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Based on document review and interview, the facility failed to ensure two (2) staff members had current CPR (Cardio-Pulmonary Resuscitation-CPR) certification (S # 1-Care Facilitator Associate and S # 2-Mental Health Technician).

Findings include:

1. The facility policy titled, "Staff Development Plan", policy number HR 520, indicated particular competencies are a condition of employment of employment for certain job descriptions. This policy was last revised in 05/2021.

2. Review of the job descriptions for S # 1 and S # 2, indicated the employment requirements were to be CPR certified and to maintain a current certification during employment

3. Review of personnel files for S # 1 and S # 2 indicated the following:
a. S # 1-CPR certification expired in 09/2021.
b. S # 2-CPR certification expired in 02/2020.

4. In interview on 10/25/2022 at approximately 4:20 pm with administrative staff member A # 5 (Human Resources Data Specialist), confirmed S # 1 and S # 2 had expired CPR certifications.

5. In interview on 10/25/2022 at approximately 4:40 pm with administrative staff member A # 3 (Compliance Manager), confirmed the staff members should have current CPR certifications.

Based on document review and interview, the registered dietitian (RD) failed to ensure a dietary assessment/consultation was completed on a client within seventy-two (72) hours following admission. (Patient # 1)

Findings include:

1. The facility policy titled "Adult Inpatient Program", policy number PD 530, indicated the RD would complete a dietary assessment and dietary consultation within seventy-two (72) hours following the clients admission. This policy was last revised in 04/2021.

2. Review of the medical record (MR) for client # 1 indicated client # 1 was admitted on 10/12/2022 at 11:34 pm and referred to the dietitian on 10/13/2022 at 9:54 am. On 10/14/2022 the dietitian documented the client was unavailable for assessment. The client was seen by the dietitian on 10/19/2022 at 11:04 am.

3. In interview on 10/24/2022 at approximately 3:30 pm with administrative staff member A # 2 (Registered Nurse-RN/Unit Manager) of inpatient services, confirmed the client should have had a nutritional assessment/dietary consult by the RD within seventy-two (72) hours of admission.

4. In interview on 10/26/2022 at approximately 10:40 am with administrative staff member A # 4 (Vice President Intensive Services), confirmed the RD should have seen the client on Monday 10/17/2022.

Based on record review, observation, and interview, the facility failed to ensure the means of egress through 1 of 3 exits with special locking arrangements for the clinical security needs of the patients were readily accessible (see tag K222), failed to ensure the egress discharge for 2 of 5 exits was provided with illumination and were arranged so the failure of any single lighting fixture would not leave the area in darkness (see tag K281), failed to ensure 1 of 2 receptacles within 6 feet from a sink were provided with ground fault circuit interrupter (GFCI) protection against electric shock (see tag K511), failed to conduct fire drills on each shift for 2 of 4 quarters (see tag K712), failed to ensure electrical receptacles in 8 of 8 patient sleeping rooms were tested at least annually for non-hospital receptacles and initially for hospital grade receptacles (see tag K914), and failed to exercise 1 of 1 diesel generators annually to meet the requirements of NFPA 110, 2010 Edition, the Standard for Emergency and Standby Powers Systems (see tag K918).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure it had implemented a systemic plan of correction to prevent recurrence, therefore failing to ensure the provision of quality health care in a safe environment.

Based on observation and interview, the facility failed to ensure the egress discharge for 2 of 5 exits was provided with illumination and were arranged so the failure of any single lighting fixture would not leave the area in darkness. LSC 7.8.1.4 requires illumination shall be arranged so that that the failure of any single lighting unit does not result in an illumination level of less than 0.2 foot-candle in any designated area. This deficient practice could affect all patients

Findings include:

Based on observations with the Facilities Manager on 11/01/22 at 11:20 a.m. and 11:45 a.m., the exit discharge outside the north exit did not have egress lighting. Also, there was only one light fixture with only one LED light outside the west exit. Based on interview at the time of observation, the Facilities Manager agreed there was only one light source outside of the west exit and no lighting out side of the north exit.

This finding was reviewed with the Facilities Manager during the exit conference.


Based on observation and interview, the facility failed to ensure 1 of 2 receptacles within 6 feet from a sink were provided with ground fault circuit interrupter (GFCI) protection against electric shock. LSC 19.5.1.1 requires utilities comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code. NFPA 70, NEC 2011 Edition at 210.8 Ground-Fault Circuit-Interrupter Protection for Personnel, states, ground-fault circuit-interruption for personnel shall be provided as required in 210.8(A) through (C). The ground-fault circuit-interrupter shall be installed in a readily accessible location.
(B) Other Than Dwelling Units. All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in 210.8(B)(1) through (8) shall have ground-fault circuit-interrupter protection for personnel.
(1) Bathrooms, (2) Kitchens, (3) Rooftops, (4) Outdoors,
(5) Sinks - where receptacles are installed within 1.8 m (6 ft.) of the outside edge of the sink.
(6) Indoor wet locations, (7) Locker rooms with associated showering facilities, (8) Garages, service bays, and similar areas where electrical diagnostic equipment, electrical hand tools.
NFPA 70, 517-20 Wet Locations, requires all receptacles and fixed equipment within the area of the wet location to have GFCI protection. Note: Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could affect 2 patients in room 118.

