| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 531311 | (X3) Date Survey Completed 04/26/2022 |
| Name of Provider or Supplier Crook County Hospital | Street Address, City, State 713 Oak Street, Sundance, WY | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| E0000 | An Emergency Preparedness survey was conducted by Healthcare Licensing and Surveys on 04/25/2022. Based on the findings it was determined the facility was in compliance with all requirements. . |
| K0000 | This STANDARD is not met as evidenced by: A Life Safety Code Survey was conducted by Healthcare Licensing and Surveys on 04/25/2022 and 04/26/2022. Requirements for Critical Access Hospitals Section 42 CFR 482.41(b) except as otherwise provided in the section, the facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code, Existing Health Care, of the National Fire Protection Association. The facility was a fully sprinklered, one story building of Type II (111) construction built in 1960. The building was equipped with a supervised automatic wet sprinkler system, a dry sprinkler system, and an addressable fire alarm system. The facility had a capacity of 16 certified Medicare and Medicaid beds with a census of 5. . |
| K0223 | Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This STANDARD is not met as evidenced by: 1. Based on observation and staff interview, the facility failed to maintain doors with self-closing devices in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain doors with self-closing devices as required could result in injury or death during an emergency. The deficiency affected two (2) of numerous doors with self-closing devices. The findings were: Observation on 4/26/2022 at 8:29 AM at the west storage door revealed the self-closing door was held open with a heavy object. Further observation at the kitchen storage self-closing door found that its door handle wrapped around the rooms shelving holding the door ajar. Interview with kitchen staff found that the door is kept open as described during the day and is closed at night. Interview with the maintenance manager at the time of observation acknowledged the doors being held open, and indicated they were aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. REF: 2012 NFPA 101, Sections: 19.2.2.2.1, 7.2.1.8.1 2. Based on observation and staff interview, the facility failed to maintain doors with self-closing devices in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain doors with self-closing as required could result in injury or death during an emergency. The deficiency affected three (3) of numerous doors with self-closing devices. The findings were: Observation on 4/26/2021 at 9:35 AM at the electrical mechanical room door revealed the the self-closing door failed to operate as designed. When dropped tested with no initial motion the door failed to shut and latch. Additional observation at 9:46 AM found the self-closing door separating the former waiting area (now office) from the corridor, found that the door failed to shut and latch when drop tested with no initial motion. Additional observation at 10:33 AM found the self-closing door separating the ambulance garage from the rear corridor unable to latch, due to missing hardware on the door frame. Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. REF: 2012 NFPA 101, Sections: 19.2.2.2.1, 7.2.1.8 . |
| K0225 | Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This STANDARD is not met as evidenced by: 1. Based on observation and staff interview, the facility failed to maintain stairs in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain stairs as required could delay egress resulting in injury or death during an emergency. The deficiency affected one (1) of two (2) exits containing stairs from the facility. The findings were: Observation on 4/26/2022 at 8:54 AM at the side/employee entrance/exit revealed the concrete stair structure, had degraded over time leaving the tread on one stair with 7 1/2" of tread depth at the minimum measurement. Interview with the maintenance manager at the time of observation acknowledged that the depth of the stair tread was insufficient, and indicated they were aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. REF: 2012 NFPA 101, Sections: 19.2.2.3, 7.2.2, Table 7.2.2.2.1.1(b) 2. Based on observation and staff interview, the facility failed to maintain stair handrails in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain stair handrails as required could delay egress resulting in injury or death during an emergency. The deficiency affected one (1) of two (2) exits containing stairs from the facility. The findings were: Observation on 4/26/2022 at 8:57 AM at the side/employee entrance/exit revealed that the stairway handrail was no longer attached to the ground, having rusted away. As an existing handrail, the handrail falls under the maintenance, inspection, and testing section of chapter 4, of the 2012 NFPA 101. Whereby any existing life safety feature shall be maintained. Interview with the maintenance manager at the time of observation acknowledged that the handrail was no longer attached to the ground, and indicated they were aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. REF: 2012 NFPA 101, Sections: 19.2.2.3, 7.2.2, 7.2.2.4.4.9, 4.6.12.1, 4.6.12.2, 4.6.12.3 . |
| K0271 | Discharge from Exits CFR(s): NFPA 101 Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7 This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain exit discharge in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain exit discharge as required could delay egress resulting in injury or death during an emergency. The deficiency affected one (1) of five (5) exits from the facility. The findings were: Observation on 4/26/2022 at 9:42 AM at the exit discharge leading from the old waiting room (currently an office), found a sign secured to both handrails at the bottom of the exit discharge stairs, that obstructed the pathway. Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were not aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. Ref: 2012 NFPA 101; Sections: 19.2.7, 7.7.1, 7.7.4, 7.2.2, 7.1.10.1 . |
