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Based on observations, and record review, the hospital failed to maintain provision of subsistence needs for staff and patients whether they evacuate or shelter in place for Emergency Preparedness Plan in accordance with 42 CFR 482.15(b)(1)

Findings:

On 05/12/2025, between 11:00 AM and 5:00 PM, this surveyor, with the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN present, observed the following:

1. No documentation in the emergency preparedness plan provision of subsistence needs for staff and patients whether they evacuate or shelter in place.

2. No ducumentation in the emergency preparedness plan for food, water, medical and pharmaceutical supplies and how they would get replenished in the event they had to evacuate or shelter in place.

3. No documentation in the emergency preparedness plan for fuel to maintain the generator to run for more then the allotted time of fuel on site.

This surveyor confirmed these findings with the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN at the time of the observation.

Based on observations, and record review, the hospital failed to develop and implement emergency preparedness policies for Hospitals at 42 CFR §482.15(b)(2) Policies and procedures. [(2) or (1)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

Findings:

On 5/12/25, between 11:00 AM and 5:00 PM, this surveyor, with the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN observed the following:

1. No documentation was provided in the emergency preparedness plan of a policy addressing arrangements with other [facilities] to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

This finding was verified by the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN at the time of observation.

Based on observations, and record review, the hospital failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be
reviewed and updated at least every 2 years. In accordance with 42 CFR §482.15(c)(7)

Findings:

On 5/12/2025, between 11:00 AM and 5:00 PM, this surveyor, with the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN present, observed the following:

1. There was no documentation in the emergency preparedness plan of a policy to provide a means of documenting 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 surveyor confirmed this finding with the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN at the time of the record review.

Based on observations, and record review, the hospital failed to maintain a training and testing program for Emergency Preparedness Plan in accordance with 42 CFR 482.15

Findings:

On 05/12/2025, between 11:00 AM and 5:00 PM, this surveyor, with the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN present, observed the following:

1. No documentation was provide in the emergency preparedness plan for a training and testing program for employees.

This surveyor confirmed this finding with the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN at the time of the observation.

Based on observations, and record review, the hospital failed to develop and maintain an Emergency Preparedness Training Program in accordance with 42 CFR §482.15.

Findings:

On 5/12/2025, between 11:00 AM and 5:00 PM, this surveyor, with the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN present, observed the following:

1. There was no evidence that the hospital has developed and maintained an Emergency Preparedness Training Program in accordance with 42 CFR §482.15.

The surveyor confirmed this finding with the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN at the time of the record review.

Federal Recertification Survey


Based on plans review and observation, the hospital failed to maintain penetrations and wall construction requirements of the 2-hour separation walls for inspection per NFPA 101, Life Safety Code, 2012 Edition, Sections 8.2.1.3., and 19.1.3.5.

Findings include:

During a survey conducted on 05/12/2025 between the hours of 11:00 AM and 5:00 PM, a surveyor with the Contract Engineer did observe the following:

1. The 2-hour separation located on the lower level separating the hospital and the medical office building was penetrated by multiple conduits and piping that was not protected by a firestop system or device in accordance with NFPA 221 (2012 edition), Standard for High Challenge Fire, section 4.9.2 Firestop Systems and Devices Required - Penetrations for cables, cable trays, conduit, pipes, tubes, combustible vents and exhaust vents, wires and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a fire stop system or device. The medical office building side of this barrier does not have appear to have any type of firestopping present.

This finding was confirmed at the time of observation by this surveyor and the Contract Engineer.

Based on observations, the Hospital failed to maintain the Exit Corridor required width in 2 egress corridors, every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency per NFPA 101, Life Safety Code, 2012 Edition, Sections 19.2.1, and 7.1.10.1

Findings:

On 05/12/2025 between 11:00 AM and 5:00 PM, Surveyors in the presence of the Maintenance Engineer, Chief Nursing Officer, and Nursing Supervisor, the following were not met:

1. Medical equipment is being stored in the exit access corridor located in the Med Surge Unit in the North Wing.

2. A Soiled Utility cart is being stored in the corridor blocking the corridor exit access door located in the Imaging Unit.

