Upper Connecticut Valley Hospital

“RADIOLOGY SERVICES CFR(s): §485.635(b)(3) Radiology services. Radiology services furnished by the CAH are provided by personnel qualified under State law, and do not expose CAH patients or personnel to radiation hazards. This Standard is not met as evidenced by: 47129 Based on record review and interview, the Critical Access Hospital (CAH) failed to check all staff regularly exposed to radiation for the level of radiation exposure in the Radiology Department. (Staff identifier is Staff C). Findings include: Interview on 3/17/26 at approximately 10:30 a.m. with Staff C (Radiology Technician) revealed that he/she had been working 3 days a week as a contracted staff member since August 2025 as an x-ray and computed tomography (CT) technician. Review on 3/17/25 of the Radiation Dosimetry Report from 7/1/25 to 9/30/25 and 10/1/25 to 12/31/25 revealed that Staff C was not listed on the report with results for radiation exposure monitoring by way of dosimetry badges. Interview on 3/17/26 at approximately 12:00 p.m. with Staff D (Director of Radiology) revealed that Staff C was not monitored by the hospital for radiation exposure. Interview on 3/18/26 at approximately 3:00 p.m. with Staff B (Director of Quality) confirmed that the CAH was not monitoring the level of radiation exposure for Staff C. Interview on 3/19/26 at approximately 12:50 p.m. with Staff C revealed that Staff C had not worn a dosimetry badge while working in the CAH’s Radiology Department. Review on 3/19/26 of the CAH’s policy titled, “Personnel Radiation Monitoring Services”, revised date 4/25, revealed, “...Each person is supplied with a cumulative dose type badge. Radiation badges are marked with the person’s first and last name. The starting date that the badge is to be placed in service is also marked on each device packet...”.”

“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: 40522 Based on interview and record review, the Critical Access Hospital (CAH) failed to document the flush and calibration procedure for the endoscope reprocessing for 3 of 3 months of cleaning and sterilization logs reviewed. Findings include: Review on 3/18/26 of the Scope Buddy (Endoscope Flushing Aid) log for endoscope reprocessing from January 2026 to March 2026 revealed missing documentation for verification and calibration procedure for the following dates: 1/27/26, 1/29/26, 2/12/26, and 3/12/26. Review on 3/18/26 of the High Level Disinfection (HLD) log for endoscope reprocessing from January 2026 through March 2026 revealed that endoscopes were disinfected on the following dates: On 1/27/26, four endoscopes were disinfected; On 1/29/26, eight endoscopes were disinfected; On 2/12/26, seven endoscopes were disinfected; and On 3/12/26, one endoscope was disinfected. Review on 3/18/26 of the patient procedure log for 6 months revealed that there were endoscopy procedures for the above mentioned dates. Interview on 3/18/26 at approximately 12:00 p.m. with Staff E (Central Sterile Technician) confirmed the above findings for January 2026. Staff E revealed that they would perform a dosing verification procedure of the Scope Buddy daily prior to use. Interview on 3/19/26 at approximately 8:30 a.m. with Staff F (Infection Preventionist) confirmed the above logs for February 2026 and March 2026. Review on 3/19/26 of the CAH’s policy titled, Cleaning of Flexible Endoscopes, revised date 4/2019, revealed “...Flexible endoscopes, accessories, and associated equipment will be visually inspected for cleanliness, integrity, and function before use, during the procedure, after the procedures, after cleaning, and before disinfection or sterilization...Endoscopic Flushing Aid: Scope Buddy Flow Validation Test: Daily prior to first use..Daily Service 2. Perform daily Quality Assurance Procedure 3. Document Quality Assurance Test Results using Daily Quality Assurance Log...Records related to flexible endoscope processing will include the date and time, identity...method and verification of cleaning and results of cleaning verification testing...”. Review on 3/19/26 of the Scope Buddy manufacturer’s instruction revealed “...Daily Maintenance At the start of each day...Perform Dosing Verification, If Dosing Verification fails, perform Dosing Calibration...Document results on SCOPE BUDDY PLUS Endoscope Flushing Aid Dosing Verification & Calibration Log...”.”

