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Based on observation, the facility failed to maintain the separation between construction types per the requirements of:

2012 NFPA 101, 19.1.3.5, and 8.2.1.3 (1)

This deficiency affects buildings 0104 and 0304.

Findings include:

During a tour of the facility, the surveyor observed an unsealed penetration of a 1/2" EMT conduit used as a chase for one blue cable, above the ceiling over the fire barrier cross corridor doors in the 4-hour fire barrier separating Building 0104 and Building 0304, between the Radiology Waiting Area and the E.D. Corridor.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the separation between construction types per the requirements of:

2012 NFPA 101, 19.1.3.5, and 8.2.1.3 (1)
2012 NFPA 221, 4.8.4.1

This deficiency affects 2 of the 3 four hour walls separating the different construction types.

Findings include:

During a tour of the facility, the surveyors observed the following:

1. An unsealed penetration of a 1/2" EMT conduit used as a chase for one blue cable, above the ceiling over the fire barrier cross corridor doors in the 4-hour fire barrier separating Building 0104 and Building 0304, between the Radiology Waiting Area and the E.D. Corridor.


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2. A non-fire rated caulk used above the ceiling over the fire barrier cross corridor doors in the 4-hour fire barrier separating Building 0104 and Building 0204 on the second floor; to seal the following penetrations:

a. A 1/2" EMT conduit
b. A 1" metal conduit c. Four wires

3. The corridor fire doors seperating Building 0104 from Building 0204 on the second floor, failed to release from the magnetic hold open device under activation of the fire alarm system

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the separation between construction types per the requirements of:

2012 NFPA 101, 19.1.3.5, and 8.2.1.3 (1)
2012 NFPA 221, 4.8.4.1

This deficiency affects 1 of 2 separations of different construction types.

Findings include:

During a tour of the facility, the surveyor observed the folowing:

1. A non-fire rated caulk used above the ceiling over the fire barrier cross corridor doors in the 4-hour fire barrier separating Building 0104 and Building 0204 on the second floor; to seal the following penetrations:

a. A 1/2" EMT conduit
b. A 1" metal conduit c. Four wires

2. The corridor fire doors seperating Building 0104 from Building 0204 on the second floor, failed to release from the magnetic hold open device under activation of the fire alarm system


A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the means of egress per the requirements of:

2012 NFPA 101, 19.2.1, and 7.1.10.1

This deficiency affects 1 of 2 stairwell exits.

Findings include:

During a tour of the facility, the surveyor observed five Freon cylinders, one cinder block, two strands of chord, two pieces of metal track, one gallon jug and one can of wasp/hornet spray on the landing between the roof and the second floor obstructing the exit discharge of this stairwell located by the second floor Nurses' Station.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain a horizontal exit per the requirements of:

2012 NFPA 101, 19.2.2.5, 7.2.4.3.1, and 8.3.5.1

This deficiency affects 1 of 6 2-hour fire/smoke walls.

Findings include:

During a tour of the facility, the surveyor observed non-fire rated caulk was used to seal the following penetrations in the 2-hour fire/smoke wall above the ceiling over the fire barrier cross corridor doors located on the second floor between the Nurses' Station and the East Hall:

1. Multiple wires
2. Around a 1" conduit

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to provide an approved method to ensure appliances that are protected under the hood, if they are moved, they are returned to the approved design location per the requirements of:

2012 NFPA 101, 19.3.2.5.1, and 9.2.3
2011 NFPA 96, 12.1.2.2, 12.1.2.3, and 12.1.2.3.1

This deficiency affects 1 kitchen hood.

Findings include:

During a tour of the facility, the surveyor observed that the facility failed to provide an approved method to ensure appliances that are protected under the hood, if they are moved, they are returned to the approved design location.

A member of maintenance staff was present when this deficiency was identified.

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Based on observation and review of documentation, the facility failed to maintain the automatic sprinkler system per requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.5
2011 NFPA 25, 5.3.1.1.1.3

This deficiency affects 2 of 2 smoke compartments.

Findings include:

During the review of the documentation, the facility failed to provide documentation that the following quick-response (QR) sprinklers had been replaced or a representative sample tested within 20 years of installation:

1. The 1999 QR sprinklers located in the Physical Therapy (PT) area

2. The 2001 QR sprinklers located in the PT Corridor, PT Bathroom/Storage area and the Morgue

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain portable fire extinguishers per the requirements of:

2012 NFPA 101, 19.3.5.12, and 9.7.4.1
2010 NFPA 10, 6.1.3.4, and 6.1.3.8.3

This deficiency affects 26 stored portable fire extinguishers located in the North Mechanical Room/Extinguisher Storage Room.

Findings include:

During a tour of the facility, the surveyor observed 15 portable fire extinguishers laying on their sides, on the floor; with another 11 extinguishers laying on top of these in the North Mechanical Room/Extinguisher Storage Room.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain a corridor door per the requirements of:

2012 NFPA 101, 19.3.6.3.2
S&C-07-18

This deficiency affects 1 corridor door.

Findings include:

During a tour of the facility, the surveyor observed the corridor door for Patient Room 207 had a 5/8 inch gap between the door and door frame when the door was closed and latched.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to limit the movement of gas fueled appliances with casters located under the kitchen hood, by a restraining device per the requirements of:

2012 NFPA 101, 19.5.1.1, and 9.1.1
2009 NFPA 54, 9.6.1.1, 9.6.1.2, and 10.12.6

This deficiency affects 2 of 2 Deep Fryers.

Findings include:

During a tour of the facility, the surveyor observed that the facility failed to provide restraining devices for the two gas fueled deep fryers with casters.

A member of maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to prohibit a portable space heating device per the requirements of:

2012 NFPA 101, 19.7.8

This deficiency affects 1 of 8 smoke compartments.

Findings include:

During a tour of the facility, the surveyor observed a portable space heating device that was on and sitting on the carpeted floor of the 2nd Floor Doctors Sleeping Room. This was located in a patient/doctor sleeping smoke compartment and the facility was unable to provide documentation that the heating element did not exceeding 212 degrees.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the diesel generator's fuel per the requirements of:

2012 NFPA 99, 6.5.1, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 1.3, and 8.3.8

This deficiency affects 1 of 1 generator.

Findings include:

During the review of the documentation, the facility failed to provide documentation that a fuel quality test was performed within the past twelve months using tests approved by ASTM standards. The last fuel quality test the facility provided was from 05/2022.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the diesel generator's fuel per the requirements of:

2012 NFPA 99, 6.5.1, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 1.3, and 8.3.8

This deficiency affects 1 of 1 generator.

Findings include:

During the review of the documentation, the facility failed to provide documentation that a fuel quality test was performed within the past twelve months using tests approved by ASTM standards. The last fuel quality test the facility provided was from 05/2022.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the electrical equipment per the requirements of:

2012 NFPA 99, 10.2.3.6, and 10.2.4
2011 NFPA 70, 400.8
S&C: 14-46-LCS

This deficiency affects 1 patient treatment area.

Findings include:

During a tour of the facility, the surveyor observed an un-approved power strip with a diagnostic computer, printer and desk phone plugged in to it. The power strip was located within 4' of a patient treatment bed in the Echocardiogram Room, on the 2nd floor.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the oxygen cylinders per the requirements of:

2012 NFPA 99, 11.6.2.3 (11)

This deficiency affects 1 of 1 Medical Gas Storage areas.

Findings include:

During a tour of the facility, the surveyor observed ten type H oxygen cylinders (150 cu.ft. each) all secured by one chain in the Medstar Air Care Services medical gas storage area next to Building 0204.

A member of the maintenance staff was present when this deficiency was identified.