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Based on observation and interview, the facility failed to ensure that the construction areas were safeguarded in accordance with NFPA241 2009 edition, and NFPA 101, Life Safety Code, section 43.8 as inspected in the facility located within the
facility. This deficient practice could affect the patients/residents, visitors, and members of facility staff in this location(s). Deficient practices have the potential of allowing the passage of smoke and/or fire from the construction area(s) into adjacent areas.

Findings Include:

Observation(s) and lnterview(s) during a Healthcare facility tour with the Carpenter on 01/07/2025 between the hours of 10:00 am and
5:30pm found the following:

1. Multiple penetrations from the Cath Lab renovation area were observed above the double doors to the cath lab corridor non-construction hospital side, as well as from the room to the right of the double doors to the cath lab corridor hospital side.

Walls were penetrated by piping, wiring, and open penetraitions that were not protected by a firestop system in accordance with NFPA 101, Life Safety Code, 2012 edition, section 8.3.5 Penetrations and has the potential of allowing the passage of smoke and/or fire into adjacent areas.

These findings were verified by the Carpenter at the time of the observation and at the exit
conference on 01/07/2025.

Based on observation and interview, the health care facility failed to ensure that Building construction type and stories meets NFPA 101 2012 edition Table 19.1.6.1 requirements for building type II (222) construction, and maintaining the fire protection rating of structural components.

Finding:

On 1/7/2025, between 10:00 AM and 5:30 PM, a surveyor, with the Carpenter present, observed the following:

1. Fire proofing on structural beams missing or has been damaged in the Cath lab construction
area.

The surveyor confirmed this finding with the Carpenter at the time of the observation.


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Based on observation and interview, the health care facility failed to ensure that Building construction type and stories meets NFPA 101 2012 edition Table 19.1.6.1 requirements for building type II (222) construction, and maintaining the fire protection rating of structural components.

Finding:

On January 7, 2025, between 10:00 AM and 5:30 PM, a surveyor, with the Facilities Coordinator present, observed the following:


1. Fire proofing on structural beam is missing or has been removed at the top of the stairwell that provides access to the level 2 staff lounge.
2. Two data cables penetrating 2hr fire barrier above ceiling located on level 2 where smoke compartments 2, 3, 4, 5 intersect, without fire stopping.

The surveyor confirmed this finding with the Facilities Coordinator at the time of the observation.

Based on observation and interview, the hospital failed to maintain the aisles, passageways, corridors, exit discharges, exit locations, and access free of all obstructions to full use in case of emergency per NFPA 101, Life Safety Code, 2012 Edition, Sections 19.2.1, and 7.1.10.1

Findings:

On 01.07.2025, between 10:00 AM and 5:30 PM, this surveyor, observed the following finding with the HVAC tech present.

1. 2 blood pressure machines were plugged into a corridor outlet and stored in the egress corridor across from room 202 in the Biewind Wing
2. A computer was plugged into a corridor outlet and stored in the egress corridor across from room 209 in the Biewind Wing
3. 3 blood pressure machines were plugged into a corridor outlet and stored in the egress corridor across from room 258 in the Strater Wing
4. A blood pressure machine was plugged into a corridor outlet and stored in the egress corridor across from room 260 in the Strater Wing
5. Operating room beds, sterile supplies and portable machines were stored in the ground level egress corridor.

The surveyor confirmed these findings with the HVAC tech at the time of the observation and review.





47175

Based on observation and interview, the healthcare facility failed to ensure that Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with NFPA 101 2012 edition Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18,2.1, 19.2.1, 7.1.10.1

Finding:

On 1/7/2025, 10:00 AM and 5:30 PM, a surveyor, with the Carpenter present, observed the following:

1. Cabinets and wheeled storage containers were found stored in the corridor in the x-ray wing.
2. Cabinets and wheeled storage containers were found stored in the corridor outside of the OR rooms.
3. Cabinets and wheeled storage containers were found stored in the corridor in the ICU wing.
4. A makeshift waiting area was found set up in front of marked exit doors leaving the MRI area blocking the door.

The surveyor confirmed this finding with The carpenter at he time of the observation.

Based on observation, the facility failed to ensure that doors in an exit passageway, starirway enclosure, or horizontal exit, smoke barrier, or hazardous area enclousre are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automaticaly closes all such doors throughout the smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and automatic sprinkler system, if installed; and loss of poer per the requirements of NFPA 101 2012 edition

Findings:

On 01/07/2025 between hours of 10:00 am and 5:30 pm. this surveyor accompanied with the Carpenter did observe the following:

1. 90 minute rated Door 1039 to the ICU waiting room on magnetic hold open was not self-closing or positive latching.
2. Rated door labeled as FD30 on magnetic hold open on the first floor was not positive latching

The surveyor confirmed this finding with the Carpenter at the time of the observation


47175

Based on observation and interview, the facility failed to enrure that doors in an exit passageway, stariway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.1 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of required manual fire alarm system, and local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system: and automatic sprinkler system, if installed; and loss of power per the requirements of NFPA 101 2012 edition.

Findings

On 01/07/2025 between hours of 10:0am and 5:30 pm. this surveyor accompanied with the Carpenter did observe the following:
1. Door in the pharmacy area found wedged open with a piece of wood.
2. Door 1042 is a storage room door that has had the self-closing device removed.
3. Tray return door in the kitchen area was blocked from closing by carts.
4. Cashier/serving area in kitchen was fixed open with door wedge.
5. The back kitchen exit door was tied open with a rope tied to a bread rack.

The surveyor confirmed this finding with the Carpenter at the time of the observation.

