Houlton Regional Hospital

“PROPER VENTILATION, LIGHTING, AND TEMPERATURE CFR(s): (5) There is proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas. This Standard is not met as evidenced by: 09447 Based on document reviews and interviews the hospital failed to maintain the temperature and humidity in the procedure rooms and the (“CSR”) Central Sterile Room, according to the 2025 Association of periOperative Registered Nurses (“AORN”) standards, the standards that the hospital adopted. Findings: The 2025 Association of periOperative Registered Nurses (“AORN”) Edition page 103 contains standards related to temperature and humidity in the following areas: Procedure Rooms 20% to 60% humidity; Sterile Processing Clean Assembly Workroom maximum 60% humidity and temperature 68 to 73 degrees Fahrenheit. 1. The Houlton Regional Hospital policy titled, Temperature and Humidity in the OR, last reviewed 3/24/2025, stated in part, “In the event that temperature and humidity readings are not within the recommended range in the operating room, the charge nurse will notify the surgeon assigned to the case ...Documentation of notification will occur on the Temperature and Humidity log sheet. Maintenance work order will be placed for temperature or humidity readings outside the recommended ranges in OR’s”. On 4/24/2025 at 12:19 PM, an interview was conducted with the Maintenance Manager, regarding the documentation of the Operating Rooms Temperatures and Humidity. He stated it is done on a daily basis. He shared todays (4/24/2025) documentation but yesterday’s (4/23/2025) documentation was unavailable due to the person who is responsible for documenting that information was not there yesterday to record it. He also stated that he does not have last weeks documentation as that person was on vacation. He stated that until today there was only person trained to do that job. He stated that another person has been trained to do that job as of 4/24/2025. On 4/24/2025 at approximately 2:40 PM, the temperature and humidity log for Operating Rooms was reviewed. This review revealed that on 4/24/2025, the humidity for Procedure Room A was 0%, Procedure Room B was 19% and Procedure Room C was 19%. There was no documentation of notification to the surgeon assigned to the cased of these results as required by the hospital policy titled “Temperature and Humidity in the OR”. 2. There was no policy that identified what the hospital would do in the event that the temperature and humidity in the Central Sterile Room were not within the recommended range as outlined in the 2025 Association of periOperative Registered Nurses (“AORN”) Edition page 103 where standards related to temperature and humidity in the Sterile Processing Clean Assembly Workroom, outlined maximum 60% humidity and temperature 68 to 73 degrees Fahrenheit. On 4/24/2025, at 2:42 PM, the temperature and humidity logs for Central Sterile for September 2024 thru April 2025 were reviewed. This review revealed that five (5) days in September 2024, one (1) day in October 2024, three (3) days in November 2024, two (2) days in March 2025 and five (5) days in April 2025, there was no temperature or humidity documented. On 4/25/2025, at approximately 10:00 AM, an interview was conducted with the Central Sterile Technician (“CST”). She was asked if she completed the documentation of the temperature and humidity logs for Central Sterile from September 2024 thru April 2025 and she stated yes. She stated that the sixteen (16) days throughout that time where there was no documentation was because she was not working then and no one recorded the temperature or humidity on the log.”

“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 document reviews, observations and interviews, the hospital failed to ensure that 1.) Construction was completed using their infection control risk assessment for one (1) of one (1) mechanical room renovation and 2.) Staff were adhering to the surgical attire while in the central sterile area for one (1) of one (1) central sterile technicians and an Operating Room Registered Nurse. Findings: The Houlton Regional Hospital (“HRH”) Infection Prevention and Control Department “Construction and Renovations (102B)” policy, last reviewed 07/2024, states in part, “ ...When planning construction or renovation projects, Infection Control issues need to be considered to assure that infection risks are minimized before, during, and after the project is completed ... Construction performed by employees of HRH, and outside contractors/sub-contractors ...Construction activity types are defined by the amount of dust generated, the duration of the activity, and the amount of shared HVAC [Heat, Ventilation, Air Conditioning] systems. Staff should contact the Infection Prevention and Control Department (Ext. 2340) if any activity is questionable under these guidelines ... Type C Any work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies. Includes by not limited to, sanding of walls for painting or wall covering, removal of floor coverings, ceiling tiles and casework, new wall construction, minor ductwork or electrical work above ceilings, major cabling activities, and any activity that cannot be completed within a single work shift ... .” 1. Construction and Renovation - On 4/23/2025 at approximately 12:00 PM, State Fire Marshall Office (“SFMO”) notified Survey Team Leader of issues the team had identified in the Central Sterile and adjacent Mechanical Room. Surveyors observed multiple gaps around two (2) sterilizers, non-intact walls, and multiple non-intact areas with significant debris in the ceiling. - On 4/24/2025 at approximately 12:23 PM, the Director of Engineering/Maintenance stated they removed a low pressure steam system and two reserve tanks. They were removed from the ceiling in the mechanical room, leaving multiple open areas in the ceiling with visible debris and dust present. He stated that this was done around [Central Sterile’s] schedule. I should have had them seal the holes as they removed each piece of apparatus [reserve tanks and pipes] from the ceiling. The work was scheduled to be completed but was pushed back due to staffing issues.” - On 4/24/2025 at 12:42, during an interview with the Director of Engineering/Maintenance, he was asked if he followed the HRH’s Infection Control Policy: Construction and Renovations for this project. The Director of Engineering/Maintenance responded, “No, I did not work with Infection Control on this project because it was small.” 2. Surgical Attire The HRH “Surgical Attire” policy, last reviewed 1/10/2025, states in part, ... “Jewelry, including earrings, necklaces, watches, and braclets that cannot be contained or confined within the surgical attire should not be worn in restricted areas. Necklaces and earrings may be worn if totally concealed ... .” On 4/23/2025, at approximately 12:42 PM, the Central Sterile Technician (“CST”), who was working in the Central Sterile Room (“CSR”), a restricted area, was observed wearing earrings that were not contained within her surgical attire. The surgical technician was asked if it was okay for her to wear earrings and she stated yes. On 4/23/2025 between 8:00 PM and 9:30 PM, the CST and the Operating Room Registered Nurse, while working in the periOperative area, a restricted area, were observed wearing earrings that were not contained within their surgical attire.”

