Cottage Hospital

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 47129 Based on interview and record review, the Critical Access Hospital (CAH) failed to ensure that supplies commonly used in life-saving procedures are available for patient use in the emergency department. Findings include: Observation on 5/19/26 at approximately 1:00 p.m. during tour of the emergency department revealed the following supplies in the pediatric code cart to be expired: Two (2) packages of Zoll, Pedi-Padz, pediatric electrodes with an expiration date of 8/10/25. Two (2) packages of Medline MedGel, pediatric, small adult ECG (electrocardiogram) electrodes with an expiration date of 4/27/26. One (1) pediatric manual resuscitator kit with pediatric mask, tube reservoir and 7 foot oxygen tubing, with an expiration date of 1/17/24. Interview on 5/19/26 at approximately 1:05 p.m. with Staff E (Director of Emergency department confirmed the above electrodes and pediatric manual resuscitator kit were expired.”

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 43002 Based on observation, interview, and record review, the Critical Access Hospital (CAH) failed to ensure that patient care equipment was maintained in safe operating condition in 1 of 1 out-patient setting visited and 1 of 1 Emergency Department observed. Findings include: Review on 5/20/26 of the facility’s policy titled “Medical Equipment Management Plan” last approved on 6/2025 revealed, “... Medical Equipment Management Plan 1. This program is designed to assure continual availability of safe, effective equipment through a program of planned maintenance, timely repair, ongoing education and training, and evaluation of all events that could have an adverse impact on the safety of patients, visitors and staff. 2. Medical equipment is defined as any item that comes in contact with patients, whether electric or battery operated that provides a therapeutic or diagnostic function in patient care ... Equipment Tracking 1. All medical equipment ... will be logged centrally ... 6. When the patient care equipment arrives at the hospital the equipment will be labeled with appropriate asset indicators and added to the appropriate database ... 7. The Biomedical Equipment Technician ... implements and maintains an in-house maintenance program which tracks repairs and maintenance of each piece of equipment by either the original manufacturer, TSP [Technical Service Partnership], or designated third party provider ...10. All equipment received is screened at the time of delivery, prior to being used. 11. TSP will manage all patient care equipment including the performance of annual electrical safety ...” Out-Patient Rehabilitation Back Gym Observation on 5/19/26 at 1:35 p.m. of the facility’s Out-Patient Rehabilitation Back Gym area revealed a Korebalance-Kinesthetic Ability Trainer (a computerized balance assessment and training system to improve stability, coordination, and posture) that did not have a sticker that it had been inspected and evaluated. Interview on 5/19/26 at 1:35 p.m. with Staff C (Senior Director of Outpatient Practices) confirmed the above. Review on 5/21/26 of the facility’s Equipment Inventory for the Korebalance revealed that it had been purchased by the facility 6/16/2017. Review on 5/21/26 of the Technical Service Manual for the Korebalance, provider by the facility, revealed, “ ... Annually, the entire Korebalance product should be checked to ensure all fasteners, stand-offs, and parts are in place and secure ...” Interview on 5/21/26 at 11:45 a.m. with Staff D (Director of Facilities) revealed that Korebalance had not been included in the annual maintenance program and confirmed that it had not had an inspection or preventative maintenance. 47129 Emergency Department Observation on 5/19/26 at approximately 1:00 p.m. during the emergency department tour revealed the following: Five (5) Welch Allen Sure Temp Plus Thermometers secured on the walls outside of the patient rooms. There was no indication that the thermometers were being maintained. Seven (7) Welch Allen Diagnostic Systems, Wall Transformer located in each of the patient rooms. There was no indication that the diagnostic systems were being maintained. Interview on 5/19/26 at approximately 1:00 p.m. with Staff E (Director of Emergency Department) Confirmed the above findings. Review on 5/21/26 of service manual for the Welch Allyn, Sure Temp Plus 690 znd 692 Series, revealed, “ ... 