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Based on observations, on 09/09/2025 between 9:30 AM and 4:30 PM, surveyors in the presence of the Assistant Director of Plant Operations, the following were not met:

1. The 2-hour separation located between Mechanical room HV on Level G was penetrated by 4 electric cables inserted through the wall into the corridor above the ceiling tiles approximately six inches in diameter that was not protected by a firestop system or device in accordance with NFPA 221 (2012 edition), Standard for High Challenge Fire, section 4.9.2 Firestop Systems and Devices Required - Penetrations for cables, cable trays, conduit, pipes, tubes, combustible vents and exhaust vents, wires and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a fire stop system or device. This deficient practice could affect the Lower level G of the facility, approximately all patients/residents, all visitors, and all members of facility staff in this location(s).

Surveyors confirmed these findings with the Assistant Director of Plant Operations at the time of the observation.


51948

Based on observation during the facility tour, critical access hospital failed to maintain wall construction requirements of the 2-hour separation wall per NFPA 101, Life Safety Code, 2012 Edition, Sections 8.2.1.3., and 19.1.3.5.

Findings:

On 09/09/2025 between 9:30 AM and 4:30 PM, surveyors in the presence of the Service Technician from the General Maintenance Department, the following were not met:

1. The 2-hour fire separation wall located in the Birthing Section, clean utility room, the backside of the exit stairwell on Level 1 the top of the wall above the ceiling tiles at the top, at the floor deck to the second floor was not firestopped. This deficient practice could affect the occupants, visitors and staff while trying to exit the building or sheltering in place.

2. The 2-hour fire separation wall located in the Medical Surgical floor, the kitchen wall on the nurse's station side on Level 2, the top of the wall above the ceiling tiles, the wall did not go all the way to the roof deck, and it was not firestopped. This deficient practice could affect the occupants, visitors and staff while trying to exit the building or sheltering in place.

3. The 2-hour fire separation wall located on the Medical Surgical floor, the wall next to the kitchen entry by the nurse's station on Level 2 the top of the wall above the ceiling tiles, a non-rated spray foam was used in place of firestopping in various spots along the wall. This deficient practice could affect the occupants, visitors and staff while trying to exit the building or sheltering in place.

Surveyors confirmed these findings with the Service Technician from the General Maintenance Department at the time of the observation.

Federal Recertification Survey:
Date: 09/09/2025

Based on observation, the critical access hospital failed to maintain the Exit Corridor required width in egress corridors per NFPA 101, Life Safety Code, 2012 Edition, Sections 18.2.1, 19.2.1, 7.1.10.1. This deficient practice could affect patients, staff, family members and general public trying to egress in an emergency.

Findings:

During a facility tour between the hours of 9:30 AM and 4:30 PM, a surveyor with the Service Technician present observed the following:

1. In the corridors located on the Medical Surgical Unit by Patient Rooms 208, 214, 219 and 226 there are trash cans located in the corridor.
2. In the corridors located in the Medical Surgical Unit by Patient Rooms 214 and 219 there are portable nurse carts plugged into the wall and were stationary and unattended for more that 30 minutes.

This findings were confirmed by the surveyor and Service Technician at the time of observation.

Based on observation and interview, the critical access hospital failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition for number of means of egress in accordance with 7.4.1.1.

Finding:

On 09/09/2025 between 9:30 AM and 4:30 PM, surveyors in the presence of the Service Technician from the General Maintenance Department, the following were not met:

1. In the Birthing Section on Level 1, the space only had one marked means of egress. I interviewed the birthing supervisor, and she stated that the one egress to the exit stairwell was the means of egress. I asked if they would exit through the Operating Room to the second exit stairwell. The supervisor stated they do not exit through the Operating Room. There were no exit signs marking any exit through to Operating Room in the birthing space.

This deficient practice could affect the occupants, visitors and staff while trying to exit the building or sheltering in place.

Surveyors confirmed this finding with the Service Technician from the General Maintenance Department at the time of the observation.

Based on observation, the Hospital failed to install the water-based fire protection system throughout the premises in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 edition, Sections 8.1.1(1), and 8.15.10(3) as referenced by NFPA 101, Life Safety Code, 2012 edition, Section 19.3.5.

Findings:

On 09/09/2025, between 09:30 AM and 4:30 PM, surveyors with the Assistant Director of Plant Operations present, observed the following:

1. The Kitchen paper supply closet located across from the preparation kitchen does not have any sprinkler coverage. This deficient practice could effect all staff, visitors and, patients located on the Ground level G.

Surveyors confirmed these findings with the Assistant Director of Plant Operations at the time of the observation.

Based on observation and record review, the long-term care facility failed to ensure that Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with 2011 NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems sections 5.3.3.2 and 5.3.3.3. This deficient practice could cause the sprinkler system to not function properly and affect residents, staff, family members and general members of the public.

Findings:

During a record review of documentation on 09-09-2025 between the hours of 9:30 AM and 4:30 PM a surveyor with the Director of Plant Operations observed the following:

1. Documents of the most recent Sprinkler Inspection/Testing Report indicate the Wet Riser Flow Switch in the food storage room and the Wet Switch in the phone room need an inspectors test valve piped in to a drain to properly test flow switch.

These findings were confirmed by the surveyor and the Director of Plant Operations at the time of record review.

