Mount Desert Island Hospital

“COMPLIANCE STATE AND LOCAL LAWS AND REGS CFR(s): All patient care services are furnished in accordance with applicable State and local laws and regulations. This Standard is not met as evidenced by: 52959 Per §485.608(b) Standard: Compliance With State and Local Laws and Regulations, “All patient care services are furnished in accordance with applicable State and local laws and regulations.” Additionally, Maine Revised Statutes, Title 22, Chapter 401: GENERAL PROVISIONS §1724... Criminal background checks, states, in part: “Beginning October 1, 2010, a facility or health care provider subject to the licensing or certification processes of chapter 405 [includes Ambulatory Surgical Centers] shall obtain, prior to hiring an individual who will work in direct contact with a consumer, criminal history record information on that individual, including, at a minimum, criminal history record information from the Department of Public Safety, State Bureau of Identification.” Based on document reviews and interviews, the facility failed to provide evidence of a completed criminal background check for three (3) of fourteen (14) employees prior to their date of hire (Employee #7, Employee #8, and Employee #9). Findings: On 04/22/2026, a personnel record review was conducted. This review revealed the following: Employee #7 was hired on 01/16/2023. However, the facility did not complete a criminal background check until 1/18/2023. Employee #8 was hired on 09/12/2022. The criminal background check was done with a third-party vendor (SimplyVerified) that did not obtain criminal records from the Department of Public Safety, State Bureau of Identification. Employee #9 was hired on 07/14/1997. The facility failed to produce evidence that a criminal background check was completed. The above findings were confirmed with Employee #6 during a review of the files.”