“42 CFR 485.623 K3 BUILDING: 101 K4 SURVEY DATE: 03/18/26 and 03/19/26 K5 Critical Access Hospital (CAH) K6 PLAN APPROVAL: 1970 K7 SURVEY UNDER: 2012 Existing Health Care Occupancies Type of Structure: The original one (1) story building with a partial basement was built in 1970, type I non-combustible fire resistant construction, with three (3) fire/smoke compartments on the main floor and one (1) smoke compartment in a partial basement area (under the Administration wing). A full remodel of the Emergency Department was completed in 2017 and a full Kitchen/Dinning room remodel was completed in 2021. The facility is equipped with a complete automatic sprinkler system (1 wet-type) providing full building sprinkler system coverage, and monitored by a Fire Alarm Control Panel (FACP) that is connected to a full time Fire Department. The effective Medicare Participation date was on: 04/01/2001. The facility was surveyed pursuant to the National Fire Protection Association (NFPA) 101 Life Safety Code, (2012 edition) Existing Healthcare Occupancies and NFPA 99 Health Facilities Code (2012 edition), as referenced in 42 CFR 485.623 Critical Access Hospital (CAH) Physical Plant and Environment on 03/18/26 and 03/19/26 with deficiencies cited.”

“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: 33306 NFPA 80 Standard for Fire Doors and Other Opening Protectives 4.2.1 Listed items shall be identified by a label. 4.2.2 Labels shall be applied in locations that are readily visible and convenient for identification by the AHJ after installation of the assembly. 4.2.3 The label or listing shall be considered evidence that sampling of such devices or materials have been evaluated by tests and that such devices or materials are produced under an in-plant, follow-up inspection programs. 5.2 Inspections 5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 5.2.4 Swinging Doors with Builders Hardware of Fire Door Hardware. 5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of the door assembly. 5.2.4.2 As a minimum, the following items shall be verified. (1) No open holes or breaks exist in the surface of the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7. (6) The self closing device is operational: that is, the active door completely closes when operated from the full open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. Based on observations and interview, it was determined the facility failed to ensure one (1) 90-minute fire-rated double door assembly, located within a two (2) hour fire-rated barrier, could automatically close to a full latched position (both door panels) when released from the full open position. The deficient practice could affect two (2) out of three (3) smoke compartments and an undermined number of staff and patients. The facility has the capacity for sixteen (16) beds and a current census of five (5) patients Findings include: Observations during tour on 03/18/26 between 2:00 p.m. and 2:30 p.m. with Staff A (Director of Facilities) and Staff B (Regional Director of Facilities) revealed the 90-minute fire-rated double door assembly, located in the main Hospital corridor, between the Ambulatory Nursing wing and the Laboratory services, and next to the corridor door labeled #111, failed to engage the upper and lower vertical locking/latching rods when the door assembly was in the full closed position. The fire door assembly was modified to install/accept an automatic door opening control system, disabling the locking/latching hardware. With the locking/latching hardware disconnected, the required minimum fire barrier door assembly rating, failed to be met. Interview on 03/18/26 between 2:00 p.m. and 2:30 p.m. with Staff A and Staff B confirmed the above findings, location, and existing 90-minute fire-rated door assembly operating and locking/latching conditions.”

“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: 33306 Based on observations and interview, it was determined the facility failed to ensure that two (2) storage room locations, in excess of fifty (50) sq. ft. and containing large quantities of combustible materials (defined as hazardous areas), were equipped with an automatic door closing device(s). The deficient practice could affect one (1) out of one (1) smoke compartments and an undetermined amount of staff (patient access is not allowed). The facility has the capacity for sixteen (16) beds and a current census of five (5) patients. Findings include: Observations during tour on 03/19/26 between 9:45 a.m. and 10:00 a.m. with Staff A (Director of Facilities) and Staff B (Regional Director of Facilities) revealed the following two (2) separate storage room locations, located in the staff only basement level area, under the administration wing, that failed to be equipped with an automatic door closing device(s): 1. The Medical records storage room, approximately 300 sq. ft. in size, located near the Staff Training Classroom, failed to have an automatic door closing device installed. 2. The storage/supply closet, approximately 144 sq. ft. in size, located near the Staff Training Classroom and the Medical Records storage room, failed to have an automatic door closing device installed. Interview on 03/19/26 between 9:45 a.m. and 10:00 a.m. with Staff A and Staff B confirmed the above findings, storage locations, and existing door closing conditions. Both of the doors in question were originally found in the closed and locked condition.”

