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Based on documentation review and interview, it was determined the facility failed to develop an emergency preparedness program, affecting the entire facility.

Findings include:
1. Review of documentation on January 23, 2025, at 12:00 p.m., revealed the facility failed to establish and maintain a comprehensive emergency preparedness program in accordance with 42 CFR 482.15 condition of participation to include the following standards:

(a) Emergency Plan
(b) Policies and Procedures
(c) Communication Plan
(d) Training and Testing

Exit interview with the Facility Administrator and the Facilities Manager on January 23, 2025, between 12:10 p.m., and 12:20 p.m., confirmed the facility failed to establish an emergency preparedness plan, required to be in-place by November 15, 2017.

Based on observation and interview, it was determined the facility failed to maintain means of egress requirements in three locations, affecting one of one floor.

Findings include:

1. Observation on January 23, 2025, between 10:54 a.m., and 11:30 a.m., revealed the following exit locations, between exit discharge and "common way," were not cleared of snow:

a. 10:54 a.m., M Wing,
b. 11:16 a.m., E Wing.
c. 11:30 a.m., Psychiatric Unit.


Exit interview with the Facility Administrator and the Facilities Manager on January 23, 2025, between 12:10 p.m., and 12:20 p.m., confirmed the means of egress deficiencies.

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in two instances, affecting one of one floor.

Findings include:

1. Observation on January 23, 2025, between 10:22 a.m., and 11:11 a.m., revealed the following:

a. 10:22 a.m., the former office, located within the Building Services area, is presently used as a storage room. The storage room door lacked a self-closing device.
b. 11:11 a.m., the M Wing mechanical room door required adjustment to fully latch within the corresponding door frame assembly.


Exit interview with the Facility Administrator and the Facilities Manager on January 23, 2025, between 12:10 p.m., and 12:20 p.m., confirmed the hazardous area enclosure deficiencies.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system six locations, affecting one of one floor.

Findings include:

1. Observation on January 23, 2025, between 10:27 a.m., and 11:23 a.m., revealed the following areas lacked either ceiling tiles, or plaster ceiling assemblies:

a. 10:27 a.m., Old Pharmacy area.
b. 10:33 a.m., Kitchen Storeroom.
c. 10:44 a.m., Electrical Room.
d. 10:55 a.m., IT Room.
e. 11:08 a.m., old Doctor's Lounge.
f. 11:23 a.m., M Wing Nurse's Station.


Exit interview with the Facility Administrator and the Facilities Manager on January 23, 2025, between 12:10 p.m., and 12:20 p.m., confirmed the automatic sprinkler system deficiencies.

Based on documentation review and interview, it was determined the facility failed to maintain heating, ventilation, and air conditioning, affecting one of one floor.

Findings include:

1. Observation on January 23, 2025, at 11:45 a.m., revealed the facility lacked fire damper preventive maintenance data past 2016.


Exit interview with the Facility Administrator and the Facilities Manager on January 23, 2025, between 12:10 p.m., and 12:20 p.m., confirmed the HVAC deficiency.

Based on documentation review and interview, it was determined the facility failed to conduct fire drills in accordance with requirements, affecting one of one floors.

Findings include:

1. Observation on January 23, 2025, at 11:50 a.m., revealed Psychiatric Hospital staff members have not taken part in fire drills since the facility opened in November of 2022. Note: only maintenance staff were listed as participants on fire drill documentation. In addition, the majority of fire drills conducted during the previous twelve month period were conducted in ancillary areas of the hospital, and not in, or around the Psychiatric Unit.


Exit interview with the Facility Administrator and the Facilities Manager on January 23, 2025, between 12:10 p.m., and 12:20 p.m., confirmed the fire drill deficiencies.

Based on documentation review and interview, it was determined the facility failed to maintain fire doors, affecting one of one floor.

Findings include:

1. Observation on January 23, 2025, at 12:00 p.m., revealed the facility lacked annual fire door functional and visual testing data.


Exit interview with the Facility Administrator and the Facilities Manager on January 23, 2025, between 12:10 p.m., and 12:20 p.m., confirmed the fire door deficiencies.

Based on documentation review and interview, it was determined the facility failed to maintain the generator set in one instance, affecting one of one floor.

Findings include:

1. Observation on January 23, 2025, at 11:55 a.m., revealed the facility lacked annual ninety-minute load bank testing data for the diesel generator set.


Exit interview with the Facility Administrator and the Facilities Manager on January 23, 2025, between 12:10 p.m., and 12:20 p.m., confirmed the generator set deficiency.