Wickenburg Community Hospital

“EQUIPMENT, SUPPLIES, AND MEDICATION CFR(s): Equipment, supplies, and medication used in treating emergency cases are kept at the CAH and are readily available for treating emergency cases. The items available must include the following: This Standard is not met as evidenced by: 52392 Based on review of manufacturer’s recommendations, facility documents, observation, and staff interview, it was determined the Administrator failed to ensure that glucometer controls and test strips were labeled with an open date and expiration date and expired glucometer controls and test strips were removed and not available for use in patient care. This deficient practice poses a potential risk to the health and safety of patients if expired glucometer controls are used leading to false and inaccurate blood glucose readings and leading to improper treatment which could cause hypo/hyperglycemic episodes, injury, or death. Findings include: Review of the manufacturer’s recommendations titled, “Accu-Chek Inform II Instructions for Use (IFU)”, revealed: “ ...Write the discard date on the bottle label. The control solution is stable for 3 months after opening or until the Expiration date on the bottle label ....” Hospital document titled, “ Accu-Chek Inform II Skills Annual Competency”, revealed: “ ...instructing the staff that controls must be dated when opened, expire in 3 months after the date the bottle was opened, and expire on the date printed on the vial if before the open date ...Skills checklist reveals: “ ...Understands that controls expire 3 months from opening and ensures that the open expiration date is written on the control solution ....” Observation during tour conducted on 05/06/2025 revealed 2 Accu-Chek Inform II test strips and controls with no documented open date or expiration date on the controls or test strips in both the Acute Care Unit and the Operating Room. Employees #1, #17, and #20 confirmed the Controls and Test strips bottles must be labeled to identify when to remove the equipment from patient care use.”

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 52392 Based on review of policies/procedures, documents, staff interviews, and observations, it was determined the administrator failed to ensure that the wheelchairs were inspected for rips and tears; and safe handles were used and cleaned in between patient usage. This deficient practice poses a risk to patient health and safety of patients and employees. Findings include: Policy titled, “Cleaning, Disinfecting, and Sterilizing of Patient Care Equipment” revealed: “ ...non-critical items: Items which normally contact intact skin only (e.g., wheelchairs ...will be cleaned with the hospital-approved disinfectant between use ...Nursing staff is responsible for cleaning patient equipment if soiled/contaminated while in use ....” Policy titled, “Infection Control” revealed: “ ...Cleaning/Disinfection/Sterilization ...All patient care items must be clean. Wash with a detergent and rinse with water if soiled ...Articles which contact mucous membranes or non-intact skin must be disinfected or sterilized prior to reuse if not disposable ....” Policy titled, “Environmental Services Scope of Service” revealed: “ ...Adequate housekeeping chemicals and supplies are made available to patient care areas for sanitizing and cleaning by hospital staff when housekeeping staff are not scheduled ...In addition, maintenance repairs/needs are identified and reported for all areas. Work orders submitted in Maintenance tracking system ....” Observation conducted on 05/06/2025, revealed 4 black wheelchairs in Lobby and Emergency Room area had rips and tears in the seats. During observation revealed: 3 wheelchairs with broken hand grips. Two (2) of the wheelchairs had exposing sharp metal from the broken hand grips and 1(one) wheelchair had red colored Coban wrapped and no hand grips. Employee #1 confirmed during observation and interview 05/06/2025, that chairs are to be cleaned between patients’ use and the wheelchairs should have been taken out of use. Employee #1 confirmed patients sit in these chairs from Lobby, Acute care, and Emergency room. Employee #19 confirmed all public areas are thoroughly cleaned nightly with disinfectant, if items are functional, we still use them. Housekeeping observes the wheelchairs and reports rips and tears to Maintenance for removal. Employee # 4 and #5 confirmed ripped and torn items cannot be thoroughly cleaned and must be replaced.”

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interview, it was determined the facility failed to ensure the medical staff bylaws and medical staff rules and regulations were reviewed and updated every three years. This deficient practice poses a potential risk of medical staff members not knowing the updated requirements for privileges, and their responsibilities in quality patient care services that meet current hospital, State, and Federal standards. This is a repeat deficiency from Event #93JH11 on 01/11/2022, Tag 0962. Findings include: Hospital document titled, “Restated Bylaws of the Medical Staff of Community Hospital Associations, Inc. dba Wickenburg Community Hospital and Clinics,” revealed last revision date of 07/23/2019. Hospital document titled, “Medical Staff Rules and Regulations for Wickenburg Community Hospital,” revealed: “ ...General ...These rules and related Hospital policies are designed to comply with standards of state and federal regulatory agencies, federal Medicare and Medicaid programs. All patient/resident care and related activities in the Hospital will be conducted in a manner consistent with these rules, Hospital policies and the indicated standards ....” The document also revealed last revision date of 06/23/2008. Review of the Plan of Correction submitted to the Centers for Medicare & Medicaid Services dated 02/23/2022, revealed: “ ...The WCH Medical Staff Committee will review and modify the WCH Medical Staff bylaws and Rules and Regulations. The WCH Medical Staff Committee meets on a quarterly basis and will review and approve the bylaws and rules and regulations at the July 12, 2022 Quarterly Medical Staff meeting. The WCH Board of Directors will hold a special meeting in July 2022 to review and approve the WCH Medical Staff bylaws and rules and regulations ....” Employee #1 confirmed during an interview conducted on 04/29/2025 that the provided medical staff bylaws, and medical staff rules and regulations are the most current approved documents. Employee #1 confirmed legal counsel were consulted on the content of the documents, but the governing body had not approved any revisions. Employee #1 confirmed the medical staff bylaws, and rules and regulations are outdated.”