Surveyors confirmed these findings with the Maintenance Engineer, Chief Nursing Officer, and Nursing Supervisor at the time of the observation.





50034

Federal Recertification Survey

Based on observation and interview, the hospital failed to maintain exit corridor width per NFPA 101, Life Safety Code, 2012 Edition, Section 19.2.2 through 19.2.11, 19.2.1, 7.1.10.1

Findings:

On 05/12/2025, between 11:00 AM and 5:00 PM, this surveyor, with the Contract Engineer present, observed the following:

1. The exit access corridor located on the lower level by the cafeteria entrance has 2 hospital beds and several photocopy machines stored in the corridor. The Contract Engineer states: These two hospital beds are broken and are waiting to be repaired." The Contract Engineer further states: :The beds will be repaired in the corridor." corridor.

2. The exit access corridor located on the lower level by the vending machine and housekeeping storage has miscellaneous items stored in the corridor.
This finding was confirmed by this surveyor and the Contract Engineer at the time of the observation.

Based on observations, the Critical Access Hospital failed to ensure the means of egress from patient rooms meet the requirements of NFPA 101, Life Safety Code, 2012 edition Security and Safety needs in accordance with 19.2.2.2, 19.2.2.2.5.

Findings:

On 5/12/25 between 11:00 AM and 4:30 PM, in the presence of the Maintenance Engineer and Nursing Supervisor, the following were not met:

1. The Patient room door located in the Emergency Department called the GYN room has a barrel bolt latch fixed to the door on the outside to lock patents in the room. The door cannot be opened from the inside of the room by anyone if the barrel bolt latch is engaged.

Surveyors confirmed these findings with the Maintenance Engineer and Nursing Supervisor at the time of the observation.

Federal Recertification Survey

Based on observation, the Hospital failed to ensure that doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 of NFPA 101 2012 edition. In 1 of 2 smoke compartments.

Findings:

During a facility tour on 05/12/2025 between hours of 11:00 AM and 5:00 PM. this surveyor, accompanied by the Contract Engineer, did observe the following:

1. The Steam Room, located on the lower level, has a 90-minute rated door into the corridor that does not have a self-closing device attached to it.
2. The Housekeeping Storage Door, located on the lower level, has a self-closing device that would not close the door and allow it to latch.
3. The Dietary Back Storage room door, located on the lower level, does not close and latch.
4. The Laundry Room door, located on the lower level was found open into the exit access corridor and does not close and latch.
5. The Kitchen Door, located on the lower level, when fully opened gets caught on the floor while closing and stops there.
6. The "old cardiac rehab" room, located on the lower level, does not have a self-closing device attached.
7. The storage area off on the kitchen that has double doors into the egress corridor is propped open by two boxes and cannot close. It also does not have a self-closing device attached.

These findings were confirmed by the Contract Engineer at the time of the survey.





51959

Based on observation, the facility failed to ensure in 1 of 2 smoke compartments that doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position. 2012 edition, NFPA 101 7.2.1.8.2 .

Findings:

On 05/12/2025 between hours of 11:00 AM and 5:00 PM, this surveyor accompanied by the Maintenance Engineer, did observe the following:

1. The Soiled Linen Room, located near the Operating Rooms, has a door into the corridor that has a self-closing device that did not allow the door to close and positive latch.

2. The Soiled Linen Room, located in inpatient corridor, has a self-closing device that would not close the door and allow it to positively-latch.

These findings were acknowledged by the Maintenance Engineer at the time of the survey.

Based on documentation and interview, the hospital failed to provide operational emergency lighting testing in accordance with NFPA 101, Life Safety Code, 2012 edition, sections 19.2.9.1, and 7.9.3.

Finding:

Documentation review with the Contract Engineer present on 05/12/2025 from 11:00 AM to 5:00 PM identified:

1) There is no monthly and annual testing of the emergency lighting. Documentation was provided for the exit signage, but not for the emergency lighting. An interview with the Contract Engineer revealed that they are not tested because they have a generator.

