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Based on observation and interview, the facility failed to protect hazardous areas in accordance with the requirements of NFPA 101 (2012 edition), sections 19.3.2, 19.3.2.1.2, 19.3.2.1.3, 19.3.2.1.5, 8.3, 8.3.1.2, 8.3.2, 8.3.2.1, 8.4, 8.4.3, 4.6.12.1, and 4.6.12.2. These deficient practices could affect an undetermined number of patients, staff, and visitors.

Findings include:

1. On 05/13/2025 at 1:06 pm, observation in the Maintenance shop revealed the 3/4-hour fire-rated double doors to the room were not equipped with coordinating hardware and if not released to close in the correct sequence, the door with the metal astragal remained opened.

2. On 05/13/2025 at 1:14 pm, observation above the ceiling on the west side of the 1-hour fire barrier wall between the Kitchen and the corridor revealed an approximate 8-inch by 8-inch gypsum scab patch that does not meet the tested and listed fire-rated wall assembly and was not protected in accordance with the listed penetration firestop assembly Gypsum Association GA-225-2019.

These findings were confirmed at the time of discovery by a concurrent interview with Staff J, Staff Y, Staff Z, Staff AA, and Staff CC.

Based on observation and interview, the facility failed to store oxygen cylinders in accordance with the requirements of NFPA 101 (2012 edition), sections 19.3.2.4; NFPA 99 (2012 edition), sections 11.3.2, 11.3.2.3, 11.3.2.6, and 11.6.2.3. These deficient practices could affect an undetermined number of patients, staff, and visitors.

Findings include:

On 05/13/2025 at 2:30 pm, observation in ACU Room 329-Storage revealed (1) E-sized oxygen cylinder was not secured in a rack or in a cylinder cart.

This finding was confirmed at the time of discovery by a concurrent interview with Staff J, Staff Y, Staff Z, Staff AA, and Staff CC.