3.1 Six- Month Maintenance: Units that are in service on a regular basis should have the following preventative maintenance performed every six months: 1. Visually inspect the thermometer for any physical damage that might cause future product failure. 2. Clean the unit per instructions in the Operator’s Manual supplied with the thermometer and/or per the the instructions below. 3.2 Twelve Month Maintenance: For units in service on a regular basis, perform the Power-On Self Test and Model 9600 or 9600 Plus Calibration Testing procedure every 12 months...” Review on 5/21/26 of the user manual for the Welch Allyn 767 Diagnostic System, Wall Transformer, revealed, “ ... Maintenance Like any other piece of electrical equipment, periodic electrical inspection should be performed by qualified personnel. Welch Allyn recommends inspections every six months, more often if used under adverse conditions...” Interview on 5/21/26 at 10:45 a.m. with Staff D revealed the thermometers and the diagnostic system had not been included in the maintenance program inventory list and confirmed they had not had an inspection or maintained per the manufacturer’s instructions. .”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 43002 Based on interview and record review, the Critical Access Hospital (CAH) failed to ensure accurate records and disposition of scheduled medication. Findings include: Interview on 5/20/26 at approximately 10:00 a.m. with Staff F (Director of Pharmacy) revealed that they do not review the automated dispensing machine overrides. Review on 5/21/26 of the facility’s policy “Pyxis: Automated Drug Distribution Policy” last approved 7/2025 revealed, “... IV. Override Function... Pharmacy will review the Pyxis [an automated dispensing machine] override report to ensure the override was appropriate...” Interview on 5/21/26 at 11:30 a.m. with Staff G (Director of Quality) confirmed that they do not review the automated dispensing machine overrides.”

“NURSING SERVICES CFR(s): A nursing care plan must be developed and kept current for each inpatient. This Standard is not met as evidenced by: 43002 Based on interview and record review, the CAH failed to develop nursing care plans based on the patient’s care needs for 7 of 20 inpatient records reviewed (Patient identifiers are #2, #4, #6, #8, #9, #10, and #11). Findings include: Patient #2 Review on 5/20/26 of Patient #2’s History and Physical dated 5/18/26 revealed that Patient #2 was admitted to the Critical Access Hospital (CAH) for gallstones and chronic pain. Review on 5/20/26 of Patient #2’s System Assessment revealed that on 5/18/26, Patient #2 was assessed to be at risk for pain and falls. Review on 5/20/26 of Patient #2’s Interdisciplinary Care Plan revealed a care plan for skin integrity. There was no other care plan developed for pain or falls. Interview on 5/21/26 at 8:30 a.m. with Staff A (Chief Nursing Officer) confirmed that Patient #2 did not have a care plan pain or falls. Patient #4 Review on 5/20/26 of Patient #4’s History and Physical dated 5/17/26 revealed that the patient was admitted to the Critical Access Hospital (CAH) for acute hypoxic respiratory failure, sepsis and pneumonia. Review on 5/20/26 of Patient #4’s Interdisciplinary Care Plan revealed a care plan for falls. There was no other care plan developed for infection or respiratory. Interview on 5/21/26 at 8:50 a.m. with Staff A confirmed the above. Patient #6 Review on 5/20/26 of Patient #6’s History and Physical dated 5/19/26 revealed that the patient was admitted to observation to the CAH for a urinary tract infection. Review on 5/20/26 of Patient #6’s Interdisciplinary Care Plan revealed a care plan for falls. There was no other care plan developed for infection. Interview on 5/21/26 at 9:00 a.m. with Staff A confirmed the above. Patient #8 Review on 5/21/26 of Patient #8’s History and Physical dated 5/1/26 revealed that the patient was admitted to the CAH for acute hypoxic respiratory failure. Review on 5/21/26 of Patient #8’s Interdisciplinary Care Plan revealed that no care plans had been developed for Patient #8. Interview on 5/21/26 at 9:30 a.m. with Staff A confirmed the above. Patient #9 Review on 5/21/26 of Patient #9’s History and Physical dated 3/26/26 revealed that the patient was admitted to the CAH for bacteremia and was on antibiotics. Review on 5/21/26 of Patient #9’s Interdisciplinary Care Plan revealed a care plan for falls. There was no other care plan developed for infection. Interview on 5/21/26 at 9:15 a.m. with Staff A confirmed the above. Patient #10 Review on 5/21/26 of Patient #10’s History and Physical dated 4/14/26 