“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: 42601 Based on document reviews, interviews and interviews, the hospital failed to provide a sanitary environment including one (1) of one (1) chemical room in the dietary department, ceiling vent of one (1) of three (3) elevators, wooden handrails outside of two (2) of three (3), and torn covebase outside the elevator outside of one (1) of three (3) elevators. Findings: On 04/23/2025 and 04/24/2025, surveyors observed the following while walking through the facility: On 04/23/2025 at 8:57 AM, the chemical room in the dietary department was observed. - The wooden storage area containing cleaning chemicals had several gouges and chipped paint which could not be properly cleaned and sanitized. - A work order to replace the wooden storage was placed on 01/24/2025. On 04/24/2025 at 1:12 PM, an elevator was observed. - The back lower panel was not intact, open, and sharp edges which could not be properly cleaned and sanitized On 04/24/2025 from 1:13 PM to 1:18 PM, the wooden handrails outside of the two (2) elevators (one was out of service) were observed. - There were several gouges in the wooden handrails which could not be properly cleaned and sanitized On 04/24/2025 at 1:18 PM, the covebase outside of an elevator was observed. - The corner piece of the covebase was not intact and could not be properly cleaned and sanitized. On 04/24/2025 at 1:19 PM, the vent in the ceiling of the elevator was observed. - The vent had a significant amount of dust build up. On 04/24/2025 at approximately 1:30 PM, the Engineering/Maintenance Director was asked if the above items were part of a preventative maintenance program. He stated the following: - No, it is not part of the program; - These items would be caught by staff members who would then place a work order to repair; and - We have a monthly surveillance committee that completes rounds in the hospital that would also identify items that need repair. On 04/25/2025, the above items were not identified by the Surveillance Committee for the minutes reviewed for 09/2024, 10/2024, 11/2024, 01/2025, 02/2025 and 03/2025.”

“EXERCISE OF RIGHTS CFR(s): The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §§ 489.100, 489.102, and 489.104 of this chapter. This Standard is not met as evidenced by: 50294 Based on document review, observation, and interviews, it was determined that the hospital was not incompliance with §485.613(b)(3) of the 42 Code of Federal Regulation part 489 Responsibilities of Medicare, in accordance with §489.100, 489.102, and 489.104 of this chapter. The hospital failed to ensure that two (2) out of five (5) patients were offered the necessary documents to execute an Advance Directive. Findings: Houlton Regional Hospital’s policy titled, “Advance Directives,” dated 06/23/2023, “If the patient has not executed an Advance Directive, information and forms necessary to execute an Advance Directive will be offered.” On 04/24/2025, at 9:15am and 9:20am, two (2) out of five (5) charts did not have documentation to support offeriing Advance Directive information to their patients who were admitted to the hospital. This was verified by the Patient Care Coordinator at that time.”

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 39983 Based on record review, and interview, the facility failed to develop and implement emergency preparedness policies and procedures, based on the emergency plan and the The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials of the Emergency Preparedness Plan in accordance with 42 CFR 482.15(b)(8). Finding: On 04/22/2025, between 11:00 AM and 4:30 PM, surveyor 39983, with the Safety Officer and Director of Security present, observed the following: 1. The hospital did not have any policy documenting the facility’s role in emergencies where the Secretary waives or modifies certain statutory and regulatory requirements for healthcare facilities in response to emergencies under section 1135 of the Act related to the provision of care at an alternate care site identified by emergency officials. In an interview with the Safety Officer, he stated that “He did not know what an 1135 waiver was, and did not have a policy in the Emergency Preparedness Program regarding it”. The surveyor confirmed this finding with the Safety Officer and Director of Security at the time of the record review.”

“Building Rehabilitation CFR(s): NFPA 101 Building Rehabilitation Repair, Renovation, Modification, or Reconstruction Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following: * Requirements of Chapter 18 and 19 * Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6 18.1.1.4.3, 19.1.1.4.3, 43.1.2.1 Change of Use or Change of Occupancy Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2 18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7) Additions Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8. 18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8) This Standard is not met as evidenced by: 51673 Based on observations, the Hospital 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 building undergoing repair, renovation, modification, or reconstruction must comply with 19.1.1.4.3 Findings include: Based on observation, on 04/22/25 between 11:00 AM and 4:00 PM, in the presence of the Maintenance Technician the following was not met: 1. Room 205 located in the Labor and Delivery Suite has been changed to a Staff sleeping room, this is required to have a plan review done from the Maine State Fire Marshal’s Office. 2. Room 205 is being used as a sleeping room for staff, the room does not have a single station smoke detector and does not have a Carbon Monoxide detector. This finding was verified by the Maintenance Technician 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: 50034 The facility has failed to ensure compliance with the Life Safety Code regarding 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 Based on observation, on 04/22/2025 between 10:00 AM and 4:00 PM and 04/23/2025 9:00 AM and 4:00 PM, Surveyor 50034 in the presence of the Maintenance Manager, the following was not met: 1. Level 3: 04/22/2025 The 2-hour fire barrier wall located in the East Wing and the Therapy Waiting area had penetrations with no fire stopping material present. The 2-hour fire barrier was designated on Life Safety Plans provided by the Maintenance Manager. 2. Level 3: 04/22/2025 The 2-hour fire/smoke rated wall separating the Therapy Waiting Room and Medical Office Building has multiple unsealed penetrations going through the wall with no fire stopping material present. The 2-hour fire/smoke wall was designated on Life Safety Plans provided my the Maintenance Manager. This was confirmed by the surveyor and Maintenance Manager at the time of observation. 51673 Based on observation, on 04/23/25 between 9:00 AM and 4:00 PM, in the presence of the Maintenance Technician the following was not met: 1. The 2 hr wall separating the hospital from the medical office wing has penetrations above the suspended ceiling system with no fire stopping material present. The locations are as follows: a. located near room 200; ridged conduit and conductor cable penetrating wall is not sealed. b. located near room 200; the sheet rock meeting the roof deck is not fire stopped. c. Entrance door to medical office wing next to vestibule, web truss is not fire stopped. d. Corridor wall located inside medical office entrance, improper patching on 2-hour fire wall. e. Corridor wall located inside medical office entrance, the sheet rock meeting the roof deck is not fire stopped. f. Corridor wall located inside medical office entrance, web truss is not fire stopped. g. Located in Gift Shop, Provide documentation that materials used, are suitable for application of sealing penetrations in a 2-hour assembly. h. Located in Foundation room, the sheet rock meeting the roof deck is not fire stopped, penetrations not fire stopped. i. Office next to Foundation room, the sheet rock meeting the roof deck is not fire stopped, penetrations not fire stopped. j. Corridor located by elevator equipment room, sheet rock not properly finished at edges where it meets. k. Corridor located by elevator equipment room, the sheet rock meeting the roof deck is not fire stopped. l. Corridor located by elevator equipment room, penetrations above door. m. Corridor entering physician office, the sheet rock meeting the roof deck is not fire stopped, penetrations not fire stopped.”

