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Based on observation and interview, the provider failed to maintain egress paths free of hazards for three of seventeen exits (adjacent to sterilization, stairwell at door 0023, and stairwell at door 0012). Findings include:

1. Observation on 10/22/24 at 9:15 a.m. revealed the path of egress adjacent to the sterilization area was very cluttered on each side of the corridor. The area was over 100 square feet in area and had combustible items (large amounts of cardboard boxes with supplies as well as carts) making the area hazardous. Paths of egress must not be through hazardous locations. An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and if so designated as an area of refuge. LSC 7.1.3.2.3

2. Observation on 10/22/24 at 9:20 a.m. revealed storage at the bottom of the stairwell accessed through door 0023. The area was directly under the stairs leading to the exit and had combustible items (4 laundry carts and five large boxes) making the stairwell a hazardous location. Paths of egress must not be through hazardous locations. An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and if so designated as an area of refuge. LSC 7.1.3.2.3

3. Observation on 10/22/24 at 9:27 a.m. revealed storage at the bottom of the stairwell accessed through door 0012. The area was directly under the stairs leading to the exit and had combustible items (carts from the sterilization area, boxes, and a bed) making the stairwell a hazardous location. Paths of egress must not be through hazardous locations. An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and if so designated as an area of refuge. LSC 7.1.3.2.3

Interview with the facilities management director at the time of the observation confirmed that condition. He was aware of the prohibition of storage in a protected exit.

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

Based on observation and interview, the provider failed to maintain two separate hazardous areas (trash storage 2451, and soiled laundry) as required. Findings include:

1. Observation on 10/21/24 at 4:25 p.m. revealed the storage room at 2451 was in fact a trash storage room containing more than 64 gallons of trash, and had no automatic door closer.

2. Observation on 10/22/24 at 7:25 a.m. revealed the door separating soiled laundry from laundry was not a rated door, nor did it have an automatic door closer. The volume of stored soiled linens was greater than 64 gallons. The integrity of this door was also very low.

Interview with the facilities management director at the times of the observations confirmed those findings.

The deficiency affected three of numerous requirements for hazardous rooms.

Based on observation, testing, and interview, the provider failed to maintain laundry airflow in a clean to dirty relationship and failed to identify a potentially hazardous breathing environment as required. Findings include:

1. Observation and testing on 10/22/24 at 7:45 a.m. of the pressure relationships between clean and dirty spaces in the laundry room revealed the following:
a. Using a tissue test, the dirty side of the laundry was determined to have a positive air pressure relationship with the corridor.
b. The folding room was immediately across the hall from the dirty laundry, and the doors were held open. This room had a negative pressure relationship to the corridor. The result of these tests show dirty air would flow into the clean area.

2. Observation on 10/21/24 at 1:30 p.m. revealed a room marked as storage on the first floor contained sixteen H-cylinders containing carbon dioxide. The Carbon Dioxide Manufacturers Association lists a "normal" storage amount as one cylinder. There is no listed prohibition or added requirements for ventilation until 3000 cubic feet of storage is reached, however displacement of air may become hazardous. Signage for compressed gas storage is required.

Interview with the facilities management director at the time of the observations confirmed those findings.

The deficiency affected two of several requirements for ventilation.