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Based on record review, and interview, the facility failed to develop and implement emergency preparedness policies and procedures, based on the emergency plan and the The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials of the Emergency Preparedness Plan in accordance with 42 CFR 482.15(b)(8).

Finding:

On 04/22/2025, between 11:00 AM and 4:30 PM, surveyor 39983, with the Safety Officer and Director of Security present, observed the following:

1. The hospital did not have any policy documenting the facility's role in emergencies where the Secretary waives or modifies certain statutory and regulatory requirements for healthcare facilities in response to emergencies under section 1135 of the Act related to the provision of care at an alternate care site identified by emergency officials. In an interview with the Safety Officer, he stated that "He did not know what an 1135 waiver was, and did not have a policy in the Emergency Preparedness Program regarding it".


The surveyor confirmed this finding with the Safety Officer and Director of Security at the time of the record review.

Based on observations, the Hospital failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition for construction type and supporting construction for health care and/or other building occupancies. A building undergoing repair, renovation, modification, or reconstruction must comply with 19.1.1.4.3

Findings include:

Based on observation, on 04/22/25 between 11:00 AM and 4:00 PM, in the presence of the Maintenance Technician the following was not met:


1. Room 205 located in the Labor and Delivery Suite has been changed to a Staff sleeping room, this is required to have a plan review done from the Maine State Fire Marshal's Office.
2. Room 205 is being used as a sleeping room for staff, the room does not have a single station smoke detector and does not have a Carbon Monoxide detector.

This finding was verified by the Maintenance Technician at the time of the observation.

The facility has failed to ensure compliance with the Life Safety Code regarding Multiple Occupancies - Construction Type: Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3

Based on observation, on 04/22/2025 between 10:00 AM and 4:00 PM and 04/23/2025 9:00 AM and 4:00 PM, Surveyor 50034 in the presence of the Maintenance Manager, the following was not met:

1. Level 3: 04/22/2025 The 2-hour fire barrier wall located in the East Wing and the Therapy Waiting area had penetrations with no fire stopping material present. The 2-hour fire barrier was designated on Life Safety Plans provided by the Maintenance Manager.

2. Level 3: 04/22/2025 The 2-hour fire/smoke rated wall separating the Therapy Waiting Room and Medical Office Building has multiple unsealed penetrations going through the wall with no fire stopping material present. The 2-hour fire/smoke wall was designated on Life Safety Plans provided my the Maintenance Manager.

This was confirmed by the surveyor and Maintenance Manager at the time of observation.





51673


Based on observation, on 04/23/25 between 9:00 AM and 4:00 PM, in the presence of the Maintenance Technician the following was not met:

1. The 2 hr wall separating the hospital from the medical office wing has penetrations above the suspended ceiling system with no fire stopping material present. The locations are as follows:

a. located near room 200; ridged conduit and conductor cable penetrating wall is not sealed.

b. located near room 200; the sheet rock meeting the roof deck is not fire stopped.

c. Entrance door to medical office wing next to vestibule, web truss is not fire stopped.

d. Corridor wall located inside medical office entrance, improper patching on 2-hour fire wall.

e. Corridor wall located inside medical office entrance, the sheet rock meeting the roof deck is not fire stopped.

f. Corridor wall located inside medical office entrance, web truss is not fire stopped.

g. Located in Gift Shop, Provide documentation that materials used, are suitable for application of sealing penetrations in a 2-hour assembly.

h. Located in Foundation room, the sheet rock meeting the roof deck is not fire stopped, penetrations not fire stopped.

i. Office next to Foundation room, the sheet rock meeting the roof deck is not fire stopped, penetrations not fire stopped.

j. Corridor located by elevator equipment room, sheet rock not properly finished at edges where it meets.

k. Corridor located by elevator equipment room, the sheet rock meeting the roof deck is not fire stopped.

l. Corridor located by elevator equipment room, penetrations above door.

m. Corridor entering physician office, the sheet rock meeting the roof deck is not fire stopped, penetrations not fire stopped.

Based on observations, architectural drawings review, and interview with the Plant Operations Director the facility failed to meet the requirements of NFPA 101, Life Safety Code, 2012 edition, section 1.6.1, regarding construction of health care occupancies.