“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: 42159 Based on observations, architectural drawings review, and interview with the Plant Operations Director the facility failed to meet the requirements of NFPA 101, Life Safety Code, 2012 edition, section 1.6.1, regarding construction of health care occupancies. Finding: On 04/23/2025, between 09:00 AM and 4:00 PM, two surveyors with the Maintenance Manager present, observed the following: 1. The structural steel above the ceiling tiles on the basement level by the entrance to the laundry suite are not treated with an approved fireproofing coating. This coating is required for the construction type of II(111). The plans provided show a type II(222) construction, and having non fireproofed structural steel above the ceiling tiles that supports the concrete floor above is not compliant with either construction type. The maintenance manager observed the unprotected steel with the surveyors and discussed the construction type of the building at the time of our observation. The surveyors acknowledged this finding with the Maintenance Manager at the time of the observation and during the exit interview. 51673 Based on observation, on 4/23/25 between 9:00 AM and 4:00 PM, in the presence of the Maintenance Technician the following was not met: 1. Fire proofing scraped off of structural steel for installation of conductor wire and pipe hangers, located in Physical Therapy Registration waiting area. This finding was verified by the Maintenance Director at the time of the observation.”

“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: 42159 Based on observation, the facility failed to ensure that doors in an exit passageway are free of obstruction and open with the proper opening forces in accordance with NFPA 101, Life Safety Code, 2012 edition, Sections 19.2.1, 7.1.10.1, and 7.2.1.4.5 Findings: On 04/23/2025, between the hours of 09:00 AM and 4:00 PM, this surveyor, accompanied by the Maintenance Manager observed the following: 1. The exterior blue boiler room exit door did not open to 90 degrees. Upon measuring the door only opened 10 inches from the edge of the door to the door frame. The door impacts the pavement outside, which doesn’t allow the exit door to open to its full capacity and function as a marked exit door. The surveyors acknowledged this finding with the Maintenance Manager at the time of the observation and during the exit interview.”

“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 Based on observations and interview, the facility failed to ensure doors in the means of egress meet the delayed egress signage requirements of NFPA 101, Life Safety Code, 2012 edition, Sections 19.2.2.2, and 7.2.1.6.1.1(4). Finding: On 04/22/2025, between 11:00 AM and 4:00 PM, two surveyors with the Maintenance Manager present identified: 1. The third floor South Wing Stairwell door leaf was held closed by a magnetic door holder. An interview with the Maintenance Manager revealed that the door 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 affect residents, guests, and staff from proper egress in the event of an emergency as they will not know that the door is delayed egress and may believe it to be locked.. This finding was acknowledged by the Maintenance Manager at the time of the observation and the exit interview. 51673 Based on observations, the Hospital failed to ensure the means of egress was Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, NFPA 101, 2012 edition, 7.2.1.6.1, Delayed Egress Locking Systems. Findings: Based on observation, on 04/22/25 between 11:00 AM and 4:00 PM, in the presence of the Maintenance Technician the following was not met: 1. The double door located in Labor and Delivery is equipped with Delayed egress and did not have a readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1/8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress: PUSH UNTIL ALARM SOUNDS, DOOR CAN BE OPENED IN 15 SECONDS This finding was verified by the Maintenance Technician at the time of the observation.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 50034 Based on observation, the facility failed to ensure that doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of required manual fire alarm system, and local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and automatic sprinkler system, if installed; and loss of power per the requirements of NFPA 101 2012 edition. In Level 3, 1 of 3 smoke compartments. Findings: On 04/22/2025 between hours of 11:00 AM and 4:00 PM and 04/23/2025 between the hours of 9:00 AM and 4:00 PM, surveyor 50034 accompanied with Maintenance Manager did observe the following: 1. Level 3: 04/22/2025 The Tech Room Door located in the Sleep Study Section of the South Wing has a self-closing device attached to the door that is missing parts of the mechanism and the door would not self-close. 2. Level 1: 04/23/2025 The storage room door, located in the the kitchen, has a self-closing device attached to it and is being held open by a hook type device. The surveyor confirmed this finding with the Maintenance Manager at the time of the observation.”

“Suite Separation, Hazardous Content, and Subd CFR(s): NFPA 101 Suite Separation, Hazardous Content, and Subdivision All suites are separated from the remainder of the building (including from other suites) by construction meeting the separation provisions for corridor construction (18.3.6.2-18.3.6.5 or 19.3.6.2-19.3.6.5). Existing approved barriers shall be allowed to continue to be used provided they limit the transfer of smoke. Intervening rooms have no hazardous areas and hazardous areas within suites comply with 18/19.2.5.7.1.3. Subdivision of suites shall be by noncombustible or limited-combustible construction. 18.2.5.7.1.2 through 18.2.5.7.1.4, 19.2.5.7.1.2, 19.2.5.7.1.3, 19.2.5.7.1.4 This Standard is not met as evidenced by: 51673 Based on observations, the Hospital failed to ensure the 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)13/4 in. (44 mm) thick, solid-bonded core wood (2)Material that resists fire for a minimum of 20 minutes. NFPA 101, Life Safety Code, 2012 Edition, 19.3.6.3 Findings: Based on observation, on 04/22/25 between 11:00 AM and 4:00 PM and in the presence of the Maintenance Technician, the following was not met: 1. The information describing the rating on the tag of the doors separating the Ambulatory Surgical Unit and Surgical Suite is not legible. 2. The astragal installed on the doors separating the Ambulatory Surgical Unit and Surgical Suite has hardware missing, creating penetrations in the doors. 3. The latch at the top of the doors separating the Ambulatory Surgical Unit and Surgical Suite when closed, does not seal the doors, allowing the passage of smoke. 4. When entering the Emergency Room from the Radiology corridor, the door closer on the right door is missing a bolt and creating a penetration through the door, which would allow the penetration of smoke. This finding was verified by the Maintenance Technician at the time of the observation.”