This finding was acknowledged by the Contract Engineer at the time of documentation review on 05/12/2025, and during the exit interview on 05/13/2025.

Based on observations, the Hospital facility failed to mark the required means of egress with appropriate signage in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, Sections 7.10, and 19.2.10.1.

Findings:

On 5/12/25 between 11:00 AM and 5:00 PM, surveyors in the presence of the Maintenance Engineer, the following was not met:

1. The exit sign located next to the elevator on the Upper Level at Med Surge entrance points to the elevator as the exit. The elevator shall not be used as an exit in case of a fire. A protected stair exit is located on the other side of the 2-hour fire doors.

Surveyors confirmed these findings with the Maintenance Engineer and Nursing Supervisor at the time of the observation.

Based on observations, the Hospital facility failed to ensure that hazardous areas are protected by the requirements of NFPA 101 2012 edition by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated self-closing doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9.

Findings:

On 05/12/2025 between hours of 11:00 AM and 5:00 PM, surveyors accompanied by the Maintenance Engineer and Nursing Supervisor, did observe the following:

1. Patient room 201 is being used as a storage room. The door self-closer has been removed. The door shall self-close and positively latch. The space is over 50 square feet.

Surveyors confirmed these findings with the Maintenance Engineer and Nursing Supervisor at the time of the observation.

Based on observation, document review, and interview, the hospital failed to protect the commercial cooking operations by ensuring the entire exhaust system was inspected for grease buildup by a properly trained, qualified, and certified person in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition Sections 11.4 and 12.1.2.2, as referenced by NFPA 101, Life Safety Code, 2012 edition, Section 19.3.2.5.1, and 9.2.3. This deficient practice could affect the kitchen area of the facility by having a commercial cooking assembly that is excessively laden with flammable grease and not properly in place under the extinguishing system.

Finding:

Observation, Interview, and Document Review during a facility tour with the Contract Engineer present on 05/12/2025 from 11:00 to 5:00PM identified:

1. The is no decal showing the latest inspection for grease buildup by a properly trained, qualified, and certified person attached to the hood. There was no documentation in the files to show that the entire exhaust system was inspected for grease buildup by a properly trained, qualified, and certified person.

This finding was acknowledged by the Contract Engineer at the time of observations and during the exit interview on 05/13/2025.



51959

Based on observation, the hospital failed to provide an appropriate hood system for the Therapy Cooking stove per NFPA 101, Life Safety Code, 2012 Edition, Sections 19.3.2.5.

Finding:

Based on observation on 05/12/2022 between hours of 11:00 AM and 5:00 PM this surveyor accompanied with the Maintenance Engineer did observe the following:

1. The Stove in the Therapy Kitchen, room 204, did not have the proper fire supression hood system per the code requirements set forth for cooking appliances. Stove was observed to be in working order and powered.

This deficient practice could affect the residents, visitors and staff.

This finding was acknowledged by the Maintenance Engineer at the time of the observation.

Federal Recertification Survey

Based on observation, the facility failed to ensure that all areas not continuously occupied has a fire alarm detection device near it per NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition, Section 10.15, as referenced by NFPA 101, Life Safety Code, 2012 Edition, Sections 9.6.1.3, 9.6.1.8.1 (1), and 19.3.4.1.

Findings:

On 05/12/2025, between 11:00 AM and 5:00 PM, this surveyor with the Contract Engineer present, observed the following:

1. There was no automatic smoke detection device installed adjacent to the fire alarm control unit.

This finding was confirmed by the surveyor and the Contract Engineer at the time of the observation.

Based on documentation review and interview, the facility failed to ensure that the Smoke Detector Sensitivity Testing was performed by a certified Fire Alarm Inspection Company per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Sections 14.4.2.2, and 14.4.5.3 as referenced by NFPA 101, Life Safety Code, 2012 Edition, Sections 19.3.4, and 9.6.1.5.

