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Based on record review and interview, the facility failed to include sewage and waste disposal in their emergency preparedness plan (EPP).

Findings include:

On 07/16/2025 at 8:47 AM, the facility's EPP lacked a process to dispose of waste in the event of a disaster.

On 07/16/2025, the Emergency Manager confirmed the EPP lacked a process to dispose of waste.

Based on document review and interview, the facility failed to ensure a person performing fire watch duties had no other duties.

Findings include:

On 07/16/2025 at 1:04 PM, the facility's Fire Watch Policy, revised 07/08/2024, failed to document a person conducting fire watch duties was not responsible for other duties.

On 07/16/2025, the Director of Facilities and Security confirmed persons conducting fire watch had no other duties.

NFPA 25, Standard for the inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

NFPA 13 National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, 2010 Edition

6.2.7 Escutcheons and Cover Plates.
6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.
6.2.7.2* Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly.
6.2.7.3 Cover plates used with concealed sprinklers shall be part of the listed sprinkler assembly.
6.2.8 Guards. Sprinklers subject to mechanical injury shall be protected with listed guards.

Based on observation, document review and interview, the facility failed to maintain the automatic fire sprinkler system as required.

Findings include:

On 07/15/2025 through 07/16/2025, the following automatic fire sprinkler system concerns were present:

- On 07/15/2025 at 12:58 PM, the recessed sprinkler in changing room had a gap between the cover and the ceiling, exposing the interstitial space.
- On 07/15/2025 at 1:35 PM, two sprinklers in the material supply overflow room lacked escutcheons, exposing the interstitial space.
- On 07/16/2025 at 9:50 AM, in the behavioral health storage room, items were stored two inches from the sprinkler.

On 07/15/2025 and 07/16/2025, the Director of Facilities and Security and Maintenance Director were present at each discovery.

Based on document review and interview, the facility failed to ensure a person performing fire watch duties had no other duties.

Findings include:

On 07/16/2025 at 1:04 PM, the facility's Fire Watch Policy, revised 07/08/2024, failed to document a person conducting fire watch duties was not responsible for other duties.

On 07/16/2025, the Director of Facilities and Security confirmed persons conducting fire watch had no other duties.

National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition

110.12 Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.
(B) Integrity of Electrical Equipment and Connections. Internal parts of equipment, including busbars, wiring terminals insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken, bent, cut, or deteriorated by corrosion, chemical action, or overheating.

Article 314 - Outlet, Device, Pull, and Junction Boxes; Conduit bodies; Fittings; and Handhole Enclosures
314.28(c) Pull and Junction Boxes and Conduit Bodies.
(c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110.

Article 400 - Flexible Cords and Cables
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
1) As a substitute for the fixed wiring of a structure
2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
3) Where run through doorways, windows, or similar openings
4) Where attached to building surfaces
Exception to 4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
6) Where installed in raceways, except as otherwise permitted in the Code
7) Where subject to physical damage

Based on observation and interview, the facility failed to ensure electrical wiring and equipment complied with the National Electric Code, National Fire Protection Association (NFPA) 70.

Findings include:

On 07/15/2025 and 07/16/2025, the following electrical concerns were present:

- On 07/15/2025 at 9:38 AM, in the Care Coordination room, a UL 1363 rated relocatable power tap (RPT) had an extension cord plugged into it, creating a daisy chain. The RPT had a computer and printer plugged into it.
- On 07/15/2025 at 10:00 AM, in the Manager office, a Keurig was plugged into a UL 1363 rated RPT.
- On 07/15/2025 at 10:18 AM, in the Equipment room, a C-MAC® for intubation and a vital sign machine were plugged into a non UL 1363A rated RPT.
- On 7/15/2025 at 11:10 AM, at the Emergency Room nurses' station, a coffee pot and a small refrigerator were plugged into a RPT.
- On 7/15/2025 at 11:22 AM, at the Emergency Room nurses' station B, a space heater was plugged into a RPT.
- On 7/15/2025 at 11:24 AM, in the Emergency Room manager office, a Keurig and a small refrigerator were plugged into a residential-style RPT.
- On 7/15/2025 at 3:00 PM, in the old pre-operative room, GFCI receptacle had a broken ground hole.
- On 7/16/2025 at 9:37 AM, in the behavioral health room, a one-plug receptacle was broken.
- On 7/16/2025 at 10:00 AM, in the Chief Nursing Officer's office, a yellow extension cord with a space heater and a computer plugged into it was plugged into a RPT, creating a daisy-chain.
- On 7/16/2025 at 10:13 AM, in the infusion manager's office, the junction box next to the sink was missing its cover.