“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: 49750 Based on record review, observations and interviews, it was determined that the facility failed to prepare and administer drugs according to established policies and acceptable standards of practice for eight (8) of eight (8) patient medication administrations. Findings: A review of Mount Desert Island’s “IV [intravenous] Compounding in the Patient Care Area” policy, last revised in 03/2024, in part states, “ ...IV medications compounded in the nursing units and patient care units will follow aseptic technique standard ...If a medication is supplied in a vial: Remove the flip top cap from vial; Swab the top of vial with alcohol swab, using several firm strokes in same position ...” On 04/22/2026, surveyor observed the following: At 8:45 AM, EMP #3 removed the flop top from the vial, inserted a needle into the vial and drew the medication in the syringe. EMP #3 failed to swab the vial with an alcohol swab. At 9:00 AM, EMP #3 removed the flop top from the vial, inserted a needle into the vial and drew the medication in the syringe. EMP #3 failed to swab the vial with an alcohol swab. At 9:02 AM, EMP #3 removed the flop top from the vial, inserted a needle into the vial and drew the medication in the syringe. EMP #3 failed to swab the vial with an alcohol swab. At 9:10 AM, EMP #3 removed the flop top from the vial, inserted a needle into the vial and drew the medication in the syringe. EMP #3 failed to swab the vial with an alcohol swab. At 9:16 AM, EMP #3 removed the flop top from the vial, inserted a needle into the vial and drew the medication in the syringe. EMP #3 failed to swab the vial with an alcohol swab. At 9:20 AM, EMP #3 removed the flop top from the vial, inserted a needle into the vial and drew the medication in the syringe. EMP #3 failed to swab the vial with an alcohol swab. At 9:22 AM, EMP #3 removed the flop top from the vial, inserted a needle into the vial and drew the medication in the syringe. EMP #3 failed to swab the vial with an alcohol swab. On 4/26/2026 at 9:25 AM, EMP #2 was made aware of the finding. EMP #2 stated that it would be addressed. Based on record review, observations, and interviews, it was determined that the facility failed to assure that all steam sterilization cycles were verified by staff for eight (8) of sixteen (16). Findings: A review of Mount Desert Island’s Aseptic Practices in Surgery, last revised 09/2024, in part states: “ ...all surgical instruments shall be sterilized according to published guidelines ...”. And, a review of Mount Desert Island’s Surgical Services Department Scope of Service, last reviewed 03/2026, in part states: “ ...The AORN [Association of perioperative Registered Nurses], ASPAN [American Society of PeriAnesthesia Nurses], Association for the Advancement of Medical Instrumentation (AAMI), the Center for Disease Control (CDC), and Public Health Department standards are references in the formulation and review of policies, procedures, and standards of practice in the Surgical Services Department ...”. On 04/22/2026 at approximately 7:15 AM, surveyor reviewed steam sterilizer cycle tapes dated 04/01/2026 to 04/06/2026 with EMP #2. It was noted that not all of the sterilizer cycles had been verified by staff. The steam sterilizer cycle tape documenting sixteen (16) sterilizer cycles between 04/01/2026 and 04/06/2026 were reviewed and revealed the following. 04/01/2026 @ 7:59 verified 04/01/2026 @ 8:25 AM-not verified 04/01/2026 @ 8:56 AM-not verified 04/01/2026 @ 11:03 AM-not verified 04/01/2026 @ 11:40 AM-not verified 04/02/2026 @ 7:58 AM verified 04/02/2026 @ 8:50 AM verified 04/02/2026 @ 9:49 AM not verified 04/02/2026 @ 10:46 AM not verified 04/02/2026 @ 2:06 PM not verified 04/03/2026 @ 6:35 AM-verified 04/03/2026 @ 7:02 AM-verified 04/03/2026 @ 8:30 AM-verified 04/06/2026 @ 7:35 AM-verified 04/06/2026 @ 8:27AM-verified 04/06/2026 @ 9:42 AM-not verified At time of review, EMP #2 was asked about the process for verifying parameters for each sterilization cycles. EMP #2 responded “They should be signed”.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 49660 Based on observations, tour of facility and interviews with staff (EMP), the facility failed to ensure the integrity of the exam rooms equipment. It was not maintained to ensure access to and safety of patents, by not maintaining chairs and an exam table in a hygienic state of repair, due to the breach of surface integrity the equipment cannot be adequately sanitized for four (4) of twelve (12) exam rooms. Exam rooms observed; room seven (7), eight (8), eleven (11) and exam room twelve (12). Findings: On 04/23/2026, at 08:30 AM tour of exam room (7) the survey team observed two (2) black chairs with tears in the fabric and on the arms of the chairs. On 04/23/2026, at 08:35 AM exam room (8) the survey team observed one (1) black chair with tears in the fabric. On 04/23/2026, at 08:35 AM exam room (8) the survey team observed a tear in the fabric of the exam table on the right front corner when facing the exam table. On 04/23/2026, at 08:40 AM exam room (11) the survey team observed tears in two(2) black chairs. On 04/23/2026, at 08:50 AM exam room (12) the survey team observed tears in one (1) black chair. EMP#1 was present during the observations and confirmed these findings 49750 Based on record review, observations, facility tour, and interviews, it was determined that the facility failed to maintain a clean and sanitary environment to avoid the spread and transmission of infection. Findings: A Review of Mount Desert Island’s Infection Prevention and Control Plan, last revised 05/2025, in part states: “ ...Infection Prevention and Control Plan; Section A. The Infection Control Committee has established an ongoing process for identifying, reporting, evaluating and controlling healthcare associated infections in all areas of the organization ...; B. Provide for surveillance, investigation and monitoring to prevent, to the extent possible, the onset and the spread of infection ...” On 04/21/2026 surveyors identified the following: On 04/21/2026 at approximately 2:54 PM, it was observed that two (2) of two (2) public restrooms on Floor #2 had a metal brace used to support the wall-mounted toilet. The surface of each metal brace had chipped paint and rusty surfaces that cannot be easily cleaned and sanitized. On 04/21/2026 at approximately 2:56 PM, it was observed that the baseboard on Floor #2 hallway outside of the Conference Room was chipped which revealed a brown surface that cannot be easily cleaned and sanitized. On 04/21/2026 at approximately 3:10 PM, it was observed that two (2) of two (2) public restrooms on Floor #3 had a metal brace used to support the wall-mounted toilet. The surface of each metal brace had chipped paint and rusty surfaces that cannot be easily cleaned and sanitized. On 04/21/2026 at approximately 3:16 PM, it was observed that the handrail in the hallway of the Inpatient Unit on Floor #3 had multiple areas of non-intact surfaces that cannot be easily cleaned and sanitized. On 04/21/2026 at approximately 3:24 PM, it was observed that the baseboard on Floor #3 hallway outside of the Outpatient Clinic was chipped which revealed a brown surface that cannot be easily cleaned and sanitized. On 4/21/2026 at approximately 4:30 PM, the above findings were acknowledged by EMP # 4 and EMP #5. On 04/22/2026 surveyors identified the following: On 4/22/2025 at approximately 7:20 AM, it was observed that the flooring in the endoscope high-level disinfection room, around the Olympus OER Elite Scope cleaning device had multiple breaks in the surface and was soiled with a build-up of brown/black matter creating a surface that cannot be easily cleaned and sanitized. On 4/22/2026 at approximately 7:20 AM, EMP #2 confirmed this finding and then stated, “I know it is cleaned regularly.””

