish in exit enclosures, including stair treads and risers, shall be not less than Class II in accordance with Section 10.2.
7.2.2.3 Stair Details. 7.2.2.3.1 Construction. 7.2.2.3.1.1 All stairs serving as required means of egress shall be of permanently fixed construction unless they are stairs serving seating that is designed to be repositioned in accordance with Chapters 12 and 13.
7.2.2.3.1.2 Each stair, platform, and landing, not including handrails and existing stairs, in buildings required in this Code to be of Type I or Type II construction shall be of noncombustible material throughout.

Findings include:

Observations while on tour June 14 and 15, 2023 revealed the stairwell in the facility has carpet in the stairs and landings. This carpet is old and not fire-rated.
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Employees #1 and #2 confirmed during the exit interview the facility had carpet in the stairs and landings.

Based on Observation, the facility failed to maintain the illumination in the stairwell in the path of egress from the second floor. Failure to maintain illumination in the stairwell could cause harm to staff and residents during an emergency.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.2.8 Illumination of Means of Egress. "Means of egress shall be illuminated in accordance with Section 7.8". Chapter 7, Section 7.8.1.3 * "The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated as follows: (1) During conditions of stair use, the minimum illumination for new stairs shall be at least 10 ft-candle (108 lux), measured at the walking surfaces. (2) The minimum illumination for floors and walking surfaces, other than new stairs during conditions of stair use, shall be to values of at least 1 ft-candle (10.8 lux), measured at the floor.

During a facility tour conducted on June 14th, 2023, it was observed that the emergency exit stairwell extending to the second did not have emergency lighting installed.

Employees #1 and #2 confirmed during the exit interview on June 15th, 2023 that the stairwell did not have emergency lighting as required by NFPA 101

Based on observation it was determined the facility failed to fill penetrations in two (2) holes of the smoke barriers in the facility. Failing seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in the time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall , floor or /ceiling assembly constructed as a smoke barrier , or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

During a facility tour conducted on June 14 and 15, 2023, revealed the facility failed to maintain the smoke barriers in the fire/ smoke barrier around the elevator enclosure Two hole were found in the barrier during the overhead inspection.

During the exit conference conducted on June 14 and 15, 2023, employees #1 and #2 confirmed by visual inspection the two holes in the fire barrier near the elevator

Based on observation and staff interview it was determined, the facility failed to ensure a protected covering over exposed wires. Failure to have the appropriate protection around exposed wires could cause harm to staff and patients.

NFPA 101, 2012 Edition Chapter 19. "19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1" " 9.1 Utilities. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, 2011 Edition Chapter 1 General "110.27(A) Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means: (1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons. (2) By suitable permanent, substantial partitions or screens arranged so that only qualified persons have access to the space within reach of the live parts. Any openings in such partitions or screens shall be sized and located so that persons are not likely to come into accidental contact with the live parts or to bring conducting objects into contact with them. (3) By location on a suitable balcony, gallery, or platform elevated and arranged so as to exclude unqualified persons. (4) By elevation of 2.5 m (8 ft) or more above the floor or other working surface."

Findings include:

Observations while on tour June 14 and 15. 2023, reveled, exposed wires coming from four (4) open junction boxes in the 2nd floor mechcanical room

Employee #1 and #2 acknowledged during the exit conference on June 15, 2023, that there were exposed wires were not cover with the appropriate J box covers.

Based on observation the facility failed to secure soiled linen or trash collection receptacles within any 64 square feet area that were not located in a hazardous room Failing to limit soiled linen or trash collection receptacles could cause harm to residents and/or staff by allowing a fire to spread.


NFPA 101: Life Safety Code, 2012 Edition - Chapter 19 Existing Health Care Occupancies
19.7.5.7 Soiled Linen and Trash Receptacles.
19.7.5.7.1 Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity and shall meet all of the following requirements: (1) The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2).
(2) A capacity of 32 gal (121 L) shall not be exceeded within any 64 ft2 (6 m2) area.
(3) Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
(4) Container size and density shall not be limited in hazardous areas.

Findings include:

Observations while on tour June 14 and 15, 2023, revealed the (ICU) Intensive Care Unit was storing Soiled linen or trash collection receptacles in amounts exceeding 34 gallons that did not have a fire door and were not rated as a hazardous area.

Employees #1 and #2 confirmed the Soiled linen or trash collection receptacles area near the ICU was not rated as a hazardous area.

Based on observation it was determined that the facility did not have written documentation of the annual inspection and testing of the facility fire doors in accordance with NFPA 80, 2010 Edition, "Standard for Fire doors and Other Opening Protective's ". Failing to inspect and test fire rated door assemblies in accordance with NFPA 80 annually could cause harm to the patients.

NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware,including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code.

NFPA 80 Section 5.2* Inspections Section 5.2.1* Fire door assemblies shall be inspected and tested not less than annually , and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

Findings include:

Observation while on tour and during review of facility documentation conducted on June 14 and 15, 2023,, revealed the facility did not have written records of the Annual Inspection and Testing of the fire doors throughout the facility in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protective's. Only 9 doors were being inspected almost all the doors in the facility are labeled as fire doors. in addition the door on the first floor og the emergency fire stairwell is not listed as a 2 hour fire door not label wqs found.

Employees #1 and #2 confirmed during the exit conference that the facility failed to conduct the NFPA 80 required testing of the facility's fire doorsfor all but 9 doors.

Based on Observation it was determined the facility allowed the use of power strips and extension cords and did not use the wall outlet receptacles for appliances. Failure to properly use power cords and outlets could lead to electrical overload or fire which could cause harm to the patients and staff.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

NFPA 101 2012, 19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 70 2011, 400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: 1. As a substitute for the fixed wiring of a structure. 2. Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors

Findings include:

Observations while on tour June 14 and 15, revealed the following locations with power strips plugged appliances with a high amperage draw). Use of extension cords as permanent equipment with heavy load drawing appliance (refrigerators, microwaves and large printers) plugged into power strips.
1. The elevator lobby had a vending machine plugged into a power strip.
2. One administrative Room had a refrigeratorand microwave plugged into a power strip.
3. The coference room had a power extension cord plugged into the wall that transended the ceiling into an unknown area.

During the exit conference conducted on June 14 and 15, Employee # 1, 2 confirmed the improper use of power strips, and extension cords.

Based on Observation the facility failed to properly store full oxygen (O2) cylinders five (5) ft. from combustible items and to label the door indicating the hazard. This could result in the combustible items becoming oxygen saturated and easily ignitable which could cause a fire to start prematurely. Failing to label the door could result in personnel entering the area unaware of the hazards inside

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."

NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 11 Gas Equipment Section 11.3.4.1 'A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING"

NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 11 Gas Equipment Section 11.3.2.3 "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft)(2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. (3)Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/ 2 hour

Findings include:

During a facility tour conducted on June 14 and 15, 2023, observed the following :
1. 400 Cubic Feet of Oxygen cylinders being stored next to combustible materials.
2. The storage room was not properly labeled indication oxygen was being stored inside this was outside the ICU.

During the exit conference conducted on June 14 and 15, 2023, employee # 1 and 2 acknowledged the following discrepancies:
1. 400 Cubic Feet of Oxygen cylinders being stored next to combustible materials.
2. The storage room was not properly labeled indication oxygen was being stored inside this was outside the ICU.