revealed that Patient #10 was admitted to the CAH for a pelvic ring fracture. Review on 5/21/26 of Patient #10 Interdisciplinary Care Plan revealed that no care plans had been developed for Patient #10. Interview on 5/21/26 at 9:55 a.m. with Staff A confirmed the above. Patient #11 Review on 5/21/26 of Patient #11’s History and Physical dated 3/16/26 revealed that Patient #11 was admitted to the CAH for Rhabdomyolysis. Review on 5/21/26 of Patient #11’s Interdisciplinary Care Plan revealed a care plan for falls. There was no other care plan developed that addressed rhabdomyolysis. Interview on 5/21/26 at 10:05 a.m. with Staff A confirmed the above. Review on 5/21/26 of the facility’s policy, “Nursing Standards of Care - Medical/Surgical Unit”, effective 6/2025, revealed “...C. RN and patient work together to develop a plan of care that precribed strategies and intervention to attain expected outcomes related to the care of the criticallty ill patient...” Interview on 5/21/26 at 8:20 a.m. with Staff A revealed that care plans should be developed based on the admission assessment. 47129”

“RECORDS SYSTEM CFR(s): The records are legible, complete, accurately documented, readily accessible, and systematically organized. This Standard is not met as evidenced by: 43002 Based on interview and record review, the Critical Access Hospital (CAH) failed to ensure that records were complete and accurate for 4 of 20 inpatient records reviewed (Patient identifiers are #2, #8, #10 and #14), for 1 of 4 outpatient records reviewed (Patient identifier is #21), and for 1 of 20 patient emergency department records reviewed (Patient identifier is #39). Findings include: Inpatients: Patient #2 Review on 5/21/26 of Patient #2’s medical record revealed that Patient #2 was admitted to the CAH on 5/18/26 as an inpatient status patient. Further review revealed no documentation that a “General/Annual” consent to treat was completed and signed by Patient #2 at admission or an annual consent on file or that Patient #2 received or acknowledged that he/she had received a copy of patient rights information. Interview on 5/21/26 at 8:30 a.m. with Staff A (Chief Nursing Officer (CNO)) confirmed that Patient #2 did not have a consent to treat completed upon admission on 5/18/26 or on file and there was no acknowledgement that Patient #2 received a copy of patient rights information. Patient #8 Review on 5/21/26 of Patient #8’s medical record revealed that Patient #8 was admitted to the CAH on 5/1/26 as an inpatient status patient. Further review revealed no documentation that a “General/Annual” consent to treat was completed and signed by Patient #8 at admisson or that Patient #8 reveived or acknowledged that he/she had received a copy of Patient Rights information. Interview on 5/21/26 at 9:30 a.m. with Staff A confirmed the above. Patient #10 Review on 5/21/26 of Patient #10’s medical record revealed that Patient #10 was admitted to the CAH on 4/10/16 and then admitted to “Swing” status on 4/14/26. Further review revealed no documentation that a “General/Annual” consent to treat was completed and signed by Patient #10 or that he/she received or acknowledged that they had received a copy of Patient Rights information. Interview on 5/21/26 at 9:50 a.m. with Staff A confirmed the above. Patient #14 Review on 5/20/26 of Patient #14’s medical record revealed a Discharge Summary dated 1/15/26 that Patient #14 had expired on 1/15/26. Further review revealed that there was no documentation of pronouncement of death, including a time of death or who pronounced. Interview on 5/20/26 at 3:15 p.m. with Staff H (Registered Nurse (RN) revealed that they had been the RN who had assessed and pronounced Patient #14’s death. Staff H confirmed that they did not document in Patient #14’s medical record their assessment/prounouncement of the patient’s death. Review on 5/21/26 of the facilty’s policy titled “Development and Content of Cottage Hospital Record” last approved 6/2025, revealed, “...Policy... hospital maintains medical records, which are complete, accurate and teimly, with documentation of pertinent facts and observations... 4. Informed Consent. There shall be evidence of appropriate informed consent. When consent is not available, the reason shall be entered in the record... 7. Clinical Observation... The medical record shall also contain clinical observations recorded by Nurses... 