| K0321 | Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain hazardous areas in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain hazardous areas as required could delay egress resulting in injury or death during an emergency. The deficiency affected one (1) of numerous rooms in the facility. The findings were: Observation on 4/26/2022 at 9:20 AM in the central supply room revealed penetrations in the wall above the door to accommodate electrical conduit that had been sealed with calking in lieu of a UL listed fire-stop material. Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. REF: 2012 NFPA 101: Sections 19.3.2; 8.7.1; 8.3.5.1 . |
| K0324 | Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain cooking areas in accordance with the 2012 NFPA 101, Life Safety Code and 2011 NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Failure to maintain cooking areas as required could result in injury or death during an emergency. The deficiency affected one (1) of one (1) kitchen in the facility. The findings were: Observation on 4/26/2022 at 10:09 AM in the kitchen at the stove found that the new wheeled stove did not have a method of returning to the approved design location. No visible markings or wheel chocks were observed. Interview with the facility maintenance at the time of observations acknowledged the deficiency, and indicated they were not aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. REF: 2012 NFPA 101, Sections 19.3.2.5.1, 9.2.3 2011 NFPA 96, Sections 12.1.2.3, 12.1.2.3.1 . |
| K0351 | Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the 2010 NFPA 13, Standard for the Installation of Sprinklers. Failure to properly maintain the fire sprinkler system could result in injury or death in the event of a fire. The deficiency was in one (1) of numerous rooms. The findings were: Observation on 4/26/2022 at the biohazard room revealed that the escutcheon had come loose and was blocking sprinkler head. Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. REF: 2010 NFPA 13, Sections: 8.6.5 . |
| K0353 | Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain sprinkler systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2011 NFPA 25, Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems. The failure to maintain sprinkler systems as required could result in injury or death during an emergency. The deficiency affected one of numerous storage areas throughout the facility. The findings were: Observation on 4/26/2022 at 8:37 in the west storage room revealed several items stacked within several inches of the sprinkler head, which resulted in an obstruction to the dispersion pattern of the affected sprinkler. Additional observation at 10:04 AM in the kitchen storage area revealed several items that were stacked to within several inches of the sprinkler head. Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. REF: 2012 NFPA 101, Sections: 19.3.5.1; 9.7.5 2011 NFPA 25, Section 5.2.1.2 . |
| K0355 | Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to provide access to fire extinguishers in accordance with the 2010 NFPA 10, Standard for Portable Fire Extinguishers, and the 2012 NFPA 101, Life Safety Code. Failure to provide access to a fire extinguisher as required may lead to injury or death during an emergency. The deficiencies affected one (1) of numerous fire extinguishers in the facility. The findings were: Observation on 4/26/2022 at 8:39 AM in the west storage area along the west wall revealed a fire extinguisher that was blocked by storage. Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. Ref: 2012 NFPA 101: Section 19.3.5.1.2, 9.7.4.1 2010 NFPA 10: Section 6.1.3.3.1 . |
| K0511 | Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain electrical systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2011 NFPA 70, National Electrical Code. The failure to maintain electrical systems as required could result in injury or death. The deficiency affected one (1) of numerous rooms in the facility. The findings were: Observation on 4/26/2021 at 9:31 AM in the electrical/mechanical room revealed a duplex receptacle within six (6) feet of the sink, which was not protected by a ground fault circuit interrupter. Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. REF: 2012 NFPA 101, Sections: 19.5.1.1; 9.1.2 2011 NFPA 70, Section: 210.8(B)(5) . |
| K0531 | Elevators CFR(s): NFPA 101 Elevators 2012 EXISTING Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter's Service is operated monthly with a written record. Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter's Service Requirements of ASME/ANSI A17.3. (Includes firefighter's service Phase I key recall and smoke detector automatic recall, firefighter's service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.) 19.5.3, 9.4.2, 9.4.3 This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain elevators in accordance with the 2012 NFPA 101, Life Safety Code. The failure to maintain elevators as required could result in injury or death during an emergency. The deficiency affected one (1) of one (1) elevators. The findings were: Interview on 4/25/22 at 4:30 PM with the maintenance manager revealed that the monthly testing of the elevator fire fighter recall system had not been completed. Further interviews revealed the elevator does not move more than 25 ft, but is equipped with a fire fighter recall system. Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were not aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. Ref: 2012 NFPA 101: Sections: 19.5.3, 9.4.6.2, 4.6.12.1, 4.6.12.4 . |