Finding:

On 05/12/2025, between 11:00 AM and 5:00 PM, a surveyor with the Contract Engineer present, observed the following:

1. Upon documentation review of the annual fire alarm inspection report dated 11/01/2024 by Maine Fire Protection Systems, there is no mention of the smoke detector sensitivity testing in this report. I requested the sensitivity report that may be listed in other documentation, and I was told by the Contract Engineer that this is all we have. I explained what the test is and he shrugged and said that this is all we have. No documentation of the sensitivity test was provided.

The surveyor confirmed this finding with the Contract Engineer at the time of the observation, and at the exit interview.

Based on observation and record review, critical access hospital failed to ensure that Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems sections 13.4.4.2.2.2, and 13.4.4.2.9 as referenced by NFPA 101, Life Safety Code, 2012 Edition, Sections 9.7.1, and 19.3.5.1.

Findings:

On 05/12/2025, this surveyor, observed the following findings with the Contract Engineer present.

1. Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested. According to the documentation on the riser, the full-flow trip test was last conducted 02/13/2018, making it due in 2021.

2. Dry pipe systems shall be tested once every 3 years for air leakage. There was no documentation provided regarding the 3-year air leakage test.

This surveyor confirmed these findings with the Contract Engineer at the time of the documentation review.




50034

Federal Recertification Survey


Based on observations, the hospital failed to ensure that Sprinkler System was inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 edition, section 5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

Findings:

During a facility tour on 05/12/2025 between the hours of 11:00 AM and 5:00 PM, this surveyor with the Contract Engineer present, observed the following on the lower level:

1. A sprinkler head located in the laundry room is loaded with foreign material.

2. In the Dietary Directors office, a suspended ceiling is obstructing the sprinkler head located directly above it, leaving the room without sprinkler coverage.

3. In the Human Resource storage room, a sprinkler head is missing an escutcheon ring.

These findings were confirmed by the surveyor and Contract Engineer at the time of observation.

Federal Recertification Survey

Based on observation, the hospital failed to install portable fire extinguishers where they are readily accessible and immediately available in the event of fire in accordance with NFPA 10, Standard for Portable Fire Extinguishers, 2010 edition, Section 10.6.1.3 as referenced by NFPA 101, Life Safety Code, 2012 edition Sections 9.7.4.1, and 19.3.5.12.

Findings:

During a facility tour on 05/12/2025 between the hours of 11:00 AM and 5:00 PM, this surveyor and the Contract Engineer observed the following:

1. The K class fire extinguisher located in the kitchen has cases of soda stored in front of it making it not readily accessible.

This finding was confirmed by the surveyor and Contract Engineer at the time of observation.

Based on observations, the Hospital facility failed to maintain the corridor doors, so they close and positively latch per NFPA 101, Life Safety Code, 2012 Edition, Sections 19.3.6.3, and 19.3.6.3.5.

Findings:

On 05/12/2025, between 11:00 AM and 5:00 PM, surveyors, with the Maintenance Engineer and Nursing Supervisor present, observed the following:

1. Patient room 203 door did not latch when attempted, door was opened and closed 5 times.

Surveyors confirmed these findings with the Maintenance Engineer and Nursing Supervisor at the time of the observation.



50034

Federal Recertification Survey

Based on observation, the hospital failed to maintain the corridor door from closing and positively latching per
NFPA 101, Life Safety Code, 2012 Edition, Sections 19.3.6.3, 19.3.6.3.5

Findings:

On 05/12/2025, between 11:00 AM and 5:00 PM, this surveyor, with the Contract Engineer present, observed the following on the lower level:

1. The housekeeping closet located near the shredder has no latching mechanism attached.
2. The shredder door located near the housekeeping closet has no latching mechanism attached.
3. The room identified as "Jackie's Closet" has no latching mechanism attached.
4. The cafeteria door is held open by an automated release and has a deadbolt with key mechanism on the exterior and the interior is a flip type device.

