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Based on observation the facility failed to maintain the enclosed stairwell enclosure and emergency exit with a 1.5-hour fire-rated door. Failing to maintain fire barriers could allow a fire to spread more rapidly through the two-hour fire barrier and give residents less time to evacuate the building.

NFPA 101 Life Safety Code, 2012, Chapter 7, Sub-Section 7.2.2.5.1.1. All inside stairs serving as an exit or exit component shall be enclosed in accordance with Section 7.1.3.2 Exits, Sub-Section 7.1.3.2.1. Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following:
(1)* The separation shall have a minimum 1-hour fire-resistance rating where the exit connects three or fewer stories.
(2) The separation specified in 7.1.3.2.1(1), other than an existing separation, shall be supported by construction having not less than a 1-hour fire-resistance rating.
(3)* The separation shall have a minimum 2-hour fire-resistance rating where the exit connects four or more stories unless one of the following conditions exists:
(a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire-resistance rating.
(b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire-resistance rating.
(c) The minimum 1-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(3).

7.2.1.8 Self-Closing Devices.
7.2.1.8.1 * A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2 unless otherwise permitted by 7.2.1.8.3.


Findings include:

Observations while on tour March 1-2, 2022, revealed the self-closing for the door in the physician's sleep quarters had been removed or inactivated by removing parts of the closure.

Employees #1 and #2 confirmed during the exit conference that the door closure in the doctor's sleeping quarters had been disabled.

Based on observation it was determined the facility failed to protect the entire facility with an automatic sprinkler system. This would result in the sprinkler system not being able to extinguish the fire and could result in injury or death to the building occupants.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 8 Obstructions to Sprinkler Discharge Pattern Development. Section 8.6.5.2.1.1 Continuous or noncontiguous obstructions less than or equal to 18 in. below the sprinkler deflector that prevent the pattern from fully developing shall comply with 8.6.5.2.

Findings include:

During a facility tour conducted on February 28-March 2, 2022 revealed that a short wall was installed in the ultrasound room that was not AHJ approved and the sprinkler was partially blocked due to the wall. A permit was requested but not provided by the AHJ.

There was one room in Nuclear medicine that had a mixture of fast and normal response heads in the same room. This has the potential to cause the normal response head to not activate during a fire due to the fast response head keeping it wet (Cold-soldering is the term traditionally applied to the phenomenon whereby one sprinkler is prevented from operating due to the water discharge from another.)

Employees #1 and #2 confirmed during the exit conference on March 3, 2022, the wall in the ultrasound room was installed without a permit and was blocking the sprinkler head. they also acknowledged the mixed heads in the Nuclear medicine area.

Based on inspection and Interview it was determined the facility did not have spare sprinkler heads as required. Failing to inspect test and maintain the sprinkler system could cause the system to be inoperable due to lack of maintenance during a fire and could cause harm to, the residents.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition.

NFPA 13, Sprinkler Systems, 2010 Edition, Chapter 6, Section 6.2.9.1 "A supply of at least six spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced." Section 6.2.9.2 "The sprinklers shall be corresponding to the types and temperature ratings of the sprinklers in the property."6.2.9.6 *
One sprinkler wrench as specified by the sprinkler manufacturer shall be provided in the cabinet for each type of sprinkler installed to be used for the removal and installation of sprinklers in the system. 6.2.9.7 A list of the sprinklers installed in the property shall be posted in the sprinkler cabinet. 6.2.9.7.1 * The list shall include the following:
(1) Sprinkler Identification Number (SIN) if equipped; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating
(2) General description
(3) Quantity of each type to be contained in the cabinet
(4) Issue or revision date of the list

Findings include:

Observation while performing a facility tour conducted on March 1-2 revealed the spare sprinkler cabinet in the riser room located in the administration closet did not have any spare sprinkler heads a box or head wrench as required in NFPA 13.

Employees number 1 and #2 confirmed during the exit conference that the spare sprinkler box was missing in the admin closet.

Based on the inspection and Interview it was determined the facility did not have a spare sprinkler Based on the interview and document review the facility failed to conduct, maintain and document electrical receptacle testing in inpatient care areas specifically in the patient care rooms throughout the facility. Failing to test the receptacles could lead to an ignition hazard in a patient care area resulting in fire and/or injury to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 4, Section 4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected or operated as specified elsewhere in the Code or as directed by the authority having jurisdiction. NFPA 99, Health Care Facilities Code, 2012, Chapter 6, Section 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.

Findings include:

Observation while on tour March 1-2, 2022, revealed the facility failed to provide documentation on the annual receptacle testing. The facility was unable to provide documentation for any years for the brown outlets in the patients' bedrooms.

