Bitterroot Health - Daly Hospital

“Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 485.623(d) for Critical Access Hospitals (CAHs), a life safety code survey was completed on 11/17/25. Under this regulatory requirement, the facility must meet the applicable provisions of the National Fire Protection Association’s (NFPA) 101 Life Safety Code, 2012 Edition, and those mandatory Codes referenced by that edition. The facility was surveyed specifically using Chapter 18 New Health Care Occupancies, Chapter 19 Existing Health Care Occupancies, and Chapter 38, New Business Occupancies of NFPA 101 where applicable. This survey added the dermatology/neurology building which is a separate business occupancy across the street from the hospital, since the last survey on 8/11/21. The hospital contains several two-hour fire barriers separating all additions added after original construction. The CAH is certified for 25 beds. The facility wings or buildings were separated as follows for this survey: Wing/Building NFPA Chapter Used: 01 Original Hospital 19 03 Nursing Services 19 04 North Inpatient Rooms 19 05 South Inpatient Rooms 19 06 Rehabilitation 19 07 Main Entrance/Radiology 19 08 Emergency Room 19 09 Swing Beds/ICU 19 10 Operating Room 18 11 Dermatology/Neurology 38 12 Laboratory 19 These requirements were not met as evidenced by the following deficiencies: Glossary NOC Night Operations Center (night shift)”

“Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 485.623(d) for Critical Access Hospitals (CAHs), a life safety code survey was completed on 11/17/25. Under this regulatory requirement, the facility must meet the applicable provisions of the National Fire Protection Association’s (NFPA) 101 Life Safety Code, 2012 Edition, and those mandatory Codes referenced by that edition. The facility was surveyed specifically using Chapter 18 New Health Care Occupancies, Chapter 19 Existing Health Care Occupancies, and Chapter 38, New Business Occupancies of NFPA 101 where applicable. This survey added the dermatology/neurology building which is a separate business occupancy across the street from the hospital, since the last survey on 8/11/21. The hospital contains several two-hour fire barriers separating all additions added after original construction. The CAH is certified for 25 beds. The facility wings or buildings were separated as follows for this survey: Wing/Building NFPA Chapter Used: 01 Original Hospital 19 03 Nursing Services 19 04 North Inpatient Rooms 19 05 South Inpatient Rooms 19 06 Rehabilitation 19 07 Main Entrance/Radiology 19 08 Emergency Room 19 09 Swing Beds/ICU 19 10 Operating Room 18 11 Dermatology/Neurology 38 12 Laboratory 19 These requirements were not met as evidenced by the following deficiencies: Glossary NOC Night Operations Center (night shift)”

“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: 32381 Based on observation and interview, the facility failed to ensure magnetic locking device doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side, in accordance with NFPA 101, 2012 Edition, Section 7.2.1.6.2. Findings include: 1. During an observation on 9/16/25 at 2:42 p.m., the surgical suite was inspected. In a corridor near some offices, there was a magnetically locked door going from the urgent care to the ER. The door was fitted with an access-controlled egress system, complete with a badge-in type unlocking system on the outside, and the motion sensing device and the push-to-exit button on the inside. The motion-sensing device was turned up toward the ceiling so it could not detect an approaching occupant. The motion-sensing device was also turned off and would not cut the power to the magnets, which kept the door shut. During an interview on 9/16/25 at 2:42 p.m., staff member B stated the motion device was opening the door every time it sensed a person, and it caused disruption to those working in the offices.”

“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: 32381 Based on observation, the facility failed to ensure access-controlled egress door assemblies met the requirements of NFPA 101, 2012 Edition, Section 7.2.1.6.2. Findings include: 1. During an observation on 9/16/25 at 3:42 p.m., the laboratory area was inspected. There was a set of cross-corridor doors leaving the lab area going to the ER, and the doors were magnetically locked. The door was fitted with an access-controlled egress system, complete with a manual release device with was mounted farther than 60 inches from the secured door opening.”

“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: 44769 Based on observation, the facility failed to ensure that all exit discharges were provided with a hard surface path to the public way. Per NFPA 101, 2012 Edition, Section 7.7.1. The findings include: 1. The exit discharge from the North Hall exit was inspected on 9/16/25 at 2:04 p.m. The discharge from the landing for the door had approximately 1.5 feet of concrete surface, and then ended, there was no hard surface path to the public way.”

“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: 32381 Based on observation the facility failed to maintain fire doors fully functioning in accordance with NFPA 101, 2012 Edition, Section 18.7.9 and NFPA 80, 2010 Edition Section 6.3.1.7.1. Findings include: During an observation on 9/16/25 at 2:43 p.m., the two-hour steel doors between the new surgical suite and the old hospital/endoscopy area were inspected. The gap between the two doors was approximately 1/4” when the doors were closed. The maximum allowable gap between fire doors in 1/8”.”

“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: 44769 Based on observation, the facility failed to ensure a hazardous area was separately maintained to prevent the passage of smoke from the hazardous area in accordance with NFPA 101-2012, Sections 19.3.2.1 and 19.3.2.1.2. Findings include: 1. During an observation on 9/16/25 at 2:44 p.m., the environmental services supply room was inspected. There was black tubing and black wiring going through an unsealed hole in the ceiling in two places.”