Finding:

On 04/23/2025, between 09:00 AM and 4:00 PM, two surveyors with the Maintenance Manager present, observed the following:

1. The structural steel above the ceiling tiles on the basement level by the entrance to the laundry suite are not treated with an approved fireproofing coating. This coating is required for the construction type of II(111). The plans provided show a type II(222) construction, and having non fireproofed structural steel above the ceiling tiles that supports the concrete floor above is not compliant with either construction type. The maintenance manager observed the unprotected steel with the surveyors and discussed the construction type of the building at the time of our observation.

The surveyors acknowledged this finding with the Maintenance Manager at the time of the observation and during the exit interview.












51673


Based on observation, on 4/23/25 between 9:00 AM and 4:00 PM, in the presence of the Maintenance Technician the following was not met:

1. Fire proofing scraped off of structural steel for installation of conductor wire and pipe hangers, located in Physical Therapy Registration waiting area.

This finding was verified by the Maintenance Director at the time of the observation.

Based on observation, the facility failed to ensure that doors in an exit passageway are free of obstruction and open with the proper opening forces in accordance with NFPA 101, Life Safety Code, 2012 edition, Sections 19.2.1, 7.1.10.1, and 7.2.1.4.5

Findings:

On 04/23/2025, between the hours of 09:00 AM and 4:00 PM, this surveyor, accompanied by the Maintenance Manager observed the following:

1. The exterior blue boiler room exit door did not open to 90 degrees. Upon measuring the door only opened 10 inches from the edge of the door to the door frame. The door impacts the pavement outside, which doesn't allow the exit door to open to its full capacity and function as a marked exit door.

The surveyors acknowledged this finding with the Maintenance Manager at the time of the observation and during the exit interview.

Based on observations and interview, the facility failed to ensure doors in the means of egress meet the delayed egress signage requirements of NFPA 101, Life Safety Code, 2012 edition, Sections 19.2.2.2, and 7.2.1.6.1.1(4).

Finding:

On 04/22/2025, between 11:00 AM and 4:00 PM, two surveyors with the Maintenance Manager present identified:

1. The third floor South Wing Stairwell door leaf was held closed by a magnetic door holder. An interview with the Maintenance Manager revealed that the door is equipped with delayed egress equipment. The door leaf is not equipped with a readily visible, durable sign that reads: PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS. The delayed egress system was tested on this door, and it released the magnetic door holder in 15 seconds.This deficient practice could affect residents, guests, and staff from proper egress in the event of an emergency as they will not know that the door is delayed egress and may believe it to be locked..

This finding was acknowledged by the Maintenance Manager at the time of the observation and the exit interview.


51673

Based on observations, the Hospital failed to ensure the means of egress was Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, NFPA 101, 2012 edition, 7.2.1.6.1, Delayed Egress Locking Systems.

Findings:

Based on observation, on 04/22/25 between 11:00 AM and 4:00 PM, in the presence of the Maintenance Technician the following was not met:

1. The double door located in Labor and Delivery is equipped with Delayed egress and did not have a readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1/8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress:
PUSH UNTIL ALARM SOUNDS, DOOR CAN BE OPENED IN 15 SECONDS

This finding was verified by the Maintenance Technician at the time of the observation.

Based on observation, the facility failed to ensure that doors in an exit passageway, stairway 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 7.2.1.8.2 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. In Level 3, 1 of 3 smoke compartments.

Findings:

On 04/22/2025 between hours of 11:00 AM and 4:00 PM and 04/23/2025 between the hours of 9:00 AM and 4:00 PM, surveyor 50034 accompanied with Maintenance Manager did observe the following:

1. Level 3: 04/22/2025 The Tech Room Door located in the Sleep Study Section of the South Wing has a self-closing device attached to the door that is missing parts of the mechanism and the door would not self-close.

2. Level 1: 04/23/2025 The storage room door, located in the the kitchen, has a self-closing device attached to it and is being held open by a hook type device.

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

Based on observations, the Hospital failed to ensure the Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following: (1)13/4 in. (44 mm) thick, solid-bonded core wood (2)Material that resists fire for a minimum of 20 minutes. NFPA 101, Life Safety Code, 2012 Edition, 19.3.6.3

Findings:


Based on observation, on 04/22/25 between 11:00 AM and 4:00 PM and in the presence of the Maintenance Technician, the following was not met:

1. The information describing the rating on the tag of the doors separating the Ambulatory Surgical Unit and Surgical Suite is not legible.
2. The astragal installed on the doors separating the Ambulatory Surgical Unit and Surgical Suite has hardware missing, creating penetrations in the doors.
3. The latch at the top of the doors separating the Ambulatory Surgical Unit and Surgical Suite when closed, does not seal the doors, allowing the passage of smoke.
4. When entering the Emergency Room from the Radiology corridor, the door closer on the right door is missing a bolt and creating a penetration through the door, which would allow the penetration of smoke.