“LEADERSHIP RESPONSIBILITIES CFR(s): (1) The governing body, or responsible individual, must ensure all of the following: (i) Systems are in place and operational for the tracking of all infection surveillance, prevention and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities. This Standard is not met as evidenced by: 49660 Based on observations, tour of facility and interviews with staff (EMP), the facility failed to ensure the integrity of the exam rooms equipment. It was not maintained to ensure the safety of patents, by not maintaining chairs and an exam table in a hygienic state of repair, due to the breach of surface integrity the equipment cannot be adequately sanitized for four (4) out of twelve (12) exam rooms . Exam rooms observed; room seven (7), eight (08), eleven (11) and exam room twelve (12) . Findings: On 04/23/2026, at 08:30 AM tour of exam room (7) the survey team observed two (2) black chairs with tears in the fabric and on the arms of the chairs. On 04/23/2026, at 08:35 AM exam room (8) the survey team observed one (1) black chair with tears in the fabric. On 04/23/2026, at 08:35 AM exam room (8) the survey team observed a tear in the fabric of the exam table on the right front corner when facing the exam table. On 04/23/2026, at 08:40 AM exam room (11) the survey team observed tears in two (2) black chairs. On 04/23/2026, at 08:50 AM exam room (12) the survey team observed tears in one (1) black chair. EMP#1 was present during the observations and confirmed these findings. 49750 Based on record review, observations and interviews, it was determined that the facility failed to prepare and administer drugs according to established policies and acceptable standards of practice for eight (8) of eight (8) patient medication administrations. Findings: A review of Mount Desert Island’s “IV [intravenous] Compounding in the Patient Care Area” policy, last revised in 03/2024, in part states, “ ...IV medications compounded in the nursing units and patient care units will follow aseptic technique standard ...If a medication is supplied in a vial: Remove the flip top cap from vial; Swab the top of vial with alcohol swab, using several firm strokes in same position ...” On 04/22/2026, surveyor observed the following: At 8:45 AM, EMP #3 removed the flop top from the vial, inserted a needle into the vial and drew the medication in the syringe. EMP #3 failed to swab the vial with an alcohol swab. At 9:00 AM, EMP #3 removed the flop top from the vial, inserted a needle into the vial and drew the medication in the syringe. EMP #3 failed to swab the vial with an alcohol swab. At 9:02 AM, EMP #3 removed the flop top from the vial, inserted a needle into the vial and drew the medication in the syringe. EMP #3 failed to swab the vial with an alcohol swab. At 9:10 AM, EMP #3 removed the flop top from the vial, inserted a needle into the vial and drew the medication in the syringe. EMP #3 failed to swab the vial with an alcohol swab. At 9:16 AM, EMP #3 removed the flop top from the vial, inserted a needle into the vial and drew the medication in the syringe. EMP #3 failed to swab the vial with an alcohol swab. At 9:20 AM, EMP #3 removed the flop top from the vial, inserted a needle into the vial and drew the medication in the syringe. EMP #3 failed to swab the vial with an alcohol swab. At 9:22 AM, EMP #3 removed the flop top from the vial, inserted a needle into the vial and drew the medication in the syringe. EMP #3 failed to swab the vial with an alcohol swab. On 4/26/2026 at 9:25 AM, EMP #2 was made aware of the finding. EMP #2 stated that it would be addressed. Based on record review, observations, and interviews, it was determined that the facility failed to assure that all steam sterilization cycles were verified by staff for eight (8) of sixteen (16). Findings: A review of Mount Desert Island’s Aseptic Practices in Surgery, last revised 09/2024, in part states: “ ...all surgical instruments shall be sterilized according to published guidelines ...”. And, a review of Mount Desert Island’s Surgical Services Department Scope of Service, last reviewed 03/2026, in part states: “ ...The AORN [Association of perioperative Registered Nurses], ASPAN [American Society of PeriAnesthesia Nurses], Association for the Advancement of Medical Instrumentation (AAMI), the Center for Disease Control (CDC), and Public Health Department standards are references in the formulation and review of policies, procedures, and standards of practice in the Surgical Services Department ...”. On 04/22/2026 at approximately 7:15 AM, surveyor reviewed steam sterilizer cycle tapes dated 04/01/2026 to 04/06/2026 with EMP #2. It was noted that not all of the sterilizer cycles had been verified by staff. The steam sterilizer cycle tape documenting sixteen (16) sterilizer cycles between 04/01/2026 and 04/06/2026 were reviewed and revealed the following. 04/01/2026 @ 7:59 verified 04/01/2026 @ 8:25 AM-not verified 04/01/2026 @ 8:56 AM-not verified 04/01/2026 @ 11:03 AM-not verified 04/01/2026 @ 11:40 AM-not verified 04/02/2026 @ 7:58 AM verified 04/02/2026 @ 8:50 AM verified 04/02/2026 @ 9:49 AM not verified 04/02/2026 @ 10:46 AM not verified 04/02/2026 @ 2:06 PM not verified 04/03/2026 @ 6:35 AM-verified 04/03/2026 @ 7:02 AM-verified 04/03/2026 @ 8:30 AM-verified 04/06/2026 @ 7:35 AM-verified 04/06/2026 @ 8:27AM-verified 04/06/2026 @ 9:42 AM-not verified At time of review, EMP #2 was asked about the process for verifying parameters for each sterilization cycles. EMP #2 responded “They should be signed”. Based on record review, observations, facility tour, and interviews, it was determined that the facility failed to maintain a clean and sanitary environment to avoid the spread and transmission of infection. Findings: A Review of Mount Desert Island’s Infection Prevention and Control Plan, last revised 05/2025, in part states: “ ...Infection Prevention and Control Plan; Section A. The Infection Control Committee has established an ongoing process for identifying, reporting, evaluating and controlling healthcare associated infections in all areas of the organization ...; B. Provide for surveillance, investigation and monitoring to prevent, to the extent possible, the onset and the spread of infection ...” On 04/21/2026 surveyors identified the following: On 04/21/2026 at approximately 2:54 PM, it was observed that two (2) of two (2) public restrooms on Floor #2 had a metal brace used to support the wall-mounted toilet. The surface of each metal brace had chipped paint and rusty surfaces that cannot be easily cleaned and sanitized. On 04/21/2026 at approximately 2:56 PM, it was observed that the baseboard on Floor #2 hallway outside of the Conference Room was chipped which revealed a brown surface that cannot be easily cleaned and sanitized. On 04/21/2026 at approximately 3:10 PM, it was observed that two (2) of two (2) public restrooms on Floor #3 had a metal brace used to support the wall-mounted toilet. The surface of each metal brace had chipped paint and rusty surfaces that cannot be easily cleaned and sanitized. On 04/21/2026 at approximately 3:16 PM, it was observed that the handrail in the hallway of the Inpatient Unit on Floor #3 had multiple areas of non-intact surfaces that cannot be easily cleaned and sanitized. On 04/21/2026 at approximately 3:24 PM, it was observed that the baseboard on Floor #3 hallway outside of the Outpatient Clinic was chipped which revealed a brown surface that cannot be easily cleaned and sanitized. On 4/21/2026 at approximately 4:30 PM, the above findings were acknowledged by EMP # 4 and EMP #5. On 04/22/2026 surveyors identified the following: On 4/22/2025 at approximately 7:20 AM, it was observed that the flooring in the endoscope high-level disinfection room, around the Olympus OER Elite Scope cleaning device had multiple breaks in the surface and was soiled with a build-up of brown/black matter creating a surface that cannot be easily cleaned and sanitized. On 4/22/2026 at approximately 7:20 AM, EMP #2 confirmed this finding and then stated, “I know it is cleaned regularly.””