“Discharge from Exits CFR(s): NFPA 101 Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7 This Standard is not met as evidenced by: 42159 Based on observation, the facility failed to ensure that exit discharge is arranged in accordance with NFPA 101 Life Safety Code 2012 edition chapter 19 section 19.2.7 Chapter 7 section 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface in accordance with survey and and certification letter 05-38. On 04/23/2025 during a facility tour from 9:00 AM to 4:00 PM, two surveyors and the Maintenance Manager identified: 1. The marked exit door from the kitchen discharges directly on a grassed surface. The walking surface in the exit discharge shall be a hard packed, uniformly all-weather slip-resistant travel surface under all foreseeable conditions. The surveyors confirmed this finding with the Maintenance Manager at the time of observation. 50034 Based on observation, the facility failed to ensure that exit discharge is arranged in accordance with NFPA 101 Life Safety Code 2012 edition chapter 19 section 19.2.7 Chapter 7 section 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface in accordance with survey and and certification letter 05-38. During a survey on 04/22/2025 between the hours of 11:00 AM and 4:00 PM and 04/23/2025 between the hours of 9:00 AM and 4:00 PM, this surveyor and the Maintenance Manager observed the following: 1. 04/23/2025 Level 1: The marked exit located in the Central Sterile Storage exits on to a lawn and not on to a all-weather, level travel surface. 2: 04/23/2025 Level 1: One of two paved walkways located off the marked exit of the Administrative Wing has pavement that is broken up in places and does not provide an all weather, level travel surface. The surveyor confirmed these findings with the Maintenance Manager at the time of observation. 51673 On 04/23/2024, between 9:00 AM and 4:00 PM, surveyor 51673, with the Maintenance Technician present, observed the following: 1. The exit discharge located in the Patient Financial wing has a piece of metal attached to the deck at the top of the stairs creating a tripping hazard. The stairs, constructed of cement are crumbling and deteriorating. 2. The exit discharge located in the medical records department exits to grass before reaching a public way. The surveyor confirmed these findings with the Maintenance Technician at the time of observation.”

“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: 42159 Based on observations and interview with the Maintenance Manager, the facility failed to install directional continuously illuminated exit signage in every location where the direction of travel to reach the nearest exit is not apparent in accordance with National Fire Protection Association 101, Life Safety Code, 2012 edition, sections 7.10.1.2.1, 7.10.2.1, and 19.2.10. Finding: On 04/23/2025 between 09:00 AM and 4:00 PM with the Maintenance Manager present during a facility tour identified: 1. There is no exit signage installed in the Administrative suite entry by the cross corridor double doors that mark the exit pathway. This finding was acknowledged by the Maintenance Manager at the time of observation and during the exit interview. 51673 Findings: Based on observation, on 04/22/25 between 11:00 AM and 4:00 PM, in the presence of the Maintenance Technician the following was not met: 1. The exit sign above the cross corridor doors located in the Waiting Room leading to the Labor and delivery unit has the arrow pointing in a direction that leads the public to a wall, not the exit. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. This finding was verified by the Maintenance Technician 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: 50034 Based on observation the facility failed to ensure that hazardous areas are protected per the requirements of NFPA 101 2012 edition 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. Findings: On 04/22/2024 between hours of 11:00 AM and 4:00 PM and 04/23/2025 between the hours of 9:00 AM and 4:00 PM. Surveyor 50034, accompanied with Maintenance Manager did observe the following: 1. Level 1: 04/23/2025. The Maintenance room located in the Administration wing has fire caulking that has separated from the 1-hour smoke enclosure wall. 2. Level 1: 04/23/2025. The Pump room located in the Administration Wing has multiple unsealed openings located in the ceiling that would allow the passage of smoke. 3. Level 1: 04/23/2025. The Boiler room located in the Maintenance department has several unsealed penetrations in the ceiling that would allow the passage of smoke. 4. Level 1 04/23/2025. The Mechanical room located off the maintenance dock has fire caulking around a pipe that has become separated from the wall. 5. Level 1 04/23/2025. The Mechanical room located in Central Surgical Supply has multiple holes throughout the ceiling to include a hole approximately 14 inches by 18 inches, a circular hole approximately 4 inches in diameter, a hole approximately 16 inches by 24 inches and a circular type hole approximately 6 inches in diameter The surveyor confirmed this finding with the Maintenance Manager at the time of the observation. 51673 Based on observation, the hospital facility failed to ensure that hazardous areas are protected per the requirements of NFPA 101 2012 edition 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. Findings: On 04/22/2024 between hours of 11:00 AM and 4:00 PM, Surveyor 51673, accompanied with Maintenance Technician did observe the following: 1. The mechanical room located in the surgery suite does not meet the requirement of smoke tight, visible openings were observed around wall mounted equipment. This finding was verified by the Maintenance Technician at the time of the observation.”

“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: 51673 Based on observations, the Hospital Facility failed to ensure that the Inspection for Grease Buildup was completed semi- annual, the entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition Table 11.4 Findings: Based on observation on 04/23/25 between hours of 9:00 AM and 4:00 PM. surveyor 51673 accompanied with Maintenance Technician did observe the following: 1. The hood and duct located in the Emergency Department Staff Kitchen is required to be inspected semi-annuall. There is an excessive buildup of debris in the vent system of the hood. This finding was verified by the Maintenance Technician at the time of the observation.”

“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: 34673 Based on record review the fire alarm sytem has not been maintained, the long-term care facility failed to maintain fire alarm initiating devices in accordance with NFPA 101, Life Safety Code, 2012 edition, sections 19.3.4.2.1, 9.7.5, 9.7.7, 9.7.8 and the NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. Findings: On 04/23/2025, between 09:00 AM and 4:00 PM, this surveyor did observed the following: 1. Fire alarm report dated August 29, 2024 indicates duct smoke detector 2 96980379 failed during testing. 2. Fire alarm report dated August 29, 2024 indicates duct smoke detector 1 96980277 not accessible and not able to be tested. These findings verified by the maintenance technician.”

“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: 42159 Based on observation, the Hospital 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. Findings: On 04/23/2025, between 09:00 AM and 4:00 PM, this surveyor with the Maintenance Manager present observed the following: 1. The current Electrical Switch Gear room is not covered by an approved automatic sprinkler system. 2. The original Switch Gear Room is not covered by an approved automatic sprinkler system. 3. The West Acute Care Exit Stairwell is not protected by the sprinkler system. This surveyor acknowledged these findings with the Maintenance Manager at the time of the observation and during the exit interview. 51673 Based on observation, on 04/23/25 between 9:00 AM and 4:00 PM, in the presence of the Maintenance Technician the following was not met: 1. Multiple sprinkler heads are obstructed when the X-ray machine is moved on the tracks in the radiology X-ray Room 1. This finding was verified by the Maintenance Technician at the time of the 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 Findings: 1. The sprinkler heads in the following locations were loaded with foreign material in the following locations: a. Acute Care clean linen area, b. Resident room 325, c. Resident room 324, d. Resident room 330, e. Laundry room by the washers and scale. The surveyors acknowledged these findings with the Maintenance Manager at the time of the observation and during the exit interview. 51673 Based on observations, the facility failed to ensure that Sprinkler System was inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. This deficiency does not meet the minimum requirements of maintaining a sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-based Fire Protection Systems, 2011 edition, Chapter 5, section 5.2.1.1.2(5), 5.2.1.1.1, 5.2.1.1.3 Findings: Based on observation, on 04/22/25 between 11:00 AM and 4:00 PM, and 04/23/25 between 9:00 AM and 4:00 PM, Surveyor 51673 in the presence of the Maintenance Technician the following was not met: 1. Sprinkler heads in the following locations have foreign materials: a. Doctor’s Lounge in the Operating Room Suite. b. Soiled utility room, clean utility room, and staff lounge in the labor and delivery suite. c. Staff locker room adjacent to the ambulance bay. 2. The sprinkler head in the closet located near the dietician office has approximately a one inch penetration in the ceiling directly adjacent to the escutcheon ring that would allow the passage of smoke. Any sprinkler that has been installed in the incorrect orientation shall be corrected by repositioning the branch line, drop, or sprig, or shall be replaced. 3. The sprinkler head located in a storage closet in the Mammography unit is obstructed by storage of materials within 18 inches of the sprinkler head. This was removed during survey by Maintenance Technician. These findings were verified by the Maintenance Technician at the time of observations.”