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 50367 Based on a review of hospital records and staff interviews, it was determined the administrator failed to follow restraint policies and procedures for three (3) patients (Patient #3, Patient #4, Patient #5). This deficient practice poses a threat to the public’s health and compromises the patients safety in following the proper protocols for restraints. Policy titled, “Restraints And Seclusion Policy,” revealed: “...A. Authorizing and Ordering Restraints and Seclusion ...2. All Restraint or Seclusion orders must be dated and timed when signed by the Licensed Practitioner responsible for the care of the patient and include: 1) criteria for release ...4) and specify duration of Restraint or Seclusion order ...7. Violent/Self -Destructive Restraints a. For Restraints used to manage Violent or Self-Destructive Behavior, a licensed Practitioner responsible for the care of the patient must evaluate the patient in-person within one hour of the initiation of Restraint or Seclusion ...The in-person evaluation and documentation must include: i. Evaluation of patient ’ s immediate situation , ii. Patient reaction to the intervention ...a. A face-to-face physical examination is required by the Licensed Practitioner responsible for the care of the patient and authorized to order Restraints or Seclusion every 24 hours for violent/self-destructive restraint to determine the clinical justification for the continued use ...3. When Restraint or Seclusion is used, there must be documentation in the patient ’ s medical record of the following ...g. Date and time of Restraint or Seclusion discontinuation...1. A patient in 3- or 4-point restraints shall have continuous observation/monitoring ...Care will not be compromised by the use of Restraints and shall include: a. Provision of nutritional needs, b. Provision of hydration needs, c. Provision of elimination needs, d. Provision of hygiene needs, e. Provision of range of motion exercises, f. Provision of patient safety and comfort, and....” Document titled, “Medical Staff Rules and Regulations for Wickenburg Community Hospital,” revealed “...O. Restraints:...The use of a restraint or seclusion must be- -...(2) In accordance with the order of a physician or other licensed independent practitioner permitted by the State and Center to order seclusion or restraint ...The time any restraint is initiated, the behavioral basis for doing so ...the time it is discontinued shall be documented in the patient record ...The condition of the patient who is in a restraint or in seclusion must continually be assessed, monitored, and reevaluated...A physician or other licensed independent practitioner must see and evaluate the need for restraint or seclusion within 1 hour after the initiation of this intervention ....” Document titled, “Registered Nurse (RN),” revealed “...Appropriately documents in the electronic health record all assessments, interventions, and other information as required ...Performs physical/social assessment on assigned patients; accurately perceives patient condition changes or complications through effective assessment skills ....” Document titled, “Restraint Checklist,” revealed: “...It is recommended that a restraint Checklist be completed with any restraint use ...6. Documented Time of restraint removal: Date:... Time:....” Patient #3’s medical record contained a note titled “Order Sheet,” dated 10/18/2024, which revealed: “...Restraints (soft) (Monitor/document every 15 mins ...Orders expire in 4 hours ....” Patient #3’s medical record failed to contain documentation of a face to face. Patient #3’s medical record failed to contain documentation of monitoring of Patient #3 while in four point restraints. Further review of Patient #3’s medical record failed to contain criteria for release. Patient #4’s medical record contained a note titled “Order Sheet,” dated 06/09/2024 which revealed: “...Restraints (soft) (Monitor/document every 15 mins, Restraint 2 point) (Protect pt. from immed. injury, Orders expire in 4 hours....” Patient #4’s medical record failed to contain documentation of a face to face. Patient #4’s medical record failed to contain a completed restraint checklist identifying restraint removal. Further review of Patient #4’s medical record failed to contain criteria for release. Patient #5 ‘s medical record contained a note titled “Order Sheet,” dated 02/13/2025 which revealed: “...Restraints (soft) (Restraint 4 point) (Protect pt. From immed.(sic) injury)....” Patient #5’s medical record failed to contain documentation of a face to face. Patient #5’s medical record failed to contain documentation of monitoring of Patient #5 while in four point restraint. Further review of Patient #5 ’ s medical record failed to contain the duration of restraints in restraint order. Further review of Patient #5’s medical record failed to contain criteria for release. Employee #13 confirmed during an interview conducted on 04/29/2025, that a face-to-face should occur with a physician an hour after the restraints are applied. Employee #13 confirmed during an interview conducted on 04/29/2025, that there needs to be a criteria for release documented for the restraints applied to the patients. Employee #13 confirmed during an interview conducted on 04/29/2025, that there needs to be a specified length of time the restraints are kept on the patient in the order. Employee #13 confirmed during an interview conducted on 04/29/2025, that there needs to be reassessment of the patients in restraints. Employee #13 confirmed during an interview conducted on 04/29/2025, that a restraint checklist is completed for each patient that is in restraints. Employee #13 confirmed during an interview conducted on 04/29/2025, that there was no documentation of restraint removal. Employee #13 also confirmed during the interview that nurse added an addendum to Patient #4 ’ s medical record approximately eight hours after Patient #4 was transferred to remove restraints. Employee #13 confirmed during an interview conducted on 04/29/2025, that there was not a duration specified time to release restraints documented in the order for Patient #5. Employee #13 confirmed during an interview conducted on 04/29/2025, that there was no reassessments documented for Patient #3 and Patient #5. Employee #13 confirmed during an interview conducted on 04/29/2025, that a face-to-face was not documented in the medical records for Patient #3, Patient #4, and Patient #5. Employee #13 confirmed during an interview conducted on 04/29/2025, that there was no indication documented for the criteria of release for Patient #3, Patient #4, and Patient #5.”