This finding was verified by the Maintenance Technician at the time of the observation.

Based on observation, the facility failed to ensure that exit discharge is arranged in accordance with NFPA 101 Life Safety Code 2012 edition chapter 19 section 19.2.7 Chapter 7 section 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface in accordance with survey and and certification letter 05-38.


On 04/23/2025 during a facility tour from 9:00 AM to 4:00 PM, two surveyors and the Maintenance Manager identified:

1. The marked exit door from the kitchen discharges directly on a grassed surface. The walking surface in the exit discharge shall be a hard packed, uniformly all-weather slip-resistant travel surface under all foreseeable conditions.

The surveyors confirmed this finding with the Maintenance Manager at the time of observation.


50034


Based on observation, the facility failed to ensure that exit discharge is arranged in accordance with NFPA 101 Life Safety Code 2012 edition chapter 19 section 19.2.7 Chapter 7 section 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface in accordance with survey and and certification letter 05-38.


During a survey on 04/22/2025 between the hours of 11:00 AM and 4:00 PM and 04/23/2025 between the hours of 9:00 AM and 4:00 PM, this surveyor and the Maintenance Manager observed the following:

1. 04/23/2025 Level 1: The marked exit located in the Central Sterile Storage exits on to a lawn and not on to a all-weather, level travel surface.

2: 04/23/2025 Level 1: One of two paved walkways located off the marked exit of the Administrative Wing has pavement that is broken up in places and does not provide an all weather, level travel surface.

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







51673




On 04/23/2024, between 9:00 AM and 4:00 PM, surveyor 51673, with the Maintenance Technician present, observed the following:

1. The exit discharge located in the Patient Financial wing has a piece of metal attached to the deck at the top of the stairs creating a tripping hazard. The stairs, constructed of cement are crumbling and deteriorating.

2. The exit discharge located in the medical records department exits to grass before reaching a public way.

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

Based on observations and interview with the Maintenance Manager, the facility failed to install directional continuously illuminated exit signage in every location where the direction of travel to reach the nearest exit is not apparent in accordance with National Fire Protection Association 101, Life Safety Code, 2012 edition, sections 7.10.1.2.1, 7.10.2.1, and 19.2.10.

Finding:

On 04/23/2025 between 09:00 AM and 4:00 PM with the Maintenance Manager present during a facility tour identified:

1. There is no exit signage installed in the Administrative suite entry by the cross corridor double doors that mark the exit pathway.

This finding was acknowledged by the Maintenance Manager at the time of observation and during the exit interview.







51673

Findings:


Based on observation, on 04/22/25 between 11:00 AM and 4:00 PM, in the presence of the Maintenance Technician the following was not met:

1. The exit sign above the cross corridor doors located in the Waiting Room leading to the Labor and delivery unit has the arrow pointing in a direction that leads the public to a wall, not the exit. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

This finding was verified by the Maintenance Technician 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 04/22/2024 between hours of 11:00 AM and 4:00 PM and 04/23/2025 between the hours of 9:00 AM and 4:00 PM. Surveyor 50034, accompanied with Maintenance Manager did observe the following:

1. Level 1: 04/23/2025. The Maintenance room located in the Administration wing has fire caulking that has separated from the 1-hour smoke enclosure wall.

2. Level 1: 04/23/2025. The Pump room located in the Administration Wing has multiple unsealed openings located in the ceiling that would allow the passage of smoke.

3. Level 1: 04/23/2025. The Boiler room located in the Maintenance department has several unsealed penetrations in the ceiling that would allow the passage of smoke.

4. Level 1 04/23/2025. The Mechanical room located off the maintenance dock has fire caulking around a pipe that has become separated from the wall.

5. Level 1 04/23/2025. The Mechanical room located in Central Surgical Supply has multiple holes throughout the ceiling to include a hole approximately 14 inches by 18 inches, a circular hole approximately 4 inches in diameter, a hole approximately 16 inches by 24 inches and a circular type hole approximately 6 inches in diameter

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













51673

Based on observation, the hospital 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 04/22/2024 between hours of 11:00 AM and 4:00 PM, Surveyor 51673, accompanied with Maintenance Technician did observe the following:

1. The mechanical room located in the surgery suite does not meet the requirement of smoke tight, visible openings were observed around wall mounted equipment.