“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: 50034 Based on observation, the facility failed to comply with 2012 Life Safety Code sections 18.3.5.12, 19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1. Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 2010 NFPA 10 6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. During a facility tour on 04/23/2025 between the hours of 9:00 AM and 4:00 PM, this surveyor and the Maintenance Manager observed the following. Findings: 1.Level 1: The fire extinguisher located in the pharmacy is mounted on the wall approximately 5’ 8” off the floor surface. 2.Level 1: The fire extinguisher located in the Kitchen Serving Area is mounted on the wall approximately 6’ 0” off the floor surface. This finding was confirmed by this surveyor and the Maintenance Manager at the time of the survey.”

“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: 50034 Based on observations, the facility 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 18.3.7.3, 19.3.7.3. Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c). (b) Not less than two separate smoke compartments shall be provided on each floor. (2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. During a facility tour on 04/22/2025 between the hours of 11:00 AM and 4:00 PM and 04/23/2025 between the hours of 9:00 AM and 4:00 PM, Surveyor 50034 along with the Maintenance Director observed the following: Findings: 1. Level 3: 04/22/2025 The east corridor wall separating the EAST WING from the ELEVATOR area has unsealed penetrations going through a 1-hour smoke barrier wall that are . Plans indicated this is a 1-hour fire smoke barrier. 2. Level 2: 04/23/2025 The smoke partition located in the hallway separating Cardiac Rehabilitation and Radiology has unsealed penetrations of wire conduit, metal piping and wiring going through the smoke partition. 3. Level 2: 04/23/2025 The smoke barrier separating nuclear medicine from cardiac rehabilitation does not go all the way to the roof decking above. These were confirmed by the surveyor and Director of Maintenance at the time of observation. 51673 Based on observation, on 04/22/2025 between 11:00 AM and 4:00 PM, in the presence of the Maintenance Technician, the following was not met: Findings: 1. Level 2, the smoke barrier wall located adjacent to the conference room across from the chief nursing office has penetrations in the smoke barrier wall above the suspended ceiling system. 2. Level 2, the smoke barrier wall above the corridor doors located in the Ambulatory Surgical Unit/Labor and Delivery waiting room leading into the Labor and delivery unit has penetrations, patches, and improperly used products attempting to seal some penetrations. 3. Level 2, the smoke barrier wall located adjacent to the mechanical room from the lab has penetrations under the flourescent light and over the door leading to the lab waiting room. 4. Level 2, metal roll-up door installed in the smoke barrier wall located at the entrance to the lab from the lab waiting area is required to be a self-closing, positive latch, rated door. 5. Level 2, the smoke barrier wall located in the lab waiting room entering the lab located above the suspended ceiling system has penetration at the top where the sheet rock meets the floor deck above. 6. Level 2, penetrations in the smoke barrier wall located in Physical Therapy Registration waiting area. 7. Level 2, two ceiling tiles missing in Radiology IT room. This finding was verified by the Maintenance Technician at the time of the observation.”

“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: 42159 Based on observation and interview, the Hospital facility was drying mops and rags in the dryer, which is prohibited per NFPA 101, Life Safety Code, 2012 Edition, Sections 19.5.1.1, and 9.1. Finding: On 04/23/2025, between 09:00 AM and 4:00 PM, two surveyors with the Maintenance Manager present identified: 1. An interview with the laundry employee indicated when asked, if mop heads or greasy rags are dried in the dryer, the facility does not dry mop heads in the dryer, but they do dry cleaning and kitchen rags in the dryer after washing them. No documentation was provided showing the drying appliances are listed for this procedure. This deficient practice could affect residents, guests, and staff if this practice leads to the rags or mops catching fire while in the dryer or after drying in storage. The surveyors confirmed this finding with the Maintenance Manager at the time of the observation and during the exit interview.”

“Gas and Vacuum Piped Systems - Other CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum 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 5 (NFPA 99) This Standard is not met as evidenced by: 51673 Based on observations, the Hospital Facility failed to ensure Central supply systems and medical gas outlets for oxygen, medical air, nitrous oxide, carbon dioxide, and all other patient medical gases shall be piped only into areas where the gases will be used under the direction of licensed medical professionals for purposes congruent with the following, NFPA 99, 2012 Edition, Health Care Facilities Code, 5.1.3.5.2 Permitted Locations for Medical Gases, (1)Direct respiration by patients (2)Clinical application of the gas to a patient, such as the use of an insufflator to inject carbon dioxide into patient body cavities during laparoscopic surgery and carbon dioxide used to purge heart-lung machine blood flow ways (3)Medical device applications directly related to respiration (4)Power for medical devices used directly on patients (5)Calibration of medical devices intended for (1) through (4). 5.1.4.8.5, Zone valve boxes shall not be installed behind normally open or normally closed doors or otherwise hidden from plain view Findings: Based on observation, on 04/22/25, between 11:00 AM and 4:00 PM, and on 04/23/25 between 9:00 AM and 4:00 PM in the presence of the Maintenance Technician the following was not met: 1. On 4/22/25 between 11:00 AM and 4:00 PM surveyors observed Medical gas outlets for patient use are located in the break room used by staff in the Surgical Suite. 2. On 04/23/25 between 9:00 AM and 4:00 PM surveyors observed a Medical gas zone valve box located in the Radiology suite partially obstructed by a door. This finding was verified by the Maintenance Technician at the time of the 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 Based on observations and interview, the facility failed to meet the requirements of NFPA 70, National Electrical Code, 2011 edition, Section 314.25, as referenced by NFPA 99, Healthcare Facilities Code, 2012 edition, section 6.3.2.1. Findings: On 04/22/2025, between 11:00 AM and 4:00 PM, two surveyors with the Maintenance Manager present, observed the following: 1. The four electric boxes in the ceiling of the war room are left uncovered when the previous electrical equipment was removed and has exposed wiring. An interview with the Maintenance Manager, revealed that the area is going to be renovated into the new pharmacy and devices are being replaced. 2. The electrical junction box in the Acute Care dayroom is missing a cover and has exposed wiring. 3.Kitchen Manager’s office, The receptacle where the clock was mounted on the wall was left uncovered exposing the electrical wiring. Interview with the Kitchen Manager revealed that the clock became unopoerational on 04/21/2025 and was discarded. The surveyors acknowledged these findings with the Maintenance Manager at the time of the observation and during the exit interview.”