“NURSING SERVICES CFR(s): A registered nurse or, where permitted by State law, a physician assistant, must supervise and evaluate the nursing care for each patient, including patients at a SNF level of care in a swing-bed CAH. This Standard is not met as evidenced by: 52757 Based on record reviews and staff interview, the Department determined the nursing staff failed to ensure the facility’s Fall Prevention policy was by failing to notify four (4) patients’ ( #18, #19, #20, and # 21) emergency contact after a patient fall. This deficient practice poses a risk to a patient safety if a patient’s family member or emergency contact is not notified after a fall leading to delay time-sensitive medical decisions, prevent the care team from obtaining important background information, and reduce necessary family involvement in monitoring and supporting the patient’s recovery. FINDINGS INCLUDE: Policy titled,”Fall Prevention”, revealed: “...POLICY: The purpose of this policy is to:... Establish guidelines to define action in the event of a fall and complete the required follow-up ...Notification after a patient fall includes:... Patient’s emergency contact ....” Hospital documents titled Investigation Reports revealed: Patient # 18’s investigation report revealed no documentation that the emergency contact was notified after patient fall. Patient # 19’s investigation report revealed no documentation that the emergency contact was notified after patient fall. Patient # 20’s investigation report revealed no documentation that the emergency contact was notified after patient fall. Patient # 21’s investigation report revealed no documentation that the emergency contact was notified after patient fall. Medical records revealed: Patient # 18 s medical record dated 10/06/2024 revealed no documentation that the emergency contact was notified after patient fall. Patient # 19’s medical record dated 07/26/2024 revealed no documentation that the emergency contact was notified after patient fall. Patient # 20’s medical record dated 03/07/2025 revealed no documentation that the emergency contact was notified after patient fall. Patient # 21’s medical record dated 02/03/2025 revealed no documentation that the emergency contact was notified after patient fall. Employee #4 confirmed while reviewing medical records and investigation reports on 04/28/2025, there was no documentation regarding family notification for Patients #18, #19, #20, and #21.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 46598 Based on facility records, Title 9 Chapter 8 Article 1, Observation and interview, it was determined the facility failed to ensure all staff wore proper hair coverings while working in the dietary department/kitchen. This deficient practice poses a risk to the health of staff, patients, and visitors when staff do not maintain sanitation practices by preventing hair from contacting exposed food, clean equipment, utensils, and linens. Findings include: Policy titled “Dress Code” revealed: “ ...POLICY: Food Service employees will dress for work in clothing suitable to the image and sanitation needs of the department. These requirements will be in addition to the facility-wide policy ...PURPOSE: To ensure all Food Service employees maintain a professional and clean appearance, protect themselves from injury, and reduce the risk of cross-contamination ...PROCEDURE: ...Hair Covering: For hair shorter than 1 ½ inches, you must wear a hair net or ball cap. For hair longer than 1 ½ inches, hair must be pulled back and secured in a hair net so there is no possibility of hair contaminating food ....” Document titled, “Title 9 Health Services Chapter 8 Department of Health Services, Food, Recreation and Institutional Sanitation. Article 1 Food and Drink”, revealed: “...Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens, and unwrapped single services and single use articles ....” Observation conducted on 04/29/2025 revealed that Employee # 16 was not wearing any beard restraints while working in the kitchen preparing food. Observation conducted on 04/30/2025 revealed a dietary worker with hair longer than 1 ½ inches wearing her hairnet on the upper part of her head with hair on the lower part of her head was exposed. While on tour of the kitchen, surveyors were told by employee # 24, that the surveyors did not have to wear a hair net in the kitchen area. Employee # 24 was not wearing a hair net or the required beard restraints. Employee # 1 confirmed during an interview conducted on 04/28/2025, that all dietary employees working in the kitchen are required to wear the proper hair coverings. There is signage posted on the door to remind all who enter that proper hair coverings are required.”

“Names and Contact Information CFR(s): §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must 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 [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: 45167 Based on review of facility documentation and interview, it was determined the facility failed to include names and contact information for staff, patient physicians, volunteers and entities providing services under arrangement in the facility communications plan. Failure to provide contact information that could be needed during an emergency event in the facility communication plan can result in vital services being interrupted during an emergency event for staff and patients. Findings include: The Wickenburg Community Hospital Communications Plan was reviewed but no names or contact information could be found, nor could reference be found for how to access or locate, names and contact information for staff, patient physicians, volunteers and entities providing services under arrangement in the facility communications plan. In an interview conducted with Employees #24 and 33 conducted on April 30, 2025, both Employees #24 and 33 confirmed that the entire communication plan including attachments had been provided.”

