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Based on a review of the facility's Emergency Plan, record review, and staff interview, it was determined, the facility failed to develop a facility-based risk assessment prior to developing the facility's emergency plan. Failure to develop emergency plans based on facility-based risk assessment poses a potential risk and may cause harm to the patients and staff during an emergency if the specific needs of both the patient and staff are not identified as part of the EP plan.

Findings include:


Observations made during document review made on Sept 6, 2023 revealed the facility failed to create a facility-based risk assessment and use it to develop the facility's emergency plan

Employees #1 and #2 confirmed during the document review that the facility did not create a facilty-based risk assessment and use it to create the facility's Emergency Plan.

Based on a review of the facility ' s Emergency Plan, record review, and staff interview, it was determined, the facility failed to develop a facility-basedrisk assessment prior to developing the facility's emergency plan. and created policies that were not risk-based. Failure to develop emergency plans based on a facility-based risk assessment may cause harm to the patients and staff during an emergency.

Findings include:

Observation during document review on Sept 6, 2023, revealed the policies provided, were not based on a current risk assessment. CFR 494.62 requires both facility and community hazard assessments be is used to develop the policy and procedures. A request was made for a facility based HVA or risk assessment but the facility could not provide one.

Employees #1 and #2 confirmed during the exit conference the facility did not have a copy of the facility-based risk assessment to provide proof it was used to create the policies and procedures.

Based on a review of the Emergency Plan (EP), facility record review, and interview, it was determined the facility failed to develop and implement emergency preparedness policies and procedures to describe its role in providing care at alternate care sites during an emergency. Failure to develop emergency policies and procedures at alternative care sites may cause harm to the residents during an emergency.

Findings include:

During the emergency plan document review on Sept 6, 2023 it was revealed the facility's Emergency Plan related to the section which addresses policies and procedures did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

Employees #1, and #2 confirmed or acknowledged during an interview that the facility EP plan did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

Based on review of the facility's Emergency Preparedness Testing Requirements, record review and staff interview, it was determined the facility failed to participate in drills as required. Failure to participate in drills may lead to untrained staff in an emergency situation and may result in harm to the residents during an emergency.


Findings include:

During document review on September 6, 2023, it was revealed the facility was missing documents proving participation in a full-scale exercise (FSE) that was community-based or facility based exercise or table top drills for the last two cycles.

Employees #1and #2 confirmed during the exit interview that the facility was not able to locate proof of participation in a full-scale exercise that was community-based or a facility based exercise in the last four years.

Based on record review and interview staff it was determined the facility failed to provide documentation of a local fire inspection. An annual local fire inspection ensures the building remains within the building codes and fire safety codes. Failure to have an annual fire inspection could bring harm to patients and staff during an emergency.

CMS State Operations Manuel Appendix A- Interpretive Guidelines §482.11 The hospital must ensure that all applicable Federal, State and local law requirements are met.. The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. NFPA 101 2012 Life Safety Code Section 4.6.12. Maintenance, Inspection, and Testing. 4.6.12 Maintenance, inspection and testing shall be performed under supervision of a responsible person who shall ensure that testing, inspection, and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

485.625 42 CFR Ch. IV (10-1-16 Edition) adversely affect the health and safety of patients.
(4) The CAH maintains written evidence of regular inspection and approval by State or local fire control
agencies.

Findings include:

Records review on Sep 6, 2023 revealed the facility failed to provide required documentation of an annual local fire inspection.

Employees #1, #2, confirmed during the exit conferance that the facility failed to provide required documentation of an annual local fire inspection.

Based on observation, it was determined the facility failed to maintain the special locking exit door located on the 2nd floor of the East Campus pediatric unit. Failing to provide manual release of the exit doors can cause the door to prevent exit during a fire which likely would result in injury or death to staff or patients.

NFPA 101 Life Safety Court, 2012, Chapter 19, Section, 19.2.2.2.4 "Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side." Exception No. 2 "Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. Section 7.2.1.6.1 "Special Locking Arrangements" " (c) An irreversible process shall release the lock within 15 to 30 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbs nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only."

