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Based upon an Emergency Preparedness Program (EPP) survey performed on 07/16/2025 at 1:00 PM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to include revisions to their emergency preparedness plans, Emerging Infectious diseases are a potential threat which can impact the operations and continuity of care within a healthcare setting.

Findings include:

During the review of the facilities Emergency Preparedness Program with the facility Compliance Director (employee #4), it was noted that the facility failed to include emerging infectious diseases ( Influenza, Ebola, Zika, etc.) in the Emergency Plan.

Based upon an Emergency Preparedness Program (EPP) survey performed on 07/16/2025 at 1:00 PM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop procedures to track the location of on-duty staff and sheltered patients in the facility's care during and an emergency.

Findings include:

During the review of the facilities Emergency Preparedness Program with the facility Compliance Director (employee #4), it was noted that the EP failed to have written procedures to document the specific name and location of the receiving facility or other location.

Based upon an Emergency Preparedness Program (EPP) survey performed on 07/16/2025 at 1:00 PM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to provide means to shelter in place for patients, staff and volunteers who remain in the facility.

Findings include:

During the review of the facilities Emergency Preparedness Program with the facility Compliance Director (employee #4), it was noted that the EP failed to have written process for activation and designation of a shelter in place area in the hospital during and after an emergency.

The Compliance Officer indicated that the staff is aware of where the shelter in place area is, but no procedures were found written in the plan.

Based upon an Emergency Preparedness Program (EPP) survey performed on 07/16/2025 at 1:00 PM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to ensure policies and procedures to facilitate the support of volunteers and other healthcare professionals in an emergency.

Findings include:

During the review of the facilities Emergency Preparedness Program with the facility Compliance Director (employee #4), it was noted that the facility failed to stablished policies and procedures to ensure and facilitate the support of volunteers and other healthcare professionals in an emergency as required under §485.15(b)(6).


Compliance Director (employee #4), stated that facility is in communication with Medical Reserve Corps to facilitate the availability of volunteers and their credentialization.

Based upon an Emergency Preparedness Program (EPP) survey performed on 07/16/2025 at 1:00 PM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain updated contact information for the following: Federal, State, tribal, regional or local emergency preparedness staff and other sources of assistance.

Findings include:

During the review of the facilities Emergency Preparedness Program with the facility Compliance Director (employee #4), it was noted that the facility failed to provide evidence of the Emergency Preparedness Communication Plan that included updated contact information for Federal, State, tribal, regional or local emergency preparedness staff and other sources of assistance.

However the facility has contacts of local and state agencies, but not contacts from federal agencies.

Based upon an Emergency Preparedness Program (EPP) survey performed on 07/16/2025 at 1:00 PM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain a means of providing information about the facility's occupancy, needs, and its ability to provide assistance during a emergency.


Findings include:

During the review of the facilities Emergency Preparedness Program with the facility Compliance Director (employee # 4), it was noted that the facility failed to have written procedures of providing information about the facility's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

The facility recognizes that through the Health Services Coalition is the mechanism to provide information to the operations centers of the State Health Department and for the State Emergency Operations Center; no written procedure was found.

Based upon an Initial Life Safety Code (LSC) survey performed from 07/15/2025 through 07/17/2025, to evaluate LSC provisions, it was determined that the facility failed to comply with NFPA 101 7.2.

Findings include:

During visual observation of the facility's interior stairway with the Compliance Director (employee #1) and Engineering Director (employee #3) on 07/15/2025 it was noted that the stairway did not provide special signage including the use of Braille within the enclosure at each floor landing.

The finding was verified by the Director of Engineering and Compliance Director at the time of the observation.

Based on observation and interview the facility failed to maintain an automatic smoke detection systems as required on NFPA 72 and NFPA 75.

Findings include:

During visual observation of the facilities with the Compliance Director (employee #1) and Engineering Director (employee #3) on 07/15/2025, it was noted that no smoke detector was observed in the server room in the anteroom of the morgue data server room.

Based on observation and interview the facility failed to maintain an automatic sprinkler and standpipe systems that are inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems.

Findings include:

During visual observation of the facilities with the Compliance Director (employee #1) and Engineering Director (employee #3) on 07/15/2025, it was noted that 12 out of 30 sprinkler heads located in the ER area were loaded. Excessive dust in sprinklers can cause a malfunction in the moment of system activation.


The finding was verified by the Director of Engineering and Compliance Director at the time of the observation.

Based on observation and interview the facility failed to ensure that the gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99)

Findings include:

Observation and interview on 07/15/2025 at approximately 10:29 AM it was noted that medical gases emergency shut off valves on the Radiology Department, ER, Intensive Care Unit and Medicine 1 and Medicine 2 area were last inspected on May 2024 by proof of stamp in valves.

The finding was verified by the Director of Engineering and Compliance Director at the time of the observation.

Based on observation and interview the facility failed to identify shutoff valves of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. . 5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99).

Findings include:

Observation and interview on 07/15/2025 at approximately 10:29 AM it was noted that medical gases emergency shut off valves on Medicine 1 and Medicine 2 were not properly labeled as required by NFPA 99.

The finding was verified by the Director of Engineering and Compliance Director at the time of the observation.

Based on observation, document review and interview, the facility did not ensure that records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.

Findings include:

1. At approximately 10:40 AM during observation of the Laboratory Department int was notice that three (3) breaker boxes had experied electrical inspection. Due date was 03/2025.

The finding was verified by the Director of Engineering at the time of the observation.

Based on observation, document review and interview, the facility did not ensure that a remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel.

Findings include:

1. At approximately 8:40 AM during observation of the basement area an inoperable generator remote annunciator was observed, Director of Engineering stated that none of the two (2) generator supplying backup power to the facility have remote annunciators. During survey facility obtained quotations for the equipment.


The finding was verified by the Director of Engineering at the time of the observation.

Based on document review and interview, the facility did not ensure documentation that generators supply service within ten seconds in accordance with the requirements of NFPA 99, 2012 Edition Section 6 and NFPA 110.

Findings include:

1. At approximately 11:50 AM document review and interview of the generator Test logs were reviewed and did not record generator transfer times.

The finding was verified by the Director of Engineering at the time of the observation.