Based on observation and interview, the Heatlhcare facility failed to maintain exit corridor width per NFPA 101, Life Safety Code, 2012 Edition, Section 19.2.3.4

Finding:

On 01/07/2025, between 10:00 AM and 5:30 PM, a surveyor, with the Carpenter present, observed the following:

1. The Corridor to MRI zone 2 outside door 1079 imaging staff area shifts from 8' wide down to 6'4" wide and then again within 6 feet as the corridor turns it is reduced down to 5'10' wide

The surveyor confirmed this finding with the Carepenter at the time of the observation

Based on record review and interview, the hospital failed to verify suites are separated from the remainder of the building (including from other suites) by construction meeting the separaton provisions for corridor contruction per NFPA 101, Life Safey Code, 2012 Edittion, Sections 19.3.6.2-19.3.6.5, 19.2.5.7.1.2, 19.2.5.7.1.3, 19.2.5.7.1.4

Findings:

On 01.07.2025, between 10:00 AM and 5:30 PM, this surveyor, observed the following finding with the director and facilities coordinator persent.

1. Upon interview the facility stated they have suites located in the building, but was unable to provide documentation to indicate type or or locations of suites. The life safety drawings that were provided did not show any suite designations and the facility stated that updated drawings were in process but were not available at the time of the survey.

These finding were verified by the facility executive director and facilities coordinator at the time of document review on 01-07-25.

Based on record review and interview, the hospital failed to verify the suite requirements per NFPA 101, Life Safety Code, 2012 Edition, Section 19.2.5.7.2 were met.

Findings:

On 01.07.2025, between 10:00 AM and 5:30 PM, this surveyor, observed the following finding with the director and facilities coordinator present.

1. Upon interview the facility stated they have suites located in the building, but was unable to provide documentation to indicate type or locations of suites. The life safety drawings that were provided did not show any suite designations and the facility stated that updated drawings were in process but were not available at time of survey.

These findings were verified by the facility executive director and facilities coordinator at the time of document review on 01-07-25

Based on record review and interview, the hospital failed to verify the requirements for non sleeping suites per NFPA 101, Life Safety Code, 2012 Edition, Section 19.2.5.7.3 were met.

Findings:

On 01.07.2025, between 10:99 AM and 5:30 PM, this surveyor, observed the following finding with the director and facilities coordinator present.

1. Upon interview the facility stated they have suites located in the building, but was unable to provide documentation to indicate type or locations of suites. The life safety drawings that were provided did not show any suite designations and the facility stated that updated drawings were in process but were not available at the time of the survey.

These findings were verified by the facility executive director and facilities coordinator at the time of the document review on 01-07-25

Based on observations and interview with the facility failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition for exit and directional signs that are displayed in accordance with 7.10, 19.2.10.1, 19.2.10.2,19.2.10.3, and 19.2.10.4.

Findings:

On 01.07.2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the HVAC tech present.

1. The area of CT and Cath Lab needs to exit signage with directional signs displaying the proper egress out of the area. The current signs are not lit and not adequate exit signage.
2. The Surgical entrance the current sign is blacked out.

This deficient practice could affect the occupants, visitors and staff while trying to exit the building under reduced visibility of the exit areas.

The surveyor confirmed these findings with the HVAC tech at the time of the observation and review.

Based on observations and interview with the Facilities Coordinator the facility failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition for vertical openings to include stariwells, shafts, in accordance with 19.3.1.1 through 19.3.1.6

Findings include:

Observations and Interview, found penetrations into stairwells and not maintaining a 2-hr fire resistive rating during a facility tour on Januay 7, 2025 between 10:00 AM and 5:30 PM with the Facilities Coordinator:

1. Two penetrations (conduit and wiring) into the stairwell above door #2254
2. Sprinkler pipe penetration into the 2-hr rated stairwell located above door #2230
3. Sprinkler pipe penetration into the 2-hr rated stairwell located across the corridor from the elevators
4. Sprinkler pipe penetration into the 2-hr rated stairwell located by door #2327
5. Grouting within the 2-hour wall is crumbling deteriorating located on level 2 elevator shaft.

This deficient practice could affect the occupants, visitors and staff while trying to exit the building and utilizing the stariwell that is not have 1-hour fire resistive rating.

These finding were verified by the Administrator, and EVS Manager and this Surveyor at the times of observation, interview, and document review on January 07, 2025 between 10:00 AM and 5:30


Based on observations and interview, the facility failed to meet the requirements of the National Fire Protrection Association (NFPA) 101, Life Safety Code, 2012 edition for vertical openings to include stairwells and shafts in accordance with 19.3.1.1 through 19.3.1.6.

Findings:

On 01.07.2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the HVAC tech present.

1. 2'" Penetration into 2-hour fire wall at the ground level stairwell outside the elevators.
2. Penetrations into 2-hour fire wall at the ground level stairwell around the Special Procedure Passageway.

The surveyor confirmed this finding with the HVAC techat thge time of the observation and review.

Based on observation and interview, the facility failed to ensure that hazardous areas were safeguarded in accordance with NFPA 101, Life Safety Code, section 19.3.2.1 and 19.3.2.1.3 in hazardous areas inspected in the facility located within the facility. This deficient practice could affect the patients/residents, visitors, and members of facility staff in this location(s).
Deficient practices have the potential of allowing the passage of smoke and/or fire from the hazardous area(s) into adjacent areas.

Findings Include:
Observation(s) and lnterview(s) during a Healthcare facility tour with the Carpenter on 01/07/2025 between the hours of 10:00 am and 5:30 pm found the following:

1.The Purchasing Department had many various locations where the spray fireproofing on the ceiling area and structural steel did not have an intact fire barrier having a 1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2 Protection from Hazards.

2.The Purchasing Department had wire penetrations in 1 hour rated wall above door 1- 109 that were not protected with an intact fire barrier having a 1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2 -Protection from Hazards.

3.The Purchasing Department had pipe penetrations in 1 hour rated wall above door 1- 108 8 that were not protected with an intact fire barrier having a 1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2 -Protection from Hazards.

