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Based on observation and interview, the facility did not provide two-hour rated building separations in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.1.3, 19.1.3.3, 8.3.4.2, & 8.3.5. This deficient practice could affect an undetermined number of patients, staff, and visitors.

Findings include:

1. On 11/09/2021 at 1:04 pm, observation in the Emergency Department (ED) Electrical Room revealed a 1-inch conduit sleeve penetration of the two-hour rated barrier, separating the original building from the from the 2008 Hospital Expansion, that was not fire stopped according to an approved method.

2. On 11/09/2021 at 1:12 pm, observation above the ceiling in the corridor, outside of the Rehab Services Window, revealed a 2.5-inch conduit sleeve penetration of the two-hour rated barrier, separating the original building from the from the 2008 Hospital Expansion. The conduit sleeve had data cables passing through and was not fire stopped according to an approved method.

3. On 11/09/2021 at 1:15 pm, observation at the two-hour rated barrier near the Rehab Services Window, separating the original building from the from the 2008 Hospital Expansion, revealed that the 90-minute fire-rated double doors did not positively latch.

4. On 11/09/2021 at 1:18 pm, observation above the ceiling in the Rehab Services Hallway revealed a 3/4-inch conduit penetration passing through a 2-inch hole in the two-hour rated barrier, separating the original building from the from the 2008 Hospital Expansion, that was not fire stopped according to an approved method.

5. On 11/09/2021 at 1:20 pm, observation at the two-hour rated barrier in the Rehab Services Hallway, separating the original building from the from the 2008 Hospital Expansion, revealed that the 90-minute fire-rated door did not positively latch.

6. On 11/09/2021 at 1:30 pm, observation at the two-hour rated barrier at the staff-only corridor, separating the original building from the from the 2008 Hospital Expansion, revealed that the 90-minute fire-rated double doors did not positively latch.

7. On 11/09/2021 at 1:39 pm, observation above the ceiling in the corridor, near the Housekeeping Closet, revealed four (4) 2.5-inch conduit sleeve penetrations of the two-hour rated barrier, separating the Clinic from the from the 2008 Hospital Expansion. The conduit sleeves had data cables passing through and were not fire stopped according to an approved method.

8. On 11/09/2021 at 1:43 pm, observation above the ceiling in the Support Staff Room revealed five (5) 1-inch conduit sleeve penetrations of the two-hour rated barrier, separating the Clinic from the from the 2008 Hospital Expansion, that was not fire stopped according to an approved method.

9. On 11/09/2021 at 1:59 pm, observation above the ceiling in the Diabetes Educator Office revealed a 1-inch conduit sleeve penetration of the two-hour rated barrier, separating the Clinic from the from the 2008 Hospital Expansion. The conduit sleeve had data cables passing through and was not fire stopped according to an approved method.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staffs C and Y.

Based on observation and interview, the facility failed to provide means of egress in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.2, 19.2.2.2.1, 19.2.2.2.4, 7.2.1.5.1, 7.2.1.5.10, 7.2.1.5.10.2, & 7.2.1.6.1. This deficient practice could affect an undetermined number of patients, staff, and visitors.

Findings include:

On 11/09/2021 at 12:51 pm, observation revealed that the locking mechanisms on the egress doors of the Ambulance Bay could not be released from the egress side of the doors without special knowledge, tools, and electricity. There were three (3) doors to the room: an electrically controlled sliding glass door leading to the outside, an electrically controlled overhead garage door leading to the outside, and double swinging doors leading to the Emergency Department Suit with key-pad access. Maintenance Director C stated that he doesn't think that the electronic locking was connected to the fire alarm system and doesn't believe it would unlock during a fire alarm. The sliding doors were not installed on an emergency break-away track to allow for emergency egress. Maintenance Director C stated that the doors were equipped with electronic locking as a security feature and confirmed that a person could not egress the room if they did not know the key-pad code.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staffs C and Y.