| K0761 | Maintenance, Inspection & Testing - Doors Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This STANDARD is not met as evidenced by: 1. Based on observation and staff interview, the facility failed to maintain fire-rated doors and frames in accordance with the 2012 NFPA 101, Life Safety Code, and 2010 NFPA 80, Standard for Fire Doors and Other Opening Protectives. The failure to maintain fire-rated doors and frames as required could result in injury or death in an emergency. The deficiency affected one (1) of numerous fire-rated doors and frames throughout the facility. The findings were: Observation on 4/26/2022 at 8:29 AM of the west storage corridor door revealed a hole that penetrated through the rated storage door frame. Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. Ref: 2012 NFPA 101, Sections: 19.7.6; 4.6.12, 7.2.1.15.2 2010 NFPA 80, Section 5.2.4.2(1) 2. Based on observation and staff interview, the facility failed to maintain fire-rated doors and frames in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 80, Standard for Fire Doors and Other Opening Protectives. The failure to maintain fire-rated doors and frames as required could result in injury or death in an emergency. The deficiency affected one (1) of numerous fire-rated doors and frames throughout the facility. The findings were: Observation on 4/26/2022 at 9:20 AM at the central supply room door revealed that the UL listing frame tag had been painted over. . Interview with the maintenance manager at the time of observation acknowledged the missing tag, and indicated they were aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. REF: 2012 NFPA 101, Sections: 19.2.2.5, 7.2.4.3.1, 8.3.3.1, 8.3.3.2, 8.3.3.2.2 . |
| K0781 | Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to provide portable space heaters in accordance with the 2012 NFPA 101, Life Safety Code. The failure to provide portable space heaters as required could result in injury or death due to an increased risk of fire. The deficiency affected one (1) of multiple rooms in the facility. The findings were: Observation on 4/26/2022 at 10:14 AM in the dining room revealed a portable space heater. The space was labeled as "staff only", but interview revealed that residents do eat within the space upon approval of their attending physician. No documentation was available to determine the maximum temperature of the heating elements. Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. Ref: 2012 NFPA 101, Section 19.7.8 . |
| K0900 | Health Care Facilities Code - Other CFR(s): NFPA 101 Health Care Facilities Code - Other List in the REMARKS section any NFPA 99 requirements (excluding Chapter 7, 8, 12, and 13) that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Health Care Facilities Code or NFPA standard citation, should be included on Form CMS-2567. This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain corridor separations in accordance with the 2012 NFPA 101, Life Safety Code. The failure to maintain corridor separations as required could result in injury or death due in an emergency. The deficiency affected one (1) smoke compartment in the facility. The findings were: Observation on 4/26/22 at 10:41 AM in the medical gas storage and manifold room revealed that the room had no ventilation provided within one foot of the floor. Per NFPA 99, ventilation must be provided either per natural ventilation including two (2) openings within one foot of the floor and ceiling, or via mechanical ventilation with an inlet drawing from within one foot of the floor. Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. Ref: 2012 NFPA 99, Sections: 9.3.7.5; 9.3.7.5.2, 9.3.7.5.3 . |
| K0902 | Gas and Vacuum Piped Systems - Other CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 5 (NFPA 99) This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain the vacuum pump room in accordance with the 2012 NFPA 99, Life Safety Code. The failure to maintain the vacuum pump room as required could result in injury or death in an emergency. The deficiency affected one (1) of one (1) vacuum pump enclosures in the facility. The findings were: Observation on 4/26/22 at 10:25 AM in the vacuum pump room revealed that the facility was storing dirty linen inside of the room. NFPA 99 requires medical-surgical vacuum sources to be in a dedicated mechanical equipment area Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were not aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. Ref: 2012 NFPA 99, Section 5.1.3.7.1.1(1) . |
| K0919 | Electrical Equipment - Other CFR(s): NFPA 101 Electrical Equipment - Other List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 10 (NFPA 99) This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain electrical systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2011 NFPA 70, National Electrical Code. The failure to maintain electrical systems as required could result in injury or death. The deficiency affected one (1) of numerous electrical equipment rooms in the facility. The findings were: Observation on 4/26/2021 at 9:31 AM in the electrical/mechanical room revealed multiple obstructions in front of the electrical breaker panels. A working space of three (3) feet in front of the panels is to be maintained. Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. REF: 2012 NFPA 101, Sections: 19.5.1.1; 9.1.2 2011 NFPA 70, Section: 210.8(B)(5) . |
| K0920 | Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain electrical equipment in accordance with the 2012 NFPA 101, Life Safety Code and the 2011 NFPA 70 National Electrical Code. The failure to maintain electrical equipment as required could result in injury or death. The deficiency affected two (2) of numerous rooms in the facility. The findings were: Observation on 4/26/2022 at 9:17 AM in Central Storage revealed that a power strip was plugged into an extension cord. Additional observation at 10:20 AM in the front of the business office found a power strip plugged into a power strip, creating a daisy chain. Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. Ref: 2012 NFPA 101, Section 9.1.2 2011 NFPA 70, Section 400.8 |