“Electrical Systems - Wet Procedure Locations CFR(s): NFPA 101 Electrical Systems - Wet Procedure Locations Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment conducted by the facility governing body. Operating rooms defined as wet locations are protected by either isolated power or ground-fault circuit interrupters. A written record of the risk assessment is maintained and available for inspection. 6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2 This Standard is not met as evidenced by: 51673 Based on observations and interview, the Hospital failed to insure Operating rooms shall be considered to be a wet procedure location, unless a risk assessment conducted by the health care governing body determines otherwise. NFPA 99, 2012 edition, 6.3.2.2.8.4, 6.4.4.2 Findings: 1. The facility failed to produce documentation that a written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. When Interviewed the Maintenance Technician stated “I don’t know if we have that” This finding was verified by the Maintenance Technician 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: 50034 Based on observation, the facility failed to comply with the 2012 Life Safety Code 9.1.3.1 Emergency Generators and stand by power systems shall be installed, tested and maintained in accordance with NFPA 110 Standard for Emergency and Standby Power Systems, 2010 NFPA 110, Standard for Emergency and Standby Power Systems, Section 5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. 5.6.5.6.1 the remote manual stop station shall be labeled. On 04/22/2025 between the hours of 11:00 AM and 4:00 PM and 04/23/2025 between the hours of 9:00 AM and 4:00 PM, surveyor 50034 with the Maintenance Manager observed the following: Finding: 1. The generator that is housed at the exterior of the facility does not have an emergency stop button located on the exterior of the housing. The surveyor confirmed this finding with the Maintenance Manager at the time of the 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 Based on observation, the Hospital facility failed to ensure that power strips 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 Chapter 10, NFPA 70 chapter 4 {400.8(1)} Findings: On 04/22/2025, between 11:00 AM and 4:00 PM, surveyor 51673, with the Maintenance Technician present, observed the following: 1. Two electric extension cords with four gang receptacle attached to the cord is being used in Surgery #2 in place of fixed wiring. 2. On 04/23/25 between 9:00 AM and 4:00 PM in the Medical records room located on Level 2, a power strip is being used to power a microwave oven and Keurig coffee machine. This was corrected during the survey. This finding was verified by the Maintenance Technician at the time of the observation.”

“Electrical Equipment - Testing and Maintenanc CFR(s): NFPA 101 Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility’s policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8 This Standard is not met as evidenced by: 51673 Based on observations, the Hospital failed to ensure the physical integrity of the power cord assembly composed of the power cord, attachment plug, and cord-strain relief shall be confirmed by visual inspection. NFPA 101, 2012 edition 10.3, Testing requirements - Fixed and Portable. Findings: Based on observation, on 04/22/25 between 11:00 AM and 4:00 PM, surveyor 51673 in the presence of the Maintenance Technician, the following was not met: 1. The cord for a power strip attached to an anesthesia pole located in Surgery #3 has electrical tape used as a temporary repair between the cord and the plug. This finding was verified by the Maintenance Technician at the time of the observation.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 50034 Based on observation, the health care facility failed to ensure compliance with the Life Safety Code 19.3.2.4 Medical Gas storage and administration areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing. Gas Equipment - Cylinder and Container Storage in a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.5.2 If empty cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders and 11.6.5.3. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. On 04/22/2025, between the hours of 11:00 AM and 4:00 PM, Surveyor 50034, with the Maintenance Manager present, observed the following: 1. The Oxygen room located in the South wing Sleep Study area has oxygen tanks in two separate metal rack systems with no signage designating which tanks are empty or full. The surveyor confirmed this finding with the Maintenance Manager at the time of the observation.”

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 48232 Based on document reviews, interviews, and observations, it was determined that the Standard for Nursing Services, also known as C-1046, was not met as evidenced by the facility’s failure to Ensure Nursing staff were scanning patient identification bracelets (“wristbands”) on patients’ wrists prior to medication administration on one (1) out of one (1) observed inpatient care unit (The Acute Care Unit). Please see Tag C-1049 for details.”

