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Based on observation and staff interview, the facility failed to protect hazardous areas in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly protect hazardous areas could result in the spread of smoke and fire, which could result in injury or death. The deficiencies affected the OR suite and the med/surg patient wing, and could impact all patients, staff, and visitors in the area.

The findings were:

Observation on 11/21/2022 at 1:27 PM revealed the anesthesia workroom located in the OR suite contained a large amount of combustible storage and was greater than 50 s.f. in size. Observation of the door into the anesthesia workroom revealed that it was a 1-hour fire rated door, but it was not equipped with an automatic-or-self-closing device. Storage rooms greater than 50 sq. ft. in size and containing combustible materials shall be separated from other spaces by smoke partitions and the doors shall be self or automatic closing.

Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.3.2.1.2, 19.3.2.1.3


Observation on 11/21/2022 at 1:30 PM revealed a room labeled "Storage" located in the OR suite, which contained a large amount of combustible storage and was greater than 50 s.f. in size. Observation of the door into the storage room revealed that it was not equipped with an automatic-or-self-closing device. Storage rooms greater than 50 sq. ft. in size and containing combustible materials shall be separated from other spaces by smoke partitions and the doors shall be self or automatic closing.

Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.3.2.1.2, 19.3.2.1.3


Observation on 11/21/2022 at 1:32 PM revealed the clean utility room located in the OR suite contained a large amount of combustible storage and was greater than 50 s.f. in size. Observation of the door into the clean utility room revealed that it was not equipped with an automatic-or-self-closing device. Storage rooms greater than 50 sq. ft. in size and containing combustible materials shall be separated from other spaces by smoke partitions and the doors shall be self or automatic closing.

Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.3.2.1.2, 19.3.2.1.3


Observation on 11/21/2022 at 2:04 PM revealed a large amount of combustible storage was being stored in an alcove located off the main corridor of the med/surg patient wing. Observation of the alcove revealed that it was greater than 50 s.f. in area, was not sprinklered, and was being used to store medical equipment, chairs, tables, and wheelchairs. Hazardous areas, including spaces larger than 50 s.f. and used for storage of combustible supplies and equipment, shall be protected by a 1-hour fire barrier or shall be protected with an automatic extinguishing system and smoke partition.

Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.3.2.1

Based on observation and staff interview, the facility failed to protect cooking facilities in accordance with the 2012 NFPA 101, Life Safety Code, and the 2011 NFPA 96, Standard for the Ventilation Control and Fire Protection of Commercial Cooking Operations. Failure to properly protect cooking facilities could result in the spread of smoke and fire, which could result in injury or death. The deficiency affected the kitchen and could impact all staff and visitors within the kitchen.

The findings were:

Observation on 11/21/2022 at 2:22 PM revealed a wheeled gas-fire cook-top under a commercial exhaust hood located in the facility's kitchen. Observation of the cook-top revealed that no means was provided to ensure it was returned to the approved location after being moved. Cooking appliances requiring fire-extinguishing protection shall be provided with a means of return to the approved location after being moved for cleaning or maintenance purposes.

Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.3.2.5.1, 9.2.3; 2011 NFPA 96 12.1.2.3

Based on observation and staff interview, the facility failed to maintain smoke compartment barriers in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly maintain smoke compartment barriers could result in spread of smoke and fire, which could result in injury or death. The deficiency affected one (1) of three (3) smoke compartment barriers and could impact all patients, staff, and visitors in the area.

The findings were:

Observation on 11/21/2022 at 2:58 PM revealed a smoke compartment barrier that runs adjacent to the OR suite along the suite's north wall. Observation above the ceiling revealed multiple penetrations of electrical conduit and plumbing piping that were unprotected. It appeared from observation that the unprotected penetrations were mostly related to the on-going renovation work being done in the area. Smoke compartment barriers shall maintain a 1/2-hour fire resistance rating and be sealed to limited the transfer of smoke.

Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.3.7.3

Based on observation, documentation review, and staff interview, the facility failed to protect wet procedure locations in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to properly protect wet procedure locations could result in electrical malfunction, which could result in injury or death. The deficiency affected the operating room and endoscopy procedure room, and could impact all patients receiving procedures in these areas.

The findings were:

Observation on 11/21/2022 at 1:40 PM revealed the operating room and endoscopy procedure room were not provided with special protection against electric shock. Observation of the rooms revealed that an isolated power system (IPS) was not provided, and observation of all electrical outlets revealed that they were not equipped with ground-fault current interruption. Operating rooms are considered wet procedure locations unless a risk assessment is conducted to determine otherwise. Wet procedure locations shall be provided with special protection against electrical shock which can include a power distribution system that inherently limits the possible ground-fault current due to a first fault to a low value, or a power distribution system in which the power supply is interrupted if the ground-fault current does, in fact, exceed the trip value of a Class A GFCI. This requirement may not apply in existing construction if a written inspection procedure is provided that is continuously enforced by a designated individual at the hospital that the electrical systems and equipment are installed and maintained in accordance with NFPA 70 and NFPA 99. No such written inspection procedure was provided at the time of the survey.

Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated they were unaware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 99 6.3.2.2.8