“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: 44769 Based on record review, the facility failed to maintain the wet chemical extinguishing system for the kitchen hood in accordance with NFPA 17A, 2009 Edition, Section 7.5.1. Findings include: 1. Review of the maintenance records on 9/16/25 showed the last hydro test on the main cylinder for the kitchen hood was completed in 2012 and was due in 2024.”

“Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: *Corridor is at least 6 feet wide. *Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols. *Dispensers shall have a minimum of 4 foot horizontal spacing. *Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room. *Storage in a single smoke compartment greater than five gallons complies with NFPA 30. *Dispensers are not installed within one inch of an ignition source. *Dispensers over carpeted floors are in sprinklered smoke compartments. *ABHR does not exceed 95 percent alcohol. *Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11). *ABHR is protected against inappropriate access. 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This Standard is not met as evidenced by: 44769 Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8). Findings include: 1. During an observation on 9/16/25 at 4:29 p.m., the reception area for the pain management clinic on the second story was inspected. An ABHR dispenser was installed within one inch over an ignition source (electrical outlet).”

“Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This Standard is not met as evidenced by: 44769 Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8). Findings include: 1. During an observation on 9/16/25 at 3:48 p.m., the lab employee breakroom was inspected. An ABHR dispenser was installed within one inch over an ignition source (light switch).”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to maintain all fire alarm systems in accordance with the standards of NFPA 72-2010, Section 10.5.5.2.1 - 10.5.5.2.4. Findings include: 1. During an observation on 9/16/25 at 2:55 p.m., the new fire alarm control panel (FACP) was inspected. The location of the electrical panel and breaker serving the FACP were not identified on the FACP. The two breakers identified in red were the old FACP and were labeled identifying the origin of the power.”

“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: 32381 Based on observation and record review, the facility failed to ensure proper sprinkler maintenance in accordance with NFPA 101-2012 and NFPA 25-2011, Sections 5.1.1.1 and Table 5.1.1.2. Findings include: 1. During an observation on 9/16/25 at 4:20 p.m., the ICU/Swing bed building was inspected. There was a sprinkler head near the storage room, which was choked with debris.”

“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: 32381 Based on observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 7.3.3.2. Findings include: 1. During an observation on 9/16/25 at 2:52 p.m., the endoscopy area was inspected. There was a portable extinguisher in the corridor, which was found to be missing the verification collar. The collar is required for all extinguishers which have undergone maintenance. The extinguisher had an initial manufacture date of 1996, so it has undergone several required maintenance dates.”

“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: 44769 Based on observation, the facility failed to maintain corridor doors in accordance with NFPA 101-2012, Section 7.2.1.4.1, and failed to maintain corridor doors to ensure a means suitable for keeping the doors closed in accordance with NFPA 101, 2012 Edition, Section 19.3.6.3.1 and 19.3.6.3.5. Findings include: 1. During an observation on 9/16/25 at 2:48 p.m., the main corridor door to the soiled linen room was exercised. The latch on the door was malfunctioning and would not catch the strike plate to latch the door.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 18.7.1.4 through 18.7.1.7 This Standard is not met as evidenced by: 44769 Based on interview and record review, the facility failed to document fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6. Findings include: 1. During a review of facility fire drills on 9/16/25 at 11:00 a.m., fire drill records reflected a missing NOC shift fire drill for the last quarter of 2024. 2. During an interview on 9/16/25 at 4:58 p.m., staff member B stated “we don’t have a 4th quarter fire drill for NOC shift.””

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 44769 Based on interview and record review, the facility failed to document fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6. Findings include: 1. During a review of facility fire drills on 9/16/25 at 11:00 a.m., fire drill records reflected a missing NOC shift fire drill for the last quarter of 2024. 2. During an interview on 9/16/25 at 4:58 p.m., staff member B stated “we don’t have a 4th quarter fire drill for NOC shift.””

“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: 32381 Based on observation, the facility failed to keep trash receptacles greater than 32 gallons in an area protected as hazardous in accordance with NFPA 101, 2012 Edition, Section 19.7.5.7.1. Findings include: 1. During an observation on 9/16/25 at 4:00 p.m., the two corridors were inspected. There was a large paper shred bin, which was greater than 32-gallons capacity, left in the corridor. Receptacles greater than 32-gallon capacity must be stored in a room with a self-closing door.”

“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: 32381 Based on record review, the facility failed to have evidence that the generator was being exercised under load 12 times a year for 30 minutes in accordance with NFPA 110 Standard for Emergency and Standby Power Systems, 2010 Edition, Sections 8.4.1 and 8.4.2.4. This deficiency affects the entire facility. Findings include: 1. Review of the emergency generator inspection records on 9/16/25, the generator documentation showed the monthly load tests were incomplete as some were missing from the record. As the generator is diesel, the facility may also use the option of performing an annual load test, in lieu of monthly tests. The last annual load test on the generator was in 2023.”