“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: 33306 Based on observations and interview, it was determined the facility failed to ensure at least seven (7) locations with Alcohol Based Hand Sanitizer (ABHS) dispensers that were installed/mounted on the walls above a potential electrical ignition source. The deficient practice could affect two (2) out of three (3) smoke compartments and an undetermined amount of staff, patients and visitors. The facility has the capacity for sixteen (16) beds and a current census of five (5) patients. Findings include: Observations during tour on 03/18/26 and 03/19/26 (throughout the facility tour) with Staff A (Director of Facilities) and Staff B (Regional Director of Facilities) revealed the following seven (7) ABHS dispenser locations that were installed/mounted above an electrical ignition source: 1. An ABHS dispenser was mounted directly above the light switch, immediately inside the Treatment room (#2122) doorway. 2. An ABHS dispenser was mounted directly above the three (3) bank light switch, immediately inside the Treatment room (#100 A) doorway. 3. An ABHS dispenser was mounted directly above the light switch immediately inside the Treatment room (#2104) doorway. 4. An ABHS dispenser was mounted directly above the light switch immediately inside the Treatment room (#2105) doorway. 5. An ABHS dispenser was mounted directly above the light switch immediately inside the Emergency Department room (#5) doorway. 6. An ABHS dispenser was mounted directly above an electrical outlet, inside the Shredding room (#6208). 7. An ABHS dispenser was mounted directly above the blue Handicap, automatic door opening control button, located inside the Physical Therapy suite. Interview on 03/18/26 and 03/19/26 (through out the facility tour), with Staff A (Director of Facilities) and Staff B (Regional Director of Facilities) confirmed the above findings, installation locations, and existing electrical (locations) conditions.”

“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: 33306 NFPA 72 National Fire Alarm and Signaling Code (2010 edition) 14.4.5.3 In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7. 14.4.5.3.1 Sensitivity shall be checked within 1 year after installation. 14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3. 14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within it’s listed and marked sensitivity range, the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. 14.4.5.3.3.1 If the frequency is extended, records of nuisance alarms and subsequent trends of these alarms shall be maintained. 14.4.4.3.3.2 In zones or in areas where nuisance alarms show an increase over the previous year, calibration tests shall be performed. Based on record review and interview, it was determined the facility failed to have documentation of the Fire Alarm Control Panel (FACP) vendor’s previous (last) smoke detector sensitivity testing requirements. The deficient practice could affect four (4) out of four (4) smoke compartments and an undetermined amount of staff, patients, and visitors. The facility has the capacity for sixteen (16) beds and a current census of five (5) patients. Findings include: Record review during tour on 03/18/26 between 7:45 a.m. and 11:00 a.m. with Staff A (Director of Facilities) and Staff B (Regional Director of Facilities) revealed the FACP smoke detector sensitivity testing (facility wide) failed to be able to be verified for the previous testing cycle. The FACP was determined to not be an addressable FACP system, which requires a manual sensitivity testing procedure for each individual device. Observation during tour on 03/18/26 between 7:45 a.m. and 11:00 a.m. revealed here were no trouble or warning lights present on the FACP. Interview on 03/19/26 between 11:00 a.m. and 11:15 a.m. with Staff A and Staff B confirmed the above findings and professional fire alarm vendor/contractor documentation presented.”

“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: 33306 NFPA 10 Standard for Portable Fire Extinguishers (2010 edition) 7.1.1 Responsibility. The owner or designated agent or occupant of a property in which fire extinguishers are located shall be responsible for inspection, maintenance, and recharging. 7.1.2.3 Persons performing 31-day inspections shall not be required to be certified. 7.2.1.2 Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a maximum of 31-day intervals. Based on observations and interview, it was determined the facility failed to ensure one (1) 10 lb. ABC type fire extinguisher received monthly/annual inspections and testing procedures for the previous three (3) calendar years. The deficient practice could affect one (1) out of one (1) smoke compartments and an undetermined amount of staff (patient access is not allowed). The facility has the capacity for sixteen (16) beds and a current census of five (5) patients. Findings include: Observations during tour on 03/19/26 between 9:55 a.m. and 10:05 a.m. with Staff A (Director of Facilities) and Staff B (Regional Director of Facilities) revealed the 10 lb. ABC type fire extinguisher, located inside the basement level Medical Records storage room was last inspected/tested by a professional vendor in April 2023, according to the inspection card affixed to the extinguisher neck and failed to have monthly (31-day) inspections. The ABC fire extinguisher has been mounted inside the secured/locked Medical Records room without vendor/staff access. The fire extinguisher appeared to still be maintaining a full charge according to the attached pressure gauge. Interview on 03/19/26 between 9:55 a.m. and 10:05 a.m. with Staff A and Staff B confirmed the above findings, location, and existing inspection card documentation affixed to the extinguisher.”