This finding was verified by the Maintenance Technician at the time of the observation.

Based on observations, the Hospital Facility failed to ensure that the Inspection for Grease Buildup was completed semi- annual, the entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition Table 11.4

Findings:

Based on observation on 04/23/25 between hours of 9:00 AM and 4:00 PM. surveyor 51673 accompanied with Maintenance Technician did observe the following:

1. The hood and duct located in the Emergency Department Staff Kitchen is required to be inspected semi-annuall. There is an excessive buildup of debris in the vent system of the hood.

This finding was verified by the Maintenance Technician at the time of the observation.

Based on record review the fire alarm sytem has not been maintained, the long-term care facility failed to maintain fire alarm initiating devices in accordance with NFPA 101, Life Safety Code, 2012 edition, sections 19.3.4.2.1, 9.7.5, 9.7.7, 9.7.8 and the NFPA 72, National Fire Alarm and Signaling Code, 2010 edition.


Findings:

On 04/23/2025, between 09:00 AM and 4:00 PM, this surveyor did observed the following:

1. Fire alarm report dated August 29, 2024 indicates duct smoke detector 2 96980379 failed during testing.

2. Fire alarm report dated August 29, 2024 indicates duct smoke detector 1 96980277 not accessible and not able to be tested.

These findings verified by the maintenance technician.

Based on observation, the Hospital facility failed to install the water-based fire protection system throughout the premises in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 edition, Sections 8.1.1(1), and 8.15.10(3) as referenced by NFPA 101, Life Safety Code, 2012 edition, Section 19.3.5.

Findings:

On 04/23/2025, between 09:00 AM and 4:00 PM, this surveyor with the Maintenance Manager present observed the following:

1. The current Electrical Switch Gear room is not covered by an approved automatic sprinkler system.
2. The original Switch Gear Room is not covered by an approved automatic sprinkler system.
3. The West Acute Care Exit Stairwell is not protected by the sprinkler system.


This surveyor acknowledged these findings with the Maintenance Manager at the time of the observation and during the exit interview.






51673

Based on observation, on 04/23/25 between 9:00 AM and 4:00 PM, in the presence of the Maintenance Technician the following was not met:

1. Multiple sprinkler heads are obstructed when the X-ray machine is moved on the tracks in the radiology X-ray Room 1.

This finding was verified by the Maintenance Technician at the time of the observation.

Findings:

1. The sprinkler heads in the following locations were loaded with foreign material in the following locations:
a. Acute Care clean linen area,
b. Resident room 325,
c. Resident room 324,
d. Resident room 330,
e. Laundry room by the washers and scale.

The surveyors acknowledged these findings with the Maintenance Manager at the time of the observation and during the exit interview.


51673

Based on observations, the facility failed to ensure that Sprinkler System was inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. This deficiency does not meet the minimum requirements of maintaining a sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-based Fire Protection Systems, 2011 edition, Chapter 5, section 5.2.1.1.2(5), 5.2.1.1.1, 5.2.1.1.3


Findings:

Based on observation, on 04/22/25 between 11:00 AM and 4:00 PM, and 04/23/25 between 9:00 AM and 4:00 PM, Surveyor 51673 in the presence of the Maintenance Technician the following was not met:

1. Sprinkler heads in the following locations have foreign materials:
a. Doctor's Lounge in the Operating Room Suite.
b. Soiled utility room, clean utility room, and staff lounge in the labor and delivery suite.
c. Staff locker room adjacent to the ambulance bay.

2. The sprinkler head in the closet located near the dietician office has approximately a one inch penetration in the ceiling directly adjacent to the escutcheon ring that would allow the passage of smoke. Any sprinkler that has been installed in the incorrect orientation shall be corrected by repositioning the branch line, drop, or sprig, or shall be replaced.

3. The sprinkler head located in a storage closet in the Mammography unit is obstructed by storage of materials within 18 inches of the sprinkler head. This was removed during survey by Maintenance Technician.


These findings were verified by the Maintenance Technician at the time of observations.

Based on observation, the facility failed to comply with 2012 Life Safety Code sections 18.3.5.12, 19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1. Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 2010 NFPA 10 6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.

During a facility tour on 04/23/2025 between the hours of 9:00 AM and 4:00 PM, this surveyor and the Maintenance Manager observed the following.

