Genesis Behavioral Hospital

“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: 35367 Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect thirteen of thirteen patients. Findings: During the facility tour on June 9, 2026 between the hours of 11:45 a.m. to 12:45 a.m. and on June 10, 2026 between the hours of 11:30 a.m. to 12:30 p.m. the fire alarm system was yellow tagged by a licensed fire alarm company due to the strobes not being in sync. The interview with Maintenance personnel revealed the facility was aware the fire alarm was in need of being serviced and was awaiting the arrival of the fire alarm technician to remedy the deficiency.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 35367 Based on visual observation the facility failed to provide properly door frame latching corridor doors for the residents sleeping rooms as per NFPA 101:3.6.3.5. When the inpatient bedroom doors latch a smoke resistive seal is formed to protect the room’s occupants. The deficient practice had the potential to affect thirteen of thirteen patients. Findings: During the facility tour on June 9, 2026 between the hours of 11:45 a.m. to 12:45 a.m. and on June 10, 2026 between the hours of 11:30 a.m. to 12:30 p.m. the patient wing corridor interior access egress patient room doors all had roller latches/ ball catches. This patient room door is prohibited by CMS. The interview with Administrator revealed the facility was not aware of the corridor patient rooms roller latches/ ball catches are prohibited by CMS.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 48050 Based on observation and interview, the hospital failed to ensure each patient has the right to personal privacy. This deficient practice had the potential to impact any of the 12 patients that were on the unit during the time of the survey and is evidenced by: 1. Failure to provide privacy during personal bathing (shower) by having no shower curtains for the shower stalls; 2. Failure to ensure each patient has the right to personal privacy by failing to provide window coverings to obscure the view from the unsecured parking lot into 5 of 9 patient rooms observed. Findings: 1. Failure to provide privacy during personal bathing (shower) by having no shower curtains for the shower stalls. Observations during a tour on 06/08/2026 from 10:05 AM to 10:35 AM revealed 2 shower stalls in the bathroom with no shower curtains to allow for privacy while performing hygiene. The patients are able to be visualized by staff unclothed while showering. In an interview during the tour on 06/08/2026, S2CNO indicated that there are no shower curtains for the 2 shower stalls used by patients. 2. Failure to ensure each patient has the right to personal privacy by failing to provide window coverings to obscure the view from the unsecured parking lot into 5 of 9 patient rooms observed. Observations during a tour on 06/10/2026 from 12:00 PM to 12:15 PM revealed 9 of 9 rooms tinted covering over the windows in the bedrooms to provide privacy. Five of the nine rooms’s window tint covering the windows in the bedrooms did not provide privacy because passerby could view in window due to an unsecure public parking lot. In an interview during the tour on 06/10/2026 at 12:45 PM, S1COO and S2CNO confirmed that people on the outside of the building would be able to see into the rooms a, b, c, d, and e due to access to the windows from the unsecured parking lot.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 48050 Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in such a manner that the safety and well being of the patients are assured. This deficient practice was evidenced by failing to ensure the preventative maintenance was maintained for emergency equipment. Findings: Review of the hospital’s policies and contracts revealed there was no documentation that the facility had a preventative maintenance program for equipment. Observations during a tour on 06/08/2026 from 10:05 AM to 10:35 AM revealed the following equipment that was stored in the medication room: portable suction, oxygen concentrator, and AED. Further observation revealed no indication that equipment had preventative maintenance. In an interview on 06/08/2026 at 10:20 AM, S2CNO confirmed the above mentioned equipment did not have preventative maintenance performed. In an interview on 06/10/2026 at 11:35 AM, S1COO verified the above mentioned equipment did not have preventative maintenance done. S1COO further verified the facility did not have a policy/procedure for preventative maintenance on equipment.”

“STAFF EDUCATION CFR(s): 482.45(a)(5) Ensure that the hospital works cooperatively with the designated OPO, tissue bank and eye bank in educating staff on donation issues; This Standard is not met as evidenced by: 52121 Based on record review and interview, the hospital failed to ensure appropriate hospital staff were educated on organ, tissue, and eye donation issues in cooperation with the designated organ procurement organization, tissue bank, and eye bank. This deficient practice was evidenced by 2 (S2CNO and S5RN) of 2 employee files reviewed lacking documented evidence of education on donation issues, and by interview confirmation that donation issues training had not been completed. Findings: Review of the personnel files for S2CNO and S5RN revealed no education was documented in their personnel/education files on donation issues for organ procurement, tissue and eye bank. An interview was conducted with S2CNO on 06/10/2026 at 9:21 AM. She confirmed no training for donation issues for organ procurement, tissue and eye bank had been completed for direct care staff.”