“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: 33306 NFPA 101 Life Safety Code (2012 edition) 8.5 Smoke Barriers 8.5.2.1 Smoke barriers required by this code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. 8.5.2.2 Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces. 8.5.6.2 Penetrations for Cables. Cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall floor, or floor/ceiling assembly constructed as a smoke barrier, or a through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke. Based on observations and interview, it was determined the facility failed to ensure (facility identified) smoke/fire barrier walls are maintained to resist the passage of smoke and/or the effects from fire, above the suspended ceiling tiles, in the concealed spaces. The deficient practice could affect three (3) out of three (3) smoke compartments and an undetermined amount of staff, patients, and visitors. The facility has the capacity for sixteen (16) beds and a current census of five (5) patients. Findings include: Observations during tour on 03/19/26 between 11:00 a.m. and 2:00 p.m. with Staff A (Director of Facilities) and Staff B (Regional Director of Facilities) revealed the following unprotected penetrations through smoke/fire barrier wall locations: 1. There is an unprotected penetration through the 2-hour barrier wall, above the suspended ceiling tiles, located inside the Laboratory Services unit (East wall). The unprotected penetration is from a five (5”) inch waste pipe. 2. There are four (4) unprotected penetrations from round holes drilled (approximately 2” each) through the 2-hour barrier wall, above the suspended ceiling tiles, located in the Laboratory Services unit (South wall), next to the Blood draw room (as labeled on the floor plan). 3. There are multiple unprotected penetrations through the smoke barrier wall, above the suspended ceiling tiles, located above the Electrical distribution panel in the Administration corridor, near the reception desk wall. 4. There is an unprotected penetration through the 2-hour barrier wall, above the suspended ceiling tiles, located between the Central Sterile supply room and the main Hospital corridor. The unprotected penetration is from an orange, electric door control cable. 5. There is an unprotected penetration through the smoke barrier wall, above the suspended ceiling tiles, located in the Emergency Department walk-in waiting room. The unprotected penetration is from an orange, electric door control cable. 6. There is an unprotected penetration through the smoke barrier wall, above the suspended ceiling tiles, located in the Emergency Department walk-in waiting room (above the wall mounted television). The unprotected penetration is from two (2) flexible metal conduits (FMC). 7. There is an unprotected penetration through the smoke barrier wall, above the suspended ceiling tiles, located above the double door assembly between the main Hospital entrance corridor and the Emergency Department corridor. The unprotected penetration is from a bundle of cables with some of the fire stopping material removed. 8. There is an unprotected penetration through the 2-hour barrier wall, above the suspended ceiling tiles, located above the single door assembly between the Central Sterile corridor and the Nurses station. The unprotected penetration is from an orange, electric door control cable. Interview on 03/19/26 between 11:00 a.m. and 2:00 p.m. with Staff A and Staff B confirmed the above findings, locations, and the existing unprotected smoke/fire barrier penetrations that were discovered.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 33306 Based on observations and interview, it was determined the facility failed to ensure that at seven (7) or more doors, located within facility identified smoke barrier walls and/or compartments, were equipped to automatically close during an emergency alarm condition. The deficient practice could affect one two (2) out of three (3) smoke compartments and an undetermined amount of staff, patients, and visitors. The facility has the capacity for sixteen (16) beds and a census of five (5) patients. Findings include: Observations during tour on 03/19/26 between 7:45 a.m. and 12:45 p.m. with Staff A (Director of Facilities) and Staff B (Regional Director of Facilities) revealed the following seven (7) separate smoke barrier door locations (according to the facility provided Life Safety compartment floor plan): 1. The Quality Manager’s office door (#3148), located inside the Administration suite smoke compartment barrier wall, failed to be equipped with the required automatic door closing device. 2. The Administration office door (#3147), located inside the Administration suite smoke compartment barrier wall, failed to be equipped with the required automatic door closing device. 3. The Information Technologies (IT) department door, located inside the Administration suite smoke compartment barrier wall, failed to be equipped with the required automatic door closing device. 4. The Chapel door, located inside the Administration suite smoke compartment barrier wall, failed to be equipped with the required automatic door closing device. 5. The Food Service’s Manager’s door, located inside the Dinning room/Main Kitchen suite smoke compartment barrier wall, failed to be equipped with the required automatic door closing device. 6. The cross corridor door, located between the Safety Director’s office and the Food Services Manger’s office and inside the Dinning room/Main Kitchen suite smoke compartment barrier wall, failed to be equipped with the required automatic door closing device. 7. The smoke barrier door assembly, located between the main Hospital registration desk and the Emergency Room registration office, failed to be equipped with the required automatic door closing device. Interview on 03/19/26 between 7:45 a.m. and 12:45 p.m. with Staff A and Staff B confirmed the above findings, existing locations, and the facility identified smoke barrier wall locations.”

