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Based on observation and interview, the facility failed to maintain a 2-hour fire rated separation between the Hospital and adjacent Business Occupancy. This deficient practice would allow smoke, fire and gases to migrate from one occupancy into the other. The facility has the capacity for 67 beds with a census of 31 on the day of survey.

Findings are:
Observation on 10-18-23 at 10:11 am and 10:43 am revealed:
1. An excessive gap between the 1½ hour fire rated doors 1A102.
2. The 1½ hour fire rated door next to room A37 failed to close and latch within the doorframe.
3. An excessive gap between the 1½ hour fire rated doors 0A103.

During an interview on 10-18-23 at 10:11 am and 10:43 am, Staff A confirmed the fire rated doors had a gap and failed to close and latch.

Based on observation and interview, the facility failed to maintain means of egress free of obstructions. This deficient practice would delay egress and not impede it to full instant use in the case of fire or other emergencies. The facility has the capacity for 67 beds with a census of 31 on the day of survey.

Findings are:
Observations on 10-18-23 at 10:02 am revealed, a patient lift in the corridor outside room A14 which caused an obstruction.

During exit interview on 10-18-23 at 10:02 am, Staff A confirmed the lift in the corridor which caused an obstruction.

Based on observation and interview, the facility failed to assure the stair door would close and latch within the doorframe. This deficient practice would allow fire, smoke and gases to spread into the stair enclosure. The facility has the capacity for 67 beds with a census of 31 on the day of survey.

Findings are:
Observation on 10-18-23 at 10:27 am and 10:38 am, revealed:
1. The stair door next to vending machines failed to close and latch within the doorframe.
2. Stair door 1C081 next to room A47 failed to close and latch within the doorframe.

During an interview on 10-18-23 at 10:27 am and 10:38 am, Staff A confirmed the stair door failed to latch.

Based on observation and interview, the facility failed to assure the door to a hazardous area would close and latch within the doorframe. This deficient practice would allow fire, smoke and gases to migrate into the exit corridor. The facility has the capacity for 67 beds with a census of 31 on the day of survey.

Findings are:
Observation on 10-18-23 between 10:20 am and 10:56 am revealed:
1. Locker room door 1B183 equipped with a self-closing device failed to latch within the doorframe.
2. Storage room door 0A152 failed to be equipped with a self-closing device.
3. Storage room door 0A150 failed to be equipped with a self-closing device.
4. Storage room door 0A150A failed to be equipped with a self-closing device.

During an interview on 10-18-23 between 10:20 am and 10:56 am, Staff A confirmed the door failed to latch within the doorframe and hazardous areas failed to provide self-closing devices.

Based on observation and interview, the facility failed to assure portable fire extinguishers were inspected. This deficient practice would not ensure a fire extinguisher was operational when needed to control a fire. The facility has the capacity of 67 beds with a census of 31 on the day of survey.

Findings are:
Observation on 10-18-23 at 10:45 am revealed, the fire extinguisher in the Generator room was last inspected on 9-6-23.

During an interview on 10-18-23 at 10:45 am, Staff A confirmed extinguisher did not have a current inspection.

Based on observation and interview, the facility failed to ensure corridor doors would resist the passage of smoke, as the doors would not prevent the spread of fire, smoke and gases within the exit corridors. The facility has the capacity for 67 beds with a census of 31 on the day of survey.

Findings are:
Observation on 10-18-23 at 10:25 am revealed, York Conference Room door failed to latch within the doorframe.

During an interview on 10-18-23 at 10:25 am, Staff A confirmed the door failed to latch.

Based on observation and interview, the facility failed to assure smoke barrier doors in the facility would close and latch. This deficient practice would increase the potential for fire, smoke and gases to spread. The facility has a capacity of 67 and a census of 31 on the survey.

Findings are:
Observations on 10-18-23 at 10:26 am and 10:29 am revealed:
1. The smoke door next to York Conference Room failed to latch within the doorframe.
2. The smoke door next to room 1C075 failed to latch within the doorframe.

During an interview on 10-18-23 at 10:26 am and 10:29 am, Staff A confirmed the smoke doors failed to latch within the doorframe.

