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Based on observation and staff interview, the facility failed to ensure door leaf encroachment in a means of egress was in accordance with the 2012 NFPA, Life Safety Code. Failure to ensure proper door leaf encroachment could obstruct the means of egress, leading to injury or death for patients, staff, and visitors using the affected exit access corridor. The deficiency affected one (1) of multiple corridor doors. The findings were:

Observations on 09/23/25 at 10:40 AM revealed the storage room door in the OB exit access corridor projected more than 7" into the required width of the exit access corridor when fully open.

Interview with the facility director at the time of the observation acknowledged the deficiency.

Interview with the facility administrator and the facility director at the time of exit confirmed the deficiency.

REF: 2012 NFPA 101, Sections 19.2.1, 7.2.1.4.3.1

Based on observation and staff interview, the facility failed to ensure doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position unless held open by a release device in accordance with the 2012 NFPA 101, Life Safety Code. Failure to ensure self-closing doors close and latch could allow for the spread of smoke and fire leading to injury or death in the event of a fire. The deficiency affected two (2) of multiple doors. The deficiency affected all residents, staff, and visitors. The findings were:

Observation on 09/23/2025 at 9:04 AM revealed the Emergency Department storage room ED123 was protected with a self-closing door due to the room being greater than 50 SF in size and the storage of flammable or combustible materials. Further observation revealed the self-closing door failed to close and latch, keeping the door in the closed position.

Observation on 09/23/2025 at 9:09 AM revealed the Emergency Department soiled holding ED128 was protected with a self-closing door due to the room being greater than 50 SF in size and the storage of flammable or combustible materials. Further observation revealed the self-closing door failed to close and latch, keeping the door in the closed position.

Interview with the facility director at the time of the observation acknowledged the deficiency.

Interview with the facility administrator and the facility director at the time of exit confirmed the deficiency.

REF: 2012 NFPA 101, Sections 19.3.2.1, 19.3.2.1.3, 8.7.1, 7.2.1.8

Based on observation and staff interview, the facility failed to provide readily visible signs to mark exit access in all cases where the exit or way to reach the exit is not readily apparent to the occupants in accordance with section 7.10 of the 2012 NFPA 101, Life Safety Code. Failure to provide exit and directional signage in accordance with the 2012 NFPA 101 could impede egress leading to injury or death in the case of an emergency. The deficiency affected one (1) of multiple exit access corridors. The deficiency could affect all patients, staff, and visitors using the facility. The findings were:

Observation on 09/23/2025 at 9:48 AM revealed the facility failed to provide readily visible exit signs to mark exit access at cross corridor doors between the Medical Surgical unit exit access corridor and the Admissions lobby, in accordance with section 7.10 of the 2012 NFPA 101, Life Safety Code.

Observation on 09/23/2025 at 10:58 AM revealed the respirator storage room door was located or arranged so that it is likely to be mistaken for an exit. Further observations revealed the facility had provided signage for the door indicating the door was not an exit, however the signage was not in accordance with the 2012 NFPA 110 section 7.10.8.3.1.

Interview with the facility director at the time of the observation acknowledged the deficiency.

Interview with the facility administrator and the facility director at the time of exit confirmed the deficiency.

REF: 2012 NFPA 101, Sections 19.2.10, 7.10, 7.10.8.3.1

Based on observation and staff interview, the facility failed to maintain doors protecting corridors in accordance with 2012 NFPA 101, Life Safety Code. Failure to protect corridor openings could result in the obstruction of a corridor resulting in injury or death in the event of a fire. The deficiency affected one (1) of multiple corridor doors in the facility and could potentially affect all patients, staff and visitors in the area. The findings were:

Observation on 09/23/2025 at 9:17 AM revealed the Trauma 2 door was a corridor door equipped with positive latching hardware. Further observations revealed the horizontal sliding door rebounded when closed, failing to keep the door in the closed position in accordance with the 2012 NFPA 101.

Interview with the facility director at the time of the observation acknowledged the deficiency.

Interview with the facility administrator and the facility director at the time of exit confirmed the deficiency.

REF: 2012 NFPA 101, Section 19.3.6.3.5, 19.2.2.2.10.2 (5)

Based on observation and staff interview, the facility failed to provide category 1 piped gas and vacuum systems with identification for shutoff valves in accordance with the 2012 NFPA 99, Healthcare Facilities Code. Failure to identify shutoff valves could lead to injury or death of patients utilizing the affected piped gases. The deficiency affected one (1) of multiple zone valve boxes. The deficiency could affect all patients utilizing rooms served by the zone valves. The findings were:

Observations on 09/23/2025 at 10:10 AM revealed the zone valve box located in the OR exit access corridor serving endoscopy rooms 1 and 2 included shutoff valves without identification in accordance with the 2012 NFPA 99, Healthcare Facilities Code.

Interview with the facility director at the time of the observation acknowledged the deficiency.

Interview with the facility administrator and the facility director at the time of exit confirmed the deficiency.

REF: 2012 NFPA 101, Section 19.3.2.4, NFPA 99, Sections 5.1, 5.1.11.2