“EP Training Program CFR(s): §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: 45167 Based on interview, review of facility emergency preparedness plan and review of facility documentation, it has been determined the facility failed to ensure each personnel member has been trained at hire and at least every two (2) years in emergency preparedness policies and procedures. Failure to ensure staff are trained both at hire and at least biennially on facility emergency preparedness policies and procedures can result in staff being unprepared in an emergency event, leading to increased likelihood of staff and patient injury or death. Findings include: Wickenburg Community Hospital Emergency Preparedness Plan indicated: “...All Wickenburg Community Hospital and Clinic (WCH) staff attend a Safety Training presentation upon hiring, and a refresher course every year thereafter.....” Documentation was requested of evidence of training of Wickenburg Community Hospital staff both at hire and annually. The documentation could not be provided. In an interview conducted with Employee #1 on April 30, 2025, Employee #1 stated the emergency preparedness training program is currently being revised and provided a sample of the revised curriculum; however, documentation of transcripts or other evidence of training provided to staff either at hire or annually could not be provided.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 45167 Based on interview, review of facility policies and procedures, and review of facility documentation, it has been determined the facility failed to ensure that a full-scale drill was conducted at least every two years followed by either a subsequent full-scale drill the following year, or else a community-based drill, functional drill, mock disaster drill, tabletop drill or real-life emergency that required activation of the facility emergency preparedness plan and the documentation of the curriculum, after-action report and documentation of a sufficient number of staff attendance retained. Failure to adequately test and document the testing of the emergency preparedness plan can result in the facility having a plan that is not actionable or practicable in a real-life disaster event, leading to increased likelihood of staff and patient injury or death. Findings include: Wickenburg Community Hospital Emergency Preparedness Plan indicated: “...Wickenburg Community Hospital and Clinics test their emergency plans as required by State and Federal regulations. WCH will conduct exercises to test the emergency plan twice per year...Analyze the facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the facility’s emergency plan, as needed.....” Documentation of disaster drills conducted throughout calendar years 2023, 2024 and 2025, including all accompanying documentation were requested. No documentation of disaster drills completed in 2023 could be provided. One (1) disaster drill was completed in 2024 which included curriculum, an after-action report and signed attendance sheets indicating the participation of three (3) departments of the hospital encompassing a total of fourteen (14) staff. Curriculum was provided for participation in a community disaster drill in 2025; however, no after-action report could be provided and no documentation of attendance by any individuals from Wickenburg Community Hospital could be provided for this drill. In an interview conducted with Employee #24 conducted on April 30, 2025, Employee #24 confirmed that no additional documentation could be provided.”

“Number of Exits - Story and Compartment CFR(s): NFPA 101 Number of Exits - Story and Compartment Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment. 18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4 This Standard is not met as evidenced by: 45167 Based on observation while on tour and interview, it was determined the facility failed to ensure that there were two separate accessible emergency exits available from the mobile MRI unit. Failure to ensure two separate accessible exits from a mobile MRI unit can result in staff or patients being trapped in a fire event, leading to increased likelihood of injury or death. NFPA 101 (2012) Chapter 19, Section 19.2.4.3. “Not less than two separate exits shall be accessible from every part of every story.” Findings include: During observation while on tour conducted on April 29, 2025 while touring the mobile MRI unit, Compliance Officer requiested that a locked door be unlocked for further inspection. Beyond this locked door was an additional room containing a designated emergency exit. This emergency exit was locked and bolted shut with a bar that could not be easily removed. In an interview conducted with Employee #24 on April 29, 2025, Employee #24 confirmed the emergency exit was not currently in use.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 45167 Based on observation and review of facility documents, it was determined the facility failed to ensure the hazardous areas have the doors be self-closing or automatic closing. Failing to maintain the self-closing hardware on the door and frame to a hazardous room has potential to cause harm to patients in time of a fire if the door does not latch and close. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.1, “Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.” Findings Include: During observation while on tour conducted on April 28, 2025 and on April 29, 2025, a room with a sign indicating the room as a biohazard room located in the hallway next to the community room area was noted to have a door that did not have a listed rating on the door. On April 29, 2025, the door was observed to be left open during the day. The door did not have a lock on it so the door could be secured. Inspections of fire doors and smoke doors completed July and August, 2024 by Employee #24 were provided. The biohazard door was not included within these provided inspection documents.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 45167 Based on observation while on tour conducted on April 28, 2025, it was determined the facility failed to ensure that a restraint chain was appropriately installed on the kitchen oven in order to protect the gas connection and that exhaust hoods were inspected and cleaned on a semi-annual basis. Failure to protect connections on appliances that are on casters or wheels can result in a rupture of gas or electric connections, resulting in risk of fire events. Failure to inspect and clean exhaust hoods for commercial kitchen equipment can result in grease build-up and/or system malfunction, leading to a fire event. NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, “Cooking Facilities.” “Cooking facilities shall be protected in accordance with 9.2.3.” Section 9.2.3, “Commercial Cooking Equipment” “Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations....” NFPA 96, 2011 Edition, Chapter 2, Section 2.1, “The documents or portions thereof listed in this chapter are referenced within this standard and shall be considered part of the requirements of this document...NFPA 54, National Fuel Gas Code, 2009 Edition....” NFPA 54, 2009 Edition, Chapter 10, Section 10.12.6. Use with Casters. Floor-mounted appliances with casters...shall be installed in accordance with the manufacturer’s installation instructions for limiting the movement of the appliance to prevent the strain on the connection. NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, “Cooking Facilities.” “Cooking facilities shall be protected in accordance with 9.2.3.” Section 9.2.3, “Commercial Cooking Equipment” “Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... Chapter 11, Section 11.2 Inspection and Testing, and Maintenance of Fire extinguishing