8. Other Reports... In the event of death, a summation statement which includes, as appropriate, the same elements contained in the discharge summary, is added to the medical record...” Outpatient: Patient #21 Review on 5/21/26 of Patient #21’s medical record revealed that Patient #21 had an outpatient appointment for Urology services on 5/4/26 for a chief complaint of retention and there was no “General/Annual consent to treat was completed, signed, or on file for Patient #21. Further review revealed that Patient #21 was roomed by a medical assistant and a bladder scan was performed. There was no signed provider note for the 5/4/26 visit that included pertinent medical history, a patient assessment, a summary of the visit, and plan of care. Interview on 5/21/26 at 2:20 p.m. with Staff C (Senior Director of Outpatient Practices) confirmed that there was no consent to treatment for Patient #21 and that there was no provider note for the 5/4/26 urology appointment. Staff C stated the provider had 72 hours after the appointment to complete and sign a progress note per the medical staff rules and regulations. Review on 5/21/26 of the facility’s policy “Consents”, last revised 4/2025, revealed, “ ...Policy: A. Patient Rights - Patient’s have the right to be free from non-consensual touching or medical treatment Patients have the right to be advised about the risks, benefits, and alternatives of a proposed treatment or procedure, to be fully informed by a HCP regarding the patient’s healthcare needs and medical condition, and to decide whether to accept (or refuse) any treatment or procedure ... Procedures: ...C. When the patient’s consent shall be obtained: 1. General/Annual Consent - shall be obtained upon the patient’s admission to the inpatient or outpatient setting. (Appendix A) general consent need only be obtained once during an inpatient episode of care. For example, if the patients presents at the emergency department and is thereafter admitted as an inpatient, the general/annual consent must be on file or obtained at the time of the admission ...” Emergency Department: Patient #39 Review on 5/20/26 of Patient #39’s medical record revealed a provider progress note, dated 2/13/26, that documented that Patient #39 had presented to the CAH emergency department with suicidal ideation. Patient #39 was evaluated and transferred to an acute hospital for inpatient psychiatric treatment. Review further revealed that there was no documentation of the accepting provider at the acute hospital, the mode of transport, or the risks and benefits of the transfer for Patient #39. Interview on 5/20/26 with Staff A confirmed that there was no documentation of the accepting provider at the acute hospital, the mode of transport, or the risks and benefits of the transfer for Patient #39. Review on 5/21/26 of the facility’s policy “Transfer Policy”, effective date 2/2026, revealed, “ ...3e. The physician certification that documents that the benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the risk of a transfer ... 6a ... The transferring hospital must document its communication with the receiving hospital, include the date and time of the transfer request and the name of the person accepting the transfer.””

“42 CFR 485.623 (a-d) K-3 BUILDING: 0101 K-4 SURVEY DATES: 05/19/26 through 05/20/26 K-5 Critical Access Hospital (CAH) K-6 PLAN APPROVAL: Original Building 1959, two additions in 1970, one addition in 1985, one addition in 1996, one addition in 2024 K-7 SURVEY UNDER: NFPA 101 Life Safety Code, 2012 Edition, Existing Health Care Occupancies Type of Structure: The original one (1) story building with a partial basement was constructed prior to opening in 1959 and has undergone multiple additions, upgrades and remodels to represent it’s current configuration. The building construction is type I (332) non-combustible construction with a total of eight (8) smoke compartments throughout the entire facility. The facility is protected by three (3) sprinkler systems (2 wet-type and 1 dry-type) providing complete facility coverage. The facility is monitored by an addressable Fire Alarm Control Panel (FACP) that is connected to the Fire Department and a full time monitoring agency. The facility provides medical services to a rural community and has the capacity for 35 beds. The effective Medicare participation date was on 06/01/2001. The facility was surveyed on 05/19/26 through 05/20/26 pursuant to the applicable provisions of National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 edition, as referenced in Requirements 42 CFR Part 485.623 (a-d) Physical Plant and Environment, for Critical Access Hospitals (CAH) with deficiencies cited.”