These findings were verified by the surveyor and Contract Engineer at the time of the observation.

Based on observation, records review, and interview, the facility failed to test all fire, smoke, and combination fire and smoke dampers in accordance with the NFPA Life Safety Code, 2012 Edition, Sections 9.2.1, and 19.5.2.1. Also reference NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 edition, Section 5.4.8., NFPA Standard NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 edition, Section 19.4, and NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protectives, 2010 edition, Section 6.5.

Finding:

An interview and documentation review, on 05/12/2025 between 11:00 AM and 5:00 PM with the Contract Engineer present:

1. Records review of the facility's fire damper testing revealed the facility failed to provide current documentation for the testing and inspection of fire, smoke, and combination fire/ smoke dampers within one (1) year of installation and every six (6) years thereafter. The interview with the contract engineer revealed that they have no documentation since they were last done in September of 2018 by Loggans Sheet Metal, making them due again in 2024.

The finding was acknowledged by the Contract Engineer at the time of documentation review and the exit interview on 05/13/2025..

Based on documentation review, and interview, the Critical Access Hospital failed to provide documentation that fire drills are conducted quarterly on each shift to familiarize personnel with the signals and emergency actions required under varied conditions per NFPA 101, Life Safety Code, 2012 edition, section 19.7.1.6.

Finding:

On 05/12/2025, between 11:00 AM and 5:00 PM, a surveyor, Contract Engineer present, observed the following:

1. The fire drill documentation in the fire drill binder was dated:
04/15/2025 at 11:30 in the OR
01/21/2025 at 13:52 med/surge
11/20/2024 at 11:30 Primary Care
06/19/2024 at 14:40 White Birch-off site business building
04/23/2024 at 11:30 White Birch Medical Building off site
02/02/2024 at 10:35 in the kitchen
01/31/2024 unknown details as the documentation was not filled out.
I asked the Contract Engineer for more documentation as these are incomplete. He said that if they are not in the binder, then that's all he has. Interview with the Infection Prevention, Emergency Preparedness, and Employee Health Director during the exit interview revealed that there should be more, but they are not in the binder. Interview also revealed that there are two shifts, and the hours are 0700-1900, and 1900-0700. There was no documented drills from the night shift in the binder for review. The White Birch drills are for the detached medical building on campus, and not part of the hospital occupancy.

The Contract Engineer acknowledged this finding at the time of the documentation review and during the exit interview on 05/13/2025.

Based on observations, the Hospital Facility failed to ensure the High-Pressure Decorative Laminate, (HPDL) -faced doors, flush wood doors, and stile and rail wood doors with fire ratings greater than 1/3 hour shall not have clearances greater than 1/8 in. between the door and frame, regardless of the door frame construction, and the meeting stiles of paired doors. NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 edition, Section 6.3.1.7.

Findings:

On 5/12/25 between 11:00 AM and 4:30 PM, Surveyors in the presence of the Maintenance Engineer and Nursing Supervisor, the following was not met:

1. The 2-hour HPDL fire doors entering Med Surge unit from the corridor have a vertical clearance between the 2 door leaves greater than 1/8". This was measured at 3/8" clearance by surveyors.

Surveyors confirmed these findings with the Maintenance Engineer and Nursing Supervisor at the time of the observation.



42159

Based on interview and documentation review, the long-term care facility failed to conduct an annual fire door inspection that ensures that all fire rated doors and hardware are inspected, tested, and maintained by individuals performing the door inspections that possess knowledge, training or experience that demonstrates ability in accordance with NFPA 80, Standard for Fire Door and Other Opening Protectives, 2010 edition Section 5.2 as referenced by NFPA 101, Life Safety Code, 2012 Edition, Sections 19.7.6, and 8.3.3.1

Finding:

Documentation review and interview with the Contract Engineer present on 05/12/2025, between 11:00 AM and 5:00 PM identified:

1. The facility had no documentation that the doors had been inspected by a trained employee or a qualified outside vendor in the last year. The most recent annual fire door inspection report provided was done by NFS in May of 2021. Upon further request for a more recent report from the Contract Engineer, he told me that this was the last time the fire doors were inspected and there is no more current paperwork.

