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Based on record review and staff interview it was determined the facility failed to ensure all essential mechanical and electrical equipment followed manufacturer-recommended maintenance activities and schedules. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 2.

Findings include:

Record review on 12/11/24 at approximately 11:24 a.m., revealed no documentation available for review during survey to show that all essential mechanical and electrical equipment was listed in an inventory, which includes a record of maintenance activities.

Record review on 12/11/24 at approximately 11:32 a.m., revealed no documentation available for review during survey to show that preventative maintenance for all essential mechanical and electrical equipment followed manufacturer's recommendations or an approved alternate equipment maintenance (AEM) program.

Interview on 12/11/24 at approximately 11:34 a.m. with the Maintenance Supervisor verified these findings. These findings were also acknowledged by the Interim President/CEO at the exit interview on 12/11/24 at approximately 12:19 p.m.

Based on observation, record review, and staff interview it was determined the facility failed to comply with the Health Care Occupancy chapter requirements of NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 2.


Findings include:

In reference to Federal Life Safety Code (FLSC) citation K 345, the facility failed to ensure that the fire alarm system was properly tested and maintained.

In reference to FLSC citation K 353, the facility failed to ensure that the sprinkler system was properly tested and maintained.

In reference to FLSC citation K 521 the facility failed to ensure that fire and smoke dampers were properly tested and maintained.

In reference to FLSC citation K 781 the facility failed to ensure that portable space heaters were properly used and tested.

In reference to FLSC citation K 918 the facility failed to ensure that the emergency generator was properly tested and maintained.

In reference to FLSC citation K 920 the facility failed to ensure that power strips were properly used.

In reference to FLSC citation K 921 the facility failed to ensure that fixed and portable patient-care equipment was properly tested and maintained.

Interview on 12/11/24 at approximately 10:32 a.m. with the Maintenance Supervisor verified these findings. These findings were also acknowledged by the Interim President/CEO at the exit interview on 12/11/24 at approximately 12:19 p.m.

Based on document reviews and interviews, it was determined the facility failed to ensure Medical Staff Bylaws, Rules and Regulations were reviewed and approved by the Governing Body every two (2) years. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

The "Medical Staff Bylaws," were reviewed, last reviewed by the Governing Body on 07/16/21. No more recent reviews or approvals were listed.

The "Medical Executive Committee Meeting" minutes were reviewed for 08/28/23 and state in part, "...Old Business: MS (Medical Staff) Bylaws/Rules & (and) Regs (Regulations)- Awaiting review by legal services. Action tabled until completion of review..."

The "Medical Executive Committee Meeting" minutes were reviewed for 12/19/23 and state in part, "...Old Business: Review of MS Bylaws/Rules & Regs - Awaiting review by legal services. Action tabled until completion of review..."

The "Medical Executive Committee Meeting" minutes were reviewed for 02/20/24 and state in part, "...Old Business: Review of MS Bylaws/Rules & Regs - Awaiting review by legal services. Action tabled until completion of review..."

The "Medical Executive Committee Meeting" minutes were reviewed for 04/16/24 and state in part, "...Old Business: Review of MS Bylaws/Rules & Regs - Awaiting review by legal services. Action tabled until completion of review..."

The "Medical Executive Committee Meeting" minutes were reviewed for 07/18/24 and state in part,"...New Business: Medical Staff Bylaws: The draft of proposed revisions to the Medical Staff Bylaws will be forwarded to [Staff #13], to review."

An interview was conducted with Staff #13 on 12/11/24 at 9:21 a.m. Staff #13 explained the updated proposals for the Medical Staff Bylaws information was sent to them for review on 07/18/24, but had not been reviewed yet. Staff #13 confirmed there were no further updates or reviews documented by the Governing Body since 07/16/21.

Based on document reviews and interviews, it was determined the facility failed to ensure the Patient Bill of Rights for Swing Beds was provided to all Swing bed patients. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A review was conducted of the admission folder presented to Swing bed patients upon admission. The folder included the "Patient Rights and Responsibilities," last approved 06/14/23 and the "Patient Bill of Rights," last approved 06/14/23. The documents did not include the following rights of swing bed patients: The resident has the right to choose his or her attending physician, The right to retain and use personal possessions, including furnishings, and clothing, as space permits, The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement, and The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service.

An interview was conducted with Staff #11 on 12/10/24 at 2:08 p.m. Staff #11 concurred there was no Swing Bed Patient Bill of Rights, which included the above Rights, provided to the Swing Bed patients.