Findings:

1.Level 1: The fire extinguisher located in the pharmacy is mounted on the wall approximately 5' 8" off the floor surface.

2.Level 1: The fire extinguisher located in the Kitchen Serving Area is mounted on the wall approximately 6' 0" off the floor surface.

This finding was confirmed by this surveyor and the Maintenance Manager at the time of the survey.

Based on observations, the facility failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition for smoke barrier enclosures in accordance with 18.3.7.3, 19.3.7.3. Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b) Not less than two separate smoke compartments shall be provided on each floor.
(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

During a facility tour on 04/22/2025 between the hours of 11:00 AM and 4:00 PM and 04/23/2025 between the hours of 9:00 AM and 4:00 PM, Surveyor 50034 along with the Maintenance Director observed the following:

Findings:

1. Level 3: 04/22/2025 The east corridor wall separating the EAST WING from the ELEVATOR area has unsealed penetrations going through a 1-hour smoke barrier wall that are . Plans indicated this is a 1-hour fire smoke barrier.

2. Level 2: 04/23/2025 The smoke partition located in the hallway separating Cardiac Rehabilitation and Radiology has unsealed penetrations of wire conduit, metal piping and wiring going through the smoke partition.

3. Level 2: 04/23/2025 The smoke barrier separating nuclear medicine from cardiac rehabilitation does not go all the way to the roof decking above.


These were confirmed by the surveyor and Director of Maintenance at the time of observation.















51673

Based on observation, on 04/22/2025 between 11:00 AM and 4:00 PM, in the presence of the Maintenance Technician, the following was not met:

Findings:

1. Level 2, the smoke barrier wall located adjacent to the conference room across from the chief nursing office has penetrations in the smoke barrier wall above the suspended ceiling system.
2. Level 2, the smoke barrier wall above the corridor doors located in the Ambulatory Surgical Unit/Labor and Delivery waiting room leading into the Labor and delivery unit has penetrations, patches, and improperly used products attempting to seal some penetrations.
3. Level 2, the smoke barrier wall located adjacent to the mechanical room from the lab has penetrations under the flourescent light and over the door leading to the lab waiting room.
4. Level 2, metal roll-up door installed in the smoke barrier wall located at the entrance to the lab from the lab waiting area is required to be a self-closing, positive latch, rated door.
5. Level 2, the smoke barrier wall located in the lab waiting room entering the lab located above the suspended ceiling system has penetration at the top where the sheet rock meets the floor deck above.
6. Level 2, penetrations in the smoke barrier wall located in Physical Therapy Registration waiting area.
7. Level 2, two ceiling tiles missing in Radiology IT room.

This finding was verified by the Maintenance Technician at the time of the observation.

Based on observation and interview, the Hospital facility was drying mops and rags in the dryer, which is prohibited per NFPA 101, Life Safety Code, 2012 Edition, Sections 19.5.1.1, and 9.1.

Finding:

On 04/23/2025, between 09:00 AM and 4:00 PM, two surveyors with the Maintenance Manager present identified:

1. An interview with the laundry employee indicated when asked, if mop heads or greasy rags are dried in the dryer, the facility does not dry mop heads in the dryer, but they do dry cleaning and kitchen rags in the dryer after washing them.
No documentation was provided showing the drying appliances are listed for this procedure. This deficient practice could affect residents, guests, and staff if this practice leads to the rags or mops catching fire while in the dryer or after drying in storage.

The surveyors confirmed this finding with the Maintenance Manager at the time of the observation and during the exit interview.

Based on observations, the Hospital Facility failed to ensure Central supply systems and medical gas outlets for oxygen, medical air, nitrous oxide, carbon dioxide, and all other patient medical gases shall be piped only into areas where the gases will be used under the direction of licensed medical professionals for purposes congruent with the following, NFPA 99, 2012 Edition, Health Care Facilities Code, 5.1.3.5.2 Permitted Locations for Medical Gases,
(1)Direct respiration by patients
(2)Clinical application of the gas to a patient, such as the use of an insufflator to inject carbon dioxide into patient body cavities during laparoscopic surgery and carbon dioxide used to purge heart-lung machine blood flow ways
(3)Medical device applications directly related to respiration
(4)Power for medical devices used directly on patients
(5)Calibration of medical devices intended for (1) through (4).
5.1.4.8.5, Zone valve boxes shall not be installed behind normally open or normally closed doors or otherwise hidden from plain view

Findings:


Based on observation, on 04/22/25, between 11:00 AM and 4:00 PM, and on 04/23/25 between 9:00 AM and 4:00 PM in the presence of the Maintenance Technician the following was not met:

1. On 4/22/25 between 11:00 AM and 4:00 PM surveyors observed Medical gas outlets for patient use are located in the break room used by staff in the Surgical Suite.