During the exit conference on March 3, 2022, Employees #1 and #2 confirmed the outlets were not tested annually as required in the Life Safety Code.

Based on observation and staff interviews, the facility failed to ensure a remote stop or kill switch for the generator was installed. This affected the entire facility and could result in a loss of power due to a generator malfunction during an emergency power outage. Failure to have an emergency stop on the generator could cause a fire or harm to the residents and/or staff.

Code reference: NFPA 110 2010 Edition; Standard for Emergency and Standby Power Systems 5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation, located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. A.5.6.5.6 For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

Findings include:

Observations while on tour conducted on March 1-22022 it was revealed the facility generator did not have the required remote stop or kill switch for the large generator.

Employees #1, #2 confirmed during the exit conference that the facility failed to install a remote stop switch for the emergency diesel generator.

Based on observation and staff interviews the facility failed to provide a record of electrical equipment tests, repairs, and modifications. Failing to conduct maintenance on patient care appliances could cause harm to the residents if the appliance malfunctions.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 10, Section 10.5.6 Record Keeping-Patient Appliances Electrical Equipment - Testing and Maintenance Requirements
"The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance, and use of electrical appliances receive continuous training."

Findings include:

Observation, record review, and staff interview on March 1-2, 2022, revealed the facility was unable to produce policies or protocols or documentation to identify all electrical equipment tests, repairs, and modifications. The facility provided documentation of a visual inspection of patient care-related electrical equipment but stated they were unaware of checking for leakage current on other equipment that makes contact with the facility's patients. The facility uses a contractor to perform this task review states the purpose of the program is to prevent electrical hazards but does not describe which equipment in this facility was to be tested. Multiple pieces of electrical equipment had expired Entech dates
Lab 3 pieces of equipment
Observation Room-scale expired 1/22/2022
PACU closet BP monitor exp Jan 2022
MRI room two pieces of infusion equipment 1/22
ICU storage monitor expired Jan 22


Employees #1 and #2 confirmed during the exit conference on March 3, 2022, the facility failed to test some pieces of electrical equipment.

Based on observation the facility failed to segregate empty and full oxygen E- type oxygen cylinders in a separate storage rack or stand in the main oxygen storage room and were storing oxygen in a room not rated for oxygen storage. Failing to segregate compressed gas medical cylinders from empty and full oxygen cylinders and incorrectly storing O2 in a non-rates room could cause harm to the patients if oxygen is not stored correctly.


NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.3.2.3 Oxidizing gases, such as oxygen and nitrous oxide shall be separated from combustibles materials by one of the following:

(1) Minimum distance 20 feet
(2) Minimum distance of 1.5m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
93) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour.

NFPA 99 2012 Edition Standard for Health Care Facilities." Chapter 5 Section 5.1.3.3.2 Design and Construction. Section 5.1.3.3.2 (5) They shall be in compliance with NFPA 70 National Electrical Code, for ordinary locations. Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements. Section 5-1.3.3.2 (5) Electrical devices should be physically protected, such as by use of a protective barrier around the electrical devices, or by location of the electrical device such that it will avoid causing damage to the cylinders or containers. The device could be located at or above the finished floor 1.5 m (5 ft) or other location that will not allow the possibility of the cylinders or containers to come into contact with the electrical device required by this section. Section 5.1.3.3.2 (10) They shall protect electrical devices from physical damage. 11.3.1 * Storage for non-flammable gases equal to or greater than 85 m3 (3000 ft3) at STP shall comply with 5.1.3.3.2 and 5.1.3.3.3. 11.3.2 *
Storage for non-flammable gases greater than 8.5 m3 (300 ft3), but less than 85 m3 (3000 ft3), at STP, shall comply with the requirements in 11.3.2.1 through 11.3.2.3. Section 11.3.2.1
Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. Section 11.3.2.2 Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor. Section 11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1? 2 hours.

Findings include:

Observation while on tour from February 28 to Mar 3rd,2022 revealed the following issues.
1. Oxygen was being stored on the second floor in a room titled "Vending Room" this room was not rated for oxygen storage this room had well over 30 cu ft of oxygen and other combustible items in the room. The room was being used to distribute O2 for at-home COVID patients.
2. The Emergency Room had a room that was not labeled was storing an unmarked full/empty rack and one unsecured O2 cylinder and storage was within 5 feet of combustibles
3. Other areas of the hospital were storing oxygen without the rooms being labeled and bottles were not segregated. Areas such as the central med gas room.

Employees # 1 and #2 confirmed during the exit conference conducted on March 3rd, 2022 that oxygen was being stored improperly in the above-listed areas.