HospitalInspections.org

Based on observation and interview during the survey walk of the facility with the Facilities Director on the morning of 7/1/2025, the previous OR suite, sterilizing and decontam rooms are being used as Storage. Not all rooms do not meet the requirements for hazardous area separation. Existing rooms under 250 SF are acceptable. Rooms 250 SF or larger, if sprinklered, must be smoke tight. The doors and walls must be smoke tight, double doors must have astragals, and doors also must have closers.

Based on review of the records and interview with the CEO and Director of Facilities on the morning of 7/1/2025, the requirement for the fire extinguishment system to be tested at 6 month intervals. Records presented were dated June of 2024 and March of 2025. Begin testing at 6 month intervals and maintain records.

Based on review of the records and interview with the CEO and Director of Facilities on the morning of 7/1/2025, the requirement for a functioning Fire Alarm system is not met. Zone 3 of the alarm system was giving false alarms. The Fire Marshall put the system out of service June 2025 and Zone 5 was not transmitting to the monitoring facility. It was determined the motherboard needs to be replaced and is obsolete. The system will need to be updated. A fire watch was implemented. Continue reports for 45 days. Send reports the ARU every two weeks and update ARU at 45 days concerning updates in repair time.

Monthly fire alarm testing requirement is not being met. The alarm must be verified to be sent to the monitoring station. No alarm logs were available at the time of inspection. Begin monthly log.

Based on review of the records and interview with the CEO and Director of Facilities on the morning of 7/1/2025, the requirement for Emergency Preparedness reports for Mock disasters is not met. Real events may substitute for mock drills. The reports provided were from March 2021 Mock Drill, February 24, 2025 Wildfire response, and Jun 17, 2025 Electrical Fire Response and Evacuation. Keep existing reports, participate in community wide disaster drills, and retain after action reports.

During the inspection walk with the Director of Facilities on the morning of 7/1/2025, it was observed the requirement for Medical Gas Alarms was not met. A master alarm is required at the Oxygen tank. It appeared there was an area alarm in wing 300, but it is not functional. If not being used, remove panel.

Based on review of the records and interview with the Director of Facilities on the morning of 7/1/2025, requirements for a Type 1 electrical system is not met and the facility failed to periodically exercise the Main feeder and circuit breakers. It was indicated that the load switch is broken and cannot be turned of to test the auto start of the generator. The voltage and amp gauges do not work. Equipment items do not come on when the generator is on due to undersize of the old generator. Generator start time is monitored during power outage events. The Director of Facilities indicated the local electrical companies will not perform basic repairs because the electrical system is so old. Records for monthly load tests only included January and March 2025. No other monthly load bank or annual testing records were provided. The existing system is indicated there will be an update in the near future, pending funding. Submit a project to the Architectural Review Unit (ARU) for update to electrical system.

"EPSS circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the EPS in the "off" position." - NFPA 110, 2010, 8.4.7*. Note: "Circuit breakers should be tested under simulated overload conditions every 2 years." - NFPA 110, 2010, A.8.4.7