“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: 33306 Based on record review and interview, it was determined the facility failed to ensure fire drills are conducted on a quarterly basis for each shift and failed to conduct fire drills at unexpected and varying times. The facility has two (2) 12-hour working shifts. The deficient practice could affect three (3) out of three (3) smoke compartments and an undetermined amount of staff, patients, and visitors. The facility has the capacity for sixteen (16) beds and a current census of five (5) patients. Findings include: Record review during tour on 03/18/26 between 7:45 a.m. and 11:00 a.m. with Staff A (Director of Facilities) and Staff B (Regional Director of Facilities) revealed the fire drill documents and signature sheets for the previous two (2) calendar years failed to contain three (3) required quarterly fire drills. The fire drill dates and consistent times that were documented/presented are as follows: First shift 6:00 a.m. - 6:00 p.m. 1st quarter 2024 not conducted 05/07/24 7:00 a.m. 05/06/24 2:00 p.m. 08/07/24 7:03 p.m. 08/26/24 3:15 p.m. 12/03/24 3:00 p.m. 03/12/25 4:00 p.m. 06/24/25 1:55 p.m. 09/26/25 7:59 p.m. 12/17/25 1:15 p.m. Second shift 6:00 p.m. - 6:00 a.m. 1st quarter 2024 not conducted 05/07/24 6:00 p.m. 08/07/24 7:45 p.m. 12/30/24 7:00 p.m. 03/19/25 6:34 p.m. 06/25/25 6:32 p.m. 09/26/25 7:49 p.m. 4th quarter 2025 not conducted Interview on 03/18/26 between 11:00 a.m. and 11:15 a.m. with Staff A and Staff B confirmed the above findings and available fire drill documentation for each shift.”

“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: 33306 GFCI (Ground Fault Circuit Interrupter) outlets should be tested regularly, at least monthly, to ensure they are functioning properly and protecting against electrical hazards. The testing procedure involves pressing the “test” button on the GFCI, which should interrupt the power, and then pressing the “reset” button to restore power. If the GFCI fails to trip when the test button is pressed, it needs to be replaced. Here’s a more detailed breakdown: 1. Regular Testing: GFCI outlets should be tested at least once a month, and more frequently in areas with high usage or where water is present. Portable GFCI units should be tested before each use. Testing helps ensure the GFCI is operational and can quickly interrupt power in case of a ground fault. 2. Testing Procedure: Step 1: Reset Button: Press the reset button to restore power to the outlet. Step 2: Plug in Device: Plug in a low-wattage device, like a lamp or nightlight, to verify the outlet is working. Step 3: Press Test Button: Press the test button on the GFCI. Step 4: Check for Power Interruption: The device plugged into the outlet should turn off when the test button is pressed. Step 5: Reset Button (Again): Press the reset button again to restore power to the outlet. Step 6: Check for Power Return: The device plugged in should turn back on. Based on record review and interview, it was determined the facility failed to ensure GFCI (Ground Fault Circuit Interrupter) outlets were tested, reset and documented on a monthly basis instead of on a quarterly basis. The deficient practice could affect four (4) out of four (4) smoke compartments and an undetermined amount of staff, patients and visitors. The facility has the capacity for sixteen (16) beds and a current census of five (5) patients. Findings include: Record review during tour on 03/18/26 between 7:45 a.m. and 11:00 a.m. with Staff A (Director of Facilities) and Staff B (Regional Director of Facilities) revealed the GFCI electrical outlets, located throughout the Hospital, failed to be tested and documented on a monthly basis. Interview on 03/18/26 between 11:00 a.m. and 11:15 a.m. with Staff A and Staff B confirmed the above findings and available GFCI inspection documents.”