4.The Purchasing Department above the gate to the pharmacy storage area had a sprinkler pipe penetration that was not protected with an intact fire barrier having a 1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2 -Protection from Hazards.

5.Open Conduits within electrical room 1129 were observed penetrating to the floor above that was not protected with an intact fire barrier having a 1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2 -Protection from Hazards.

6.Open penetrations around electrical conduit was observed within the mechanical room on floor 1 behind the Dristeem Humidifier unit labeled as #13 that was not protected with an intact fire barrier having a 1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2
-Protection from Hazards.

7.LB Conduit elbow boxes at door 1061 mechanical room penetrations were observed as not protected with an intact fire barrier having a1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2 -Protection from Hazards.

8.Electrical Conduit within 1 hour rated wall in the telecommunication room above door 1060 was observed as not protected with an intact fire barrier having a 1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2 -Protection from Hazards.

9.Penetrations were observed at elevator machine room at doors 1225 and 1226 as not protected with an intact fire barrier having a
1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2 -Protection from Hazards.

10. Ceiling penetrations in multiple areas within the boiler room located below what was thought to be the medical records area did not have an intact fire barrier having a 1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2-Protection from Hazards.

11.There was no fire resistive barrier between the emergency department and the garage storage area and emergency ambulance unloading area at double sliding doors 1017. It was observed that the garage doors were closed and an emergency vehicle was unloading a patient within the hazardous area during the survey.

12.Elevator machine room door 1226 was not self closing or positive latching.

13.Elevator machine room door 1225 was not self closing or positive latching.

Walls were penetrated by piping, wiring, and open penetrations that were not protected by a firestopping system in accordance with NFPA 101, Life Safety Code, 2012 edition, section 8.3.5 Penetrations and has the potential of allowing the passage of smoke and/or fire into adjacent areas.

These findings were verified by the Carpenter at the time of the observation and at the exit conference on 01/07/2025.
Based on observation and interview, the hospital failed to maintain hazardous areas. per NFPA 101, Life Safety Code, 2012 Edition, Sections 19.3.2.1.3.
Findings:

On 01.07.2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the HVAC tech present.
1.Storage room next to Data Room 5 on the Biewind Wing does not positive latch.

2.Shower across from Room 213 on the Biewind Wing has been converted to storage. The room is filled with medical equipment that does not allow the door to self-close and latch.

3.Closet in the Education area of the Biewind Wing has magnets to close door. The doors do not positive latch.

4.Patient room 2 in Strater Wing has been converted to a storage room. The door is required to self-close and positive latch.

5.Education Room 223 on the Strater Wing has been converted to a storage room. The door is required to self-close and positive latch.

6.Manifold room on ground level for medical gas does not self-close and positive latch.

7.Electrical/Boiler room on ground level does not self-close and positive latch. When door is released the air pressure from the hallway does not allow door to close and latch.

The surveyor confirmed these findings with the HVAC tech at the time of the observation and review.

Based on observation and interview, the facility failed to ensure that hazardous areas are protected per the requirements of NFPA 101 2012 edition by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4.3.5. Doors shall be self-closing or automatic-closing and permitted to have non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.


Findings:

On 01/07/2025 between hours of 10:00 am and 5:30 pm. this surveyor accompanied with the Carpenter did observe the following:

1. Temporary storage area set up for the mobile Cath lab was not equipped with a self-closing door to protect from the corridor providing exit access.

The surveyor confirmed this finding with the Maintenance Director and the Administrator at the time of the observation.

Based on observation, the facility failed to ensure that hazardous areas are protected per the requirements of NFPA 101 2012 edition by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4.

Findings:

On January 7, 2025, between hours of 10:00 am and 5:30 pm. this surveyor accompanied with facilities coordinator, did observe the following:

1. Penetrations in the 1-hour rated fire wall between general receiving and the pharmacy.

2. Penetrations in the 1-hour rated wall between the large storage room into the corridor across from the kitchen.

3. Penetrations (pipes cut off and left in place) in the rated floor ceiling assembly in storage room directly in front of the piping tunnel.

4. Penetration in the 1- hour rated wall between the storage room and into the corridor across from the sleep room.

5. Penetration in the 1-hour rated will between the boiler room and the electrical room.

The surveyor confirmed this finding with the facilities coordinator at the time of the observation

Based on observation and interview, the Healthcare facility failed to maintain the proper shutoff mechanism for the Therapy Cooking stove per NFPA 101, Life Safety Code, 2012 Edition, Sections 19.3.2.5 and NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, section 11.6 and 11.72. This deficient practice could affect the resident, visitors and staff.

Findings:

Based on interview and observation on 01-07-2026 between hours of 10:00 am and 5:30 pm. this surveyor accompanied with the Carpenter did observe the following:

1. The Grease exhaust hood and grease removal devices, appurtenances and equipment in th location of the carbroiler was found to be heavily contaminated with an excess of grease or oily sludge.

2. The grease exhuast hood and grease removal devices and appurtenances for the griddle was found to be contaminated with an excess of grease or oily sludge.

This was observed at the time by this surveyor along with carpenter.

Based on observation, the Healthcare facility failed to install their fire alarm system in accordance with NFPA 72, 2010 edition and failed to meet the requirements of 18.5.4.

Finding:
Based on observations on 01-07-2025 10:00 AM and 5:30 PM, a surveyor observed the following:

1. Two different model fire alarm notification devices within 10' of each other found in the in the corridor of smoke compartment #2 on level 1 outside of clean utility leading to ICU.

Based on observation and interview, the Healthcare facility, the facility failed to maintain accessibility for the manual fire alarm pull stations throughout the facility per NFPA 101, 2012 edition, sections 19.3.4.2.1 and 19.3.4.2.2, 9.6.2.3 and NFPA 72 2010 edition, Section 17.14

Finding:

Based on observation and interview on 01-07-2025 10:00 AM and 5:30 PM, a surveyor, with the Carpenter, observed the following:

1. The fire alarm pull station located at the exit to the emergency room was observed to be obstructed by wheelchairs.

The surveyor confirmed this finding with the Carpenter at the time of the observation.