“General Requirements - Other CFR(s): NFPA 101 General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General 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. This Standard is not met as evidenced by: 39983 Federal Recertification Survey Survey Date: 04/21/2026 Based on observations the facility failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition for the construction of fire barriers used to provide enclosure, subdivision, or protection under this code, construction for health care and/or other building occupancies. A 1-hour separation was not provided in accordance with section 8.3.1, 8.3.1.2, Fire barriers shall comply with one of the following: (1) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. (2) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, and from the floor to the bottom of the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire resistance rating not less than that of the fire barrier. Findings include: Observations, and review of construction documents during a facility tour on 04/21/2026 between 11:00 AM and 4:00 PM surveyors with the Maintenance Director identified: 1. MRI Zone II unscreened patient space, leading into the control room, located above the doorway has nine (9) through penetrations in the one (1) hour rated wall. The penetrations are various diameters with various items penetrating the wall that was not protected by a firestop system or device. Penetrations for cables, cable trays, conduit, pipes, tubes, combustible vents and exhaust vents, wires and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a fire stop system or device. This deficient practice could affect the patients/residents, visitors, and members of facility staff in this location. These findings were verified by the Maintenance Director at the time of the observation.”

“Multiple Occupancies - Construction Type CFR(s): NFPA 101 Multiple Occupancies - Construction Type Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows: * The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1 * The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters. 18.1.3.5, 19.1.3.5, 8.2.1.3 This Standard is not met as evidenced by: 39983 Federal Recertification Survey Survey Date: 04/21/2026 Based on observations, the facility failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition for construction type and supporting construction for health care and/or other building occupancies. A 2-hour separation was not provided in accordance with section 8.2.1.3. Findings include: Observations, and review of construction documents during a facility tour on 04/21/2026 between 11:00 AM and 4:00 PM surveyors with the Maintenance Director identified: 1. The 2-hour separation located above the cross corridor doors in the separation corridor between conference room A and conference room B on the second floor was penetrated by a hole with what looks to be a steel ring approximately six (6) inches in diameter that was not protected by a firestop system or device in accordance with the National Fire Protection Association, NFPA 221 (2012 edition), Standard for High Challenge Fire, section 4.9.2 Firestop Systems and Devices Required - Penetrations for cables, cable trays, conduit, pipes, tubes, combustible vents and exhaust vents, wires and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a fire stop system or device. This deficient practice could affect the 2nd floor of the facility, approximately all patients/residents, visitors, and members of facility staff in this location. 2. The 2-hour separation located between the mechanical room and storage room next to the exit and vestibule by the MRI zone on the second floor has a penetration that has been sealed up with bricks and mortar, the mortar has crumbled away and reveled a penetration in the wall that was not protected by a firestop system or device in accordance with National Fire Protection Association, NFPA 221 (2012 edition), Standard for High Challenge Fire, section 4.9.2 Firestop Systems and Devices Required - Penetrations for cables, cable trays, conduit, pipes, tubes, combustible vents and exhaust vents, wires and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a fire stop system or device. This deficient practice could affect the 2nd floor of the facility, approximately all patients/residents, visitors, and members of facility staff in this location. These findings were verified by the Maintenance Director at the time of the observation. 42159 Findings: On 04/21/2026, from 11:00 AM, to 4:00 PM, a surveyor, with the Physical Plant Director present identified: 1. The two hour wall between the electric room and the air handling room has a piece of cement missing in the corner. 2. A flexible conduit penetration in the two-hour wall between the 1962 and the 1968 wing on the third floor in the medical surgical wing above the cross corridor doors is not firestopped. 3. Large penetrations of conduit in the 1962-1968 wing wall by the mechanical room through both sides of a two hour wall is not firestopped. 4. A conduit and internet wire penetration in the attic two hour wall is not firestopped. 5. In the environmental services room, the life safety plans show the wall as a two hour wall, but it only has one layer of 5/8 sheet rock on each side with large penetrations of gray 3 inch conduit that is not firestopped. These findings were acknowledged by the Physical Plant Director at the time of observation, and document review.”