The Contract Engineer acknowledged this finding at the time of the documentation review and during the exit interview on 05/13/2025.

Federal Recertification Survey

Based on observations, the hospital failed to comply with the 2012 Life Safety Code Section 19.7.8 Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius).

Findings:

During a facility tour on 05/12/2025 between the hours of 11:00 AM and 5:00 PM, this surveyor along with the Contract Engineer did observe the following:

1. A personal portable heating device was located in the oncology reception area that did not have any anti-tip protection. This device was removed at the time of the survey by oncology staff.

2. A personal portable heating device was located in the office labeled Sandra Bafara that did not have any anti-tip protection.

This finding was was confirmed by this surveyor and the Contract Engineer at the time of survey.

Based on observation, document review, and interview, the hospital failed to install all master, area, and local alarm systems used for medical gas and vacuum systems comply with appropriate category warning system requirements in accordance with NFPA 99, Healthcare Facilities Code, 2012 edition, Sections 5.1.9.2.4., and 5.1.9.5.2

Findings:

Documentation Review of the Medical Gas and Vacuum systems inspection report by Acute Medical Gas dated 11/21/2024, during a facility tour with the Contract Engineer present on 05/12/2025 from 11:00 to 5:00PM identified:

1. The CO alarm only initiates at the Plant Operations Panel. The master alarm shall indicate at least one signal from the source equipment to indicate a problem.

2. There are no secondary alarm points located on either master alarm panel. An alarm indication when or just before changeover to the secondary supply system shall be installed.

The Contract Engineer was aware of the deficiencies annotated in the report and I was told that nothing has been fixed yet because the facility is under a construction project and the medical gas is part of the project. These deficiencies were annotated on the AMG report from 2023 as well.

These findings was acknowledged by the Contract Engineer at the time of observations and during the exit interview on 05/13/2025.

Based on observation, document review, and interview, the hospital failed to install all master, area, and local alarm systems used for medical gas and vacuum systems comply with appropriate category warning system requirements in accordance with NFPA 99, Healthcare Facilities Code, 2012 edition, Sections 5.1.3.2, 5.1.3.3, 5.1.3.5, 5.1.4.8.3, and 5.1.8.2.1,

Findings:

Documentation Review of the Medical Gas and Vacuum systems inspection report by Acute Medical Gas dated 11/21/2024, during a facility tour with the Contract Engineer present on 05/12/2025 from 11:00 to 5:00PM identified:

1. On the Oxygen B-1 system, the pressure and vacuum indicators shall be readable from a standing location. The main line pressure indicator is located within a confined space and is not readable from a standing location.

2. On the NOM-1 system there is only one final line regulator and there is no check valve. All positive pressure supply systems shall be provided with duplex line pressure regulators piped in parallel with isolation valves on the source side of the regulator, and the patient side of the regulator.

3. On the NOM-1 system the manifold relief vents are vented into the manifold room and not outside of the building.

4. On the NOM-1 system, there is no pressure relief valve between the final line regulator and the source valve.

5. On the NOM-1 system, the manifolds shall have a local signal that visibly indicated the operating status of the equipment. There are no local signals on the manifold system.

6. On the NOM-1 system, the manifold on the central supply system does not appear to have a check valve on the header.

7. On the NOM-1 system, the manifolds shall consist of two equal headers with the headers connected to the final line pressure system in such a manner that either header can supply the system. The system is currently set up as a 1X1 configuration, and not a 2X2 configuration.

8. The NIM-1 system is just one nitrogen tank with a duplex regulator attached to the tank, that is not monitored except for pressure. This doesn't meet the requirements of Category 1 Central Supply Systems.

9. In the OXB-1 system, there are not guard posts or another approved means to protect the equipment from vehicular damage. The fencing installed does not provide vehicular protection.