Systems. Section 11.4 Inspection for grease buildup The entire exhaust system shall be inspected for grease buildup by properly trained, qualified; and certified persons acceptable to the authority having jurisdiction and in accordance with Table 11.4. Systems serving moderate -volume cooking operations Inspection frequency semi-annually...Systems serving low-volume cooking...annually.” NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, “Cooking Facilities.” “Cooking facilities shall be protected in accordance with 9.2.3.” Section 9.2.3, “Commercial Cooking Equipment” “Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... “Chapter 11, Procedures for the use , Inspection, Testing, and Maintenance of Equipment. Section 11.2 “Maintenance of the fire extinguishing systems and listed exhaust hoods containing a constant or fire activated water system that is listed to extinguish a fire in the grease removal devices hood exhaust plenums and exhaust ducts shall be made by properly trained, qualified, and certified persons acceptable to the authority having jurisdiction at least 6 months.” Findings include: During observation while on tour on April 28, 2025, an oven was observed in the kitchen that was on casters (wheels). This oven did not appear to have a restraint chain or any other restraint apparatus that would prevent strain on the gas connection. In an interview conducted on April 28, 2025 with Employee #24, Employee #24 confirmed there was no restraint chain or any other restraint apparatus on the oven. During observation while on tour on April 28, 2025, an oven in use in the rehabilitation therapy area was observed that had an operating exhaust hood. In an interview conducted with Employee #24 on April 28, 2025, Employee #24 confirmed the oven was in use and operational and was used for occupational therapy with patients. Documentation was requested for semi-annual cleaning and inspection of fire systems for the kitchen range and hood observed in the commercial kitchen seen while on tour on April 28, 2025 and documentation was requested for annual cleaning and inspection of the exhaust hood located in the rehabilitation area. Documentation was provided for one semi-annual cleaning of the commercial kitchen hood conducted on October 15, 2024. One inspection of fire systems on the hood was conducted on August 23, 2024 and a deficient item was noted. Documentation of the correction of the deficient item was requested but could not be provided. In an interview conducted with Employee #24 on April 30, 2025, Employee #24 stated that the cleanings and inspections on the commercial hood had been conducted semi-annually but the documentation had not been retained by the facility and could not be provided. No documentation could be provided of any inspections or cleanings of the rehabilitation exhaust hood. In an interview conducted with Employee #24 on April 20, 2025, Employee #24 confirmed that this exhaust hood had not been inspected or cleaned since installation.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 45167 Based on observations and staff interviews, the facility failed to ensure monthly and annual testing for the fire alarm control panel in the mobile MRI unit. Failure to test the fire alarm system could cause harm to staff and residents during an emergency. This is a repeat deficiency from Event ID #93JH22, February 25, 2022. 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 for 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 and service. Findings include: During observation while on tour conducted on April 29, 2025, a fire alarm control panel was observed behind a locked door in the mobile MRI unit. The FACP (fire alarm control panel) had a tag attached to it from Unifour Fire & Safety with an address in Hickory, North Carolina bearing an inspection date of June 22, 2021. The tag indicated the FACP was new and the expiration date of the inspection was twelve (12) months from the date punched on the inspection tag. An interview was conducted with Employee #24 on April 29, 2025 who confirmed that a more recent inspection could not be provided for the FACP.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing 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. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 45167 Based on observation while on tour, review of facility documentation and interviews, it was determined that the facility failed to ensure that escutcheons were maintained in order to appropriately cover annular spaces in accordance with NFPA 13. Failing to perform the required inspections may cause harm to patients and staff if sprinklers fail to function properly. This is a repeat deficiency for Event ID #93JH22 February 25, 2022. 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 9.7.1.1. “Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following...NFPA 13, Standard for the Installation of Sprinkler Systems....” NFPA 13 (2010), Chapter 6, Section 6.2.7.1. indicated, “Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.” Findings Include: Observation while on tour conducted on April 28 and April 29 revealed the following: -Ceiling penetrations around the escutcheon in the ladies’ locker room; -Escutcheon falling down around sprinkler in pharmacy storage; -Missing escutcheon, sprinkler on administration stairwell; -Utility hall closet, fire caulking applied around the exterior of a damaged escutcheon; -Escutcheon hanging in case management office in acute care; -Two (2) Escutcheon pulling away from ceiling away in lab; -Two (2) Escutcheon with ceiling panels cracked around them in Radiology 2; -Missing escutcheon, OR (operating room) storage; A review of monthly maintenance reports indicated that visual inspections had been conducted and that no issues were reported. In an interview conducted on April 28, Employee #24 confirmed the escutcheons were not covering the annular spaces in accordance with NFPA 13.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 45167 Based on observation and staff interview, it was determined the facility failed to ensure that fire extinguishers were protected and properly installed. Failing to protect and have proper installation of fire extinguishers has potential to cause harm to staff and patients. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 “Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1” Section 9.7.4.1 “Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.” NFPA 10, Section 6.1.3.7 “Fire extinguishers installed under conditions where they are subject to physical damage (e.g., from impact, vibration, the environment) shall be protected against damage.” Section 6.1.3.8.1 “Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Section 6.1.3.8.2 “Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor.” NFPA 10, Chapter 7, Section 7.2.2 Periodic inspections or electronic monitoring of fire extinguishers shall include a check of at least the following items: No obstruction to access or visibility. NFPA 10 2010 Edition 6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, 6.3.1.2 Fire extinguishers shall be located so that the maximum travel distances do not exceed those specified in Table 6.3.1.1. NFPA 30 2012 edition 4.2.2 Combustible liquids Any liquid that has a closed cup flash point at or above 100 f as determined by the test procedures and apparatus set forth in section 4.4 NFPA 10 2012 edition 5.2.2 Class B fires are fires in flammable liquids, combustible liquids, petroleum greases, tars, oils, oil-based paints, solvents, lacquers, alcohols, and flammable gases. 6.3.1 Other Than for Fires in Flammable Liquids of Appreciable Depth. 