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Based on observation and interview, the facility did not maintain doors in the rated walls to be self-closing doors or automatic closing devices complying with NFPA 101, 2012 edition, Sections 19.2.2.2.7, 7.2.1.8, 8.3.3.3, and 8.5.4.4. This deficient practice could affect all patients, outpatients, and an undetermined number of staff and visitors.

Findings include:

1. On 09/12/2022 at 10:03 AM, observation in the Electrical Room in the Basement revealed the rated, corridor door LL021 was equipped with a self-closing device, but the door did not fully close after three attempts.

2. On 09/13/2022 at 9:49 AM, observation in the open stair revealed the door 0543B, within a two hour rated wall, was equipped with a self-closing device, but the door did not fully close after three attempts.

3. On 09/13/2022 at 9:52 AM, observation in the IT Room revealed the door FRD021 was equipped with a self-closing device, but the door did not fully close after three attempts.

These deficient practices were confirmed by Staff Z and AA at the time of discovery.

Based on observation and interview, the facility did not protect a hazardous area in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.2.2.2.7, 19.3.2.1, 7.2.1.8.2, and 8.7.1.3. This deficient practice could affect an undetermined number of staff and visitors.

Findings include:

On 09/13/2022 at 1:24 PM, observation in the Lab Suite C revealed a penetration in the 1 hour wall separating the Lab from the OR Suite, that was not fire stopped according to an approved method. The 1-1/2 inch diameter PVC pipe, used for the water purification machine piping, was not sealed at the wall under the sink of the processing station containing a sink.

This deficient practice was confirmed by Staff Z and AA at the time of discovery.

Based on record review, observation, and interview, the facility did not maintain the automatic sprinkler system in accordance with NFPA 101, 2012 edition, Sections 19.3.5.1, 19.3.5.7, 19.3.6.2.4, 9.7.1.1, 9.7.5, 9.7.7, 9.7.8, 8.4.2, 8.4.4, 8.5.2, and 8.5.6; NFPA 13, 2010 edition, Sections 8.1.1, 8.5.6, 8.6.5.3, 8.6.6.1, and 8.8.6, as well as NFPA 25, 2011 edition, Sections 4.7. 5.2.1.2, 7.2.1, 7.3.2, 7.3.2.1, and 7.4.2.1. This deficient practice could affect all patients, outpatients, and an undetermined number of staff and visitors.

Findings Include:

1. On 09/13/2022 at 10:26 AM, observation in Patient Room101 within the full height cabinet revealed that a chair headrest and (10) ENT Suction bags was stored 8 inches below a pendant sprinkler head.

2. On 09/13/2022 at 10:31 AM, observation in Patient Room 102 within the full height cabinet revealed that a cleaning spray bottle and (4) ENT Suction bags was stored 8 inches below a pendant sprinkler head.

3. On 09/13/2022 at 11:03 AM, observation in the Xray/Fluoroscopy Room Shielded Area revealed an 8 inch by 1/2 inch missing ceiling tile channel. This missing tile channel does not duplicate the smoke tight conditions that were used in the sprinkler UL certification test.

4. On 09/13/2022 at 12:58 PM, observation in the Lab Room 107 revealed a missing ceiling tile inside the top of the full height cabinet by the room entry. This missing tile does not duplicate the smoke tight conditions that were used in the sprinkler UL certification test.

5. On 09/13/2022 at 1:42 PM, observation in the Outpatient Therapy Bay 1 revealed a missing ceiling tile inside the top of the full height cabinet. This missing tile does not duplicate the smoke tight conditions that were used in the sprinkler UL certification test.

6. On 09/13/2022 at 1:45 PM, observation in the Outpatient Therapy Bay 2 revealed a missing ceiling tile inside the top of the full height cabinet. This missing tile does not duplicate the smoke tight conditions that were used in the sprinkler UL certification test.

These deficient practices were confirmed by Staff Z and AA at the time of discovery.

Based on observation and interview, the facility did not maintain smoke barriers in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.7.3, 8.5, 8.5.2 and 8.5.6. This deficient practice could affect all patients, outpatients, and an undetermined number of staff and visitors.

Findings include:

1. On 09/13/2022 at 11:27 AM, observation above the ceiling in CT Restroom revealed a penetration in the smoke barrier wall that was not fire stopped according to an approved method. The 2 hour wall penetration included an 1/2 inch diameter conduit that was not sealed.