10. In the LMC-1 system, there is combustible storage in the same rooms as the gas cylinders. Only gas cylinders, reusable shipping containers and their accessories shall be permitted to be stored in these areas. The cardboard boxes are not allowed.

11. The LMC-1 door to the manifold room is not lockable. The locations for central supply systems shall be secured with lockable doors or gates.

12. Waste Anesthetic Gas Disposal, (WAGD), networks shall provide an inlet in all locations where nitrous oxide or halogenated gas is administered. Neither of the two Operating Rooms have inlets, to correspond with the outlets. Zone 02-03, and 02-04.

13. In zone 02-02, the medical air outlet leaks at the backbody.

14. In Zone 02-04A, the medical air outlet leaks when it is in use.

15. in Zone 02-06, the first oxygen outlet constantly leaks, whether in use or not.

16. There was no zone valve gauge located on the patient side of the zone valve in 02-04A Med Surge.

17. There was no zone valve gauge located on the patient side of the zone valve in 02-05 Med Surge.

18. There was no zone valve gauge located on the patient side of the zone valve in 02-06 Med Surge.

19. There was no zone valve gauge located on the patient side of the zone valve in 02-07 Med Surge.

20. There was no zone valve gauge located on the patient side of the zone valve in 02-09 Anesthesia.


The Contract Engineer was aware of the deficiencies annotated in the report and I was told that nothing has been fixed yet because the facility is under a construction project and the medical gas is part of the project. These deficiencies were annotated on the AMG report from 2023 as well.

These findings were acknowledged by the Contract Engineer at the time of observations and during the exit interview on 05/13/2025.

Based on document review, and interview, the hospital failed to identify the station outlets in accordance with NFPA 99, Healthcare Facilities Code, 2012 edition, Sections 5.1.5.5, and 5.1.11.3

Finding:

Documentation Review of the Medical Gas and Vacuum systems inspection report by Acute Medical Gas dated 11/21/2024, during a facility tour with the Contract Engineer present on 05/12/2025 from 11:00 to 5:00PM identified:

1. The outlet in Zone 02-07 is missing the finished identification faceplate.


The Contract Engineer was aware of the deficiency annotated in the report and I was told that nothing has been fixed yet because the facility is under a construction project and the medical gas is part of the project. This deficiency was annotated on the AMG report from 2023 as well.

This finding was acknowledged by the Contract Engineer at the time of observations and during the exit interview on 05/13/2025.

Federal Recertification Survey

Based on observation, the hospital failed to comply with the 2012 Life Safety Code Section 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2011 NFPA 70 225.19

Findings:

During a survey conducted on 05/12/2025 between the hours of 11:00 AM and 5:00 PM, this surveyor and the Contract Engineer observed the following:

1. The electrical panels located in the kitchen have 3 chairs and a food cart stored up against them.

This finding was confirmed by the surveyor and the Contract Engineer at the time of observation.


51959

Based on observations, the facility failed to meet the requirements of NFPA 70, National Electrical Code, 2011 edition, Section 314.25, 110.7 as referenced by NFPA 99, Healthcare Facilities Code, 2012 edition, section 6.3.2.1.
Findings:
On May 12, 2025, between 11:00 AM and 5:00 PM, this surveyor, with the Maintenance Engineer, and Nurse Supervisor, observed the following:
1. Exposed wiring hanging from the ceiling of the Chemistry Lab.
2. Electrical outlet pulled out from the wall in the patient registration office.
These findings were acknowledged by the Maintenance Engineer at the time of observation.

Based on observation, and interview, and generator inspection documentation review during the facility tour, the Critical Access Hospital failed to maintain the Essential Electric System Generator per NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, sections 8.3.7., 8.3.8, and 8.4.1, and NFPA 99, Healthcare Facilities Code, 2012 edition, section 6.4.4.1.1.3.This deficient practice could affect the patients/residents, visitors, and members of facility staff in this location.

