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Based on document review and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Emergency Management Staff that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.625(b)).

Findings include:

On 6/25/2024, during record review between 9:00 am and 10:30 am, the facility failed to develop and implement EP policies and procedures, based on the risks identified in the Hazards Vulnerability Assessment (HVA).

Emergency Management staff indicated they coordinated the Emergency Plan with county officials and it was a high level overview and did not include detailed policies and procedures for all identified risks on the HVA as required by CMS.

Surveyor was accompanied by the Facility Administrator and Emergency Management Staff who acknowledged the existence of these conditions.

Based on document review and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Emergency Management Staff that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.625(b)(1)).

Findings include:

On 6/25/2024, during record review between 9:00 am and 10:15 am, the facility failed to provide evidence of a secure and stable patient environment in the event of an elongated emergency, to include: (i) defined policies and/or protocols for medical, and pharmaceutical supplies of staff.

Surveyor was accompanied by the Facility Administrator and Emergency Management Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facility Administrator Emergency Management Staff that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.625(b)(2)).

Findings include:

On 6/25/20224, during record review between 9:00 am and 10:15 am, the facility failed to provide a defined system to track the location of on-duty staff during an emergency.

Surveyor was accompanied by the Facility Administrator and Emergency Management Staff who acknowledged the existence of these conditions.

Based on document review and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Emergency Management that the facility failed to comply with Federal, State and local Emergency Preparedness (EP) requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.625(d)(2)).

Findings include::

On 6/25/2024, during record review between 9:00 am and 10:15 am, during interviews Emergency Management staff indicated facility testing exercises (drills) were provided to leadership and all staff did not participate in the exercises.

Surveyor was accompanied by the Facility Administrator and Emergency Management Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections unless modified by 19.2.2 through 19.2.11 for 1 of the sampled corridors of the building. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 19.2.1, 7.1.10.1).

Findings include:

On 06/25/2024, at 12:30 p.m., the egress corridor leading from the pharmacy to the exit discharge was obstructed by chairs placed in the corridor on both sides, reducing the clear width to less than 48 inches.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on record review, observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to ensure that piped-in medical gas complied with NFPA 99 for the facility (NFPA 99, 5.1.4.8.7, 5.1.9.3, 6.4.2.2.4.2 & LSC 8.7, 19.3.2.3, S&C 13-58 and S&C 15-27). This resulted in the potential for injury to patients during medical procedures.

Findings include:

On 06/25/2024, during record review of the facility's humidity policies and procedures dated 07/20/2017 and documentation of humidity records it was noted by the surveyor that the policy had a stated range of 30%-60%. Record review identified the following recorded humidity recorded below the established range in OR1 and OR2:
January 2024, OR1, had humidity levels documented at below 30% on the 15th, 16th and 20th.
OR2 had humidity levels documented at below 30% on the 14th, 15th, 16th and 20th.
February 2024, OR1, had humidity levels documented at below 30% on the 4th.
March, OR1, had humidity levels documented at below 30% on the 1st, 2nd, 3rd, 4th and 7th.
OR2 had humidity levels documented at below 30% on the 7th.
April, OR1, had humidity levels documented at below 30% on the 17th and 18th.

Surveyor requested a copy of the Risk Assessment for the equipment used within the OR's to ensure they can operate safely in the lower humidity range. The facility could not produce the Risk Assessment or other documentation to show compliance.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to install/maintain an approved ventilation hood and duct system. This resulted in the potential for fire spread due to inappropriate and/or inadequate fire protection (LSC 19.3.2.5.1 – 19.3.2.5.4, 19.3.2.5.1 – 19.3.2.5.5, 9.2.3, NFPA 96, TIA 12-2, UL300).

Findings include:

On 06/25/2024, at 12:42 p.m., it was observed by the surveyor that a 2-burner cooking appliance was being used for cooking in the kitchen. This cooking appliance was brought in due to the existing burners not working, however the suppression heads for the cooking hood did not cover the new 2-burner appliance. The suppression system and head locations were designed and installed for the commercial cooking appliances and not the replacement 2-burner appliance.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of the following conditions.

Based on the observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to install and protect alcohol based hand rub (ABHR) dispensers in areas that are not protected by sprinklers within the building. This resulted in the potential for injury to residents/patients and staff (LSC 39.3.2.6, 8.7.3.1, 42 CFR 403, 418, 460, 482, 483, and 485, NFPA 30).

Findings include:

On 06/25/2024, at 2:30 p.m., there were ABHR dispensers located throughout the facility that were placed over carpeted areas. The facility was not equipped with a fire sprinkler system. ABHR dispensers are not allowed to be located over carpeted floors in buildings that do not have sprinkler coverage.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to select, install, inspect and maintain fire extinguishers in accordance with adopted standards for 3 of the extinguishers of the facility. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.12, NFPA 10).

Findings include:

1. On 06/24/2024, at 3:43 p.m., there was a fire extinguisher located in the generator room that did not have the required monthly inspection performed by evidence of missing documentation on tag.

2. On 06/24/2024, at 3:45 p.m., there was a fire extinguisher located in the elevator mechanical room that did not have the required monthly inspection performed by evidence of missing documentation on tag.

3. On 06/24/2024, at 3:54 p.m., there was a designated smoking area that did not have an accessible fire extinguisher located in the area or within 75 foot travel distance.

4. On 06/25/2024, at 9:05 a.m., there was a fire extinguisher located in the surgical suite that did not have the required monthly inspection performed by evidence of missing documentation on tag.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to provide fire drills for all staff affecting the entire building. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 39.7.1.4 - 39.7.1.7).

Findings include:

1. On 06/25/2024, during record review between 9:15 a.m. and 11:00 a.m., facility fire drill documentation for the main hospital showed missing fire drills in quarters 1 of 2024, 3 of 2023 and 4 of 2023 for night shift and quarters 1 and 3 for swing shift.

2. On 06/25/2024, during record review between 11:00 a.m. and 11:30 a.m., fire drill documentation requested for review for the satellite business office could not be provided. According to staff, fire drills were not being performed at that location.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.