6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, except as modified by 6.3.1.5. Table 6.3.1.1 Fire Extinguisher Size and Placement for Class B Hazards Type of Hazard ...Basic(moderate) ...Minimum Extinguisher Rating ...20-B ...Travel Distance to Extinguishers ...50 ft ...6.4.1 Fire extinguishers with Class C ratings shall be required where energized electrical equipment can be encountered..” NFPA 10 2010 Edition, Chapter 5, Section 5.6.1. Where portable fire extinguishers are required to be installed, the following documents shall be reviewed for the occupancies outlined in their respective scopes...(16) NFPA 418, Standard for Heliports NFPA 418 2011 Edition, Chapter 9, Section 9.1 The selection, installation, and maintenance of portable fire extinguishers shall comply with NFPA 10, Standard for Portable Fire Extinguishers. Section 9.2. At least one portable fire extinguisher as specified in Table 9.2 shall be provided for each takeoff and landing area, parking area, and fuel storage area. Findings Include: During observation while on tour conducted on April 28, 29 and 30, 2025, the following observations were detailed: -When touring the mobile MRI (magnetic resonance imaging) unit, a portable fire extinguisher was observed on the ground beside the designated emergency exit. -When touring the helipad, a purple K fire extinguisher was observed mounted on the wall enclosing the helipad. The fire extinguisher bore an inspection sticker indicating the fire extinguisher had been most recently inspected in 2023. The month of inspection was not legible as the sticker was worn. In an interview conducted with Employee #24 on April 29, 2025, Employee #24 stated the facilities staff of Wickenburg Community Hospital was not responsible for inspecting or maintaining this extinguisher and the flight crew for the helicopter was responsible for maintaining it. -When touring the vicinity of the helipad, a fuel tank was observed for the helipad. A fire extinguisher was observed beside the fuel tank for the helipad sitting on the ground that was unmounted. -When touring the diesel generator, no fire extinguisher could be located within 50 feet of the generator housing. In an interview conducted with Employee #24 on April 29, 2025, Employee #24 confirmed there was no fire extinguisher within 50 feet of the generator -When touring the electrical room housing ATS (automatic transfer switches) and circuit boxes, no fire extinguisher could be found. In an interview conducted with Employee #24 on April 29, 2025, Employee #24 confirmed no fire extinguisher was in or around the electrical room.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 45167 NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1, “Utilities shall comply with the provisions of Section 9.1.” Section 9.1.2 “Electrical wiring and equipment shall be in accordance with NFPA 70, 2011 Edition, “National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.” NEC, 2011 ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. “Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.” Table 110-26(a) Working Space Minimum of three (3) feet in all directions. Section 9.1.2, “Electrical wiring and equipment installed shall be in accordance with NFPA 70, 2011 Edition, “National Electrical Code.” NEC, 2011, Article 110, Section 110-27 (b) Prevent Physical Damage.” In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage. NFPA 70, 2011, Chapter 4, Section 406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as completely cover the opening and seat against the mounting surface. Receptacle faceplates mounted inside a box having a recess mounted receptacle shall effectively close the opening and seat against the mounting surface.” NFPA 70, 2011 Edition Chapter 1 General “110.27(A) Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means: (1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons. (2) By suitable permanent, substantial partitions or screens arranged so that only qualified persons have access to the space within reach of the live parts. Any openings in such partitions or screens shall be sized and located so that persons are not likely to come into accidental contact with the live parts or to bring conducting objects into contact with them. (3) By location on a suitable balcony, gallery, or platform elevated and arranged so as to exclude unqualified persons. (4) By elevation of 2.5 m (8 ft) or more above the floor or other working surface.” Findings include: Observation while on tour conducted on April 28, April 29 and April 30, 2025 revealed the following: -Information systems room contained a receptacle that was missing a cover. -Pharmacy contained a receptacle cover with a brown staining liquid that was dripping from the interior. In an interview conducted on April 28, 2025, Employee #24 stated that the pharmacy once had a hydrogen peroxide misting system and this caused the leakage but that there was no corrosion; however, the cause of the staining could not be explained. -Electrical room contained many stored items including sandwich board signs, chairs, boxes, loops of CAT cable, construction materials, piping, ladders, rolling carts and electronic items. Some of these items were leaning on circuit boxes. -One open junction box was observed in the medical vacuum room. A canister of diesel fuel and cardboard boxes were stored beside the medical vacuum. -In the boiler room, electrical wiring was observed to be grounded to a pipe that was painted green. In an interview conducted with Employee #24 on April 29, 2025, Employee #24 stated that this pipe was a natural gas pipe.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 45167 Based on record review and interview with staff, it was determined the facility failed to have written documentation of the Annual Inspection and Testing of Door openings in accordance with NFPA 80, 2010 Edition, Standard for Fire doors and Other Opening Protectives. Failing to properly inspect and test fire rated door assemblies in accordance with NFPA 80 annually could potentially cause risk of 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.” NFPA 80 Section 13.4 Automatic closing Section 5.2.5 “Horizontal sliding , Vertically Sliding, and Rolling Doors.” Section 5.2.14.3 “All horizontal or vertical sliding or rolling fire doors shall be inspected and tested annually to check for proper operation at frequent intervals to ensure operation.” Findings include: During observation while on tour conducted on April 28 and April 30, 2025, the following findings were observed: -Fire Doors next to Rehabilitation area, the passive leaf of the door did not independently latch. -Fire Doors near information system would not freely latch -Two rolling fire doors were observed in the pharmacy department, one of which (the larger door) had automatic closure and one did not have the ability of automatic closure. -Fire door to acute hall closest to courtyard does not independently latch -CT (computed tomography) room door had a door frame rated 1.5 hours but the door did not have a listed rating -Radiology room 1 door was cracked Fire door inspection reports were requested and inspection reports for fire doors dated July and August, 2024 completed by Employee #24 were provided. These inspection reports indicated the following: “...Does the active door leaf completely close when operated from the full open position...Yes...Does the inactive leaf close before the active leaf when a coordinator is used...Yes...Does the latching hardware operate and secure the door in the closed position...Yes...Are the doors, hinges, frame, hardware and threshold secure, alighned and in working order with no visible signs of damage...Yes....” In all instances where a double door was inspected, these were the answers provided in the inspection report. All doors were noted to be free of damage.”