Based on observation and interview, the facility failed to cover electrical junction boxes. This deficient practice would create electrical injury hazard, and increase a fire hazard. The facility has the capacity for 67 beds with a census of 31 on the day of survey.

Findings are:
Observation on 10-18-23 at 11:04 am revealed, an open electrical junction box on the ceiling above Chiller #2.

During an interview on 10-18-23, at 11:04 am, Staff A confirmed the open junction box.

Based on observation and interview, the facility failed to prohibit the use of extension cords as a substitute for adequate wiring. This deficient practice would create an increased fire hazard. The facility has the capacity for 67 beds with a census of 31 on the day of survey.

Findings are:
Observation on 10-18-23 at 10:55 am revealed, extension cords were used to power a full-sized refrigerator and a microwave in the contractors area in the basement.

During an interview on 10-18-23 at 11:05 am, Staff A confirmed the extension cords.

Based on observation and interview the facility failed to restrain medical gas systems and to provide required safety equipment/signage. The deficient practice would increase the potential for containers to fall and would not alert occupants of liquid oxygen storage within the room. The facility has the capacity for 67 beds with a census of 31 on the day of survey.

Findings are:
Observation on 10-18-23 between 9:50 am and 10:20 am revealed:
1. Two liquid oxygen units in room 1A143 failed to be chained.
2. No liquid oxygen signage was posted outside room 1A143.
3. Two liquid oxygen units in room 1B184.1 failed to be chained.
4. No liquid oxygen warning signage was posted outside room 1B184.1

During an interview on 10-18-23 between 9:50 am and 10:20 am, Staff A confirmed the lack of restraint and signage for liquid oxygen.


During an interview on 10-18-23 at 1010 a.m. with the Administrator and Maintenance Supervisor revealed the facility was unaware of a requirement for safety warning signage.


Actual NFPA Standard:
NFPA 99, (2012) Chapter 11, HealthCare Facilities Code 11 Gas Equipment,
11.5.2.3 Transfilling Liquid Oxygen. Transfilling of liquid oxygen shall comply with 11.5.2.3.1 or 11.5.2.3.2, as applicable.
11.5.2.3.1 Transfilling to liquid oxygen base reservoir containers or to liquid oxygen portable containers over 344.74 kPa (50 psi) shall include the following:
(1) A designated area separated from any portion of a facility wherein patients are housed, examined, or treated by a fire barrier of 1 hour fire-resistive construction.
(2) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring.
(3) The area is posted with signs indicating that transfilling is occurring and that smoking in the immediate area is not permitted.
(4) The individual transfilling the container(s) has been properly trained in the transfilling procedures
11.7.2 Information and Instructions. The liquid oxygen seller shall provide the user with documentation that includes, but is not limited to, the following:
(1) Manufacturer's instructions, including labeling for storage and use of the containers
(2) Requirements for storage and use of containers away from ignition sources, exits, electrical hazards, and high temperature devices
(3) Methods for container restraint to prevent falling
(4) Requirements for container handling
(5) Safeguards for refilling of containers
11.7.3.3* Liquid oxygen base reservoir containers shall be secured by one of the following methods while in storage or use to prevent tipping over caused by contact, vibration, or seismic activity:
(1) Securing to a fixed object with one or more restraints
(2) Securing within a framework, stand, or assembly designed to resist container movement
(3) Restraining by placing the container against two points of contact
11.7.3.5 The transfilling of containers shall be in accordance with the manufacturer's instructions and the requirements of 11.7.3.5.1 through 11.7.3.5.2.
11.7.3.5.1 Liquid oxygen containers shall be filled outdoors or in compliance with 11.5.2.3.1.
11.7.3.5.1.1* A drip pan compatible with liquid oxygen shall be provided under the liquid oxygen base reservoir container's filling and vent connections used during the filling process, unless the filling is performed on a noncombustible surface such as concrete.
11.7.3.5.2 Liquid oxygen portable containers shall be permitted to be filled indoors when the liquid oxygen base reservoir container is designed for filling such containers and the written instructions provided by the container manufacturer are followed.