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Based on record review and staff interview, the facility failed to ensure that the fire alarm system was tested and maintained in accordance with NFPA (National Fire Protection Association) 72. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 2.

Findings include:

Record review on 12/09/24 at approximately 1:43 p.m., revealed the documentation for smoke detector sensitivity testing did not include the manufacturers' listed sensitivity range, the actual tested sensitivity, or a pass/fail for all smoke detectors located throughout the facility.

Interview on 12/09/24 at approximately 1:44 p.m. with the Maintenance Supervisor verified this finding. This finding was also acknowledged by the Interim President/CEO at the exit interview on 12/11/24 at approximately 12:19 p.m.

Based on record review and staff interview, the facility failed to ensure that the automatic sprinkler system was tested and maintained in accordance with NFPA (National Fire Protection Association) 25. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 2.

Findings include:

Record review on 12/09/24 at approximately 1:18 p.m., revealed two (2) sprinkler gauges dated 10/01/19, which had not been calibrated or replaced in the previous five (5) years.

Interview on 12/09/24 at approximately 1:19 p.m. with the Maintenance Supervisor verified this finding. This finding was also acknowledged by the Interim President/CEO at the exit interview on 12/11/24 at approximately 12:19 p.m.

Based on record review and staff interview, the facility failed to ensure that fire and smoke dampers were installed and maintained in accordance with NFPA (National Fire Protection Association) 90A. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 2.

Findings include:

Record review on 12/09/24 at approximately 2:37 p.m., revealed the fire damper inspection report did not include the location of fire dampers located throughout the building.

Interview on 12/09/24 at approximately 2:38 p.m. with the Maintenance Supervisor verified this finding. This finding was 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, the facility failed to ensure that portable space heaters were used in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 2.

Findings include:

Observation on 12/10/24 at approximately 9:51 a.m., revealed a portable space heater in the Med Surge Shower Room, near the Short Hall.

Observation on 12/10/24 at approximately 2:24 p.m., revealed a portable space heater in use in the Human Resources Office. No documentation was provided during survey to show that the elements in this space heater did not exceed 212 degrees Fahrenheit.

Interview on 12/10/24 at approximately 2:25 p.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 record review and staff interview, the facility failed to ensure that the emergency generator was tested and maintained in accordance with NFPA (National Fire Protection Association) 110. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 2.

Findings include:

Record review on 12/09/24 at approximately 2:12 p.m., revealed no documentation available for review during survey to show that the emergency generator battery electrolyte fluid level had been checked weekly for the previous twelve (12) months.

Interview on 12/09/24 at approximately 2:13 p.m. with the Maintenance Supervisor verified this finding. This finding was also acknowledged by the Interim President/CEO at the exit interview on 12/11/24 at approximately 12:19 p.m.

Based on observation and staff interview, the facility failed to ensure power strips were used in accordance with NFPA (National Fire Protection Association) 99. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 2.

Findings include:

Observation on 12/09/24 at approximately 11:31 a.m., revealed a refrigerator and a coffee pot plugged into a power strip in the Pharmacy.

Observation on 12/10/24 at approximately 8:47 a.m., revealed a power strip in use in Operating Room 1, which appeared to be a residential style power strip and did not appear to meet UL 1363A or UL 60601-1.

Observation on 12/10/24 at approximately 9:51 a.m., revealed a refrigerator, two (2) coffee pots, and a toaster plugged into a power strip in Cardiopulmonary.

Observation on 12/10/24 at approximately 2:33 p.m., revealed a microwave, refrigerator, and a coffee pot plugged into a power strip in the Infection Control Office.

Observation on 12/10/24 at approximately 2:45 p.m., revealed two (2) power strips, which were being used to power a microwave, refrigerator, two (2) coffee pots, and an ice maker in the Clinic Breakroom.

Observation on 12/11/24 at approximately 8:45 a.m., revealed a microwave, refrigerator, and toaster plugged into a power strip in the Maintenance Supervisor's Office.

Observation on 12/11/24 at approximately 10:29 a.m., revealed a refrigerator, toaster, coffee pot, and a microwave plugged into a power strip in the Cashier's Office.

Interview on 12/11/24 at approximately 10:30 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 record review and staff interview, the facility failed to maintain the testing and maintenance requirements for fixed and portable patient-care equipment in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 2.

Findings include:

Record review on 12/10/24 at approximately 8:32 a.m., revealed no documentation available for review during survey to show that the testing of the physical integrity of the power cord assembly, electrical resistance, or touch/leakage current testing for an Olympus Video Connector, Olympus Endoscope Video Connector, or an Olympus Water Pump used on the Scope Tower in Operating Room 2 had been completed since March of 2023.

Record review on 12/10/24 at approximately 8:35 a.m., revealed no documentation available for review during survey to show that the testing of the physical integrity of the power cord assembly, electrical resistance, or touch/leakage current testing for two patient warmers (BC00084) and (SR000289) in use in Operating Room 2 had been completed in the previous twelve (12) months.

Record review on 12/10/24 at approximately 8:38 a.m., revealed no documentation available for review during survey to show that the testing of the physical integrity of the power cord assembly, electrical resistance, or touch/leakage current testing for a water pump (BC000033) in use in Operating Room 2 had been completed since March of 2023.

Record review on 12/10/24 at approximately 8:55 a.m., reveled no documentation available for review during survey to show that the testing of the physical integrity of the power cord assembly, electrical resistance, or touch/leakage current testing for a Sequential Compression Device in use in Operating Room 1 had been completed since September of 2022.

Record review on 12/10/24 at approximately 9:20 a.m., revealed no documentation available for review during survey to show that the testing of the physical integrity of the power cord assembly, electrical resistance, or touch/leakage current testing for a Buffalo Smoke Evacuation Filter in use in Operating Room 1 had been completed in the previous twelve (12) months.

Record review on 12/10/24 at approximately 9:45 a.m., revealed no documentation available for review during survey to show that the testing of the physical integrity of the power cord assembly, electrical resistance, or touch/leakage current testing for an EKG Machine in use in the Cardiopulmonary Outpatient Testing Room had been completed since March of 2023.

Interview on 12/11/24 at approximately 9:46 a.m., with the Vice President Of Operations 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.