Based on observation and interview the facility failed to maintain that all suites are separated from the remainder of the building by construction meeting the separation provisions for corridor construction in accordance with NFPA 101 (2012 edition) Sections 19.2.5.7.1.2, 19.2.5.7.1.3, 19.2.5.7.1.4, 19.3.6.2-19.3.6.5. This deficient practice could affect an undetermined number of patients, staff, and visitors.

Findings include:

1. On 11/09/2021 at 12:27 pm, observation revealed that the suit separation door to the emergency department (ED) treatment suite, between the ED waiting room and the Hospital Lobby, was not equipped with positively latching hardware. The only equipped means of latching was a deadbolt lock. The deadbolt lock needed to be manually engaged, in order to latch the door to the door frame.

2. On 11/09/2021 at 12:50 pm, observation revealed that the suit separation doors, between the ED and the Ambulance Bay, were not positively latching. Maintenance Director C stated that the door latching is manually controlled by a switch at the Nurses Station, and if the switch is off, the doors will not latch.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staffs C and Y.

Based on observation and interview, the facility did not mark the exit access in accordance NFPA 101 (2012 edition) Sections 19.2.10, 7.10.1.5. This deficiency had the potential to affect all patients within the Emergency Department, and an undetermined number of staff and visitors.

Findings include:

On 11/10/2021 at 11:45 am, observation revealed there was no visible exit signage located at the corridor intersection by the Emergency Department Nurses Station. It was not readily apparent where to go in order to egress the suite to the exit or exit access corridor.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staffs C and Y.

Based on observation and interview, the facility failed to protect hazardous areas in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.2.1, 19.3.2.1.2, 19.3.2.1.3, 19.3.2.1.5, 19.3.6.3.5(1), 19.3.6.3.11. This deficient practice could affect an undetermined number of patients, staff, and visitors.

Findings include:

On 11/09/2021 at 3:17 pm, observation revealed that the fire-rated door to the Kitchen Dry Storage Room, equipped with self-closing hardware, did not close as the door was being held open by a wooden floor wedge. The room was enclosed by 1-hour fire-rated construction.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staffs C and Y.

Based on record review, observation, and interview, the facility did not inspect the kitchen range hood equipment in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.2.5 & 9.2.3; and NFPA 96 (2011 edition) Sections 11.4, 11.6, 11.6.1, 11.6.2, 11.6.13, 11.6.14, 11.6.15. This deficient practice could affect an undetermined number of patients, staff, and visitors.

Findings include:

1. On 11/08/2021 at 4:15 pm, review of inspection records for the kitchen-hood exhaust system revealed that the exhaust cleaning service, conducted by D&V Pro Cleaning Services in September 2021, did not include a cleaning report listing the date of service, the name of the technician, and the areas that were cleaned or inaccessible.

On 11/09/2021 at 3:24 pm, observation in the Kitchen revealed that the exhaust cleaning service placed a service sticker on the hood. The sticker displayed a date of September 2021, but did not specify a day, and the name of technician was not included.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staffs C and Y.

Based on observation and interview, the facility did not install smoke detectors in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.4, and 9.6; NFPA 72 (2010 edition) Section 17.7.4, 17.7.5.3.3, 17.7.5.6.5.1. This deficient practice could affect all inpatients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 11/08/2021 at 2:00 pm, observation in the Surgery Core Room revealed that a smoke detector was installed 30-inches away from an air supply diffuser, subject to airflow.

2. On 11/09/2021 at 12:29 pm, observation in the emergency department (ED) Consult Room revealed that a smoke detector was installed 18-inches away from an air supply diffuser, subject to airflow.

3. On 11/09/2021 at 12:40 pm, observation in the ED Exam 2 Room revealed that a smoke detector was installed 18-inches away from an air return grille, subject to airflow.

4. On 11/09/2021 at 12:41 pm, observation in the ED Exam 3 Room revealed that a smoke detector was installed 18-inches away from an air return grille, subject to airflow.

5. On 11/09/2021 at 12:42 pm, observation in the ED Treatment 4 Room revealed that a smoke detector was installed 1-foot away from an air supply diffuser, subject to airflow.

6. On 11/09/2021 at 12:43 pm, observation in the ED Treatment 5 Room revealed that a smoke detector was installed 1-foot away from an air supply diffuser, subject to airflow.