“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: 39983 Federal Recertification Survey Survey Date: 04/21/2026 Based on observation and interview the facility failed to ensure that aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, Chapter 7, and that the means of egress is continuously maintained free of all obstructions to full use in case of emergency unless modified by NFPA 101, Life Safety Code, 2012 edition, sections 18/19.2.2 through 18/19.2.11, 18.2.1, 19.2.1, and 7.1.10.1. Findings include: Observations and Interviews during a facility tour on 04/21/2026 from 11:00 AM to 4:00 PM, surveyors accompanied by the Maintenance Director, identified the following: 1. Patient beds are being stored in the imaging corridor on the first floor located outside the boiler room across from the exit access stairwell. When I interviewed the Maintenance Director and the Physical Plant Director they stated, the beds are stored there for the staff in the imaging department to use for patients if needed. This deficient practice could affect the patients/residents, visitors, and members of facility staff in this location. These findings were verified by the Maintenance Director and Physical Plant Director at the time of the observation. 51673 Federal Recertification Survey Date 04/21/2026 Findings: During a survey between the hours of 11:00 AM and 4:00 PM, a surveyor, with the Director-Physical Plant present, observed the following: 1. The corridor behind the Emergency Department leading to Physical Therapy had chairs and a mobile patient monitor stored in it. This deficient practice could effect an indeterminate number of staff, visitors, vendors, patients and family of patients by obstructing the path of egress in the event of an emergency. The surveyor confirmed this finding with the Director-Physical Plant at the time of the observation.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 42159 Federal Recertification Survey Date: 04/21/2026 Based on observation and interview, the Critical Access Hospital failed to provide a readily accessible and unobstructed exit access to one of two exits from the 1968 wing by having special locking arrangements in accordance with NFPA 101, Life Safety Code, 2012 edition, Sections 19.2.2.2.4, 19.2.2.2.5, 19.2.2.2.5.2 and 7.2.1.6. This deficient practice could affect exiting from the designated exits, as well as an indeterminable number of residents, staff, vendors, and visitors from the 1968 wing. Finding: Observation on 04/21/2026, from 11:00 AM to 4:00 PM with the Physical Plant Director present during the facility tour identified: 1. The facility designated exit number 4 on the 3rd floor stairwell had a coded exit by key code controlled by staff without any means to provide visitors or oriented residents access to the means of exit. Interview with the Physical Plant Director during the facility tour stated the door was badge only controlled, and visitors must have a staff escort to leave. The door has no delayed egress, or a number coded magnet release device. The Director stated that the magnet releases with the activation of the fire alarm and the employee badge only. This patient care area is identified on the life safety plans as the Med Surge Sleeping Suite and is not a memory care dementia wing. The Physical Plant Director acknowledged this finding at the time of the observation. 51673 Findings: On 04/21/2026, between 11:00 AM and 4:00 PM, the surveyor with the Director-Physical Plant present identified: 1. The third floor stairwell door leaf is equipped with delayed egress equipment. The door leaf is not equipped with a readily visible, durable sign that reads: PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS. The delayed egress system was tested on this door and it released the magnetic door holder in 15 seconds. This deficient practice could effect an indeterminate number of patients, guests and staff from proper egress in the event of an emergency. This finding was acknowledged by the Director-Physical Plant at the time of the observation.”

“Protection - Other CFR(s): NFPA 101 Protection - Other List in the REMARKS section any LSC Section 18.3 and 19.3 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. This Standard is not met as evidenced by: 39983 Federal Recertification Survey Survey Date: 04/21/2026 Based on observation and interview, the facility failed to ensure that areas were safeguarded in accordance with the National Fire Protection Association, NFPA 101, Life Safety Code, section 19.3, NFPA 25, Sprinkler System Inspection, Testing and Maintenance, and NFPA 1, Fire Code, 13.3.3.3, where automatic sprinklers are installed, ceilings necessary for the proper actuation of the fire protection device in accordance with NFPA 13 shall be maintained, if the ceiling opens to a non-sprinklered concealed space above, NFPA 13 requires sprinkler coverage to extend above the opening to protect that space. This deficient practice could affect the patients/residents, visitors, and members of facility staff in this location. Deficient practices have the potential of allowing the passage of smoke and/or fire from the hazardous area into adjacent areas. Findings Include: Observation and Interview during a facility tour on 04/21/2026 between the hours of 11:00 AM and 4:00 PM surveyors with the Maintenance Director identified: 1. Exam room #3 located across from exam room #2 in the breast health center on the second floor is missing ceiling tiles in two (2) locations. 2. The IT Server room located on the second floor next to the quiet room is missing most of the drop ceiling tiles. During an interview with the Maintenance Director and Director of Physical Plant, this surveyor was told the tiles were removed to better dissipate the heat from the servers therefore allowing them to not overheat. These findings were verified by the Maintenance Director at the time of the observation.”

