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Based on observation and interview, the facility failed to maintain the 2-hour fire resistance rated wall between the health care occupancy of the hospital and the business (non-patient care) occupancy, in accordance with NFPA 101, 19.1.3.4.1.

This failure could allow the transfer of fire/smoke and affect the safety of the building's occupants in the event of a fire or emergency.

Findings included:

During observations and interviews on 05/06/25 from 4:55 p.m. to 5:00 p.m., the fire-rated wall between the health care and business occupancies in the hospital had above the doors (on the hallway connector side): a ½ inch hole around a flexible conduit penetration, 1-inch hole around another flexible conduit penetration, a 1-inch hole around a low voltage wire penetration. The maintenance supervisor said this fire-rated wall was the wall that separated the older portion of the hospital (non-patient use) from the patient care side and confirmed the observations when the surveyor discussed the finding.

Based on observation and interview, the facility failed to ensure 1 of 1 hazardous mechanical room (off the main corridor past the surgical suite) was protected with a 1-hour fire rated fire barrier, in accordance with NFPA 101, 19.3.2.1.

This failure could allow the transfer of fire/smoke and affect the safety of the building's occupants in the event of a fire or emergency.

Findings included:

During observations and interviews on 05/06/25 from 4:20 p.m. to 4:30 p.m., in the mechanical room containing gas-fired boilers, the room's fire-rated concrete masonry block wall separating it from the corridor had the following unsealed openings in it near the ceiling: 1 flex conduit penetration, 1 rigid conduit penetration, 2 hot water plumbing pipe penetrations, a group of 4 additional rigid conduit penetrations, and 2 additional flexible conduit penetrations. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.

Based on observation and interview, the facility failed to maintain sprinkler heads free of foreign material in the dietary kitchen in the hospital, in accordance with NFPA 25, 5.2.1.1.2(5).

This failure could delay activation of fire sprinkler heads in the event of a fire, allow a fire to spread, and adversely affect the safety of the building's occupants in the event of a fire.

Findings included:

During observations and interviews on 05/07/25 from 9:55 a.m. to 10:00 a.m., in the dietary kitchen, all 10 fire sprinkler heads around the cooking, preparation and ware washing area were loaded with dust. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.

Based on observation, interview, and record review, the facility failed to ensure 52 of 52 portable fire extinguishers throughout the facility had monthly inspections performed, in accordance with NFPA 101, 19.3.5.12, 9.7.4.1 and NFPA 10, 7.2.1.2.

This failure could affect the reliability/function of portable fire extinguishers to extinguish a fire in an emergency, could allow a fire to spread, and adversely affect the safety of the building's occupants.

Findings included:

During observations and interviews on 05/06/25 from 2:00 p.m. to 5:15 p.m., the tags on portable fire extinguishers were inspected and indicated the last annual service inspection was conducted during September 2024. None of the observed fire extinguisher tags contained evidence that monthly (quick check) inspections were performed for the months of October 2024, November 2024, December 2024, January 2025, February 2025, March 2025, and April 2025. The maintenance supervisor said there were 52 total fire extinguishers in the hospital and that additional written records were kept of monthly inspections. Review of available maintenance records for monthly inspections of fire extinguishers only included the months of January through May for the year 2024.

Based on observation and interview, the facility failed to ensure 2 of 2 smoke barrier walls (one dividing the patient rooms and another between the separating the patient room from the imaging rooms and support spaces) were constructed to least a ½-hour fire resistance rating and all penetrations sealed, in accordance with NFPA 101, 19.3.7.3.

This failure could allow fire/smoke to spread from one smoke compartment to another, and adversely affect the safety of the building's occupants in the event of a fire or emergency.

Findings included:


During observations and interviews on 05/07/25 from 10:05 a.m. to 10:35 a.m., the smoke barrier wall by the doctor's lounge and room 141 had above the corridor ceiling, a 1-inch hole in the wall and an electrical conduit sealed with a foam product (could not be verified for use in fire resistance rated walls). The smoke barrier wall above the corridor doors (on the nurse station side) had openings around 5 low voltage wire penetrations. The portion of the smoke barrier wall that ran along the IT closet was not sealed to the underside of the roof deck, had openings in the wall, unsealed penetrations from structural members, openings around a bundle of electrical conduit, and scab patches present in the gypsum board wall. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.

Based on observation and interview, the facility failed to a door located in 1 of 2 smoke barrier walls (the one dividing the patient rooms) was self or automatic-closing, in accordance with NFPA 101, 19.3.7.8(1).

This failure could allow fire/smoke to spread from one smoke compartment to another, and adversely affect the safety of the building's occupants in the event of a fire or emergency.

Findings included:

During observations and interviews on 05/07/25 from 10:05 a.m. to 10:35 a.m., the smoke barrier wall that ran along the toilet room in the doctor's lounge had a door that was not equipped with a self or automatic closing device. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.

Based on interview and record review, the facility failed to conduct fire drills at least quarterly on each shift, in accordance with NFPA 101, 19.7.1.4 through 19.7.1.7.

This failure could delay staff response in the event of a fire or emergency and potentially adversely affect the safety of the building's occupants.

Findings included:

During interviews and record reviews on 05/07/25 from 8:30 a.m. to 12:00 p.m., the only documentation available for fire drills conducted in the facility were for April 2024 and October 2024. During the exit interview, the chief operating officer said the hospital had two twelve hour shifts for staff. The surveyor provided an opportunity for additional fire drill records, but none were provided. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.

Based on interview and record review, the facility failed to provide a documented categorical risk assessment, in accordance with NFPA 99, Chapter 4.

This failure could compromise the hospital's building systems and could adversely affect the safety of the patients in the event such systems failed.

Findings included:

During interviews and record review on 05/07/25 from 8:30 a.m. to 12:00 p.m., the facility's records did not include a documented categorial risk assessment based on the facility's systems (essential electrical system, information technology and communications, plumbing, and mechanical) and their possible failure and potential effect on the delivery of healthcare services for a hospital. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.

Based on interview and record review, the facility failed to test electrical receptacles at patient care areas at internals not exceeding 12 months, in accordance with NFPA 99, 6.3.4.

This failure could result in issues with the electrical system and adversely affect the safety of the patients.

Findings included:

During interviews and record reviews on 05/07/25 from 8:30 a.m. to 12:00 p.m., the facility's records did not include any documentation that electrical receptacles at patient care areas were tested at any interval. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.

Based on observation, interview, and record review, the facility failed to maintain 2 of 2 generators (one interior and one exterior) that provided emergency power to the facility as follows:

*Testing was not conducted under load at least monthly for at least 30 minutes, including operating the transfer switches, in accordance with NFPA 110, 8.4, 8.4.1, 8.4.2,
*The time delay to transfer to emergency power, delay to restoration to normal power, and delay on shutdown were not recorded in the generator testing logs, in accordance with NFPA 110, 8.4.5.
*A 4-hour loaded test every 36 months was not performed, NFPA 110, 8.4.9.

This failure could affect the reliability of the emergency power system during a power outage and potentially adversely affect the safety of the building's occupants.

Findings included:

During observations, interviews, and record reviews on 05/06/25 from 3:30 p.m. to 4:30 p.m. and on 05/07/25 from 8:30 a.m. to 12:00 p.m., two separate generators (one interior and one exterior) and their automatic transfer switches were installed that provided emergency power to the hospital. Available generator testing logs available only indicated a run time of 12 minutes each week, with no transfer time to emergency power, delay to restoration to normal power, and delay on shutdown, or indication that the generator was under load when tested. There was no documentation that a 4-hour load test was conducted every 36 months. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.