“NURSING SERVICES CFR(s): §485.635(d)(3) All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. This Standard is not met as evidenced by: 48232 Based on document reviews, interviews, and observations, the facility failed to ensure Nursing staff were scanning patient identification bracelets (“wristbands”) on patients’ wrists prior to medication administration on one (1) out of one (1) observed inpatient care unit (The Acute Care Unit). Findings: Houlton Regional Hospital’s policy titled, “Bedside Medication Verification,” last revised 04/2024 states in part, “...The bar code on the medication package is scanned by the nurse. The nurse will verify correct drug, dose, route, and time completing appropriate pop-up screens. 4. The nurse then scans the bar code on the patient’s wristband to ensure correct patient identification and the absence of contraindications...” Houlton Regional Hospital’s policy titled, “Medication Administration,” last revised 11/2019 states in part, “...The following information will be known/verified each time a medication is given. a. Right patient identification (name, [Medical Record#], [Identification #], [Date of Birth]... e. Medication Carts will be locked at all times when not being used...” On 02/10/2025 at 10:57 AM, observations were conducted on the Acute Care Unit accompanied by Infection Preventionist #1, a Registered Nurse (“RN”). On 02/10/2025 at 11:00 AM it was observed that a Computer on Wheels (“COW”) also known as a Workstation on Wheels (“WOW”) was in the hallway of the Acute Care Unit which was labeled, “Med COW 7.” It was observed that a drawer on “Med COW 7,” labeled, “324 [Patient #1 initials]” was left open and unsecured. It was observed that the unsecured drawer contained a patient identification wristband for Patient #1. RN #1 assisted in unlocking other drawers of “Med COW 7”, and “Med COW 8,” which was in the hallway directly next to “Med COW 7.” It was observed that there were patient identification wristbands in the medication storage drawers for the following patients: Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, & Patient #8. During an in-person interview on 02/10/2025 at 11:05 AM with RN #2, they stated if there was a patient in a COVID or tuberculosis room, Nursing staff don’t take the medication scanner into the patient’s room. They stated that they will scan the bracelets in the drawer of the COW instead when administering medications. During an in-person interview on 02/10/2025 at 11:23 AM with Licensed Practical Nurse (“LPN”) #1 they stated that for patients on isolation, staff sometimes put bracelets out where they can scan them rather than bring the scanner into the room. LPN #1 stated, “Everyone is supposed to wear bracelets.” On 02/10/2025 at 11:24 AM, RN #2 stated, “”You wouldn’t want the wand [scanner] going into a room where there is a patient with an infection.” During an in-person interview on 02/10/2025 at 1:24 PM, RN #3 stated that nursing staff don’t bring the scanners into the isolation rooms because they don’t want to contaminate the scanner. RN #3 stated they scan bracelets that are in the anteroom (a small room that leads to the isolation room where the patient resides). RN #3 stated the bracelets for isolation patients are attached to the wall of the anteroom. RN #3 stated the bracelets would be attached to the wall of the anteroom toward the window. RN #3 stated they scan the bracelet on the wall then scan the medications, then bring the medications into the room. On 02/10/2025 at 2:32 PM observations were conducted on the Acute Care Unit accompanied by the RN Patient Care Coordinator. The RN Patient Care Coordinator indicated that there was a patient in room 306 who was on isolation precautions. The surveyor and the RN Patient Care Coordinator entered the anteroom of room 306. It was observed that the anteroom had an area for staff to don and doff personal protective equipment. It was observed that there was a large window that looked into the room where the Patient #9 was, and a door leading from the anteroom into Patient #9’s room. It was observed that there was a patient identification wristband for Patient #9 taped to the window on the inside of the anteroom (located outside of the patient’s room). Patient #9 indicated he/she was agreeable to speaking with the surveyor and the RN Patient Care Coordinator. Patient #9 stated that when they were administering medications, nurses would scan the bracelet taped to the window outside of his room, and not a bracelet physically located in his/her room or on his/her body. During an in-person interview on 02/10/2025 at 2:39 PM, the RN Patient Care Coordinator confirmed that scanning bracelets that were taped to the walls of the hospital or located within the drawers of the COWs/WOWs prior to medication administration was not the hospital’s policy and was not encouraged. They stated in the past they have found bracelets in the medication drawers of the COWs/WOWs. The RN Patient Care Coordinator confirmed on 02/10/2025 at 2:42 PM that extra patient identification bracelets should not be in the medication drawers of the COWs/WOWs. They stated the process for medication administration should be that the nurse goes in the Pyxis (medication dispensation machine), pulls out the medications, scans the patient’s bracelet in the patient’s room, then scans the medications and administers them. The RN Patient Care Coordinator stated the bracelet that is scanned for medication administration needs to be on the patient’s body. On 02/10/2025 at 2:53 PM an in-person interview was conducted with Respiratory Therapy Staff #1. Respiratory Therapy Staff #1 stated they did administer medications, and that they administer nebulizers. Respiratory Therapy Staff #1 stated they obtain the medication from the Pyxis, scan the patient’s wrist band on their wrist, scan the medication, then document what they are doing. Respiratory Therapy Staff #1 stated that they were aware that a patient had a bracelet taped to their wall. Respiratory Therapy Staff #1 stated that the bracelet needs to be on the patient’s wrist to ensure that you have the correct patient. Respiratory Therapy Staff #1 stated the risk the risk of scanning a bracelet that was not on the patient’s body would be administering the wrong medication to the wrong patient. Respiratory Therapy Staff #1 stated that the scanner they use to scan medications can be cleaned with wipes after patient use. On 02/11/2025 at 9:11 AM an in-person interview was conducted with Infection Preventionist #1. Infection Preventionist #1 stated that the scanners on the COWS can be cleaned with wipes. Infection Preventionist #1 stated the scanners can go into isolation rooms. Infection Preventionist #1 stated the risk of scanning a bracelet on the wall as opposed to scanning a bracelet on a patient’s wrist would be medication errors - giving the wrong medications to the wrong patient. On 02/11/2025 at 9:16 AM an in-person interview was conducted with the Nurse Manager of the Acute Care Unit. The Nurse Manager of the Acute Care Unit stated bracelets were being taped to the wall outside of the room and scanned prior to medication administration in the past. The Nurse Manager of the Acute Care Unit stated this occurred over 1 year ago (the date of the interview was 02/11/2025). The Nurse Manager of the Acute Care Unit stated his/her plan of action to prevent something like this from happening again was he/she, “told them that can’t happen.” He/she stated he/she told the staff after the past incident that the bracelets had to be on the patients. The Nurse Manager of the Acute Care Unit stated the standard is to have the bracelet on the patient. He/she stated that the risk of scanning a bracelet in the COW/WOW drawer or on the wall as opposed to scanning a bracelet on the patient’s wrist is that it could be the wrong patient. The Nurse Manager of the Acute Care Unit stated that the scanners on the cows can be brought into isolation rooms and that they can be wiped down afterward. The Nurse Manager of the Acute Care Unit confirmed on 02/11/2025 at 9:20 AM that scanning was not always occurring at the bedside. On 02/11/2025 at 10:30 AM an in-person interview was conducted with Respiratory Therapy Staff #2. Respiratory Therapy Staff #2 stated he/she has noticed staff on the Acute Care Unit putting bracelets in the drawers of the COWs/WOWs. Respiratory Therapy Staff #2 stated he/she has noticed staff on the Acute Care Unit taping bracelets to the wall. Respiratory Therapy Staff #2 stated it depends on the nurse, but they could have a bracelet on the wall and the nurse could have an additional bracelet in the COW/WOW. Respiratory Therapy Staff #2 stated he/she has witnessed a nurse on the Acute Care Unit scanning a bracelet that was not on the patients body prior to administering medication. Respiratory Therapy Staff #2 stated this happened as recently as the week of 02/02/2025 - 02/08/2025. On 02/11/2025 at 10:44 AM an in-person interview was conducted with RN #4. RN #4 stated he/she has witnessed patient identification bracelets taped to the walls of the Acute Care Unit.”