Based on observation the critical care hospital failed to maintain the corridor door from closing and positively latching per NFPA 101, Life Safety Code, 2012 Edition, Sections 19.3.6.3, 19.3.6.3.5.

Findings:

On 09/09/2025 between 9:30 AM and 4:30 PM, surveyors in the presence of the Service Technician from the General Maintenance Department, the following were not met:

1. In the Operating Section on level 1, the equipment room corridor doors, both leaf's at the top and bottom, the flush bolts did not latch when closed.

2. In the Endoscopy Section on Level 1, the entrance corridor doors, both leaf's at the top and bottom, the flush bolts did not latch when closed.

This deficient practice could affect the occupants, visitors and staff while trying to exit the building or sheltering in place.

Surveyors confirmed these findings with the Service Technician from the General Maintenance Department at the time of the observation.

1. Observation during a facility tour with the Assistant Director of Plant Operations on 09/09/25 between 9:30 AM and 4:30 PM indicated that a smoke barrier located at the Emergency Department entrance on Level G, did not fully extend beyond the ceiling. The interstitial space was not protected on the bottom by a construction assembly providing smoke resistance equivalent to a smoke barrier. This is not in accordance with the requirement of National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, section 8.5.2.2. Smoke barriers shall be continuous through all concealed spaces, such as those above a ceiling, including interstitial spaces. This deficient practice could affect the lower level G of the facility, approximately all patients/residents on level G, all visitors, and all members of facility staff in this location(s).

2. Observation during a facility tour with the Assistant Director of Plant Operations on 09/09/25 between 9:30 AM and 4:30 PM indicated that a smoke barrier located above the entrance from the Emergency Department registration back hallway was penetrated by electrical conduit pipe and conduit that were not properly sealed and would allow the passage of smoke from one smoke compartment to another. This is not in accordance with the requirement of National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, section 8.5.6.2 Penetrations for .... shall be protected by a system or material capable of resisting the transfer of smoke. This deficient practice could affect the lower level G of the facility, approximately all patients/residents on level G, all visitors, and all members of facility staff in this location(s).

Surveyors confirmed these findings with the Assistant Director of Plant Operations at the time of the observation.
















51948

Based on observation the critical access hospital failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition for smoke barrier enclosures in accordance with 19.3.7.3.

Finding:

On 09/09/2025 between 9:30 AM and 4:30 PM, surveyors in the presence of the Service Technician from the General Maintenance Department, the following were not met:

1. The 1-hour smoke separation wall located in the Birthing Section in the storage room and the IT room on Level 1 the wall above the ceiling tiles at the top had open penetrations that were not fireproffed. This deficient practice could affect the occupants, visitors and staff while trying to exit the building or sheltering in place.

Surveyors confirmed this finding with the Service Technician from the General Maintenance Department at the time of the observation.

Federal Recertification Survey
Date: 09/10/2025

Based on observation, interview and record review, the critical access hospital failed to comply with NFPA 99 2011 Edition Chapter 5. The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 5.1.12.2.6.6, 5.1.4.8.8, 5.1.11.2, 5.1.5.16, 5.1.3.6.3.12 (E), 5.1.10.3.1 and 5.1.10.4
This deficient practice could impact patients, staff, family members and the general public in an event of a system failure.

Findings:

During a documentation review on 09/10/2025 between the hours of 8:00 AM and 2:00 PM, a surveyor with the Plant Operations Manager observed the following:

The Medical Gas Report has deficiencies listed as follows:

Maintenance Deficiencies:

1. Emergency Room 8: Medical air outlet leaks from back check.
2. Radiology CT Scan: Vacuum inlet leaks
3. Day Surgery Room 3: 2nd Vacuum inlet leaks
4. Endoscopy Procedure Room 2: 2nd Vacuum inlet leaks.
5. Operating Room 3: 3rd Vacuum inlet on wall leaks.
6. Special Care Unit Room 4: 3rd Vacuum inlet Leaks

Compliance Deficiencies:

1. Radiology: Zone valves located right of DEXA Room need to be labeled, X-Ray 1-3, Ultrasound, Nuc Medicine, DEXA.
2. Operating Rooms 1-3: There are no dedicated WGAD inlets installed in these Anesthetizing locations. 5.1.10.2.3
3. Medical Air Compressor: Medical air intake is piped inside the air handler for the operating room filtered air. If the ventilation system has fans with motors or drive belts then this shall not be used as a source for the medical air intake.
4. Vacuum Pump: Vacuum main line piping has sections that are soft soldered and not completed using acceptable joining methods.

Documentation was provided on work orders that were issued on some of the deficiencies at the time of survey but they have not been completed.

These observations were confirmed by the surveyor and Plant Operations Director at the time of documentation review.

Based on observation, the critical access hospital failed to ensure that Gas Equipment - Cylinder and Container Storage in a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." This deficient practice could affect staff, patients, family members and general public while trying to exit the building or shelter in place.

Findings:

On 09/09/2025, between 9:30 AM and 4:30 PM, a surveyor, with the Maintenance present, observed the following:

1. The storage room located in the medical surgical patient area has 2 oxygen tanks stored inside it with no signage present annotating oxygen storage.
2. The Pulmonary Function Testing Storage room has approximately 8 type E tanks stored in a rack system (under 300 cubic feet) and does not have any signage present on the exterior annotating oxygen storage.

The surveyor confirmed this finding with the Maintenance at the time of the observation.