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Based on observation and interview the facility failed to ensure all corridor doors could be opened with one action as required.

Findings:

On 06/23/21 at 10:05am the surveyor observed a deadbolt with a turn knob on several corridor doors within the facility.

On 06/23/21 at 10:05am the surveyor asked Staff C why there were deadbolts on the exit access corridor doors. Staff C stated he did not know other than for security but will take them off to be in compliance. The surveyor explained it would take more than one action for a person to gain access to the emergency exit egress corridor pathway which is not complaint to code.

Based on observation and interview the facility failed to ensure each emergency exit discharge area was provided with emergency powered lighting.

Findings:

On 06/24/21 at 2:04 pm the surveyor observed each of the facility's emergency exit discharges did not have battery backed up emergency powered lighting or could not be confirmed while on survey if they were generator wired emergency powered lighting.

On 06/24/21 at 2:04 pm Staff C stated he will confirm what lights are emergency powered on the generator and if the exit discharges are not on generator get battery backed up lighting at each of the exit discharges or have emergency exit discharge lighting wired to the emergency generator at each of the exits of the facility in order to meet compliance.

Based on observation and interview the facility failed to ensure exit signage was displayed as required.

Findings:

On 06/23/21 at 10:17am the surveyor observed a door leading to an enclosed courtyard with no signage indicating it was not an exit as required.

On 06/23/21 at 10:18am the surveyor asked staff C why there was no signage indicating the two doors leading into the enclosed courtyard was not an exit. Staff C stated they were not aware of the code but will ensure signage is placed to be in compliance.

Based on observation and interview the facility failed to ensure a hazardous area was properly protected/separated from other use spaces.

Findings:

On 06/24/21 at 3:12pm the surveyor observed a hazardous area electrical closet in the emergency room that had an electrical panel. The surveyor observed the hazardous area electrical closet in addition had a oxygen storage sign with over 12 E oxygen cylinders stored within it along with multiple combustible items: two plastic back boards, wooden shelve on wheels, plastic bin containers, PVC tubing, cloth dressing supplies.

On 06/24/21 at 3:13pm the surveyor asked Staff C why the hazardous electrical closet had not only combustible items stored in it, but had also oxygen stored within it. Staff C stated he was not sure why. The surveyor stated to staff C the area is out of compliance with fire code as combustible items are not to be stored within oxygen or electrical hazardous area closets, and oxygen is not to be stored within hazardous electrical closets. Staff C stated they will correct the issue with the noncompliant storage.

Based on record review and interview the facility failed to ensure ASHRAE 170-2008 ventilatory standards were maintained as required.

Findings:

Record review showed the facility had one annual test and balance dated 10/03/07. The one test and balance inspection report did not include data indicating if any of the tested rooms were positively or negatively ventilated as required nor how many air exchanges per hour (ACH) each air handler actually performed for each room as required. The facility has two isolation rooms, an operating room where they perform endoscopic procedures, a clean endoscopic tube processing room, a dirty endoscopic tube processing room, and soiled utility room in the surgical area. The surgical area rooms in the facility could not be verified to be in compliance with ASHRAE 170-2008 ventilatory standards as required.

Record review showed the facility did not complete temperature and relative humidity (RH)logs for the surgical area rooms as required. There were no temperature and RH logs for the operating procedure room, and sterile storage.

Record review showed the facility did not complete manometer reading logs as required for the HVAC unit that serves the surgical area.

On 06/23/21 at 10:27am the surveyor asked staff C why they only have the one test and balance from 2007 and without the required ventilatory data. Staff C stated they are new to the healthcare field and are learning. Staff C stated they will get a test and balance completed for the surgical area rooms as required then complete it annually to be in compliance.

On 06/24/21 at 1:34pm the surveyor asked staff B for the temperature and RH logs. staff B stated that a past surveyor told them it was not required if they call the operating room a procedure room. The surveyor stated that is not correct and showed staff B the ASHRAE 170-2008 standards at table 7.1 which included temperature and RH 30-60%. Staff B asked what will happen since they were told by past surveyors it was not required to be documented. The surveyor stated it is a citation because it is required by CMS.

On 06/24/21 at 11:00am the surveyor asked staff C for the manometer readings from the HVAC unit that serves the surgical area. Staff C stated they have a vendor Luckinbill that does their HVAC filter changes but they do not have manometer logs. Staff C stated they will start recording the manometer readings to be in compliance.

Based on record review and interview the facility failed to include the transmission of a fire alarm signal on each fire drill.

Findings:

Record review showed the fire drills for 2020 and 2019 did not document transmission of a fire alarm signal.

On 06/23/21 at 11:17am the surveyor asked staff C why the fire drills did not contain documentation of the transmission of a fire alarm signal as required. Staff C stated that he was not familiar with that requirement but will ensure it is documented from this time forward.

Based on observation and interview the facility failed to ensure space heaters were not placed in sleeping staff areas as required.

Findings:

On 06/23/21 at 10:50am a space heater was observed in a patient care room being used for a doctors sleeping room.

On 06/23/21 at 10:51am the surveyor asked staff C was asked why there was a space heater in a sleeping staff room. Staff C stated they did not know it was noncompliant. The surveyor stated to staff C space heaters are prohibited in patient care areas, can only be utilized in nonsleeping staff areas and only with manufactuers documentation indicating the heating element does not exceed 212 degrees Fahrenheit.

Based on record review and interview the facility failed to ensure the building system risk assessments were completed.

Findings:

Record review showed the facility EES (Essential Electrical System) and Medical Gas building system risk assessment were not completed.

On 06/23/21 at 11:23am during record review the surveyor asked Staff C for the EES and Medical Gas building system risk assessments. Staff C stated he is new to healthcare life safety but will get the building system risk assessment completed.

Based on record review and interview the facility failed to ensure line isolation monitor (LIM) inspection and testing was completed for the surgical suite.

Finding:

Record review showed the facility did not complete LIM inspection and testing for 2020, 2019 and 2018.

Record review showed the facility did not complete annual impedance testing of patient care related electrical receptacles.

On 06/23/21 at 1:12pm the surveyor asked staff C for documentation for the inspection and testing for the surgical area LIM system. Staff C stated the LIM annual inspections were not completed for 2020, 2019 and 2018.

On 06/23/21 at 1:26pm the surveyor asked staff C why the annual impedance testing of patient care related electrical receptacles was not completed for 2020, 2019, and 2018. Staff C stated he is new to the position, is learning and it will get scheduled to be complete annually. Staff C stated he does not know why it was not done by the person before him.

Based on record review and interview the facility failed to ensure operating room staff completed specific training on features of fire protection and fire loss prevention in operating rooms as required.

Findings:

Record review showed no fire drills for operating room staff for emergency procedures which included each of the the following required elements: equipment fires, alarm activation, evacuation, equipment shutdown, and control operations in addition to continuing education specific to operating room fire prevention. The operating room fire drills and emergency procedures training did not include surgeons/doctors as required in NFPA 99, 15.13.

On 06/23/21 at 10:04am the surveyor asked staff B if the operating room staff performed practical fire drills in the operating room which included each of the items as outlined in the CMS 2786R document at K933. Staff B stated they do fire drills but will document each of the elements of K933 in the future. The surveyor stated they will have to include each of the outlined items in K933 to also include doctors in the drill.