Irwin County Hospital

“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: 46048 Based on review of the Irwin County Hospital Emergency Preparedness Program and interviews with staff it was determined that the facilities plan was not in substantial compliance set forth in Appendix Z. This could place all residents at risk in the event of an emergency The findings include: During a review of the facilities Emergency Preparedness Program on 04/08/2025 between 9:30 am and 1:00 pm it was noted that the facility did not provide two exercises, therefore the facilities emergency prepardness program did not meet the requirements of Appendix Z. These findings were confirmed by Staff M at the time of discovery.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 46048 Based on observation, and staff interviews it was determined the facility failed to ensure that the means of egress was not blocked This could affect patients and staff near and in the OR. The findings include: During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that the exterior side of the exit door is blocked. These findings were confirmed by Staff M at the time of discovery. Reference:2012 NFPA 101, Chapter 19, Section 19.2.1 and Chapter 7, Section 7.1.10.2.1”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 46048 Based on observation, and staff interviews it was determined the facility failed to ensure emergency lights were operational. This affects the CT area. The findings include: During a tour of the facility with Staff M on 04/08/2025 between 09:30 AM and 1:00 PM observation revealed that the emergency lights were not operational . These findings were confirmed by Staff M at the time of discovery. Reference: 2012 NFPA 101, 19.2.9.1, 7.9.1, 7.9.2”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 46048 Based on observation, and staff interviews it was determined the facility failed to ensure exit signs are operational This affects the Radiology office The findings include: During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that the exit sign was not properly working at radiology. These findings were confirmed by Staff M at the time of discovery. Reference: 2012 NFPA 101, 19.2.10.1, 7.10.5.1”

“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: 46048 Based on observation, review of facility records, and staff interviews it was determined the facility failed to get proper maintenance and cleaning completed on kitchen hood suppression systems. This affects the kitchen The findings include: During a tour of the facility with Staff M on 04/08/2025 between 09:30 AM and 1:00 PM observation revealed that that the hood suppression system is due for service and cleaning, last service and cleaning was completed in September of 2024. These findings were confirmed by Staff M at the time of discovery. Reference: 2012 NFPA 101 Chapter 19, Section 19.3.2.5.1 and Chapter 9, Section 9.2.3, and 2011 NFPA 96 Chapter 11, Section 11.2.1, 11.4, 11.5”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 46048 Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure smoke detector was properly mounted to the ceiling. This affects the kitchen pantry. The findings include: During a tour of the facility with Staff M on 04/08/2025 between 09:30 AM and 1:00 PM observation revealed that the smoke detector in the kitchen pantry was hanging down from its mount. These findings were confirmed by Staff M at the time of discovery. Reference: 2012 NFPA 101, Chapter 19, Section 19.3.4.1 and Chapter 9, Section 9.6.1.8.1”

