HospitalInspections.org

Based on observation and interview, the facility failed to meet multiple occupancy requirements for one of one exit door between Component 01 and Component 99.

Findings include:

Observation on December 11, 2025, at 11:59 a.m., revealed the first floor building separation from Component 01 to Component 99 was the direction of egress from Component 01. The fire door does not have fire exit hardware allowing push-to-open access to the exit corridor. When the doors were closed, the left door was locked from the Component 01 side. The facility was unaware if the door could be unlocked in the event of an emergency.

Interview with the maintenance technician on December 11, 2025, at 11:59 a.m., confirmed the deficiency at the time of the survey.

Based on observation and interview, the facility failed to meet sprinkler system requirements on two of three building levels.

Findings include:

1. Observation on December 11, 2025, between 9:10 a.m. and 11:40 a.m., revealed the sprinkler escutcheons were missing in the following locations:

A (9:10 a.m.) First floor stock room;
B.(10:00 a.m.) First floor ER corridor, near the exit;
C. (10:47 a.m.) First floor, near X-ray 2;
D. (11:40 a.m.) First floor kitchen.

Interview with the maintenance technician on December 11, 2025, at 11:40 a.m., confirmed the locations were missing sprinkler escutcheons.

2. Observation on December 11, 2025, at 9:10 a.m. revealed the penthouse sprinkler line had wires taped to the sprinkler piping.

Interview with the maintenance technician on December 11, 2025, at 9:10 a.m., confirmed the wires were taped to the sprinkler piping.

Based on document review and interview, the facility failed to meet requirements for HVAC systems for one of one system.

Findings include:

Document review on December 11, 2025, at 10:08 a.m., revealed the facility was unable to provide fire/smoke damper inspection documentation for the new ER addition of the hospital. The dampers were newly installed in 2023 and need the one-year, after-install inspection.

Interview with the maintenance director on December 11, 2025, at 10:08 a.m., confirmed the facility was unable to provide the documentation. The facility is in the process of scheduling a fire/smoke damper inspection.

Based on observation and interview, the facility failed to meet requirements for maintenance, inspection, and testing of doors on one of three building levels.

Findings include:

Observation on December 11, 2025, at 10:03 a.m., revealed the second floor east wing fire door to delivery had multiple holes through the door.

Interview with the maintenance technician on December 11, 2025, at 10:03 a.m., confirmed the deficiency at the time of the survey.

Based on observation and interview, the facility failed to meet electrical receptacle requirements on one of three building levels.

Findings include:

Observation on December 11, 2025, at 9:33 a.m., revealed the first floor OR 21 scrub room had receptacles located within six feet of the sink that were not protected by a ground fault circuit interrupter.

Interview with the maintenance director on December 11, 2025, at 9:33 a.m., confirmed the deficiency at the time of the survey.

Based on document review and interview, the facility failed to meet essential electrical equipment requirements for one of two generators.

Findings include:

Document review on December 11, 2025, at 9:30 a.m., revealed the fuel sample, dated March 3, 2025, was rated as "action required" and required fuel polishing or filtration. The facility failed to have the deficiency corrected at the time of the survey.

Interview with the maintenance director on December 11, 2025, at 9:30 a.m., confirmed the fuel sample deficiency was not corrected.

Based on observation and interview, the facility failed to meet gas equipment requirements on one of three building levels.

Findings include:

Observation on December 11, 2025, at 10:33 a.m., revealed the second floor corridor oxygen storage failed to have distinct separation betwen full and empty cylinders.

Interview with the maintenance director on December 11, 2025, at 10:33 a.m., confirmed the deficiency at the time of the survey.