The hospital failed to provide policy for Fire Alarm Out Of Service more than 4 hours in a 24 hour period in accordance with NFPA 101 Section 9.6.1.6

Findings:

Based on record review and interview on 01-07-2025 between hours of 10:00 AM and 5:30 PM, a surveyor observed the following:

1. There is no documentation that the facility has Fire Alarm Out of Service Policy if the fire alarm system is out of services for more than 4 hours in a 24-hour period.

This was confirmed in interview with the Executive Director

Based on observation and interview, during a Healthcare facility tour, the facility failed to ensure that hazardous areas were safeguarded in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 edition Life Safety Code, section 8.1.1.(1) in two hazardous area of the smoke compartments inspected in the facility that sprinklers are to be installed throughout the premises. This deficient practice could affect the patients/residents, visitors, and members of facility staff in this location(s). Deficient practices have the potential of allowing the passage of smoke and/or fire from the hazardous area(s) into adjacent areas. This deficient practice could affect the patients/residents, visitors, and members of facility staff in this location(s).
Findings:

Observation(s) and lnterview(s) during a facility tour with the Carpenter on 01/07/2025 from 10:00 AM to 5:30 PM identified:

No sprinkler coverage was observed within the elevator hydraulic machine room at door1185

Based on observation and interview, during a Healthcare facility tour, the facility failed to ensure that hazardous areas were safeguarded in accordance with NFPA 13, Standard for Installation of Sprinkler Systems, 2010 edition, section 8.9.5.3.2 in 2 hazardous areas of 5 smoke compartments inspected in the facility.
This deficient practice could affect the patients/residents, visitors, and members of facility staff in this location(s). Deficient practices have the potential of allowing the passage of smoke and/or fire from the hazardous area(s) into adjacent areas. This deficient practice could affect the patients/residents, visitors, and members of facility staff in this location(s).

Based on interview and observation on January 7, 2025 between hours of 10:00 am and 5:30 pm. this surveyor accompanied with the Facilities Coordinator did observe the following:

a. No sprinkler coverage was observed under the garage door in level 1 soiled linen room - access to
mobile MRI.

b Escutcheon plate not seated in Pharmacy.

These findings were confirmed with the Facilities Coordinator

Based on observation, the healthcare facility failed to ensure that Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA25 2011 edition, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems sections Chapter 5, section 5.2.1.1.1
On 01/07/2025, between 10:00 AM and 5:30 PM, surveyor, with the Carpenter observed the following:

1. Sprinkler heads found loaded with excessive amounts of dust throughout level 1, areas include:
a. Corridor outside of housekeeping storage room
b. Various locations within the pharmacy
c. Within the vestibule between the two sets of double sliding doors to ambulance bay at door 1-017
d. Various corridor locations

2. Storage found located closer than 18" to a sprinkler head
a. Within the Temporary Cath Lab storage room
b. Within the storage closet with bi-fold doors in the speech therapy room
3. Items temporarily affixed to a sprinkler pipe Within the Gath Lab construction area in various locations

The surveyor confirmed these findings with the Carpenter at the time of the observation.

Based on observation and interview, the healthcare facility failed to ensure that Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 2011 edition, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems sections Chapter 5, section 5.2.1.1.1.

Findings:

On 01/07/2025, between 10:00 AM and 5:30 PM, surveyor, with the Carpenter observed the following:

1. Sprinkler heads found loaded with excessive amounts of dust throughout level 1, areas include:
a. Housekeeping floor 1 MRI room
b. Kitchen multiple locations
c. Operating rooms 3 and 4
d. Various corridor locations
2. Temporary lighting fixtures in the new construction Cath lab area was found hanging from and tied to
sprinkler piping.
3. Escutcheon ring was found missing on a sprinkler head in the OR dirty equipment room.

The surveyor confirmed these findings with the Carpenter at the time of the observation.

Based on observation and interview, the healthcare facility failed to ensure that Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 2011 edition, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems sections Chapter 5, section 5.2.1.1.1.

Findings:

On January 7, 2025, between 10:00 AM and 5:30 PM, surveyor, with the Facilities Coordinator observed the following:

1. Items permanently affixed to a sprinkler pipe: Within the large boiler room.
2. Sprinkler Pipe is covered by short pieces of CPVC schedule 40 pipe:
a. Level 1 window washing heads - heading toward cafeteria from main hospital
b. Level 2 window washing heads - heading into smoke compartment 4 from smoke compartment 3.
3. Blaze master sprinkler piping being used above the ceiling in smoke compartment 4 for sprinkler piping.
4. Conduit and wires hung from sprinkler pipe located above the ceiling between the elevators and where the
three wings converge.

The surveyor confirmed these findings with the Facilities Coordinator at the time of the observation.


Based on observation, the facility failed to ensure that Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA25 2011 edition, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems sections Chapter 5, section 5.2.1.2.

Findings:

On 01.07.2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the HVAC tech present.

1. Storage found located closer than 18" to a sprinkler head. Central Sterile Storage has storage stacked 1O" below bottom of the sprinkler deflector.

The surveyor confirmed these findings with the HVAC tech at the time of the observation and review.The surveyor confirmed these findings with the HVAC tech at the time of the observation and review.

Findings:

Based on record review and interview on 01-07-2025 between hours of 10:00 AM and 5:30 PM, a surveyor observed the following:

1. There is no documentation that the facility has Fire Alarm Out of Service Policy if the fire alarm system is out of services for more than 4 days in a 24-hour period.

This was confirmed in interview with Executive Director.