“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: 48232 1. Based on document reviews, interviews, and observations, the hospital failed to ensure patient food was being stored in sanitary conditions, including failing to ensure food stored in patient refrigerators was labeled and dated, failing to ensure the food stored in patient refrigerators was not expired, and failing to ensure that food belonging to staff was not being stored with patient food items in three (3) out of four (4) observed patient food refrigerators (Emergency Department, Acute Care Unit and the main hospital kitchen.) Findings: Houlton Regional Hospital’s policy titled, “Environment of Care Guidelines,” dated 02/26/2020 states in part, “...Patient food and Staff food shall be stored in separate refrigerator units...” On 02/10/2025 at 10:19 AM, observations of the Emergency Department kitchen revealed the refrigerator had two (2) white containers labeled, “Beef Stew,” with no date on the containers. The refrigerator was also observed to contain a bowl full of an unidentified orange substance that was unlabelled and was not dated. This was brought to the attention of Housekeeper #1 who stated the items should not have been in the refrigerator. On 02/10/2025 at 11:20 AM it was observed that the Acute Care Unit Patient Refrigerator contained a bowl of a white food substance with that was unlabelled and not dated. It was observed the refrigerator also had a “Vegetable Snack Tray With Dip,” that was labeled with an expiration date of 02/07/2025 - indicating that it was expired. It was observed the refrigerator additionally contained an open bag of “Pepperoni” that was not labeled with an opened date. Certified Nursing Assistant (“CNA”) #1 was present and was made aware of the unlabelled, undated, and expired items. On 02/10/2025 at 11:51 AM, during an observation of the main hospital kitchen accompanied by the Kitchen Supervisor, it was observed that a fast-food restaurant iced coffee/tea beverage belonging to a kitchen staff member was being stored in a refrigerator containing patient food. The Kitchen Supervisor instructed the staff member to move the beverage to a different refrigerator intended for staff food. 2. Based on document reviews, interviews, and observations the hospital failed to ensure ultrasound and medical gels were labeled with the opened date and disposed of if/when expired, on one (1) out of two (2) observed patient care units (The Emergency Department). Findings: Houlton Regional Hospital’s policy titled, “Ultrasound and Medical Gels,” last revised 07/2014 stated in part, “...Ultrasound gel can be a potential source of infection if not used appropriately. In order to ensure the safe use and minimize the health risks associated with the use of ultrasound and medical gels these recommendations are made by the Infection Control Department... When opening a new gel bottle, date the bottle and discard unused gel after one month...” On 02/10/2025 at 10:41 AM, during observations of the Emergency Department accompanied by Infection Preventionist #1, it was observed that the Emergency Department supply area had two (2) opened bottles of undated ultrasound gel which were present on the ultrasound carts, and one (1) opened bottle of undated ultrasound gel which was present on the shelf. All three (3) of the bottles of ultrasound gel had a sticker on the bottle which stated, “Date Opened [blank] Discard After 30 Days.” No date was written in the blank “date opened” space. This was brought to the attention of Infection Preventionist #1 who confirmed these findings. 3. Based on document reviews, interviews, and observations, the hospital failed to ensure expired supplies were removed from circulation in one (1) out of two (2) observed medication rooms (the Acute Care Unit medication room). Findings: On 02/10/2025 at 11:27 AM, during observations of the Acute Care Unit medication room, an opened bottle of “Dyna-Hex 4 Chlorhexidine Gluconate 4% Solution” was observed which had a sticker that stated, “Discard After 1 Year,” and had another sticker that stated, “Date Opened: 01/2024.” Infection Preventionist #1 was present for the observation and confirmed this finding. 4. Based on document reviews, interviews, and observations, the hospital failed to ensure patient medications were stored in a sanitary condition in one (1) out of two (2) observed medication rooms (the Acute Care Unit medication room). Findings: Houlton Regional Medical Center’s policy titled, “Storage of Medications Brought In By Patients,” last reviewed 05/15/2024 states in part, “...If a medication is brought into the hospital by a patient, it should be sent home with the patient’s family. If the patient has no means to send a medication home it is to be packaged and stored in the pharmacy according to the following procedure and then returned to the patient at the time of discharge...” On 02/10/2025 at 11:27 AM, during observations of the Acute Care Unit medication room, it was observed that a paper bag which was partially torn open was sitting directly on the floor of the Acute Care Unit medication room. Infection Preventionist #1, who was present for the observations, assisted the surveyor with looking into the bag and the bag was observed to contain three (3) boxes of lidocaine patches belonging to Patient #11. Infection Preventionist #1 confirmed that this medication should not be stored directly on the floor. 5. Based on interviews, and observations, the hospital failed to ensure the patient lab specimen freezer in the hospital lab was maintained in a sanitary condition in one (1) out of one (1) observed laboratory areas (The main hospital laboratory). Findings: On 02/10/2025 at 11:47 AM, during observations of the main hospital laboratory accompanied by Infection Preventionist #2 (who was a member of the laboratory staff), an unidentified yellow substance on the bottom of the inside of the lab specimen freezer, and on the bottom of the shelf on the door of the lab specimen freezer. Infection Preventionist #2 confirmed these findings.”

“RESTRAINT AND SECLUSION CFR(s): Staff training requirements. The patient has the right to safe implementation of restraint or seclusion by trained staff. This Standard is not met as evidenced by: 48232 Based on document reviews and interviews, the hospital failed to ensure staff completed restraint training for three (3) out of five (5) nursing staff who were involved in patient restraints in 2023 (for Patients #8, #9, & #10). Findings: 1. Houlton Regional Hospital’s policy titled “RESTRAINTS,” last reviewed 06/01/2023 states in part: “ ...Education: 1. Staff must be trained and able to demonstrate competency in the application of restraints, monitoring, assessment, and providing care for a patient in restraint. Staff must be trained before performing any of the actions specified in this paragraph. As part of orientation. Annually for all staff who have direct patient care responsibilities ...” 2. At 3:04 PM on 01/03/2024 an in-person interview was conducted with the Chief Nursing Officer (“CNO”) which revealed the following information: CNO stated that annual Registered Nurse restraint training did not happen in 2023. She stated that due to an error, nursing staff were not assigned to complete annual restraint training in HealthStream (the hospital’s online training system). She stated that the last time most of the nurses completed annual restraint training on HealthStream was in 2022. 3. Patient #8’s medical record was reviewed and revealed that Patient #8 was placed in soft limb restraints on 03/11/2023. IT Clinical Analyst confirmed at 8:42 AM on 01/04/2024 that RN #1 was the nurse who applied restraints to Patient #8 on 03/11/2023. At 8:30 AM on 01/04/2024 CNO confirmed that RN #1 was not current on her restraint training when she applied the restraint on 03/11/2023. 4. Patient #9’s medical record was reviewed and revealed that Patient #9 was placed in leather restraints on 04/08/2023. IT Clinical Analyst confirmed at 8:56 AM on 01/04/2024 that RN #2 was the nurse who applied restraints to Patient #9 on 04/08/2023. At 8:30 AM on 01/04/2024 CNO confirmed that RN #2 was not current on her restraint training when she applied the restraint on 04/08/2023. 5. Patient #10’s medical record was reviewed and revealed that Patient #10 was placed in leather restraints on 08/12/2023. IT Clinical Analyst confirmed at 8:58 AM on 01/04/2024 that RN #3 was the nurse who applied restraints to Patient #10 on 08/12/2023. At 8:30 AM on 01/04/2024 CNO confirmed that RN #3 was not current on her restraint training when she applied the restraint on 08/12/2023.”