“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: 42159 Federal Recertification Survey Date: 04/21/2026 Based on observation, the Critical Access Hospital failed to ensure that hazardous areas are protected with a smoke resistant partition in accordance with NFPA 101, Life Safety Code, 2018 edition, Sections 8.7.1, 8.4.3.5, 19.3.2.1.3, and 19.3.2.1.2, in one of 4 smoke compartments on the first floor. This deficient practice could affect the patients, visitors, staff and vendors. Finding: On 04/21/2026, between 10:00 AM and 4:00 PM, a surveyor, with the Physical Plant Director present identified: 1. The 20-minute fire rated door to the laundry storage room did not self-close and latch. The door was not equipped with any closing hardware. The door to the room shall self-close and latch as part of the protection rating of the door assembly. This finding was acknowledged by the Physical Plant Director at the time of observation.”

“Interior Wall and Ceiling Finish CFR(s): NFPA 101 Interior Wall and Ceiling Finish 2012 EXISTING Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted. 10.2, 19.3.3.1, 19.3.3.2 Indicate flame spread rating(s). _____________________ This Standard is not met as evidenced by: 39983 Federal Recertification Survey Survey Date: 04/21/2026 Based on observations, and interview the facility failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition for 19.3.3.2* Interior Wall and Ceiling Finish. Existing interior wall and ceiling finish materials complying with Section 10.2 shall be permitted to be Class A or Class B. 10.2.1.4* Fixed or movable walls and partitions, paneling, wall pads, and crash pads applied structurally or for decoration, acoustical correction, surface insulation, or other purposes shall be considered interior finish and shall not be considered decorations or furnishings. This deficient practice could affect the patients/residents, visitors, and members of facility staff in this location. Findings include: Observations and interview during a facility tour on 04/21/2026 between 11:00 AM and 4:00 PM, surveyors accompanied by the Maintenance Director identified the following. 1. A large piece of Plexiglas that is located hanging at the main entrance at the reception desk being used as a separation from the receptionist and the public does not meet the code requirements for interior finish. During an interview with the staff at the reception desk and the Maintenance Director it was stated the Plexiglas was installed temporarily for the COVID pandemic and should have been removed. These findings were verified by the Maintenance Director at the time of the observation.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 39983 Federal Recertification Survey Survey Date: 04/21/2026 Based on observations and interview, the facility failed to install the water-based fire protection system throughout the premises in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 edition, Sections 8.1.1(1), and 8.15.10(3) as referenced by NFPA 101, Life Safety Code, 2012 edition, Section 19.3.5. This deficient practice could affect several areas of the facility, all patients/residents, visitors, and members of facility staff in this locations. Findings include: Observations and interview,during a facility tour on 04/21/2026 between 11:00 AM and 4:00 PM surveyors with the Maintenance Director present identified the following: 1. The food pantry storage closet located next to the elevators on the second floor does not have any sprinkler protection. 2. The public restroom located in the corridor next to the main entrance on the second floor does not have any sprinkler protection. 3. The Oncology office located in the vestibule at the main entrance on the second floor does not have any sprinkler protection. 4. The IT Server room located next to the quiet room on the second floor does not have any sprinkler protection. 5. The small office in administration across from the CFO office on the second floor does not have any sprinkler protection. 6. The Switch room located on the first floor next to the maintenance office does not have any sprinkler protection. 7. The Exit access stairs located on the first floor next to the biohazard area does not have any sprinkler protection. 8. The corridor located on the first floor outside of the switch room leading into the maintenance office does not have any sprinkler protection. 9. The corridor located at the entrance to the biohazard area on the first floor on both sides of the door does not have any sprinkler protection. 10. The main boiler room located on the first floor does not have any sprinkler protection. 11. The corridor located on the first floor at the construction barrier next to the dark room in the imaging corridor does not have any sprinkler protection. These findings were verified by the Maintenance Director at the time of the observations. 42159 Findings: On 04/21/2026, between 11:00 AM and 4:00 PM, a surveyor with the Physical Plant Director present on identified: 1. A list of the spare sprinklers shall be posted in the sprinkler cabinet that includes the Sprinkler Identification Number, General description, Quantity of each type to be contained in the cabinet, and issue or revision date of the list. None of the three spare sprinkler head boxes in the 1968 wing riser area are equipped with a spare head list. 2. The sprinkler head in the on the third floor of the 1968 wing by the nurses station is missing an escutcheon. 3. Patient Room 3227 is missing an escutcheon. These findings were acknowledged by the Physical Plant Director at the time of observation.”