“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: 46048 1. Based on observation, and staff interviews it was determined the facility failed to ensure ceiling tiles were properly placed. This affects all patients and staff in facility The findings include: During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that ceiling tiles were missing These findings were confirmed by Staff M at the time of discovery. Reference: : 2012 NFPA 101, Chapter 19, Section 19.3.5.1, Chapter 9, Section 9.7.1.1.(1) and 2010 NFPA 13, Chapter 8, Section 8.5.4.1.1. 2.Based on observation, and staff interviews it was determined the facility failed to ensure wires were not being supported by the sprinkler piping. This affects all patients and staff in facility The findings include: During a tour of the facility with Staff M on 04/08/2025 between 09:30 AM and 1:00 PM observation revealed that electrical wires were being supported by sprinkler pipes on the main hall and OR entrance. These findings were confirmed by Staff M at the time of discovery. Reference: 2012 NFPA 101, Chapter 19 Sections 19.1.1.1.3, 19.3.5, 19.3.5.1, Chapter 9, Section 9.7.1.1, 9.7.5, Chapter 4, Section 4.6.12.1 2011 NFPA 25, Chapter 5, Section 5.2.2.2, 2010 NFPA 13, 9.1.1.7 3.Based on observation, and staff interviews it was determined the facility failed to ensure sprinkler systems were properly cleaned throughout the facility. This affects all patients and staff in facility The findings include: During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that sprinkler heads had dust covering the fusible link These findings were confirmed by Staff M at the time of discovery. Reference: 2012 NFPA 101, Chapter 19, Section 19.3.5.1, 19.1.1.1.3, 4.6.12.1, 9.7.5 and 2011 NFPA 25, Chapter 5, Section 5.2.1.1.2, 5.2.1.1.4 4.Based on observation, and staff interviews it was determined the facility failed to ensure that escutcheon rings were not missing. This affects all patients and staff in facility The findings include: During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that escutcheon rings were missing from the sprinkler assembly These findings were confirmed by Staff M at the time of discovery. Reference: 2012 NFPA 101, Chapter 19, Sections 19.1.6.1, 19.3.5.1, 19.3.5.3, 19.3.5.4, Chapter 9, Sections, 9.7.5, 9.7.6, 9.7.1.1 and 2011 NFPA 25. Chapter 5, Sections; 5.2.1.1.2 & 5.2.1.1.4, (explanation in Annex E, E.1, Table E.1), and 2010 NFPA 13, Chapter 6, Section 6.2.7 5.Based on observation, and staff interviews it was determined the facility failed to ensure the fire suppresion system is fully operational with no deficiencys. This affects all patients and staff in facility The findings include: During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that the fire suppression system has been yellow tagged These findings were confirmed by Staff M at the time of discovery. Reference:2012 NFPA 101,19.3.5.1, 9.7.1.1, 9.7.5, 9.7.7, 9.7.8, 4.6.12.1, 2011 NFPA 25, 4.1.4.1 6.Based on observation, and staff interviews it was determined the facility failed to ensure the gauges on the fire suppression system were up to date. This affects all patients and staff in facility The findings include: During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that the fire suppression system gauges were out of date These findings were confirmed by Staff M at the time of discovery. Reference:2012 NFPA 101, 19.1.1.1.3, 19.1.6.1, 19.3.5.4, 9.7.1, 2011 NFPA 25, 5.3.2.1”

“Subdivision of Building Spaces - Smoke Compar CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Compartments 2012 EXISTING Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier. 19.3.7.1, 19.3.7.2 Detail in REMARKS zone dimensions including length of zones and dead-end corridors. This Standard is not met as evidenced by: 46048 Based on observation, and staff interviews it was determined the facility failed to ensure fire caulk was not mixed while closing penetrations This affects the respriatory therapy area The findings include: During a tour of the facility with Staff M on 04/08/2025 between 09:30 AM and 1:00 PM observation revealed that fire caulk was mixed when it was applied to fill a penetration. These findings were confirmed by Staff M at the time of discovery. Reference: 2012 NFPA 101, 19.3.7.1, 19.3.7.3, 8.3.5, 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.1, 8.5.6.2, 8.5.6.3, 4.6.12.1”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 46048 Based on observation, and staff interviews it was determined the facility failed to ensure continuity of fire walls This affects main hall, fire wall near room 101, and fire wall near the OR entrance. The findings include: During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that there are multiple penetrations and or unsealed openings. These findings were confirmed by Staff M at the time of discovery. Reference:2012 NFPA 101 , Chapter 19, Sections 19.3.7.1, 19.3.7.3, Chapter 8 Sections 8.3.5, 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.1, 8.5.6.2, 8.5.6.3, Chapter 4, Section 4.6.12.1”

“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: 46048 1. Based on observation, and staff interviews it was determined the facility failed to ensure that junction boxes are properly secured This affects main hall and the OR entrance. The findings include: During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that there are open junction boxes in the main hall and OR entrance. These findings were confirmed by Staff M at the time of discovery. Reference:2012 NFPA 101 Chapter 19, Section 19.5.1.1, Chapter 9, Section 9.1.2 and 2011 NFPA 70 Article 314.28 (C) and 110.27 2. Based on observation, and staff interviews it was determined the facility failed to ensure proper instillation and mainenance of electrical equipment This affects the kitchen and radiology The findings include: During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that there were open spaces left in the electrical panels. These findings were confirmed by Staff M at the time of discovery. Reference:2012 NFPA 101, Chapter 19, Sectin 19.5.1.1, Chapter 9, Section 9.1.2 and 2011 NFPA 70, Article 408.7”

“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: 46048 Based on observation, review of facility records, and staff interviews it was determined the facility failed to insure proper testing and maintenance of fire doors. This could affect all patients and staff of the facility The findings include: During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation review and interviews revealed that required testing has not been conducted or documented. These findings were confirmed by Staff M at the time of discovery. Reference: 2012 NFPA 101, 19.7.6, 8.3.3.1, 2010 NFPA 80, 5.2, 5.2.3, CMS S&C 17-38-LSC”