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Based on observation and interview, the facility failed to maintain the building construction. This was evidenced by unsealed penetrations in the wall. This affected three of eight smoke compartments and could result in the spread of fire and smoke in the event of a fire.

Findings:

During a tour of the facility and interview with Maintenance Staff on 4/29/25, the walls were observed.

1. At 10:07 a.m., three separate one by one inch wall penetrations with conduits were observed in the Environmental Services closet of the Medical-Surgical area, lacking proper fire stopping. Upon interview, the Maintenance Staff stated that he was not aware of the unsealed penetrations.

2. At 10:11 a.m., the storage room (DS101) in the kitchen area was observed with a one by one inch penetration with a conduit running through the wall. Upon interview, the Maintenance Staff stated that he was not aware of the unsealed penetration.

3. At 10:23 a.m., four separate one by one inch penetrations were observed in the sterilizer room (RD107) with data cables running through the wall. Upon interview, the Maintenance Staff stated that he was not aware of the unsealed penetrations.

Based on observation and interview, the facility failed to maintain emergency lighting in the Operating Room (OR). This was evidenced by the failure to have battery-powered emergency lighting in the OR. This affected one of eight smoke compartments and could result in potentially hazardous conditions during a power outage, compromising patient safety and staff ability to effectively manage surgical procedures in low-visibility situations.

NFPA 99, Health Facilities Code, 2012 edition.
6.3.2.2.11 Battery-Powered Lighting Units.
6.3.2.2.11.1 One or more battery-powered lighting units shall be provided within locations where deep sedation and general anesthesia is administered.
6.3.2.2.11.2 The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room.
6.3.2.2.11.3 The sensor for units shall be wired to the branch circuit(s) serving general lighting within the room.
6.3.2.2.11.4 Units shall be capable of providing lighting for 1 1/2 hours.
6.3.2.2.11.5 Units shall be tested monthly for 30 seconds, and annually for 30 minutes.

Findings:

During a tour of the facility and interview with Maintenance Staff on 4/29/25, the lighting fixtures in the OR were observed.

At 2:36 p.m., the OR was observed without battery-powered lighting units. Upon interview, the Maintenance Staff confirmed that the OR did not have battery-powered lighting units and stated that they were unaware of the requirement.

Based on observation and interview, the facility failed to maintain a hazardous enclosure. This was evidenced by the failure to have a self-closing device on the exit door to a storage room. This could result in the passage of smoke in the event of a fire, and affected one of eight smoke compartments.

Findings:

During a tour of the facility and interview with Maintenance Staff on 4/29/25, the storage rooms were observed.

At 11:51 a.m., the dry food storage room (DS107) located in the kitchen area failed to have a self-closing device on the exit door. The room was approximately 119 square feet and contained dry food storage. Upon interview, the Maintenance Staff stated that he was not aware that a self-closing device was required on the exit door.

Based on document review and interview, the facility failed to maintain the facility's Smoke Detectors. This was evidenced by missing records of biennial smoke detector sensitivity testing. This affected three of three patients and eight of eight smoke compartments, and could result in a non-detected system malfunction in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1* General.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
Chapter 14 Inspection, Testing, and Maintenance
14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.
14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.

Findings:

During document review and interview with Maintenance Staff on 4/29/25, the smoke detectors were observed and records were requested.

At 12:36 p.m., the facility failed to provide upon request the smoke detector sensitivity test records. The last test was unknown. Upon interview, the Maintenance stated that no documentation was available for review.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system. This was evidenced by the failure to maintain the pressure gauge on the facility's wet system riser. This affected eight of eight smoke compartments and three of three patients, and could result in a delay of extinguishment in the event of a fire.

NFPA 101 Life Safety Code, 2012 edition
19.3.5 Extinguishment Requirements.
19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition
5.3.2* Gauges.
5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge.
5.3.2.2 Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

Findings:

During a tour of the facility and interview with Maintenance Staff on 4/29/25, the sprinkler system was observed.

At 9:57 a.m., the wet sprinkler system riser was observed with a pressure gauge that was dated 2019. The wet sprinkler system riser was located in the mechanical room that was only accessible from the exterior of the facility. There was no indication the pressure gauge had been tested by comparison with a calibrated gauge. Upon interview, Maintenance Staff admitted they were unaware the gauge was over five years old or whether the vendor had tested its viability.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced a fire extinguisher that was obscured from view. This affected one of eight smoke compartments, and could result in delayed use of the fire extinguishers in the event of a fire.

NFPA 101 Life Safety Code 2012 edition
19.3.5.12 Portable fire extinguishers shall be provided in all
health care occupancies in accordance with 9.7.4.1.
9.7.4 Manual Extinguishing Equipment.
9.7.4.1* Where required by the provisions of another section
of this Code, portable fire extinguishers shall be selected, installed,
inspected, and maintained in accordance with
NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 edition
6.1.3.3 Visual Obstructions.
6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.

Findings:

During a tour of the facility and interview with Maintenance Staff on 4/29/25, the facility's fire extinguishers were observed.

At 10:20 a.m., the telecom equipment room was observed with an ABC fire extinguisher that was obstructed from view. Two cardboard boxes were placed directly in front of the extinguisher. Upon interview, the Maintenance Staff confirmed that the ABC extinguisher was obstructed from view.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by a corridor door that failed to latch and by corridor doors that were obstructed. This affected two of eight smoke compartments and could result in the inability to contain smoke and/or fire to a room.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.6.3.10* Doors shall not be held open by devices other than those that release when the door is pushed or pulled.