“Gas and Vacuum Piped Systems - Information an CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Information and Warning Signs Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol 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) This Standard is not met as evidenced by: 45167 Based on observation while on tour and interview, it has been determined the facility failed to appropriately label medical gas piping. Failure to appropriately label medical gas piping can result in confusion or error. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 “Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.” NFPA 99 2012 Edition Chapter 5, Section 5.1.11.1 Pipe Labeling indicated: “...Piping shall be labeled by stenciling or adhesive markers that identify the patient medical gas, the support gas, or the vacuum system and include the following...Name of the gas or vacuum system or the chemical symbol per Table 5.1.11...Gas or vacuum system color code per Table 5.1.11...the operating pressure...Pipe labels shall be located as follows...At intervals of not more than 6.1m (20ft)....” Findings include: Observation while on tour conducted on April 28 and April 29, 2025 revealed the following: -Unlabeled copper piping of the type that could contain medical gas was found in the boiler room. It is unknown what this piping contains. -Multiple unlabeled copper pipes were found in the network room. In an interview conducted with Employee #24 on April 29, 2025, Employee #24 stated this piping contained medical gas.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 45167 Based on observation while on tour and interview, it has been determined the facility failed to ensure that power strips were provided strain relief or were permanently mounted if utilized in a patient care area. Failure to ensure that power strips are utilized appropriately can result in an increased likelihood of a fire event. This is a repeat deficiency from Event ID #93JH22, February 25, 2022. NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 “Mandatory References” NFPA 99 “Standard for Health Care Facilities, “ 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2, “All Patient Care Areas,” Sections 6.3.2.2.6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)” Minimum Number of Receptacles.” “The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters. State Operations Manual Appendix A Interpretive Guidelines §482.41(a) The hospital must ensure that the condition of the physical plant and overall hospital environment is developed and maintained in a manner to ensure the safety and well-being of patients. This includes ensuring that routine and preventive maintenance and testing activities are performed as necessary, in accordance with Federal and State laws, regulations, guidelines, and manufacturer’s recommendations, by establishing maintenance schedules and conducting ongoing maintenance inspections to identify areas or equipment in need of repair. The routine and preventive maintenance and testing activities should be incorporated into the hospital’s QAPI plan. The hospital must be constructed and maintained to ensure risks are minimized for patients as well as for employees and visitors. Hospitals are expected to demonstrate how they are addressing important safety features in accordance with nationally recognized standards. Although the following items are expected to be addressed when applicable, the list is not all-inclusive. Accessibility o A hospital must ensure all buildings at all locations of the certified hospital meet State and Federal accessibility standards (e.g. Office of Civil Rights requirements). The requirements apply to the interior and exterior of all buildings. Life Safety Code surveyors assess the use of power strips in healthcare facilities. However, the following guidance is provided as a reference for healthcare surveyors as they survey the physical environment along with other CoP requirements. Any observed power strip deficiencies should be conveyed to the LSC surveyors for citation. If line-operated medical equipment is used in a patient care room/area, inside the patient care vicinity: o UL power strips would have to be a permanent component of a rack-, table-, pedestal-, or cart-mounted & tested medical equipment assembly o ...In non-patient care areas/rooms, other UL strips could be used with the general precautions. NFPA 99, 2012 Edition Section 10.5.2.3.1 indicated: Adapters and extension cords meeting the requirements of 10.2.4 shall be permitted to be used. 10.2.4.2. Section 10.2.4.2.3. The cabling shall comply with 10.2.3. Section 10.2.3.5.1 Cord strain relief shall be provided at the attachment of the ppower cord to the appliance so that mechanical stress, either pull, twist, or bend, is not transmitted to internal connections. Findings include: Observation while on tour conducted on April 28, 2025 revealed the following: -A power strip was observed to be dangling without support in the pharmacy area; -A power strip was observed to be dangling without support in the Foundation office; -A power strip was observed to be dangling without support in the administration offices; -A power strip was observed to be dangling without suppoort behind the nurse’s station in the acute patient care area; -A power strip was observed to be sitting on a desk but in use in OR In an interview conducted with Employee #24 on April 28, 2025, Employee #24 acknowledged the deficient practice but stated this had been a condition that was difficult to correct because the Facilities Department had felt this was a condition that should be corrected by IT (information technology) and IT felt this was a condition that should be corrected by Facilities so the corrections had not been made.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 45167 Based on observation and staff interview the facility failed to keep combustible material 5 ft away from oxygen storage. Failure to keep combustible material away from oxidizing gases could cause an increase to the fire load which could harm staff and patients. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 “Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.” NFPA 99 2012 Edition Chapter 11, Section 11.3.2. Storage for nonflammable gases greater than 85 m3 (300 ft3) but less than 85 m3 (3000 ft3) at STP shall comply with the requirements in 11.3.2.1 through 11.3.2.3. Section 11.3.2.2. Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor. Section 11.3.2.3 “Oxidizing gases, such as oxygen and nitrous oxide shall be separated from combustibles materials by one of the following...Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. Findings included: During observation conducted while on tour on April 28, 2025, an oxygen storage room was observed in the cardiopulmonary section of the hospital. On entry, 52 canisters of oxygen were observed to be stored within the room. Twenty-seven (27) of the canisters were marked as being full or partially full and the rest were not known to be full or empty. Additionally, within the room were three (3) yellow canisters, one (1) silver canister labeled as empty and three (3) white canisters. Cardboard boxes were stored within the room. The deficient practice was acknowledged in an exit interview conducted on April 30, 2025.”