2. On 04/23/25 between 9:00 AM and 4:00 PM surveyors observed a Medical gas zone valve box located in the Radiology suite partially obstructed by a door.

This finding was verified by the Maintenance Technician at the time of the observation.

Based on observations and interview, the facility failed to meet the requirements of NFPA 70, National Electrical Code, 2011 edition, Section 314.25, as referenced by NFPA 99, Healthcare Facilities Code, 2012 edition, section 6.3.2.1.

Findings:

On 04/22/2025, between 11:00 AM and 4:00 PM, two surveyors with the Maintenance Manager present, observed the following:

1. The four electric boxes in the ceiling of the war room are left uncovered when the previous electrical equipment was removed and has exposed wiring. An interview with the Maintenance Manager, revealed that the area is going to be renovated into the new pharmacy and devices are being replaced.

2. The electrical junction box in the Acute Care dayroom is missing a cover and has exposed wiring.

3.Kitchen Manager's office, The receptacle where the clock was mounted on the wall was left uncovered exposing the electrical wiring. Interview with the Kitchen Manager revealed that the clock became unopoerational on 04/21/2025 and was discarded.

The surveyors acknowledged these findings with the Maintenance Manager at the time of the observation and during the exit interview.

Based on observations and interview, the Hospital failed to insure Operating rooms shall be considered to be a wet procedure location, unless a risk assessment conducted by the health care governing body determines otherwise. NFPA 99, 2012 edition, 6.3.2.2.8.4, 6.4.4.2

Findings:

1. The facility failed to produce documentation that a written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. When Interviewed the Maintenance Technician stated "I don't know if we have that"

This finding was verified by the Maintenance Technician at the time of the observation.

Based on observation, the facility failed to comply with the 2012 Life Safety Code 9.1.3.1 Emergency Generators and stand by power systems shall be installed, tested and maintained in accordance with NFPA 110 Standard for Emergency and Standby Power Systems, 2010 NFPA 110, Standard for Emergency and Standby Power Systems, Section 5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. 5.6.5.6.1 the remote manual stop station shall be labeled.

On 04/22/2025 between the hours of 11:00 AM and 4:00 PM and 04/23/2025 between the hours of 9:00 AM and 4:00 PM, surveyor 50034 with the Maintenance Manager observed the following:

Finding:

1. The generator that is housed at the exterior of the facility does not have an emergency stop button located on the exterior of the housing.

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

Based on observation, the Hospital 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)}


Findings:

On 04/22/2025, between 11:00 AM and 4:00 PM, surveyor 51673, with the Maintenance Technician present, observed the following:

1. Two electric extension cords with four gang receptacle attached to the cord is being used in Surgery #2 in place of fixed wiring.
2. On 04/23/25 between 9:00 AM and 4:00 PM in the Medical records room located on Level 2, a power strip is being used to power a microwave oven and Keurig coffee machine. This was corrected during the survey.


This finding was verified by the Maintenance Technician at the time of the observation.

Based on observations, the Hospital failed to ensure the physical integrity of the power cord assembly composed of the power cord, attachment plug, and cord-strain relief shall be confirmed by visual inspection. NFPA 101, 2012 edition 10.3, Testing requirements - Fixed and Portable.

Findings:

Based on observation, on 04/22/25 between 11:00 AM and 4:00 PM, surveyor 51673 in the presence of the Maintenance Technician, the following was not met:

1. The cord for a power strip attached to an anesthesia pole located in Surgery #3 has electrical tape used as a temporary repair between the cord and the plug.

This finding was verified by the Maintenance Technician at the time of the observation.

Based on observation, the health care facility failed to ensure compliance with the Life Safety Code 19.3.2.4 Medical Gas storage and administration areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing. 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 11.6.5.2 If empty cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders and 11.6.5.3. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.

On 04/22/2025, between the hours of 11:00 AM and 4:00 PM, Surveyor 50034, with the Maintenance Manager present, observed the following:

1. The Oxygen room located in the South wing Sleep Study area has oxygen tanks in two separate metal rack systems with no signage designating which tanks are empty or full.

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