2. On 09/13/2022 at 11:34 AM, observation above the ceiling in the corridor outside of the Radiology Office revealed a penetration in the smoke barrier wall that was not fire stopped according to an approved method. The corridor wall penetration included an 1/2 inch conduit that was not sealed.

3. On 09/13/2022 at 12:02 PM, observation above the ceiling and adjacent to the double smoke barrier doors outside of the Nuclear Medicine Room, revealed a penetration in the smoke barrier wall that was not fire stopped according to an approved method. The corridor wall penetration included a 4 inch diameter cable conduit with 10 cables that was not sealed.

4. On 09/13/2022 at 1:56 PM, observation above the ceiling of the Registration Office 166 revealed a penetration in the smoke barrier wall that was not fire stopped according to an approved method. A 3/4 inch diameter conduit with blue and yellow cabling was not sealed.

These deficient practices were confirmed by Staff Z, AA, and BB at the time of discovery.

Based on observation and interview, the facility did not maintain doors in smoke barrier doors in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.7.6, 19.3.7.8, 8.2.2.4, 8.5.4, 7.2.1.8 and 7.2.1; as well as NFPA 80, 2010 edition, Section 6.3.1.7.1. This deficient practice could affect an undetermined number of staff and visitors.

Findings include:

1. On 09/12/2022 at 10:15 AM, observation revealed that the 1 hour, double smoke doors in the Basement, adjacent to the Soiled Holding Room and near the Loading Dock, did not fully close after three attempts.

2. On 09/13/2022 at 2:04 PM, observation at the Entrance to the Office Administration Suite from the Main Corridor revealed a smoke door that had automatic closing hardware that was not able to operate as the arm was missing from the closing mechanism.

These deficient practices were confirmed by Staff Z and AA at the time of discovery.

Based on observation and interview, the facility did not ensure the electrical wiring and equipment met the requirements of NFPA 101, 2012 Edition, Sections 19.5.1.1, 9.1.1, and 9.1.2, as well as NFPA 70, edition 2011, Articles 110.3(B), 110.8, 210.8(B), and 400.8. This deficient practice could affect all patients, outpatients, and an undetermined number of staff and visitors.

Findings Include:


1. On 09/13/2022 at 10:41 AM, observation in the Exam Room 4 in the Emergency Department revealed an electrical receptacle was located approximately 3-feet from a sink. The facility was not able to confirm that ground-fault circuit-interrupter (GFCI) protection was provided within 6-feet from a sink.

2. On 09/13/2022 at 10:43 AM, observation in the Exam Room 3 in the Emergency Department revealed an electrical receptacle was located approximately 3-feet from a sink. The facility was not able to confirm that ground-fault circuit-interrupter (GFCI) protection was provided within 6-feet from a sink.

3. On 09/13/2022 at 10:45 AM, observation in the Exam Room 2 in the Emergency Department revealed an electrical receptacle was located approximately 3-feet from a sink. The facility was not able to confirm that ground-fault circuit-interrupter (GFCI) protection was provided within 6-feet from a sink.

4. On 09/13/2022 at 10:49 AM, observation in the Exam Room 1 in the Emergency Department revealed (1) duplex and (1) quad electrical receptacle was located approximately 3-feet from a sink. The facility was not able to confirm that ground-fault circuit-interrupter (GFCI) protection was provided within 6-feet from a sink.

5. On 09/13/2022 at 1:51 PM, observation in the Outpatient Therapy Gym for Cardio Rehab revealed a flexible cord multi-outlet strip device (power strip) plugging into a multi-outlet strip device (power strip) with battery backup.

These deficient practices were confirmed by Staff Z and AA at the time of discovery.

Based on observation and interview, the facility did not store oxygen cylinders in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.2.4 and 8.7, as well as NFPA 99, 2012 edition, Sections 11.3.1 and 5.1.3.3.2(4). This deficient practice could affect all patients, outpatients, and an undetermined number of staff and visitors.

Findings include:

On 09/12/2022 at 10:13 AM, observation in the Medical Gas Storage Room in the Basement revealed the vinyl wall base installed was not a noncombustible or limited-combustible material and did not meet the 1-hour fire resistance rated construction requirement for walls, floors, and ceiling of a room storing greater than 3,000 cbft of non-flammable gases. The room was storing (4) "H" sized tanks of nitrous oxide, (6) "H" sized tanks of carbon dioxide, (4) "H" sized tanks of Nitrogen, and (17) "E" sized tanks of oxygen.

This deficient practice was confirmed by Staff Z and AA at the time of discovery.