7. On 11/09/2021 at 12:44 pm, observation in the ED Treatment 6 Room revealed that a smoke detector was installed 18-inches away from an air return grille, subject to airflow.

8. On 11/09/2021 at 12:58 pm, observation in the ED Nurse Manager's Office revealed that a smoke detector was installed 1-foot away from an air return grille, subject to airflow.

9. On 11/09/2021 at 1:00 pm, observation in the ED Equipment Storage revealed that a smoke detector was installed 18-inches away from an air return grille, subject to airflow.

10. On 11/09/2021 at 1:22 pm, observation in the Rehabilitation Treatment 2 Room revealed that a smoke detector was installed 18-inches away from an air return grille, subject to airflow.

11. On 11/09/2021 at 1:24 pm, observation in the Rehabilitation Patient Education Room revealed that a smoke detector was installed 18-inches away from an air return grille, subject to airflow.

12. On 11/09/2021 at 1:53 pm, observation in the corridor, near the entrance lobby, revealed that a smoke detector was installed 18-inches away from two (2) air return grilles, subject to airflow.

13. On 11/09/2021 at 2:06 pm, observation in the Triangle Room revealed that a smoke detector was installed 18-inches away from an air return grille, subject to airflow.

14. On 11/09/2021 at 2:50 pm, observation at the two-hour fire-rated occupancy separation barrier, separating the skilled nursing facility from the critical access hospital, revealed that the nearest smoke detector was located 11-feet away from the fire-rated doors. The doors were held open by electromagnetic hold open devices that were tied into the fire alarm system.

15. On 11/09/2021 at 3:49 pm, observation in the Mail Room revealed that a smoke detector was installed 18-inches away from an air supply diffuser, subject to airflow.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staffs C and Y.

Based on record review and interview, the facility did not perform testing and inspections of the fire alarm system in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.4 and 9.6.1.3 and NFPA 72 (2010 edition) Sections 14.3.1 and 14.4.5.3.1. This deficient practice could affect all of the inpatients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 11/08/2021 at 4:20 pm, review of fire alarm inspection and testing documents revealed that the semi-annual visual inspection of alarm initiating devices for smoke detectors, heat detectors, duct detectors, electromechanical releasing devices (door hold opens), and manual fire alarm boxes (pull stations) was conducted once, on 12/30/2020, by Summit within the last year.

2. On 11/08/2021 at 4:25 pm, review of fire alarm inspection and testing documents revealed that the last sensitivity testing of the fire alarm system was conducted on 12/14/2018 by Simplex Grinell. Maintenance Director C stated that the fire alarm panel and all devices were replaced in January 2020. No sensitivity testing was recorded within 1-year after installation.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff C.

Based on record review and interview, the facility failed to provide a fire alarm outage policy in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.4.1, 9.6.1.6. This deficient practice could affect all of the inpatients, as well as an undetermined number of staff and visitors.

Findings include:

On 11/09/2021 at 4:39 pm, record review of "Burnett Medical Center Fire Watch Policy", dated 3/15/2017, revealed that the policy required a fire watch after the fire alarm system was out of service for more than 10-hours in a 24-hour period. The policy did not address what should be done when the fire alarm system was out of service for more than 4-hours in a 24-hour period. In addition, the policy required the facility to contact the WI-DHS engineer using incorrect contact information.

This deficient practice was confirmed by an interview with Staffs B and C.

Based on record review and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 (2012 edition) Sections 19.3.5.1 & 9.7.5; NFPA 25 (2011 edition) Sections 4.3, 5.1.1.2, 5.2.1.1, & 14.2.1. This deficient practice could affect all inpatients, as well as an undetermined number of staff and visitors.

Findings include:

On 11/08/2021 at 3:45 pm, review of sprinkler system maintenance records for the past 36-months revealed that the facility could not provide documentation of quarterly inspection and testing on the sprinkler system for the year of 2019 and the first quarter of 2020.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff C.