“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: 42159 Federal Recertification Survey Date: 04/21/2026 Based on observation and interview, the Critical Access Hospital failed to maintain the water-based fire protection heads free of foreign material in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, Sections 5.2.1.1.4. and Section 5.2.1.1.1 as referenced by NFPA 101, Life Safety Code, 2012 edition, Sections 19.3.5.1 and 9.7.5. in 2 of 4 smoke compartments on the third floor. This deficient practice could affect the facility by hindering the activation of the sprinkler heads. Findings: On 04/21/2026, between 11:00 AM and 4:00 PM, a surveyor with the Physical Plant Director present identified: 1. Two sprinkler heads on the 1968 wing on the third by the nurses station were loaded by a linty, dusty type covering. 2. A sprinkler head in the 1968 wing medical surgical break room was loaded by a linty, dusty type covering. 3. A sprinkler head in the 1968 wing nourishment room was loaded by a linty, dusty type covering. These findings were acknowledged by the Physical Plant Director at the time of observation. 51673 Findings: Based on interview and observation on 04/21/2026 between hours of 11:00 am and 4:00 PM. this surveyor accompanied with Director-Physical Plant did observe the following: 1. One sprinkler head located in the storage room near the soiled utility room and across from room 3210 had boxes stacked up to less than 8 in. obstructing the sprinkler head. The shelf is located less than 18 in. from the sprinkler head. This could affect the operation of the sprinkler head. This deficiency does not meet the minimum requirements of maintaining a sprinkler system. This deficient practice could affect an indeterminate number of patients, visitors, and members of facility staff the 3rd floor of this facility. These findings were verified by the Director-Physical Plant at the time of observation.”

“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: 42159 Based on observation, the Critical Access Hospital failed to properly maintain and install portable fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers, 2010 edition, Sections 6.1.3.8.3, 7.2.1.2, and 7.3.1.1. as referenced by NFPA 101, Life Safety Code 2012 edition, Sections 19.3.5.12, and 9.7.4.1. Findings: Federal Recertification Survey Date: 04/21/2026 Observations during a facility tour with the Physical Plant Director present on 04/21/2026, between 11:00 AM and 4:00 PM identified: 1. The ABC portable fire extinguisher in the attic was sitting on the floor and not secured in a bracket ensuring there is at least 4 inches of clearance between the floor and the bottom of the extinguisher. 2. The same ABC extinguisher from Finding #1 has a 2022 annual maintenance tag attached. The extinguisher was not labeled to be out of service. It was next to electrical wire spools. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification. 3. The portable fire extinguisher in Operating Room #1, was not inspected monthly by staff in the month of February, 2026. Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of once per calendar month. The Physical Plant Director acknowledged these findings with the surveyor at the time of observation.”

“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: 39983 Federal Recertification Survey Survey Date: 04/21/2026 Based on observation and interview, the facility failed to ensure that doors were protecting corridor openings in accordance with the National Fire Protection Association (NFPA) 101, Life Safety Code, section 19.3.6.3 - Corridor Doors, Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following: (1) 1 3/4 in. (44 mm) thick, solid-bonded core wood (2) Material that resists fire for a minimum of 20 minutes Findings: Observations and Interviews during a facility tour on 04/21/2026 from 11:00 AM to 4:00 PM, surveyors with the Maintenance Director identified: 1. The Radiology lounge located on the first level across from the control room has a thin vinyl accordion style door installed where a substantial door was located. This deficient practice could affect the residents, visitors, and members of facility staff in this location. These findings were verified by the Maintenance Director at the time of observations.”

“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: 51673 Federal Recertification Survey Date: 04/21/2026 Based on observation the Hospital failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition for smoke barrier enclosures in accordance with 19.3.7.3. Findings: On 04/21/2026 between 11:00 AM and 4:00 PM this surveyor with the Director-Physical Plant present observed the following. 1. The smoke partition wall located inside Mechanical Room #2 on the first floor has several penetrations, therefore not maintaining a smoke tight resistive rating. 2. The smoke partition wall located inside Electrical Room on the first floor has a penetration with a conduit, therefore not maintaining a smoke tight resistive rating. These deficient practices could affect the first floor of the facility, and an indertermined amount of patients, visitors, and members of facility staff in this location. The surveyor confirmed these findings with the Director-Physical Plant at the time of the observation.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 42159 Federal Recertification Survey Date: 04/21/2026 Based on observation and interview, the Critical Access Hospital failed to maintain the cross corridor doors in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives, 2010 edition, Section 4.5.1, which references NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 edition, Section 6.1.3.7.1 as referenced by NFPA 101, Life Safety Code, 2012 edition, Sections 19.3.7.8. This deficient practice could affect smoke in the corridor entering the ICU, as well as an indeterminable number of residents, staff, vendors, and visitors in the ICU. Finding include: Observation on April 21, 2026, from 11:00 AM to 4:00 PM during the facility tour with the Physical Plant Director present, identified: 1. The clearances between the top and vertical edges of the door and the frame, and the meeting edges of doors swinging in pairs shall not exceed 1/8 in. for wood doors. The gap between the vertical edges of the doors in the center of the corridor was a half inch wide from top to bottom. There was previously gasketing attached to the right hand door leaf, but is not there anymore. The Physical Plant Director acknowledged this finding at the time of the observation.”