“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: 33306 NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (2011 edition) 11.4 Inspection for Grease Buildup. 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 table 11.4. Table 11.4 Volume of Cooking Inspection Frequency Solid fuel cooking Monthly 24-Hour cooking Quarterly Moderate volume Semi-annual Low Volume Annually 11.6.1 Upon inspection, if the exhaust system is found to be contaminated with deposits from grease-laden vapors, the contaminated portions of the exhaust system shall be cleaned by a properly trained, qualified, and certified person(s) acceptable to the AHJ. 11.6.2 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to remove combustible contaminants prior to the surfaces becoming heavily contaminated with grease or oily sludge. Based on record review and interview, it was determined the facility failed to ensure documentation of the professional vendors’ semi-annual commercial exhaust hood cleaning was available for review and confirmation. The deficient practice could affect one (1) out of eight (8) smoke compartments and an undetermined number of staff, patients, and visitors. Findings include: Record review during tour on 05/19/26 between 9:30 a.m. and 12:30 a.m. with Staff A (Director of Facilities) revealed the following semi-annual commercial exhaust hood cleaning reports provided by a professional vendor that were available for review: 05/05/26 (completed and reviewed) 11/12/25 (completed and reviewed) Spring 2025 failed to be located Fall 2024 failed to be located Spring 2024 failed to be located 10/25/23 (completed and reviewed) Spring 2023 failed to be located Interview on 05/20/26 between 2:45 p.m. and 3:15 p.m. with Staff A confirmed the above findings and available documentation.”

“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 Alcohol Based Hand Sanitizer (ABHS) dispensers were not placed within 48” of each other. The deficient practice could affect one (1) out of eight (8) smoke compartments and an undetermined number of staff, patients, and visitors. Findings include: Observations during tour on 05/20/26 between 10:30 a.m. and 11:00 a.m. with Staff A (Director of Facilities) revealed three (3) Alcohol Based Hand Sanitizer Dispensers were mounted and in use within 48” of each other. One dispenser was mounted on the corridor wall between patient room # 202 and # 204 with one dispenser mounted directly inside each room’s doorway, approximately under 36” apart from each other. Interview on 05/20/26 between 10:45 a.m. and 11:00 a.m. with Staff A confirmed the above findings, conditions, and existing locations.”

“Fire Alarm System - Notification CFR(s): NFPA 101 Fire Alarm - Notification 2012 EXISTING Positive alarm sequence in accordance with 9.6.3.4 are permitted in buildings protected throughout by a sprinkler system. Occupant notification is provided automatically in accordance with 9.6.3 by audible and visual signals. In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire. 19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, 9.6.4, 9.7.1.1(1) This Standard is not met as evidenced by: 33306 NFPA 101 Life Safety Code (2012 Edition) 9.6.3 Occupant Notification. 9.6.3.1 Occupant notification shall be provided to alert occupants of a fire or other emergency where required by other sections of the code. 9.6.3.2 Occupant notifications shall be in accordance with 9.6.3.3 through 9.6.3.10.2 unless otherwise provided in 9.6.3.2.1 through 9.6.3.2.4. 9.6.3.5 Unless otherwise provided in 9.6.3.5.1 through 9.6.3.5.8 notification signals for occupants to evacuate shall be audible and visible signals in accordance with NFPA 72 National Fire Alarm and Signaling Code, and ICC/ANSI A 117.1 American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction (AHJ) shall be provided. 9.6.3.7 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level that exists under normal conditions of occupancy. 9.6.3.8 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in a given building. Based on observations and interview, it was determined the facility failed to ensure four (4) locations, where occupants (Staff and professional vendor access only) may be present but audible and visible alarm notification appliances were not installed. Findings include: Observations during tour on 05/20/26 between 11:00 a.m. and 2:00 p.m. with Staff A (Director of Facilities) revealed the partial basement mechanical rooms and maintenance/storage departments, as well as two (2) rooftop (penthouse) mechanical rooms failed to be equipped with any fire alarm visual/audible notification devices to indicate a potential fire emergency. The four (4) mentioned areas are commonly occupied by Hospital Staff and professional service vendors that would not have any way to know if the Fire Alarm system was activated. Interview on 05/20/26 between 11:00 a.m. and 2:00 p.m. with Staff A confirmed the above findings, locations, and existing conditions but never realized the missing notification devices in these specific areas.”