Based on observation, the facility failed to ensure portable fire extinguishers are installed and maintained in accordance with NFPA 101, Life Safety Code, 2012 edition, Sections 4.6.12, 9.7.4.1, and 19.3.5.12.. Also reference NFPA 10, Standard for Portable Fire Extinguishers, 2010 edition, sections 7.2.1.2.

Finding:
On 01/07/2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the Carpenter present.

1. Fire extinguisher access was found blocked by trash cans in the laboratory area in the room to the right of the main entrance to the lab.

The surveyor confirmed this finding with the Carpenter at the time of the observation and review.
Based on observation, documentation review, and interview the facility failed to ensure portable fire extinguishers are installed and maintained in accordance with NFPA 101, Life Safety Code, 2012 edition, Sections 4.6.12, 9.7.4.1, and 19.3.5.12.. Also reference NFPA 10, Standard for Portable Fire Extinguishers, 2010 edition, sections 7.2.1.2.

Finding:

On 01.07.2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the HVAC tech present.
1. The red ABC extinguisher in the PACU rear egress corridor has no monthly inspections annotated on the attached tag for November and December, of 2024.

The surveyor confirmed this finding with the HVAC tech at the time of the observation and review.

Based on observation and interview, the facility failed to ensure portable fire extinguishers are installed and maintained in accordance with NFPA 101, Life Safety Code, 2012 edition, Sections 4.6.12, 9.7.4.1, and 19.3.5.12.. Also reference NFPA 10, Standard for Portable Fire Extinguishers, 2010 edition, sections 7.2.1.2.

Finding:
On 01/07/2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the Carpenter present.

1. Fire extinguisher access was found blocked in the OR clean equipment room by storage of wheeled carts.

The surveyor confirmed this finding with the Carpenter at the time of the observation and review.

Findings:

On January 7, 2025, between 10:00 AM and 5:30 PM, surveyor with the Facilities Coordinator observed the following:

1. Door number 2265 is a 45-minute rated door and is located in a 2-hour rated wall. This door should have a 90-minute rating.

2. 90-minute Rated door has had decoratively painted - This door is located between the corridor and General Receiving Storage.

The surveyor confirmed these findings with Facilities Coordinator at the time of the observation.

Based on observation and interview, the hospital failed to ensure that doors were protecting corridor openings in accordance with NFPA 101, Life Safety Code, section 19.3.6.3 - Corridor Doors. This deficient practice could affect the residents, visitors, and members of facility staff in this location.

Findings:

On 01-7-2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the Carpenter present.

1. Patient rooms with 2 leaf doors in the ICU suite do not protect the corridor from the smoke and/or fire due to the undercut at the bottom of the door. This is not in accordance NFPA 101, Life Safety Code, 2012 edition, section 19.3.6.3.1 - doors shall resist the passage of smoke. This failure occurred in all of the patient room doors within the ICU suite.

2. Double doors to the ICU suite at doors 1043 exceed the allowable undercut at the bottom of the door and do not protect the corridor from the smoke and/or fire. This is not in accordance NFPA 101, Life Safety Code, 2012 edition, section 19.3.6.3.1 - doors shall resist the passage of smoke. This failure occurred in all of the patient room doors within the ICU suite.
3. 90 minute rate Door 1020 to ED patient room 7 was found fixed open with door wedge.
4. Rated corridor doors on the first floor 1132 was not positive latching.
5. Rated Door 1-085 to x-ray reading room was found to not fully close or positively latch.

The surveyor confirmed these findings with the Carpenter at the time of the observation.


45039

Based on observation and interview, the hospital failed to ensure that doors were protecting corridor openings in accordance with NFPA 101, Life Safety Code, section 19.3.6.3 - Corridor Doors. This deficient practice could affect the residents, visitors, and members of facility staff in this location.

Findings:

On 01.07.2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the HVAC tech present.

1. Patient rooms with 2 leaf doors in Biewind Wing do not protect the corridor from the smoke and/or fire due to the gaps around the door and the frame. This is not in accordance NFPA 101, Life Safety Code, 2012 edition, section 19.3.6.3.1 - doors shall resist the passage of smoke. This failure occurred in 10 of 24 patients' doors in the Biewind Wing.

2. Patient rooms with 2 leaf doors in the Strater Wing do not protect the corridor opening from the smoke and/or fire due to the gaps around the door and the frame. This is not in accordance NFPA 101, Life Safety Code, 2012 edition, section 19.3.6.3.1 - doors shall resist the passage of smoke.

3. Housekeeping closet in Strater wing has roller latch installed on door.
4. Clean utility on Strater Wing has roller latch installed on door.
5. Linen room on Strater Wing has roller latch installed on door.

The surveyor confirmed these findings with the HVAC tech at the time of the observation and review.





51959

Based on observation and interview, the hospital failed to ensure that door were protecting corridor openings in accordance with NFPA, 101. Life Safety Code, 2012 edition, section 19.3.6.3 - Corridor Doors.

Findings:

On January 7, 2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the Facilities Coordinator present.

1. Cross Corridor Door, door number 2251 has a gap at the bottom exceeding 3/4" and does not resit the passage of smoke.

2. Cross Corridor Door, door number 2280 has a gap at the bottom exceeding 3/4" and does not resit the passage of smoke.

3. Cross Corridor Door, door number 2211 has a gap at the bottom exceeding 3/4" and does not resit the passage of smoke.

4. Cross Corridor Door, door number 2403 has a gap at the bottom exceeding 3/4", excessive median door gap, and does not resit the passage of smoke.

5. Cross Corridor Door, door number (not found but heading from door number 1153 toward cafeteria, has a gap at the bottom exceeding 3/4" and does not resist the passage of smoke.

6. Door number 2265 is located in a 2-hour rated wall assemply - this door needs to have a rating of at least 90-minutes and is rated at 45-minutes.

