Every finding on record at Benefis Hospitals Inc.

Based on observation, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Section 7.1.10.1, 7.1.10.2.1, 19.2.3.4(5). This deficiency affects 1 of 4 main floor smoke compartments. Findings include: --- 1. During an observation on 10/15/24 at 2:36 p.m., the main entrance corridor was inspected. There were several wheelchairs in the corridor, lined up from the sitting room to the main entrance. They reduced the corridor width to less than six feet, obstructing the path to an emergency exit. The unobstructed width of the corridor must not be less than 6 feet.

Based on observation, the facility failed to assure hazardous rooms/areas had doors which were able to close, and latch in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3. These deficiencies affect 1 of 1 basement smoke compartment. Findings include: --- 1. During an observation on 10/15/24 at 3:19 p.m., the basement PH-10 store room was inspected. This room is greater than 50 square feet and is considered a hazardous area. The corridor door failed to close and latch because the inactive leaf would not also latch into the jamb to ensure the set of doors would not open.

Based on an observation, the facility failed to ensure accessibility to a manual fire alarm box in accordance with NFPA 101, 2012 Edition, Section 9.6.2.7 This deficiency affects 1 of 4 smoke compartments. Findings include: --- 1. During an observation on 10/15/24 at 3:25 p.m., the sitting area at the end of a corridor was inspected. There was a shelf of puzzles blocking the pull station from clear view.

Based on record review, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6. This deficiency affects all smoke compartments. Findings include: --- 1. During a review of facility fire drills on 10/15/24 at 1:30 p.m., it was determined the facility had not completed fire drills for the following shifts: -all shifts of the fourth quarter of 2023 -NOC shift of the first quarter of 2024 -day and NOC shifts of the third quarter of 2024

Based on record review, the facility failed to maintain the receptacles in patient areas in accordance with NFPA 99 Health Care Facilities Code, 2012 Edition, Section 6.3.4.1. The deficient practice affected all main floor smoke compartments. Findings include: --- Record review on 10/15/24 at 1:30 p.m. revealed there was no documentation that non-hospital grade receptacles located in resident rooms had annual retention testing as required by sections 6.3.4.1.2 and 6.3.4.1.3 in NFPA 99, Health Care Facilities Code, 2012 Edition. In an email dated 10/18/24, staff member B stated the work had been completed but there was no documentation as proof of it being done.

Based on observation, interview, and record review, staff members C and D failed to adhere to accepted standards of practice for infection prevention related to the proper cleaning of equipment, after performing in home assessments for 2 (#'s 2 and 3) of 4 observed patient home visits. Findings include: --- During an observation of a home visit on 10/8/24 at 10:12 a.m., staff member C had performed a physical assessment of patient #2. Staff member C donned gloves to clean the vital sign equipment she had used for the assessment. Staff member C wiped down each piece of equipment, immediately placed the equipment into a plastic bag, then placed the plastic bag into her travel work bag. During an interview on 10/8/24 at 10:18 a.m., staff member C stated she used purple "Sani wipes" to clean her vital sign equipment (thermometer, pulse oximeter, blood pressure cuff, and stethoscope). Staff member C stated she did not know a timeframe the equipment needed to be wet or dry. During an observation on 10/8/24 at 2:12 p.m., staff member D had entered the home of patient #3, greeted the patient and placed her work bag onto the sofa without a barrier under the bag. Patient #3 had a small dog in the home and the dog was up on the sofa, greeting staff member D. During an observation on 10/8/24 at 2:23 p.m., staff member D performed her physical assessment, which included vital signs, then placed the used equipment onto a barrier sheet on the sofa. Staff member D continued the interview and assessment of patient #3. During an observation on 10/8/24 at 2:41 p.m., staff member D had completed her assessment of patient #3, picked up the barrier with used equipment off the sofa, and placed it into her work bag. No cleaning of the equipment took place in patient #3's home. During an interview on 10/8/24 at 2:45 p.m., staff member D stated she had forgot to place a barrier under her work bag. Staff member D stated she cleaned her vital sign equipment in her vehicle, after she exited the home. During an interview on 10/9/24 at 1:48 p.m., staff member A stated it was not acceptable to pick up a barrier from a sofa with equipment on it and place it into a travel bag. She stated placing the used barrier cloth into a work bag would make the whole bag dirty. Staff member A stated equipment used in a home visit needs to be cleaned in the home. Review of the manufacturer's label for purple "Super Sani Wipes," on 10/9/24 at 1:45 p.m., showed, "Contact time: Use wipe to thoroughly wet surface. Allow surface to remain visibly wet for 2 minutes. Let air dry."

Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7 and section 19.2.2.2.8. This deficiency affects 1 of 3 basement smoke compartments. Findings include: 1. During an observation on 11/15/21 at 2:49 p.m., the basement west wing fire doors were exercised and inspected. There was a heavy rubber gasket on the bottom of the door, rubbing on the floor, that prohibited closing via the self-closing device.

Based on observation, the facility failed to ensure all exit signs were totally visible in accordance with NFPA 101 2012 Edition, Section 7.10.1.8. This deficiency affects 3 of 4 main floor smoke compartments. Findings include: 1. During an observation on 11/15/21 at 3:27 p.m., the exit signs going from the nurses station to corridors to rooms 1-8 and 9-12 were found to be obstructed from view by large headers built in to the ceiling in front of the signs. Occupants in the center of the intersection of the three corridors would not see the signs.

Based on observation and record review, the facility failed to maintain spare sprinklers in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.5. This deficiency affects all smoke compartments. Findings include: 1. During an observation 11/15/21 at 3:22 p.m., the spare sprinkler head box was found to be missing directional replacement sprinkler heads. The facility had many directional heads in the additions to the building, but there were no directional heads in the spare box.

Based on observation, the facility failed to ensure the installation of a direct vent fireplace met all regulatory criteria in accordance with NFPA 101 2012 Edition, Section 19.5.2.3 and 9.8. This deficiency affects 1 of 4 main floor smoke compartments. Findings include: 1. During an observation on 11/15/21 at 3:09 p.m., the fireplace room was inspected. There was a direct vent fireplace installed in the room. There was no electronically supervised carbon monoxide detector installed in the room with the fireplace.

Based on record review, the facility failed to maintain the receptacles in patient areas. The deficient practice affected the entire facility. Findings include: Record review on 11/15/21 revealed non-hospital grade receptacles located in resident rooms throughout the facility did not have annual retention testing as required by sections 6.3.4.1.2 and 6.3.4.1.3 in NFPA 99, Health Care Facilities Code, 2012 Edition. Actual NFPA Standard: NFPA 99 (2012), 6.3.4.1 Maintenance and Testing of Electrical System. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. 6.3.4.1.3 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. 6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Based on observation, the facility failed to ensure oxygen storage rooms were lockable to unauthorized entry in accordance with NFPA 99 Health Care Facilities Code, 2012 Edition, Sections 11.3.2.1. This deficiency affects 1 of 3 basement smoke compartments. Findings include: 1. During an observation on 11/15/21 at 3:00 p.m., the basement oxygen storage room was inspected. The room was not lockable and there was no means from keeping the room free from unauthorized entry.