On 07/15/2025 and 07/16/2025, the Director of Facilities and Security and Maintenance Director were present at each discovery.

Based on observation and interview, the facility failed to conduct fire drills once per shift, per quarter.

Findings include:

On 07/15/2025 and 07/16/2025, the facility lacked documented evidence of a fire drill conducted during the third quarter night shift (7:00 PM to 7:00 AM) and fourth quarter night shift.

On 07/15/2025 and 07/16/2025, the Director of Facilities and Security and Maintenance Director confirmed the missing fire drills.

National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition

210.8 Ground-Fault Circuit-Interrupter Protection for Personnel. Ground-fault circuit-interruption for personnel shall be provided as required in 210.8(A) through (C). The ground-fault circuit-interrupter shall be installed in a readily accessible location.
(A)(7) Sinks - located in areas other than kitchens where receptacles are installed within 1.8 m (6 ft) of the outside edge of the sink.

Based on observation and interview, the facility failed to install ground fault circuit interrupters (GFCI) in areas less than six feet from a sink edge.

Findings include:

On 07/15/2025 and 07/16/2025, the following receptacles were not GFCI receptacles as required:

- On 07/15/2025 at 2:13 PM, in Exam Room 3, a duplex receptacle was 13.5 inches from the sink edge; however, the receptacle was not the required GFCI.
- On 07/15/2025 at 2:16 PM, in Exam Room 5, a duplex receptacle was 14 inches from the sink edge; however, the receptacle was not the required GFCI.
- On 07/16/2025 at 9:46 AM, in the Behavioral Health corridor, a duplex receptacle was 11 inches from the sink edge; however, the receptacle was not the required GFCI.
- On 07/16/2025 at 10:09 AM, in a vacant office in the old cardiology office, a duplex receptacle was 16 inches from the sink edge; however, the receptacle was not the required GFCI.
- On 07/16/2025 at 10:11 AM, in the dietician's office, a duplex receptacle was 15 inches from the sink edge; however, the receptacle was not the required GFCI.
- On 07/16/2025 at 10:12 AM, in the authorization specialist's office, a duplex receptacle was 15.5 inches from the sink edge; however, the receptacle was not the required GFCI.
- On 07/16/2025 at 10:13 AM, in the infusion manager's office, a duplex receptacle was 17 inches from the sink edge; however, the receptacle was not the required GFCI.
- On 07/16/2025 at 10:15 AM, in the project manager's office, a duplex receptacle was 17 inches from the sink edge; however, the receptacle was not the required GFCI.

On 07/15/2025 and 07/16/2025, the Director of Facilities and Security and Maintenance Director were present at each discovery.

S&C: 14-46-LSC

Power strips providing power to non- patient-care-related electrical equipment must be Relocatable Power Taps (RPT) listed as UL 1363.

Power strips providing power to patient care-related electrical equipment must be Special-purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL 60601-1.

National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition

Article 400 - Flexible Cords and Cables
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
1) As a substitute for the fixed wiring of a structure
2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
3) Where run through doorways, windows, or similar openings
4) Where attached to building surfaces
Exception to 4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
6) Where installed in raceways, except as otherwise permitted in the Code
7) Where subject to physical damage

Based on observation and interview, the facility failed to ensure residential-style relocatable power taps (RPT) were not used to power personal electronics and patient care related electrical equipment (PCREE).

Findings include:

On 07/15/2025 through 07/16/2025, the following PCREE was not plugged into the required UL 1363A rated RPT:

- On 07/15/2025 at 10:18 AM, in the Equipment room, a C-MAC® for intubation and a vital signs machine were plugged into a residential-style RPT.
- On 07/15/2025 at 2:06 PM, in Exam Room 1, a vital signs machine was plugged into a six-plug UL 1363 rated RPT.
- On 07/15/2025 at 2:13 PM, in Exam Room 2, an exam table was plugged into a six-plug UL 1363 rated RPT.

On 07/15/2025 and 07/16/2025, the Director of Facilities and Security and Maintenance Director were present at each discovery.

National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 Edition

4-3.5.2.2 (b) 2, if stored within the same enclosure, empty oxygen cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed quickly.

11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.

Based on observation and interview, the facility failed to include signage on the door to the room containing greater than 300 cubic feet of oxygen.

Findings include:

On 07/15/2025 at 9:45 AM, the supply room contained 17 e-sized cylinders; however, the door to the supply room lacked the required signage.

On 07/15/2025 at 9:45 AM, the Director of Facilities and the Engineering employee confirmed the 17 e-sized cylinders were greater than 300 cubic feet, thus considered in storage. The Director of Facilities and the Engineering employee confirmed the door to the supply room lacked the required signage.