7. Cross Corridor Door is a 90-minute rated fire door and has had decorative painting applied to one side.

This surveyor confirmed these findings with the HVAC tech at the time of the observation and review.

Based on observation and interview with the carpenter on 01/07/2025 between 10:00 am and 5:30 PM the facility failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, sections 8.5 and 19.3.7. When required by Chapter 11 through 43 smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.

Findings include:

1. Ceiling tile penetrations and openings outside of door FD33 on the gift shop, apothecary side within the corridor.

These findings were verified by the Carpenter at the times of observation, interview, and document review on 01/07/2025 between 10 am and 5:30 PM.


50053

Based on observation and interview with the Facilities Coordinator on 01/07/2025 between 10:00 am and 5:30 PM the facilities failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, sections 8.5 and 19.3.7. When required by Chapter 11 through 43 smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.

Findings include:

1. Ceiling tile penetrations of 1 1/2" x 1 1/2" in corridor near adult health near elevator.
2. Ceiling tile penetrations of 1 1/2" x 1 1/2" in corridor near stairwell near main elevators.


These findings were verified by the Facilities Coordinator at the times of observation, interview, and document review on 01/07/2025 between 10 am and 5:30 PM.

Based on observation and interview, the health care facility failed to ensure that combustible decorations shall be prohibited unless one of the following is met: Flame retardant or treated with approved fire-retardant coating that is listed and labeled for product. Decorations meet NFPA 701 (2010). Decorations exhibit heat release less than 100 kilowatts in accordance with NFPA 289 (2009). Decorations, such as photographs, paintings and other art are attached to the walls, ceilings and non-fire-rated doors in accordance with 18.7.5.6(4) or 19.7.5.6(4). The decorations in existing occupancies are in such limited quantities that a hazard of fire development or spread is not present. 19.7.5.6.

Finding:

On 1/7/2025, between 10:00 AM and 5:30 PM, a surveyor, with the Carpenter present, observed the following:

1. A fire rated door leading into the pharmacy had a decorative wreath hung and no evidence could be provided to show that it had
been sprayed with a fire-retardant coating, or that it met the requirements of NFPA 701 (2010) or NFPA289 (2009).

The surveyor confirmed this finding with the Carpenter at the time of the observation.

Based on observation and interview, the Health Care Facility failed to inspect and maintain rated fire door assemblies in accordance with NFPA 80, Standard for Fire Door and Other Opening Protective's in accordance with NFPA 101 18.7.6, 19.7.6, 8.3.3.1, NFPA 80 5.2, 5.2.3.

Findings:

On 1/7/25, between 10:00 AM and 5:30 PM, this surveyor, observed the following findings with the Facility Coordinator:

1. Painted fire rated door tag located in stairwell on level 1 near MRI room.
2. Painted fire rated door tag located in solid utility on level 1.
3. Painted fire rated door tag located in clean utility on level 1.
4. Painted fire rated door (#1227) tag located in storage room across from kitchen on level 1.
5. Painted fire rated door (#2327) tag located in stairwell near access to employee lounge on level 2.
6. Painted fire rated door, located within stairwell where smoke compartments 2, 3, 4, and 5 intersect.
7. Painted fire rated door, located within corridor outside pharmacy on level 1.
8. Hinge pin located on door entering waiting area for breast health suite on level 2 was not seated, required set pin adjustment.

This surveyor confirmed this finding with the Facility Coordinator at time of the observation and review.

Based on document review and interview, the facility failed to ensure that Medical Gas System was not inspected, tested, and maintained in accordance with NFPA 99, health Care Facilities Code (2012), 5.1.4.8, 5.1.14.1.3, 5.1.14.1.4, 5.1.4.8.8, 5.1.11.2, 5.1.8.3, 5.1.3.3.2(3), 5.1.3.5.6.4, 5.1.10.3, 5.1.3.6.3.12(B), 5.1.10.3.1, 5.1.10.4, 5.1.11.1.3
This deficient practice could affect the facility. patients/residents. visitors, and members of facility staff in the facility.

Findings:

On 01/07/25 between 10 am-5:30 pm during document review and interview the facility failed to provide documentation that the facility had corrected deficiencies listed on the testing report provided for the 9/16/24 inspection/testing. The following deficiencies were noted:

1. Room 2-medical air outlet is not supplied throught a zone valve

2. Scope room (L119) both vacuum inlets are being used for non medical applications

3. Operating rooms
a. Zone valves located left of OR 2 are installed behind a normally open or normally closed door
b. Zone valves located right or OR 3 are blocked by a cart
c. Sterile room, medical air outlet located in this room is not being used for the application of human respiration and calibration of
medical devices for respiratory application.
d. The sterile room medical air outlet located in this room is not supplied through a zone valve.

4. Operating room 1
a. 1st Vacuum inlet on the boon has a low flow of 2.25scfm
b. 2nd vacuum inlet on boom has a low flow of 2.5 scfm
c. WAGD inlet on the boom has a low flow of 2.5 scfm and leaks

5. Operating room 2
a. Nitrogen zone valve located left of OR two leaks at the stem in the on and off positions
b. 1st vacuum inlet on the boom has a low flow of 1.5 scfm
c. 2nd vacuum inlet on the boom has low flow of 2.25 scfm
d. WAGD inlet on the boom has low flow of 2.5 scfm

6. Operating room 3
a. 1st vacuum inlet on boom has low flow of 2.25 scfm
b. 2nd vacuum inlet on the boom has low flow of 2.25 scfm
c. WAGD inlet on the boom has low low of 2.25 scfm

7. Operating room 40Nitrous oxide outlet on boom 1 drops 9 psig at 3.5 scfm

8. Operating room 5
a. Durin the 10 minute standing pressure teset, the nitrogen system lost 17 psig
b. Nitrous Oxide outlet on boom 2 drops 9 psig at 3.5 scfm
c. Vacuum outlet on boon 2 has defective latch