“Soiled Linen and Trash Containers CFR(s): NFPA 101 Soiled Linen and Trash Containers Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended. Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent. 18.7.5.7, 19.7.5.7 This Standard is not met as evidenced by: 42159 Federal Recertification Survey Date: 04/21/2026 Based on observation, the Critical Access Hospital failed to maintain mobile soiled linen collection receptacles in room protected as a hazard area in 1 of 8 wings on the third floor per NFPA 101, Life Safety Code, 2012 Edition, Sections 19.7.5.7 Finding: On 04/21/2026, between 11:00 AM and 4:00 PM, a surveyor, with the Physical Plant Director present, observed the following: 1. There are three 30 gallon soiled linen receptacles across from room 3210 in the corridor. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. The Physical Plant Director acknowledged this finding at the time of the observation.”

“Gas and Vacuum Piped Systems - Maintenance Pr CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Maintenance Program Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040. 5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99) This Standard is not met as evidenced by: 35163 Federal Recertification Survey Date: 04/21/2026 Based on interview and document review the Critical Access Hospital, failed to ensure that the medical gas equipment was maintained in accordance with NFPA 99, Healthcare Facilities Code, 2012 edition, Section 5.1.10.11.10 This deficient practice could affect an undetermined amount of patients in the referenced areas. Findings: The medical gas verification report for 2025 that was provided indicated the following deficiencies: 1. Vacuum station outlet/inlet located in the PACU recovery was leaking. 2. Room 2 vacuum station outlet/inlet located in the operating room area was leaking. 3. Room 3203 vacuum station outlet/inlet located in the medical surgical unit was leaking. Upon interview with the maintenance director it was stated that the repairs were completed by maintenance staff. No documentation could be provided to indicate that the staff that made the repairs were qualified, competent technicians who are experienced in performing such installations as required by NFPA 99 (2012) These findings were acknowledged by the Maintenance Director at the time of observation.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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 6 (NFPA 99) This Standard is not met as evidenced by: 42159 Federal Recertification Survey Date: 04/21/2026 Based on observations, the Critical Access Hospital failed to maintain electrical assemblies in accordance with NFPA 70, National Electric Code, 2011 edition sections 314.25, and 324.28(c) as referenced by NFPA 99, Healthcare Facilities Code, 2012 edition, Section 6.3.2.1. in one of three mechanical rooms, and in both sides of the attic. This deficient practice poses an electrical hazard as people could accidentally come in contact with the wires. Findings: 04/21/2026, between 11:00 AM and 4:00 PM, a surveyor, with the Physical Plant Director present, observed the following: 1. Seven electrical junction boxes in the attic are without covers in the attic, on both sides of the 2-hour wall. 2. One junction box in the mechanical room is without a cover. These findings were acknowledged by the Physical Plant Director at the time of observation.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 50034 Federal Recertification Survey Date: 04/21/2026 Based on observation, interview and document review the Critical Access Hospital, failed to ensure that receptacles listed as hospital-grade in Patient Care Rooms are tested at intervals not exceeding 12 months in accordance with NFPA 99, Healthcare Facilities Code, 2012 edition, Section 6.3.3.2. and 6.3.4.1.1. This deficient practice could affect patients, staff, visitors, vendors and family of patients in the event of an electrical incident in 1 of 3 smoke compartments on the floor. Findings: During a survey conducted on 04/21/2026 between the hours of 11:00 AM and 4:00 PM, a surveyor in the presence of the Maintenance Director, noted the following: 1. The annual testing of the hospital grade receptacles located in the MED SURG and ICU Care Rooms has not been completed and documented in the last 12 months. The Maintenance Director stated that they are not allowed in certain rooms when there are patients in them and this is why they had not been completed. This finding was confirmed by the surveyor and the Maintenance Director at the time of the observation.”

“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: 35163 Federal Recertification Survey Date: 04/21/2026 Based on interview and documentation review , the Hospital failed to ensure that generator or other alternate power source and associated equipment was maintained in accordance with NFPA® 110, Standard for Emergency and Standby Power Systems Handbook, 2010 edition, Section 8.3.8.This deficient practice could affect all the patients, visitors, staff and vendors in the facility. Findings: 1. No documentation could be provided to indicate that the facility had performed a generator fuel quality test within the last 12 months, using tests approved by ASTM standards These findings were acknowledged by the Maintenance Director at the time of observation.”

“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: 51673 Federal Recertification Survey Date: 04-21-2026 Based on observation, the Hospital failed to ensure that power strips and extension cords are not used for non-PCREE (Patient-care-related electrical equipment) and that power strips are not used as a substitute for fixed wiring in accordance with NFPA 99 2012 Edition, section 10.2.4, NFPA 70, National Electric Code chapter 4 {400.8(1)}. Findings: On 04/21/2026, between 11:00 AM and 4:00 PM, this surveyor, with the Director-Physical Plant present observed the following: 1. In the Draw Room located on the first floor of the building, a refrigerator was plugged into a powerstrip. This deficient practice could affect the first floor of the facility, and an an indeterminate number of patients, visitors, and members of facility staff in this location. 2. In the C Nurses station located on the third floor, an extension cord was being used as permanent wiring. This deficient practice could affect the 3rd floor of the facility, and an indeterminate number of patients, visitors, and members of facility staff in this location. The surveyor confirmed this finding with the Director-Physical Plant at the time of the observation.”