Findings:

Review of documentation and interview with the Contract Engineer present on 05/12/2025 between 11:00 AM and 5:00 PM identified the following deficiencies:

1) Emergency Power Supply Systems, including all appurtenant components, shall be inspected weekly. The only documentation provided was the monthly load test. During an interview with the Contract Engineer, he stated that the generator is monitored by Omnicare, but it is not inspected weekly in person. Documentation from the CMS site regarding generator inspection requirements was provided to the Contract Engineer at the exit interview.

2) No documentation showing an annual fuel quality test was provided on the generator testing and maintenance documentation. A fuel quality test shall be performed at least annually using appropriate ASTM standards or the manufacturer's recommendations.

The Contract Engineer acknowledged these findings at the time of documentation review on 05/12/2025 and at the exit interview on 05/13/2025.

Based on observations, the Hospital facility failed to ensure that power strips are not used for non-PCREE (Patient-care-related electrical equipment) and that power strips are not used as a substitute for fixed wiring in accordance with NFPA 99, Healthcare Facilities Code, 2012 edition, Chapter 10, NFPA 70, National Electrical Code, 2010, Section 400.8(1)

Findings:

On 05/12/2025, between 11:00 AM and 5:00 PM, surveyors with the Maintenance Engineer, Nursing Supervisor, and Chief Nursing Officer present observed the following:

1. In patient room 214 in the Med Surge Unit, an orange extension cord is being used to power a negative pressure unit as a permanent power source.

2. An orange extension cord is being used as a permanent power supply for an appliance in the O.R. Unit staff lounge.

3. An extension cord power strip is being used as a permanent power supply for a microwave oven, toaster, and coffee maker in the Diagnostic Imaging Unit in the closet by C.T.


Surveyors confirmed these findings with the Maintenance Engineer, Nursing Supervisor, and Chief Nursing Officer at the time of the observation.

Based on observation, the health care facility failed to ensure that Gas Equipment - Cylinder and Container Storage rooms are equipped with precautionary signage in accordance with NFPA 99, Healthcare Facilities Code, 2012 Edition, Section 11.3.4.

Finding:

On 5/12/2025, between 1:00 PM and 4:00 PM, a surveyor, with the Maintenance Engineer present, observed the following:

1. The storage room (210) in the inpatient wing was found being used for oxygen cylinder storage with less than 300 cubic feet and was not marked with a precautionary sign, readable from a distance of 5 feet stating "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING"

The surveyor confirmed this finding with the Maintenance Engineer at the time of the observation.

Federal Recertification Survey

Based on observation, the hospital failed to comply with 2012 NFPA 101 19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing. 2012 NFPA 99 11.3.2.6 Cylinder or container restraints shall comply with 11.6.2.3. 11.6.2.3

Findings:

On 05/12/2025 between the hours of 11:00 AM and 5:00 PM, surveyors and the Contract Engineer observed the following:

1. In the Oxygen Storage room, located on the lower level near the cafeteria, a K size oxygen tank is not properly chained or supported in a cylinder stand or cart.

This finding was confirmed by the surveyor and Contract Engineer at the time of the survey.

Based on interview and documentation review the Critical Access hospital failed to document Fire Loss Prevention procedures in operating rooms in accordance with NFPA 99, Healthcare Facilities Code, 2012 Edition, Section 15.13.

Findings

On 05/12/2025 from 11:00 and 5:00 PM with the Contract Engineer present identified the following:

1. A periodically reviewed hazard assessment was not provided that documents hazards including, but not limited to environmental, equipment, and electrical hazards.
2. Documented procedures for operating room/surgical suite emergencies were not available that include but are not limited to chemical spills, extinguishing drapery, clothing, or equipment fires alarm actuation, evacuation, and equipment shutdown procedures and provisions.
3. Documented procedures for controlling and preventing emergencies that could occur in the operating room, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department were not provided.
4. No documentation of employee training on emergency operating room specific procedures and hazards was provided.

The MRH department specific fire plan for the operating room did not give adequate details and explanations for these required topics.

This surveyor confirmed these findings with the Contract Engineer at the time of the documentation review.