9. Imaging Fluoroscopy-1st oxygen outlet leaks with the adapter attached

10. Emergency Department
a. Room 1-1st oxygen outlet leaks with the adapter attached
b. Room 3-1st vacuum inlet has defective latch
c. Room 9-1st vacuum inlet leaks

11. Cardiology/Sleep Lab
a. Sleep 1-2nd oxygen outlet leaks with adapter attached
b. Sleep Office-1st oxygen outlet leaks with adapter attached

12. Patient Wing
a. Oxygen zone valve located left of room 200 leaks at the left flange and the stem in the on and off positions
b. Oxygen zone valve located left of room 211 leaks at the left flange and the stem in the on and off positions
c. Room 205-1st oxygen outlet leaks with adapter attached
d. Room 206-2nd oxygen outlet leaks with adapter attached
e. Shower room A (2350)-Oxygen outlet, leaks with adapter attached
f. Shower room B (2338) Vacuum inlet has a defective latch
g. Room 223-Vacuum has low flow of 2.0 scfm

13. Adult Health
a. Room 250 has vacuum inlet leaks and medical air outlet leaks with adapter attached
b. Room 254-medical air outlet leaks with adapter attached

14. Cardiology/Sleep
a. Zone valves located right of vascular lab need to be relabeled as follows: For oxygen Rooms 2213, 2216, 2217, 2218, 2234,
2237, 2238, 2245, 2246, 2247, and 2248. For vacuum-Rooms 2213, 2216 and 2217.

15. Family Care
a. Vacuum zone valve located right of nursery 8 has no vacuum indicator on the station inlet side of the zone value.

16. Room 260-Oxygen outlet leaks with the adapter attached

17. Oxygen Buylt Tank
a. Piping as it enters the ground is not protected against possible physicl damage.
b. Existing guard posts are not spaced 4 ft between posts on center
c. Leaves need to be cleaned up from around the tank as it is combustible material
d. Emergency oxygen supply connection-pressure relief vent line needs to be relabeled outside in accordance with 5.1.11.1 to
distinguish itself from the medical gas pipeline.

18. In house oxygen components-the gas specific demand check located at the high/low pressure switch is defective and leaks when the pressure switch is removed.

19. Nitrous Oxide Manifold
a. Pressure relief vent line needs to be relabeled outside in accordance with 5.1.11.1 to distinguish itself from the medical gas
pipeline.
b. Pressure relief vent piping on roof is painted
c. After the source valve there are multiple threaded connections on the pipelines

20. Nitrogen Manifold-after the source valve there are multiple threaded connections.

21. Carbon Dioxide manifold- Pressure relief vent line needs to be relabeled outside in accordance with 5.1.11.1 to disginguish itself
from the medical gas pipeline.

22. Medical Air Compressor-Medical air intake is not located a minimum of 25 feet from ventilating system echausts, fuel storage
vents, combustion vents, plumbing vents, vacuum and WAGD discharges, or areas that can collect vehicular exhausts or other
noxious fumers.

23. Vacuum/WAGD Pump
a. A section of the main piping is soft soldered and not made with acceptable joining methods
b. Exhaust piping on the roof is painted

These findings were verified by the facility executive director and facilities coordinator at the time of document review on 01-07-25.



Based on observation, the health care facility failed to ensure that Gas Equipment - Medical Gas zone valves shall be readiliy accessible outside each vital life-support area, critical care area, and anesthetizing areas in accordance with NFPA 101, LIfe Safety Code 2012 edition section 19.3.2.4 and NFPA 99, Health Care Facilities Code, 2012 edition 5.1.4.8.7 (5.1.4.8.4). This deficient practice could affect the patients/residents, visitors, and members of facility staff in location(s). Deficient practices have the potential of allowing an emergent condition to enhance due to the lack of accessibility to the control isolation valves.

Findings:

On 1/7/2025, between 10:00 AM and 5:50 PM a surveyor, with the Carpenter present, observed the following:

1. The Medical Gas zone valve control located between the utility storage and clean utility room in the ICU suite was blocked from access by stored items.

The surveyor confirmed this finding with the Carpenter at the time of the observation.

Based on document review and interview, the facility failed to ensure that Medical Gas System was not inspected, tested, and maintained in accordance with NFPA 99, Health Care Facilities Code (2012), 5.1.9.3, 5.1.9.2.1 (1), 5.1.8.2.2 (2), 5.1.9.1 (1). This deficient practice could affect the facility, patients/residents, visitors, and members of facility staff in the facility.

Findings: On 01/07/25 between 10 am- 5:30 pm during document review and interview the facility failed to provide documentation that the facility had corrected deficiencies listed on the testing report provided for the 9/16/24 inspection/testing. The following deficiencies were noted:

1. Area alarm located at back office, left of room one, has no accurate pressure displays.

2. Master alarm panel locted at the back switchboard is not installed at a location in the office or workspace of the on-site individual
responsible for the maintenance of the medical gas and vacuum piping system.

3. Special Procedure - Area alarm panel located in back office left of room 1
a. Has no pressure/vacuum indicator at the alarm panel for each system that is monitored.
b. Medical air is not monitored for this department

4. Imaging
a. Area alarm panel located right of reading room in the back area is non-compliant Black ohio panel which does not distinguish
between increase or decrease of 20 percent from the normal line pressure and has recall for a potential fire hazard.

5. ICU Area alarmpanel located at the nurses station.
a. Vacuum needs the alarm sensor installed on the patient or use side of the zone valve box assembly
b. Is a non-complaint Black ohio panel which does not distinguish between increase or decrease of 20 percent from the normal line
pressure and has recall for a ptential fire hazard.