“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* Testing Frequency. Unless otherwise permitted by other sections of this code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction. A 14.4.5 It is suggested that the annual test be conducted in segments so that all devices are tested annually. The intent of 14.4.5 is to prevent a test from being made at intervals exceeding those allowed by Table 14.4.5. Annual tests shall be made every 12 months; monthly tests should be made every 30-days, and so forth. Table 14.4.5 section frequency (1) FACP (Fire Alarm Control Panels) annually (6) Batteries semi-annual (15) (b) Door holders annually (15) (e) Heat detectors annually (15) (j) Smoke detectors annually (20) (a) Audible devices annually (c) Visible devices annually 14.6.2.4 A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4: (1) Date (2) Test frequency (3) Name of Property (4) Address (5) Name of the person performing the inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone. (6) Name, address, and representative of approving agency(ies) (7) Designation of the detector(s) tested (8) Functional test of detectors (9) Functional test of required sequence of operation (10) Check of all smoke detectors (11) loop resistance for all fixed temperature, line-type heat detectors (12) Functional test of mass notification system control units (13) Functional test of signal transmission to mass notification systems (14) Functional test of ability of mass notification system to silence fire alarm notification appliances (15) Tests of intelligibility of mass notification system speakers (16) Other tests as required by the equipment manufacturers published instructions (17) Other tests as required by the Authority Having Jurisdiction (18) Signatures of tester and approved authority representative (19) Disposition of problems identified during tests (e.g. system owner notified, problem corrected / successfully re-tested / device abandoned in place) Based on record review, observations and interview, it was determined the facility failed to ensure identified fire alarm emergency backup batteries are maintained in an operational and functional condition. Identified Fire Alarm Control Panel (FACP) battery deficiencies failed to be corrected in a timely manner. The deficient practice could affect eight (8) out of eight (8) smoke compartments and all staff, patients, and visitors. The facility has the capacity for 35 beds. Findings include: Record review during tour on 05/19/26 between 9:30 a.m. and 12:30 p.m. with Staff A (Director of Facilities) revealed the following professional Fire Alarm vendor reports that identified multiple emergency back-up battery testing failures that need to be corrected: Inspection report dated: 02/26/26 lists “booster batteries #2, #3, #4, #5, and #6 failed testing and need to be replaced.” Inspection report dated: 09/12/25 lists “booster batteries #2, #4, and #7 failed testing and need to be replaced.” Inspection report dated: 02/26/25 lists “booster batteries #2, #4, and #7 failed testing and need to be replaced.” Interview and observations on 05/20/26 between 1:30 p.m. and 1:45 p.m. with Staff A confirmed the above findings and that not all the failed batteries have been replaced. The Fire Alarm Control Panel devices are additionally covered by an emergency generator.”