Based on observation and interview the facility failed to provide corridor wall separations in accordance with NFPA 101 (2012 edition) sections 19.3.6.1, 19.3.5.8, 19.3.5, 9.7. This deficient practice could affect an undetermined number of patients, staff, and visitors.

Findings include:

On 11/09/2021 at 3:02 pm, observation revealed that the Central Smoke Compartment was not sprinkler protected throughout and had a cafe and a waiting room open to the corridor. The Data Closet by the Kitchen was not sprinkler protected.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staffs C and Y.

Based on observation and staff interview, the facility failed to maintain corridor doors in accordance with NFPA 101(2012 edition) Sections 19.3.6.3. This deficient practice could affect all inpatients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 11/08/2021 at 2:11 pm, observation revealed that the corridor doors to PAR Entry, equipped with self-closing hardware, did not positively latch.

2. On 11/09/2021 at 3:05 pm, observation revealed that the corridor door to the Dish Room did not positively latch, as the door frame was equipped with an electronic strike plate controlled by a toggle switch on the wall. The switch needed to be manually engaged in order for the door to latch into the door frame.

3. On 11/10/2021 at 8:33 am, observation revealed that the corridor door to Acute Care Linen Room, equipped with self-closing hardware, did not positively latch.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staffs C and Y.

Based on observation and interview, the facility did not maintain smoke barriers in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.7, 19.3.7.1, 19.3.7.3, 19.3.7.8, 19.2.2.2.7, 8.5, 8.5.2 and 8.5.6. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 11/09/2021 at 2:33 pm, observation above the ceiling at the East Wing smoke barrier revealed multiple penetrations that were not protected by a system or material capable of restricting the transfer of smoke. Unprotected penetrations include three (3) 3-inch conduits passing through a 5"x4" hole in the wall, a 3"x2" hole in the wall with data cables passing through, a 2"x2" hole in the wall with data cables passing through, and 2-inch conduit sleeve with data cables passing through.

2. On 11/09/2021 at 2:41 pm, observation above the ceiling at the Acute Care smoke barrier revealed a 3-inch conduit sleeve penetration of the smoke barrier. The conduit sleeve had data cables passing through and was not protected by a system or material capable of restricting the transfer of smoke

3. On 11/09/2021 at 2:44 pm, observation revealed that corridor doors to Patient Recovery Rooms 1506 and 1508 were in a smoke barrier wall and were not equipped with self-closing or automatic-closing hardware.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staffs C and Y.

Based on observation and interview, the facility failed to install, protect, and maintain electrical equipment in accordance with the requirements of NFPA 101 (2012 edition), Sections 19.5.1, 9.1.2, 9.1.3; NFPA 70 (2011 edition), Sections 110.27, 210.8 (B); NFPA 110 (2010 edition) Sections 7.3. This deficient practice could affect all inpatients, staff, and visitors.

Findings include:

1. On 11/08/2021 at 2:16 pm, observation in the PAR Kitchen area revealed an electrical receptacle was located approximately 5-feet from a sink. The facility was not able to confirm that ground-fault circuit-interrupter (GFCI) protection was provided within 6-feet from a sink.

2. On 11/09/2021 at 2:11 pm, observation in the Transfer Switch Room revealed that battery-powered emergency lighting was not provided.

3. On 11/09/2021 at 3:22 pm, observation in the Bakery revealed an electrical receptacle was located approximately 3-feet from a sink. The facility was not able to confirm that GFCI protection was provided within 6-feet from a sink.

4. On 11/09/2021 at 3:23 pm, observation at the Oven Countertop in the Kitchen revealed an electrical receptacle was located approximately 5-feet from a sink. The facility was not able to that GFCI protection was provided within 6-feet from a sink.

5. On 11/09/2021 at 3:43 pm, observation in the Lab revealed an electrical receptacle was located approximately 3-feet from a water deionizer with outlet. The facility was not able to confirm that GFCI protection was provided within 6-feet from a sink.

6. On 11/10/2021 at 8:45 am, observation in the Infusion Room revealed an open electrical junction box was located on the wall, with exposed wiring. Maintenance Director C stated that they removed a clock from the wall and never replaced it or added a cover plate over the box.

