Washington County Hospital and Clinics

“42 CFR 482.41(b) Washington County Hospital and Clinics was found to be NOT in compliance with the requirements for participating in Medicare/Medicaid at 42 CFR 482.41(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition. Washington County Hospital and Clinics is a one-story building of Type II (000) unprotected and Type III protected construction that was built in 1965 and 1978. The building is sprinklered and there is supervised smoke detection located in the corridors, resident rooms and spaces open to the corridors. Resident rooms have smoke detectors that are connected to the nurse call system. The facility has 22 certified beds. At the time of survey, the census was 14. The requirement at 42 CFR 482.41(b) is NOT MET as evidence by:”

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 49482 Based on observation and interview, the facility failed to maintain minimum construction requirements in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.1.6), 2012 Edition. This deficient practice affects all residents and staff in Radiology. This facility has a capacity of 22 and a census of 14. Finding include: Observation and interview on 1/6/26 at approximately 1:07 p.m., revealed the facility failed to maintain the ceiling in Radiology. This area contained 4 Sprinkler devices with an approximately ½ inch gap between the sprinkler head escutcheon ring and ceiling. Maintenance Staff verified these observations at the time of the survey process.”

“Smoke Detection CFR(s): NFPA 101 Smoke Detection 2012 EXISTING Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1. 19.3.4.5.2 This Standard is not met as evidenced by: 49482 Based on record review and interview, the facility failed to maintain complete documentation of sensitivity testing of the smoke detectors every two years in accordance with in accordance with National Fire Prevention Association (NFPA) 72, National Fire Alarm and Signaling Code, 2010 edition, 14.4.5.3. The deficient practice of not providing complete and verifiable documentation of the fire alarm system’s inspection, testing and maintenance did not ensure proper operation and prompt repair affecting all occupants in six of six smoke zones. This facility had a capacity of 22 and a census of 14 residents at the time of the survey. Findings include: Record review on 1/6/26 at approximately 1:44 p.m., revealed documentation of facility’s sensitivity test was not available for review. This deficient practice was confirmed by Maintenance Staff at the time of discovery.”

“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: 49482 Based on observation, record review and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.2.1.1.2, by ensuring sprinklers were replaced if corroded. This deficient practice of failing to provide prompt correction of deficiencies did not ensure proper operation and prompt repair of the system. This affected all staff and residents. This facility has a capacity of 22 and a census of 14 residents at the time of the survey. Findings include: Observation and interview on 1/6/26 at approximately 1:29 p.m., revealed five soiled Sprinkler Heads in the E.R near the nurses station. This deficient practice was confirmed by Maintenance Staff at the time of discover”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 49482 Based on record review and interview, the facility failed to adequately document and hold fire drills under varied conditions at different times of the day in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1.6/19.7.1.6 for four of four quarters reviewed. The documentation did not show the drills have been held as required, including varying conditions (such as timing). This had the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility had a capacity of 34 and a census of 32 residents at the time of the survey. Findings include: Record review on 1/6/26 at approximately 10:40 a.m., of the facility fire drill documentation conducted during 2026/2025 revealed documentation for “who” was involved/participated in the fire drills conducted was not available. Results of the record review were acknowledged by Maintenance Staff at the time of discovery.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 49482 Based on record review and interview, this facility did not maintain the emergency generator by maintaining complete weekly and monthly documentation as required by National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.1 or 8.3.4. The deficient practices of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the generator did not ensure proper operation and prompt repair affecting all occupants. This facility had a capacity of 22 and a census of 14 residents at the time of the survey. Findings include: Record review on 1/6/26 at approximately 11:19 a.m., of the facility’s generator inspection testing and maintenance records from 2025/2026 revealed no documentation of a monthly load test for the month of December. These deficient practices were confirmed by Maintenance Staff at time of survey”