“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: 33306 NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (2011 Edition) 5.1.1 Minimum Requirements. 5.1.1.1 This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. 5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. TABLE 5.1.1.2 Summary of Sprinkler System Inspection 5.2.5 Water-flow Alarm and Supervisory Devices. Water-flow alarm and supervisory alarm devices shall be inspected quarterly to verify that they are free from physical damage. 5.3.3.1 Mechanical water-flow alarm devices, including but not limited to, water motor gongs, shall be tested quarterly. 5.2 Inspection 5.2..1 Sprinklers 5.2.1.1 Sprinklers shall be inspected from the floor level annually. 5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation. 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5) Loading (6) Painting unless painted by the sprinkler manufacturer Based on observations, record review and interview, it was determined the facility failed to ensure that at least three sprinkler heads have maintained fluid in the glass bulb heat response element and one required quarterly inspection failed to be conducted for (approximately) November 2025. The deficient practice could affect eight (8) out of eight (8) smoke compartments and all staff, patients, and visitors. The facility has the capacity for 35 beds. Findings include: Observations during tour on 05/19/26 between 1:30 p.m. and 1:45 p.m. with Staff A (Director of Facilities) revealed the three (3) sprinkler heads, located in the main corridor between the Administration wing and the Hospital, were found to have lost the fluid in the glass bulb heat response element. Additionally, the professional sprinkler vendor reports that were presented, were dated: 02/10/26 and 08/21/25, almost six (6) months between professional quarterly (required) testing and inspections. Interview on 05/20/26 between 2:45 p.m. and 3:00 p.m. with Staff A confirmed the above findings, locations, and available sprinkler documentation.”

“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 are tested on a monthly basis. The deficient practice could affect eight (8) out of eight (8) smoke compartments and all staff, patients, and visitors. The facility has the capacity for 35 beds. Findings include: Record review during tour on 05/19/26 between 9:30 a.m. and 12:30 p.m. Staff A (Director of Facilities) revealed the facility is conducting GFCI (Ground Fault Circuit Interrupter) testing on a semi-annual basis in March and September each calendar year (documented) but failed to do the GFCI testing on a monthly basis. Interview on 05/20/26 between 2:45 p.m. and 3:15 p.m. with Staff A confirmed the above findings, testing frequencies, and available documentation.”

“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: 33306 NFPA 110 Standard for Emergency and Standby Power Systems (2010 edition) 8.3.7 Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturers specifications. 8.3.7.1 Maintenance of lead acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted. 8.3.7.2 Defective batteries shall be replaced immediately upon discovery of defects. 8.4.9 Level 1 Emergency Power Standby Systems (EPSS) shall be tested at least once within every 36-months. 8.4.9.1 Level 1 EPSS shall be tested continuously for the duration of it’s assigned class. 8.4.9.2 Where the assigned class is greater than 4-hours, it shall be permitted to terminate the test after 4 continuous hours. 8.4.9.3 The test shall be initiated by operating at least one transfer switch test function and then by operating the test function of all remaining Automatic Transfer Switch’s (ATS), or by opening all switches or breakers supplying normal power to all ATS’s that are part of the EPSS being tested. 8.4.9.5.1 For a diesel powered EPS, loading shall not be less than 30 percent of the nameplate kW rating of the EPS. A supplemental load bank shall be permitted to be used to meet or exceed the 30 percent requirement. 8.4.9.6 The test required in 8.4.9 shall be permitted to be combined with one of the monthly tests required by 8.4.2 and one of the annual tests required by 8.4.2.3 as a single test. 8.4.9.7 Where the test required in 8.4.9 is combined with the annual load bank test, the first 3 hours shall be at not less than the minimum loading required by 8.4.9.5 and the remaining hour shall be at not less than 75 percent of the nameplate kW rating of the EPS. Based on record review and interview, it was determined the facility failed to ensure the emergency Generator received a 4-hour load bank test/exercise at least every 36-months, and failed to test/document the Generator starting batteries on a monthly basis. The deficient practice could affect eight (8) out of eight (8) smoke compartments and an undetermined number of staff, patients, and visitors. The facility has the capacity for 35 beds. Findings include: Record review during tour on 05/19/26 between 9:30 a.m. and 12:30 p.m. with Staff A (Director of Facilities) revealed the emergency Generator received a 4-hour test/exercise with only the available building load during a monthly exercise. The actual 4-hour load bank test (professional vendor task) documentation failed to be available for at least the previous 42-month period. The facilities Emergency Generator is equipped with sealed lead-acid batteries and require’s monthly electrolyte specific gravity testing documented on the monthly load test forms. Interview on 05/20/26 between 2:45 p.m. and 3:15 p.m. with Staff A confirmed the above findings and available vendor inspection/testing documentation.”