7. On 11/10/2021 at 8:47 am, observation at the Nurses Station by the Infusion Room revealed an open electrical junction box was located on the wall, with exposed wiring. Maintenance Director C stated that they removed a clock from the wall and never replaced it or added a cover plate over the box.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staffs C and Y.

Based on observation and interview, the facility failed to provide an effective response to emergency evacuation in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.7.1.1, 19.7.2.1.1. This deficiency had the potential to affect all patients within the Emergency Department, and an undetermined number of staff and visitors.

Findings include:

On 11/10/2021 at 11:40 am, observation revealed two (2) emergency evacuation plans were posted on the corridor walls in the Emergency Department (ED) suite. One plan was posted outside of ED Treatment Room 6 and the other plan was posted outside of the ED Electrical Room. Both evacuation plans diagram the "escape route" on a floor plan, leading only into the Ambulance Bay. The escape route is not shown to go through any other exits or exit access doors. Observation revealed that there was no exit sign at the doors entering into the Ambulance Bay. Maintenance Director C stated that the evacuation plans were wrong because the Ambulance Bay is not an exit.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staffs C and Y.

Based on record review and interview, the facility failed to conduct fire drills in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.7.1, 19.7.1.4, 19.7.1.6, 4.7.1, 4.7.2, 4.7.6. This deficient practice could affect all of the inpatients, as well as an undetermined number of staff and visitors.

Findings include:

On 11/09/2021 at 4:25 pm, review of the facility fire drill reports for the last 12-months revealed that the facility did not perform a fire drill on the 2nd shift of the 4th quarter in 2020, the 3rd shift of the 1st quarter in 2021, the 2nd and 3rd shifts of the 2nd quarter in 2021, and the all shifts of the 3rd quarter in 2021. 1st shift fire drills were held on 10/28/20, 3/24/21, and 5/11/21. One 2nd shift drill was performed, held on 3/11/21. One 3rd shift drill was performed, held on 12/31/20.

This deficient practice was confirmed by interview with Staffs B and C.

Based on observation and interview, the facility did not inspect and test the required elements of the medical gas and vacuum systems as part of a maintenance program in accordance with the requirements of 42 CFR § 485.623(d); NFPA 99 (2012 edition) Sections 5.1.14.2.1, 5.1.14.2.2, 5.1.14.2.3, 5.2.13, 5.1.14.2.3.2. This deficient practice could affect all inpatients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 11/08/2021 at 1:45 pm, observation in the Operating Room revealed that a non-stationary boom was installed in the room with medical gas lines in the boom. Maintenance Director C stated he did not know when the medical gas lines in the boom were last inspected and tested by a certified or credentialed inspector. Maintenance Director C stated they did not have a schedule or policy regarding the inspections, testing, and maintenance (ITM) of the medical gas lines in the boom.

OR Manager K confirmed that active medical gas lines are in the boom, with outlets, but stated that the medical gas lines are rarely used as they choose to use tanked gas during surgery. OR Manager K stated that the boom had "a Nitrogen leak about 3-months ago," and that "they don't make parts for it anymore." Maintenance Director C stated he had to cap the Nitrogen line because they were not able to fix the leak otherwise, and that the Nitrogen outlet is no longer functional.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staffs C and K.

2. On 11/08/2021 at 2:15 pm, observation in PAR revealed that the medical gas outlets were provided in-wall at patient bed recovery locations. Maintenance Director C confirmed that in-wall medical gas is provided at patient bed locations, and other areas, throughout the facility. Maintenance Director C stated they did not have a schedule or policy regarding the ITM of the medical gas components including piping, outlets, alarms, and valves. Compliance Officer B confirmed that the facility does not have a policy regarding the ITM of the medical gas components.

Maintenance Director C stated that the medical gas central supply is inspected annually, but confirmed that there is no policy for this, and stated the inspection is localized to the central supply equipment, and does not include components for the entire system.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staffs B and C.

