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Based on observation and interview during the survey walk of the facility with the Facilities Director on the morning of 6/24/2025, the Body Hold Room and Assisted Bathing were being used as Storage, the double doors at the central storage room did not close and latch properly, and the janitor room in the kitchen did not have a closer.

NFPA 101, 2012: 19.3.2.1 Any hazardous areas shall be protected in accordance with Section 8.7, and the areas described in Table 19.3.2.1 shall be protected as indicated. The doors shall be a minimum ¾ hour fire rated doors set in rated frames. With that classification, the door's hardware, including door closers device and latching hardware, must meet the requirement for storage rooms.

Unrelated items for building support spaces, such as grills, tables, plywood, and miscellaneous equipment was observed being stored in the riser and electrical rooms. The clearances around the panels and riser were not maintained.
2012 NFPA 101 7.13.1.2 - Building service equipment support areas shall not
contain fuel-fired equipment or be used for the storage of
combustibles.

2010 NFPA 110, 7.11.1 - Protection. The room in which the EPS equipment is located shall not be used for other purposes that are not directly related to the EPS. Parts, tools, and manuals for routine maintenance and repair shall be permitted to be stored in the EPS room.

Based on observation during the survey walk of the facility on the morning of 6/24/2025 with the COO, CEO and Maintenance Director, the requirement was not met. The HVAC unit was out of service for the Administration area, and temporary units were in place. It was noted the unit is scheduled for repair. A project is required to be submitted to ARU for construction projects.

HLR §505.167 (a)(1) Hospital owners/operators may not begin construction of a new building, additions to or renovations or conversions of existing buildings until the department approves final construction documents.

Based on review of records during the survey of the facility on the morning of 6/24/2025 with the COO, CEO and Maintenance Director, the facility failed to provide written after-action reports of the annual community disaster drills. Ensure the facility is included in community drills and maintain reports.

Based on review of the records on the morning of 6/24/2025, with the Administrator, the facility failed to provide proper paperwork for the Evacuation and Relocation Emergency Plan. The last review and update was in January 2023. The requirement is to review and update every 2 years. The files were not readily available in one place. There was no documentation located in the notebook for Emergency policies and procedures for the required food provision. Based on interview the food required for subsistence was managed by the Dietary department. This procedure was not listed in the Emergency Preparedness plan or referenced where to locate it. A log for testing the Emergency Preparedness twice yearly was not found. Consolidate location of emergency plans and indicate staff responsible for maintaining documentation.

Based on observation during the survey walk of the facility on the morning of 6/24/2025 with the COO, CEO and Maintenance Director, the facility failed to maintain the facility. The film room adjacent to the Rad room did not have flooring installed. The Isolation Exam and adjacent Toilet had flooring peeling at the seams. This does not provide a clean, safe environment.

Hospital Licensing Rules Title 26 TAC (HLR) §505.162 (d)(1) (A) Physical environment. A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each hospital. The physical premises of the hospital and those areas of the hospital's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and Subchapters H and I of this chapter.

HLR §505.162 (2)(B)(iii) Floor finishes. Flooring shall be easy to clean and have wear resistance appropriate for the location involved.

Based on observation during the survey walk on the morning of 6/24/2025, the Director of Facilities informed the surveyor the Medical Air Compressors had been decommissioned in or around year 2017. The State was not notified, and a project was not submitted. Hospitals are required to have Medical Air.
Refer to HLR §505.169(f) Table 6 STATION OUTLETS FOR OXYGEN, VACUUM, AND MEDICAL AIR SYSTEMS

During the survey walk of the facility on the morning of 6/24/2025 with the COO, CEO and Maintenance Director, it was observed the Fire Alarm control panel and accessory devices were not powered from the Life Safety Branch.

Based on review of the records and interview with the CEO, COO and Director of Facilities on the morning of 6/25/2025, the facility failed to document testing of the hospital grade receptacles at the patient bed locations. GFCI testing log was provided. This does not meet the requirements. Document testing at the intervals required by documented performance data. Provide this information with the testing for review of conformity in the future.

"Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device." - NFPA 99, 2012, 6.3.4.1.1

"Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data." - NFPA 99, 2012, 6.3.4.1.2

Based on review of the records and interview with the CEO, COO and Director of Facilities on the morning of 6/25/2025, the facility failed to periodically exercise the Main feeder and circuit breakers. Thermal imaging reports for breakers were provided for 2023 and 2025. The 2024 report was missing. Documentation indicating the dates of exercising the breakers and main feeder was not provided.
Begin exercising breakers and maintain a log.

"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

Based on review of the records and interview with the Director of Facilities on the morning of 6/24/2025, the facility failed to periodically exercise the Main feeder and circuit breakers. A log documenting the dates of exercising the breakers and main feeder was not provided. Exercise the main feeder and breakers and maintain a log.