Findings:

During a tour of the facility and interview with Maintenance Staff on 4/29/25, the corridor doors were observed and tested.

1. At 10:02 a.m., the corridor door to room 102/103 in the medical-surgical area failed to latch when tested. The door latch did not line up with the strike plate. Upon interview, the Maintenance Staff confirmed that the door latching hardware was not lining up with the strike plate.

2. At 10:59 a.m., the corridor door for room CL206 was observed obstructed by a door wedge that held the door wide open. Upon interview, the Maintenance Staff stated that staff placed the door wedge on the door.

3. At 11:01 a.m., the Administrator area corridor door was observed obstructed by a door wedge that held the door wide open. Upon interview, the Maintenance Staff stated that staff placed the door wedge on the door.

4. At 11:06 a.m., the Nursing Supervisor corridor door was observed obstructed by a door wedge that held the door wide open. Upon interview, the Maintenance Staff stated that staff placed the door wedge on the door.

Based on record review and interview, the facility failed to maintain the Fire Dampers. This was evidenced by the failure to perform the initial Fire damper inspection after installation. This affected three of three patients and eight of eight smoke compartments, and could result in malfunction of the Fire dampers.

NFPA 101 Life Safety Code, 2012 edition
19.5.2 Heating, Ventilating, and Air-Conditioning.
19.5.2.1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer ' s specifications, unless otherwise
modified by 19.5.2.2.
9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 edition.
5.4.7 Installation.
5.4.7.1* Fire dampers, including their sleeves; smoke dampers; and ceiling dampers shall be installed in accordance with the conditions of their listings and the manufacturer ' s installation instructions and the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives.
5.4.8 Maintenance.
5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, standard for Fire Doors and Other Opening Protectives.

NFPA 80, Standard for Fire Doors and Other Opening Protectives, for inspection and maintenance of fire dampers, ceiling dampers, and combination fire/smoke dampers.
19.4 Periodic Inspection and Testing.*
19.4.1 Each damper shall be tested and inspected 1 year after installation.
19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.
19.4.2 All tests shall be completed in a safe manner by personnel wearing personal protective equipment.
19.4.3 Full unobstructed access to the fire or combination fire/smoke damper shall be verified and corrected as required.
19.4.4 If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in place if so equipped.

Findings:

During record review and interview with Maintenance Staff on 4/29/25, the Fire Damper documentation was requested.

At 2:34 p.m., the facility failed to provide upon request the fire damper test documentation that was required to be performed on the facility's fire dampers one year after installation. The facility was built in 2020. Upon interview, the Maintenance Staff stated that they were unaware of the initial testing requirement for the fire dampers and confimed that the facility had not performed the required initial fire damper test.

Based on record review and interview, the facility failed to maintain the hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia was administered. This was evidenced by the failure perform the initial electrical receptacle tension and polarity testing on the hospital grade receptacles at patient bed locations and the Operating Room (OR). This affected three of three patients and two of eight smoke compartments and could cause a malfunction.

NFPA 99, 2012 edition.
6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations here deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.

Findings:

During record review and interview with Maintenance Staff on 4/29/25, the electrical wiring and equipment documentation was requested.

At 12:50 p.m., the facility was unable to provide requested records of electrical receptacle tension and polarity testing for hospital-grade receptacles in patient bed locations and the OR. During an interview, Maintenance Staff confirmed that testing had not been conducted since the facility's move into the building in 2020.

Based on observation and interview, the facility failed to maintain the electrical wiring and equipment . This was evidenced by an electrical panel that was obstructed and a power switch that failed to have a cover plate. This affected two of eight smoke compartments and could result in potential electrical hazard.

NFPA 101, Life Safety Code, 2012 Edition
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1 Utilities.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition
110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.
(2) Width of Working Space. The width of the working space in front of the electrical equipment shall be the width of the equipment or 762 mm (30 in.), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.
314.25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, lampholder, or luminaire canopy, except where the installation complies with 410.24(B).
(A) Nonmetallic or Metal Covers and Plates. Nonmetallic or metal covers and plates shall be permitted. Where metal covers or plates are used, they shall comply with the grounding requirements of 250.110.

Findings:

During a tour of the facility and interview with Maintenance Staff on 4/29/25, the electrical wiring and equipment were observed.

1. At 10:57 a.m., the electrical panel located in the CT scan room CAT1 was observed with a rolling cart that was parked approximately three inches in front of the panel. Upon interview, the Maintenance Staff confirmed that the electrical panel was obstructed.

2. At 11:09 a.m., the dry sprinkler riser located by the front lobby area closet was observed without a cover faceplate for the air compressor power switch. Upon interview, the Maintenance Staff stated that he was not aware that the face plate was missing.

Based on observation and interview, the facility failed to maintain the electrical equipment and wiring. This was evidenced by the non-compliant use of a relocatable power tap. This affected one of eight smoke compartments,and could result in an electrical fire.

NFPA 101, Life Safety Code, 2012 Edition
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
Chapter 9 Building Service and Fire Protection Equipment
9.1 Utilities.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition
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
(7) Where subject to physical damage

Findings:

During a facility tour and interview with Maintenance Staff 4/29/25, the electrical equipment and wiring was observed.

At 11:04 a.m., the Administrator area was observed with a relocatable power tap that was connected to another relocatable power tap underneath the executive assistant desk. Upon interview, the Maintenance Staff stated that he was not aware that the relocatable power taps were connected.