Findings include:

Based on observations with the Facilities Manager on 11/01/22 at 12:35 p.m., there was an electric receptacle 29 inches from a sink in the restroom of room 118. The electric receptacle was not GFCI protected and did not trip when tested. Based on interview at the time of observation, the Facilities Manager agreed the electric receptacle was not GFCI protected when tested.


Based on observation, record review and interview, the facility failed to ensure electrical receptacles in 8 of 8 patient sleeping rooms were tested at least annually for non-hospital receptacles and initially for hospital grade receptacles. NFPA 99, Health Care Facilities Code 2012 Edition, Section 6.3.4.1.3 states receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. Additionally, Section 6.3.3.2, Receptacle Testing in Patient Care Rooms requires the physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed; and retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 grams (4 ounces). This deficient practice could affect all patients.

Findings include:

Based on observations with the Facilities Manager on 11/01/22 between 11:00 a.m. and 12:00 p.m., the facility's patient sleeping rooms contained five to eight electrical receptacles with a mix of hospital and non-hospital grade receptacles. Based on records review at 10:30 a.m., there was no documentation available to show receptacle testing for the sleeping rooms. Based on interview at the time of the observation and records review, the Facilities Manager stated the receptacles will need to be tested.

This finding was reviewed with the Facilities Manager during the exit conference.

Based on observation and interview, the facility failed to ensure the means of egress through 1 of 3 exits with special locking arrangements for the clinical security needs of the patients were readily accessible by remote control of locks; keys carried by staff at all times; or other such reliable means available to the staff at all times. This deficient practice could affect 8 patients in the west hall

Findings include:

Based on observations with the Facilities Manager on 11/01/22 at 11:13 a.m., the west exit door was marked as a facility exit, was locked with a dead bolt, and could be opened using a key carried by staff, but when tested the dead bolt did not release. Based on interview at the time of observation, the Facilities Manager stated the lock was broken and did replace the lock and was functioning when tested a second time.


This finding was reviewed with the Facilities Manager during the exit conference.


Based on record review and interview, the facility failed to conduct fire drills on each shift for 2 of 4 quarters. LSC 19.7.1.6 states drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficient practice affects all occupants.

Findings include:

Based on records review with the Facilities Manager on 11/01/22 at 10:02 a.m., the following shifts were missing documentation of a completed fire drill:
a) A third shift fire drill in the second quarter of 2022.
b) A third shift fire drill in the third quarter of 2022.
c) A first shift fire drill in the third quarter of 2022.
Based on interview at the time of record review, the Facilities Manager stated the aforementioned drills were not conducted.

This finding was reviewed with the Facilities Manager during the exit conference.

Based on record review and interview, the facility failed to exercise 1 of 1 diesel generators annually to meet the requirements of NFPA 110, 2010 Edition, the Standard for Emergency and Standby Powers Systems, Chapter 8.4.2. Section 8.4.2 states diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS (Emergency Power Supply) nameplate kW rating.
Section 8.4.2.3 states diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS (Emergency Power Supply System) load and shall be exercised annually with supplemental loads (Load Bank Test) at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. This deficient practice could affect all occupants.

Findings include:

Based on records review with the Facilities Manager on 11/01/22 at 10:07 a.m., the monthly load tests showed that load percentage for the diesel-powered generator for the months of October 2021 thru May 2022 were under 30%, and no annual load bank test was available for review. Based on interview at the time of record review, the Facilities Manager stated the generator load did not achieve 30 % of the generator's name plate rating for 8 of 12 months. Additionally, the Maintenance Director stated a load bank test for the generator was not conducted during the past year.

This finding was reviewed with the Facilities Manager during the exit conference.

Based on document review and interview, the facility failed to ensure the blood glucose meter (Easy Touch) was being cleaned/disinfected, according to the manufacturers guidelines, for eight (8) clients one hundred twenty-six (126) instances. (06/01/2022 - 10/01/2022)

Findings include:

1. The policy titled "Blood Glucose Monitoring", policy number NR 814, indicated to clean and disinfect meter using an IC (Infection Control) Committee approved alcohol containing disinfectant wipe after each use. Allow meter to air dry completely before next use. This policy was last revised in 06/2022.