Findings include:

Observations while on tour on September 6, 2023, revealed that all outside exit doors were locked without an emergency release mechanism in addition only the RN and facility manager had keys to open these doors in the event of an emergency. The doors are listed below:
Main Entrance outside gate
Receiving outside door
Southwest exterior exit
Northwest exterior exit
Northwest lobby exit
The staff was provided keys during the survey and all staff are now able to get all patients and staff out of the building in an emergency.


Employees #1 and #2 confirmed during the walk down and at the exit conference on September 6, 2023, that some of the staff did not have keys to all exit doors and the doors did not release upon activation of the fire alarm

Based on Observation, the facility failed to perform the monthly fire alarm system test/inspection. Failure to test the fire alarm system could cause harm to staff and residents during an emergency.

NFPA 101, Life Safety Code, 2012 Edition, Chapter 9, Section 9.6.1.3 "A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use". NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition, Chapter 14, Section 14.2.2.1, "The property or building or system owner or the owner ' s designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system". Chapter 26, Section 26.3.5.2.2 "The subsidiary facility shall be inspected at least monthly by central station personnel for the purpose of verifying the operation of all supervised equipment, all telephones, all battery conditions, and all fluid levels of batteries and generators". NFPA 72, National Fire Alarm and Signaling Code, Section14.6.2.1, Records shall be retained until the next test and fore 1 year thereafter. CMS requires 3 years.
NFPA 72 Chapter 14, section 14.2.5 Releasing Systems.
Requirements pertinent to testing the fire alarm systems initiating fire suppression system releasing functions shall be covered by 14.2.5.1 through 14.2.5.6. and must be inspected in accordance with section 14.3 Inspection which requires Monthly and Annual inspection amd service.

Findings include:

During the review of the facility's documentation on Sept 6, 2023, there was no documentation of monthly testing of the following systems.

Employees #1 and #2 confirmed during the exit conference that the facility failed to provide the required documentation for a monthly inspection of the fire alarm system.

Based on the record review it was determined that the facility failed to perform the monthly and five (5) year inspections of the facility's sprinklers systems. Failing to perform the required inspections may cause harm to patients and staff


NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, "Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems." NFPA 25, 2011 Edition, "Water Based Extinguishment Systems," requires monthly, quarterly and annual testing of automatic sprinkler systems.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.1.1.1.3. General "The provisions of Chapter 4, General, shall apply." Chapter 4, Section 4.6.12.3, "Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed." Section 4.6.12.4, "Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. NFPA 13, "Installation of Sprinkler Systems." Chapter 26, Section 26.1, General, "A sprinkler system installed in accordance with this standard shall be properly inspected, tested and maintained by the property owner or their authorized representative in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed." NFPA 25, Chapter 14, Section 14.2 "Internal Inspection of Piping" "Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and be removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material."

Findings Include:

Observations while on tour Sept 6, 2023, revealed the facility failed to show proof of monthly testing of the sprinkler systems in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

Observations while on tour on Sept 6, 2023, revealed the facility failed to show proof of five (5) year testing of the sprinkler systems in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.


Employees #1, and #2 confirmed during the exit conference that the facility failed to conduct the required monthly and five (5) year testing of the sprinkler systems.

Based on observation it was determined the facility failed to fill penetrations in two (2) of the smoke barriers in the facility. Failing to seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in the time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall , floor or /ceiling assembly constructed as a smoke barrier , or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

During a facility tour conducted on Sept 6, 2023, revealed the facility failed to maintain the fire barriers intact. Two holes were found in the barrier during the overhead inspection.

During the exit conference conducted on Sept 6, 2023, employee #1 confirmed by visual inspection the two holes in the fire barrier in the firewall separating the east and west sides of the facility

Based on observation, interview, and record review it was determined the facility failed to inspect and maintain the facility's fire /smoke dampers or fusible links. Failing to inspect and maintain the facility's smoke dampers may cause harm to the patients and staff.