“Gas Equipment - Qualifications and Training CFR(s): NFPA 101 Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment. 11.5.2.1 (NFPA 99) This Standard is not met as evidenced by: 45167 Based on review of facility documentation and interview, it was determined the facility failed to ensure that continuing education in safety guidelines and usage of maintenance and operation of medical gas equipment was provided. Failure to ensure that continuing education is provided in the safety guidelines and usage of, maintenance and operation of medical gas and equipment can lead to errors in the use of medical gas, resulting in injury to patients and/or staff. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 “Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.” NFPA 99 2012 Edition Chapter 11 Section 11.5.2.1. Personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained ont he risks associated with their handling and use. A.11.5.2.1.1. “Personnel” typically includes physicians, nurses, nursing assistants, respiratory therapists, engineers, technicians and others. 11.5.2.1.2. Health care facilities shall provide programs of continuing education for their personnel. 11.5.2.1.3. Continuing education programs shall include periodic review of safety guidelines and usage requirements for medical gases and their cylinders. Findings include: Documentation of periodic continuing education provided to staff regarding the safe use, maintenance and operation of medical gas and equipment was requested for calendar year 2024. Employee #1 provided documentation of self-assessments completed by staff that indicated an assessment completed by individual staff and signed off by a preceptor who evaluated demonstration of the listed skills. Although these self-assessments were indicated as orientation self-assessments, Employee #1 indicated these self-assessments were completed annually. The self-assessments included Location of Oxygen, gas shut-off valves and Oxygen tank and safety. In an interview conducted with Employee #1 on April 30, 2025, Employee #1 confirmed that documentation of ongoing education provided to employees regarding oxygen or other medical gases could not be provided other than these self-assessments that included oxygen. Documents of assessment of an employee’s knowledge of other medical gases could not be provided.”

“Features of Fire Protection - Other CFR(s): NFPA 101 Features of Fire Protection - Other List in the REMARKS section any NFPA 99 Chapter 15 Features of Fire Protection requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 15 (NFPA 99) This Standard is not met as evidenced by: 45167 Based on observation while on tour and interview, it has been determined the facility failed to ensure that flammable and/or combustible liquids were safely stored to prevent the likelihood of fire. Failure to ensure flammable and/or combustible liquids are safely stored can increase the likelihood of a fire event, leading to injury or death of patients and/or staff. NFPA 99 (2012), Chapter 15, Section 15.3.1, “The storage and handling of flammable liquids or gases shall be in accordance with the following applicable standards...NFPA 30, Flammable and Combustible Liquids.” NFPA 30 (2012), Chapter 3, Section 3.3.4. For the purposes of this Code, a story of a building or structure having one-half or more of its height below ground level and to which access for fire-fighting purposes is restricted. Chapter 4, Section 4.1.2., “The definitions and classifications of this chapter shall apply to any liquids within the scope and subject to the requirements of this Code.” 4.2.2. Combustible Liquid. Any liquid that has a closed-cup flash point at or above 100°F (37.8C)....42.3 Flammable Liquid. Any liquid that has a closed-cup flash point below 100°F (37.8C)...and a Reid vapor pressure that does not exceed an absolute pressure of 40 psi....4.3.1. Flammable liquids...shall be classified as Class I liquids.... Chapter 9, Section 9.3.6. Class I liquids shall not be permitted to be stored in basements as defined in 3.3.4. Section 9.17.2. Liquids shall be separated from Level 2 and Level 3 aerosols in accordance with NFPA 30B, Code for the Manufacture and Storage of Aerosol Products. Section 9.17.3. Flammable and combustible liquids shall be separated from oxidizers by at least 25 ft....Section 9.17.4. Materials that are water-reactive...shall not be stored in the same control area with liquids. Findings include: During observation while on tour conducted on April 29, 2025, large quantities of stored liquids and aerosols were observed that were stored in a basement area in the boiler room. These items were not easily accessible and were not clearly labeled. Some of the items appeared to be lawn chemicals, paint and paint thinner, but the exact nature of the items could not be clearly deduced. 57 (fifty-seven) separate containers could be viewed without climbing down into the basement area. In an interview conducted with Employee #24 on April 29, 2025, Employee #24 confirmed that the facility did have fireproof cabinets for the storage of combustible and flammable materials, but these were already in use for other stored materials.”