2. Review of the client diabetic records from 06/01/2022 through 10/01/2022, indicated the direct care staff used the blood glucose meter for eight (8) clients one hundred twenty-six (126) instances.

3. In interview on 10/26/2022 at approximately 2:00 pm with Easy Touch Manufacturing Company employee C # 1 (S.L), confirmed the Easy Touch HealthPro and Easy Touch are cleaned/disinfected the same way. Documentation received via email indicated to use an EPA (Environmental Protection Agency) registration number 46781-8 (Cavi wipes). Other agents have not been validated with the meter. The meter should be cleaned prior to each disinfection and to achieve disinfection the meter should remain wet for two (2) minutes.

4. In interview on 10/26/2022 at approximately 2:30 pm with administrative staff member A # 4 (Vice President/Intensive Services), confirmed the facility was using the IC approved disinfectant Super Sani Cloth EPA # 9380-4. The meter was being cleaned/disinfected incorrectly.

Based on document review and interview, the facility failed to ensure one (1) staff member had infection control annual training. (S # 1-Care Facilitator Associate)

1. The facility policy titled, "Staff Development Plan", policy number HR 520, indicated infection control annual training is required annually. This policy was last revised in 05/2021.

2. Review of S # 1's training transcript, indicated the staff member lacked infection control annual training.

3. In interview on 10/25/2022 at approximately 4:20 pm with administrative staff member A # 5 (Human Resources Data Specialist), confirmed S # 1 lacked annual training for infection control.

4. In interview on 10/25/2022 at approximately 4:40 pm with administrative staff member A # 3 (Compliance Manager), confirmed the staff member should have current annual training for infection control.

Based on document review and interview the facility failed to ensure the appropriate number of personnel were staffed on three (3) shifts. (9/26 evening/night shift & 9/28 night shift)

Findings include:

1. The facility policy titled "Adult Inpatient Program", policy number PD 530, indicated nursing care was provided twenty-four (24) hours a day. The staffing guideline matrix indicated for 7 (seven) or less clients, there should be two (2) Registered Nurses (RN's), one (1) Mental Health Tech (MHT) or vice versa and eight (8) to twelve (12) clients should be staffed with two (2) RN's and two (2) MHT's. This policy was last revised in 04/2021.

2. Review of the Staffing Pattern Worksheet indicated the following:
a. Monday 09/26/2022 - evening shift - two (2) RN's and one (1) MHT were staffed with a census of twelve (12) clients. The shift was short staffed one (1) MHT.
b. Monday 09/26/2022 - night shift - two (2) RN's and one and a half (1.5) MHT's were staffed with a census of twelve (12) clients. The shift was short staffed a half (0.5) MHT.
c. Wednesday 09/28/2022 - night shift - one and a half (1.5) RN's and two (2) MHT's were staffed with a census of eleven (11) clients. The shift was short staffed a half (0.5) RN.

3. In interview on 10/25/2022 at approximately 9:25 am with administrative staff member A # 1 (RN/Director of Nursing-DON/Infection Control Nurse) confirmed the facility was short staffed on the above shifts.

Based on document review and interview the facility failed to ensure treatment plans were signed by the client in a timely manner with three (3) of four (4) open medical records (MR's) reviewed (Client # 1, Client # 2 and Client # 3).

Findings include:

1. The facility policy titled "Planning Care, Treatment and Services", policy number HI 150, indicated an individual treatment plan is created for every client seeking ongoing care, treatment and/or services. The plan is based on the assessed needs of the client, the client's preferences, and the clinical, rehabilitative and other treatments/services. An interdisciplinary and person-centered approach that includes the client is utilized. The treatment plan discussed with the individual (client) and they are then asked to sign the treatment plan to confirm their participation in the development of the plan and agreement to proceed with services outlined in the plan. This policy was last revised in 05/2021.

2. Review of "Client Rights" for H # 2 (Psychiatric Hospital), indicated the client could actively participate in the planning for treatment.

3. The following client treatment plans were reviewed for clients signature confirming participation:
a. Client # 1 was admitted on 10/12/2022 at 11:34 pm. The clients treatment plan was signed on 10/24/2022 at 2:30 pm.
b. Client # 2 was admitted on 10/22/2022 at 2:20 pm. The clients treatment plan was signed on 10/24/2022 at 1:31 pm.
c. Client # 3 was admitted on 10/12/2022 at 7:57 pm. The clients treatment plan was signed on 10/17/2022 at 2:12 pm.

4. In interview on 10/24/2022 at approximately 3:40 pm with administrative staff member A # 2 (Registered Nurse-RN/Unit Manager) of inpatient services, confirmed the client should sign the treatment plan when completing it. It is unacceptable.