3. On 11/10/2021 at 1:15 pm, record review of "Medical Annual Inspection Report" by Airgas, revealed that the most recent annual inspection of the medical gas central supply was performed 20-months ago, on 3/13/2020.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff C.

Based on record review, observation, and staff interview, the facility did not ensure that functional tests of the battery powered emergency task illumination equipment was provided in accordance per the requirements of 42 CFR § 485.623(d); NFPA 99 (2012 edition) Sections 6.1.1.1.1. This deficient practice could affect an undetermined number of patients.

Findings include:

1. On 11/08/2021 at 1:46 pm, observation in the Operating Room revealed that a battery powered emergency task light was installed in the room.

On 11/09/2021 at 9:15 am, record review of the "Back Up Lighting Test Log" revealed that the light was last functionally tested for 30-seconds monthly on 5/4/2020, and 30-minutes annually on 1/25/2018.

On 11/09/2021 at 4:15 pm, interview with OR Manager K revealed that general anesthesia is administered in the Operating Room.

This deficient practice was confirmed by interviews with Staffs C and K.

Based on observation and interview, the facility failed to test electrical receptacles in accordance with the requirements of 42 CFR § 485.623(d); NFPA 99 (2012 edition) Sections 6.3.3.2, 6.3.3.2.1, 6.3.3.2.2, 6.3.3.2.3, & 6.3.3.2.4. This deficient practice could affect all inpatients.

Findings include:

On 11/08/2021 at 1:47 pm, observation in the Operating Room revealed hospital grade electrical receptacles (outlets) were installed at patient care locations. Interview with Maintenance Director C confirmed that the facility had no documentation of annual continuity of ground in circuit, polarity, or retention testing of the electrical outlets in patient care locations.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff C.

Based on record review and interview, the facility did not perform inspections and testing of the emergency generator in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.5.1 and 9.1.3.1; and NFPA 110 (2010 edition) Sections 8.3.7, 8.4.1, 8.4.2, 8.4.2.3, & 8.4.6. This deficient practice could affect all inpatients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 11/08/2021 at 3:26 pm, review of the weekly generator inspection records revealed that no weekly inspections were documented prior to May 2021.

2. On 11/08/2021 at 3:30 pm, record review of monthly generator exercises under load revealed that, prior to October 2021, no data was recorded for the load runs, with the exception of the date. Maintenance Director C stated that the generator was run automatically on the weekends when no staff were available to record the data.

3. On 11/08/2021 at 3:32 pm, review of the monthly generator documentation revealed that neither specific gravity testing nor conductance testing of the generator batteries was recorded on a monthly basis. Maintenance Director C confirmed that specific gravity test is not performed, and neither is a battery conductance test.
Note: A battery conductance test is permitted in lieu of a specific gravity test.

4. On 11/08/2021 at 3:35 pm, review of load bank testing records revealed that the most recent annual load bank test of their diesel fueled generator was performed 9/22/2020. Maintenance Director C stated that the next load bank was scheduled for February 2022.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff C.

Based on observations and staff interview, the facility failed to properly maintain electrical devices in accordance with NFPA 101 (2012 edition), Sections 19.5.1.1 and 9.1.2, and NFPA 70 (2011 edition) Sections 400.8, 590.2(B). This deficient practice could affect an undetermined number of patients, staff, and visitors.

Findings include:

1. On 11/09/2021 at 2:59 pm, observation in the Social Services Office revealed a flexible cord multi-outlet strip device (power strip) powering a personal-sized refrigerator and a coffee maker.

2. On 11/09/2021 at 3:39 pm, observation in the Lab Break Room revealed a power strip powering a microwave, toaster, and a coffee maker. Observation revealed another power strip powering a toaster oven.

3. On 11/09/2021 at 3:59 pm, observation in the Business Office revealed an extension cord powering a microwave.

4. On 11/10/2021 at 8:44 am, observation in the Infusion Room revealed a 6-port receptacle (outlet) adapter plugged into the duplex receptacle on the wall under the TV. The cords plugged into the adapter were pulling the adapter out of the wall receptacle, exposing 1/4-inch of the electrical leads (prongs).

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staffs C and Y.