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Based on observation and interview, the provider failed to ensure the intensive care unit (ICU) doors to close and latched as required. Findings include:

1. Observation on 11/16/22 at 8:45 a.m. revealed the ICU rooms in the inpatient care unit had sliding glass corridor doors which were not able to close and latch.

Interview with the maintenance director at the time of the observation confirmed that finding. Interview with a nursing supervisor also present at the time of observation revealed she did not believe they were supposed to close and latch.

The deficiency had the potential to affect any occupant of the two ICU rooms.

Based on observation, testing, and interview, the provider failed to maintain a separation at two of seven stair enclosures (ending in radiology, and adjacent to cardiac rehabilitation) to the hospital. Findings include:

1. Observation on 11/16/22 at 10:30 a.m. revealed the fire sprinkler main serving the building was not fire sealed at the bottom level of the stair enclosure ending in radiology. Interview with the environmental services director at the time of the observation confirmed that condition.

2. Observation on 11/16/22 at 11:40 a.m. revealed the second level of the stair enclosure adjacent to cardiac rehabilitation had three 3-inch pipes which were not fire sealed. Interview with the environmental services director at the time of the observation confirmed that condition.

The deficiency had the potential to affect 100% of the two smoke compartment occupants.

Based on observation and interview, the provider failed to maintain a one-hour fire resistive enclosure for the abandoned laundry chute. Findings include:

1. Observation on 11/16/22 at 2:00 p.m. revealed the abandoned laundry chute originating in the second floor communications room and terminating in the housekeeping break room had a 2-inch by 5-inch hole in the masonry chute. Interview with the environmental services director at the time of the observation revealed he was unaware of the laundry chute, and unaware of the chute penetration.

The deficiency affected one of numerous requirements for protecting vertical openings.

Based on observation, document review, and interview, the provider failed to continuously maintain automatic sprinklers in reliable operating condition (replacement of system gauges). Findings include:

1. Observation of the sprinkler main control room on 11/16/22 at 10:30 a.m. revealed no gauge date on the surface of the system gauge. Document review on 11/16/22 at 3:30 p.m. revealed the required replacement of the gauge in 2015 had not occurred. Interview with the environmental services director at the time of the observation confirmed the finding.

Failure to continuously maintain the automatic sprinkler system as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous required tests for the automatic sprinkler system.

Ref: 2012 NFPA 101 Section 9.7.5, 2011 NFPA 25 Section 13.2.7.2

Based on observation and interview, the facility failed to provide a maintenance plan for piped medical gases as required.

Findings include:

1. Record review on 11/16/22 at 3:30 p.m. revealed a plan to provide a medical gas outlet and system maintenance was not available. Interview with the environmental services director and administration during the facility tour on 11/16/22 revealed no planning for maintenance or repair was available.

The deficiency could impact any patients within the hospital.

Based on observation and interview, the facility failed to protect medical gas storage as required. Large quantities of storage were found in an unvented room. Findings include:

1. Observation on 11/16/22 at 3:00 p.m. revealed greater than 6600 cubic feet of medical gas were stored in a small room off the receiving area. The maximum storage allowed in an unvented room (3000 cubic feet) was not maintained as required in this area.

The deficiency affected one of eight smoke compartments. The director of environmental services was not aware of the maximum amount of stored gas jrequirement.