Based on document review and interview the facility failed to provide documentation to ensure that the operating rooms were protected by either isolated power or ground-fault circuit interrupters or that a risk assessment was completed for these locations per NFPA 99, Health Care Facilities Code (2012). 6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2. This deficient practice could affect the facility, patients/residents, visitors, and members of facility staff in the facility.

Findings;

1. It could not be determined if the facilities operating rooms which are considered wet locations had appropriate protection or that risk assessment had appropriate protection or that risk assessment had been completed. No documentation wa provided upon request at time of inspection.

These findings were verified by the facility executive director and facilities coordinator at the time of document review 01-07-25.

The Healthcare facility failed to test hospital grade receptacles and Line isolation monitors in accordance with NFPA 99 Section 6.3.4 and records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99)

Finding:

Based on observation and interview on 01-07-2025 between the hours of 10:00 AM and 5:30 PM, a surveyor observed the following:

1. Record review shows no documentation that hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of. 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals < 12 months. There are no records maintained of required test and associated repairs,or modification, containing date, room or area tested, and results.


An interview with facillity electrician confirmed this finding.

The hospital failed to maintain and test the Essential Electrical System in accordance with NFPA99, NFPA 110.

Findings:

Based on record review and interview on 01-07-2025 between hours of 10:00 AM and 5:30 PM, a surveyor observed the following:

1. There is no documentation for maintenance and testing of the generator transfer switches are performed in accordance with NFPA 110 for the facilities four generators.

2. There is no documentation generator sets(four generators) are exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. The facility electrician confirmed these findings

Based on observation, the health care facility failed to ensure that electrical equipment components are mainteained and protected in accordance with the requirements described in NFPA 70 (2011) National Electrical Code and that all pull boxes, junction boxes, and fittings shall be provided with covers. If metal covers are used, they shall be grounded. In energized installations each outlet box shall have a cover, faceplate, or fixture canopy.

Finding:

On 1/7/2025, between 10:00 AM and 5:30 PM, a surveyor, with the Carpenter present, obsreved the following:

1. An electrical junciton box was found in the purchasing office in the receiving area missing the faceplate cover leaving the interior wiring exposed.

The surveyor confirmed this finding with the Carpenter at the time of the observation.




50053

Based on observation, the health care facility failed to ensure that electrical equipment components are maintained and protected in accordance with the requirements described in NFPA 70 (2011) National Electrical Code and that all pull boxes, junction boxes, and fittings shall be provided with covers. If metal covers are used, they shall be grounded. In energized installations each outlet box shall have a cover, faceplate, or fixture canopy.

Finding:

On 1/7/2025, between 10:00 AM and 5:30 PM, a surveyor, with the Carpenter present, observed the following:

1. An electrical junction box was found in the stairwell on level 2 where smoke compartments 2, 3, 4, 5 intersect missing the faceplate cover leaving the interior wiring exposed.
2. 1. An electrical junction box was found on level 2 of stairwell in some compartment #1 missing the faceplate cover leaving the interior wiring exposed.

The surveyor confirmed this finding with the Facility Coordinator at the time of the observation.

Based on observation and interview, the long-term care facility failed to ensure that power strips are not used for non-PCREE (Patient-care-related electrical equipment) and that power strips are not used as a substitute for fixed wiring in accordance with NFPA 99 Chapter 10, NFPA 70 chapter 4 {400.8(1)}

On 01/07/2024, between 10:30 AM and 5:30 PM, surveyor, with the Carpenter present observed the following:

1. A mini-fridge was found plugged into a portable power tap which was daisy chained to another portable power tap under a desk
located at the X-Ray reading room office behind door 1- 082

The surveyor confirmed this finding with the Carpenter at the time of the observation. Based on observation and interview, the long-term care facility failed to ensure that power strips are not used for non-PCREE (Patient-care-related electrical equipment) and that power strips are not used as a substitute for fixed wiring in accordance with NFPA 99 Chapter 10, NFPA 70 chapter4 {400.8(1)}

On 01/07/2024, between 10:30 AM and 5:30 PM, surveyor, with the Carpenter present observed the following:

1. Portable heaters were found plugged into power strips rather than fixed wiring in the following areas:
a. In X-ray waiting room underneath the receptionist desk. Underneath a technicians desk in the laboratory.

The surveyor confirmed this finding with the Carpenter at the time of the observation.

Based on document revie and interview, the facility failed to ensure that Gas and Cylinder Storage was maintained in accordance with NFPA 99, Health Care Facilities Code (2012). 11.6.2.3 (11), 11.3.2.3, 11.6.5.2 This deficient practice could affect the faciliy, patients/residents, visitors, and members of facility staff in the facility.

Findings:

1. The medical gas tank storage room (near hazardous waste room) had oxygen cylinders that were free standing and not secured.

2. Themedical gas tank storage room (near hazardous waste room) had combustible itesmwithin locatedin the room and within 5' of the stored oxygen cylinders (wooden studs on walls and cardboard boxes with combustible materials not associated with oxygen delivery equipment

3. The medical gas tank storage room (near haxardous waste room) had dylinders that were not properly labeled/separated from full and empty cylinders.

On 01/07/25 between 10 am-5:30 pm during document review and interview the facility failed to provide documentation that the facility had corrected deficiencies listed on the testing report provided for the 9/16/24 inspection/testing. The following deficiencies were noted.


47175

Based on observartion, the health care facility failed to ensure that Gas Equipment - Cylinder and Container Storage in a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.3 in NFPA 99 (2012). A precautionary sign readable from 5 feet is on each door or gate of cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING,"

Finding:

On 1/07/2025 between 10:00 AM and 5:30 PM, a surveyor, with the Carpenter observed the following;:

1. The clean utility room in the ICU was found being used for oxygen tank storage less than 300 cubic feet and was not marked with a sign readable from 5 ft stating "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING"

The surveyor confirmed this finding with the Carpenter at the time of the observation.