NFPA 101 Life Safety Code, 2012 Edition Chapter 19, Section 19.5.2, "Heating Ventilating and Air Conditioning." Section 19.5.2.1 "Heating, ventilating and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacture's specifications" Section 9.2.1 " Air Conditioning, Heating, Ventilating, Ductwork, and Related Equipment." Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90 A." "Standard for Installation of Air Conditioning and Ventilating Systems, NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 90 A 2012 Edition Section 5.4.8 Maintenance Section 5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80 Standard for Fire Doors and Other opening Protective's. Section 5.4.8.2 Smoke dampers shall be maintained in accordance with NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 80 Standard for Fire Doors and Other opening Protective's Chapter 19 Installation, Testing, and Maintenance of Fire Dampers, Section 19.4* Periodic Inspection and Testing The test and inspection frequency shall be every 4 years, except in hospitals, where the frequency shall be every six years.

Section 19.4.4 if the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in place if so equipped. Section 19.4.5 The operational test of the fire damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts. Section 19.4.6 The damper frame shall not b penetrated by any foreign objects that would effect fire damper operations. Section 19.4.7 The fusible link shall be reinstalled after testing is complete. Section 19.4.8.1 if the link is damaged or painted, it shall be replaced with a link of the same size, temperature and rating. Section 19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. Section 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. Section 19.4.11 Periodic inspections and testing of a combination fire/smoke damper shall also meet the inspection and testing requirements contained in Chapter 6 of NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's Chapter 6 Installation, Testing and Maintenance smoke dampers. Section 6.5.2 Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except hospitals, where the frequency shall be every 6 years.

Section 6.5 Periodic Inspection and Testing. Section 6.5.11 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. Section 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. Section 6.5.11

Section 6.6 Maintenance.

Section 6.6.1 Any reports of abrupt changes in airflow or noise from the duct system shall be investigated to verify that it is not related to damper operation. Section 6.6.2* All exposed moving parts of the damper shall be dry lubricated as required by the manufacturer. Section 6.6.3 if the damper is not operable, repairs shall begin as soon a s possible. Section 6.6.4 Following any repairs, the damper shall be tested for proper operation in accordance with Section 6.6.5 Smoke damper actuation shall be initiated at a time interval recommended by the actuator manufacturer. Section 6.6.6 All maintenance shall be maintained and records shall be retained in accordance with 6..5.11 and 6.5.12.

Findings Include:

Observations during the review conducted on Sept 6, 2023, revealed the facility had fire or smoke dampers, but no documentation was found indicating that the smoke dampers were maintained in the past six years.

Employees #1 and #2 confirmed during the exit conference that the facility failed to test the HVAC dampers every six years..

Based on observation it was determined that the facility did not have written documentation of the annual inspection and testing of the facility fire doors in accordance with NFPA 80, 2010 Edition, "Standard for Fire doors and Other Opening Protective's ". Failing to inspect and test fire-rated door assemblies in accordance with NFPA 80 annually could cause harm to the patients.

NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware,including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code.

NFPA 80 Section 5.2* Inspections Section 5.2.1* Fire door assemblies shall be inspected and tested not less than annually , and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

Findings include:

Observation while on tour and during documentation review conducted on Sept6, 2023, revealed the facility did not have written records of the Annual Inspection and Testing of the fire doors throughout the facility in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protective's.

Employees #1 and #2 confirmed during the exit conference that the facility failed to conduct the NFPA 80 required testing of the facility's fire doors.

Based on interview and document review the facility failed to conduct, maintain and document electrical receptacle testing in patient care areas specifically to the patient care rooms throughout the facility. Failing to test the receptacles could lead to an ignition hazard in a patient care area resulting in fire and/or injury to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 4, Section 4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected or operated as specified elsewhere in the Code or as directed by the authority having jurisdiction. NFPA 99, Health Care Facilities Code, 2012, Chapter 6, Section 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.

Findings include:

Observation while on tour on Sept 6, 2023, revealed the facility failed to provide documentation on the annual receptacle testing. The facility was unable to provide documentation for any years in the patient's bedrooms.

Employees #1 and #2 confirmed the outlets were not tested annually as required in the Life Safety Code.