Community Hospital of Bremen Inc.

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment This Condition is not met as evidenced by: 35731 Based on observation, document reveiw, and interview, the facility failed to ensure 5 of 6 receptacles within 6 feet from a sink or located in a wet location were provided with ground fault circuit interrupter (GFCI) protection against electric shock; and failed to ensure the penetrations caused by the passage of wires and/or conduits through 4 of 6 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier with a proper firestop system. The cumulative effect of these systemic problems resulted in the facility’s inability to ensure the provision of quality health care in a safe environment.”

“CONSTRUCTION CFR(s): The CAH is constructed, arranged, and maintained to ensure access to and safety of patients, and provides adequate space for the provision of services. This Standard is not met as evidenced by: 35731 Based on observation and interview, the facility failed to ensure 5 of 6 receptacles within 6 feet from a sink or located in a wet location were provided with ground fault circuit interrupter (GFCI) protection against electric shock. LSC 19.5.1.1 requires utilities comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code. NFPA 70, NEC 2011 Edition at 210.8 Ground-Fault Circuit-Interrupter Protection for Personnel, states, 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. (B) Other Than Dwelling Units. All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in 210.8(B)(1) through (8) shall have ground-fault circuit-interrupter protection for personnel. (1) Bathrooms, (2) Kitchens, (3) Rooftops, (4) Outdoors, (5) Sinks - where receptacles are installed within 1.8 m (6 ft.) of the outside edge of the sink. (6) Indoor wet locations, (7) Locker rooms with associated showering facilities, (8) Garages, service bays, and similar areas where electrical diagnostic equipment, electrical hand tools. NFPA 70, 517-20 Wet Locations, requires all receptacles and fixed equipment within the area of the wet location to have GFCI protection. Note: Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. Findings include: Based on observations with the Facilities Services Coordinator and Maintenance Tech II on 06/10/25 at 1:28 p.m., by each of the three work-sinks in the lab had two receptacles 3 feet from a water source. One receptacle was GFCI protected but the other five receptacles were not GFCI Protected. Based on an interview at 1:28 p.m., the Facilities Services Coordinator agreed there were receptacles by each work-sink in the lab that were not GFCI protected. This finding was reviewed with the President, Facilities Services Coordinator, Emergency Preparedness Coordinator, and Maintenance Tech II during the exit conference at 3:10 p.m.”

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 35731 Based on observation, records review, and interview, the facility failed to ensure the penetrations caused by the passage of wires and/or conduits through 4 of 6 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier with a proper firestop system. LSC Section 19.3.7.5 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. LSC Section 8.5.2.1 requires smoke barriers to be continuous from an outside wall to an outside wall, from a floor to floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. 8.5.6.2 requires penetrations for cables, cable trays, conduits, pipes, tubes, 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 smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the movement of smoke. LSC 8.2.3.1 states the fire resistance of structural elements and building assemblies shall be determined in accordance with test procedure set forth in ASTM E 119, Standard Test Methods for Fire Tests of Building Construction and Materials, or ANSI/UL 263, Standard for Fire Tests of Building Construction and Materials; other approved test methods; or analytical methods approved by the AHJ. The AHJ requires penetrations in smoke barriers to be sealed with a firestop system or device tested in accordance with ASTM E 814. Findings include: Based on observation with the Facilities Services Coordinator and Maintenance Tech II on 06/10/25 between 2:10 p.m. and 2:30 p.m., the following smoke walls had unsealed penetrations or a firestop system not meeting ASTM E 814: a.) Above the ceiling tiles of the lab smoke wall, blue caulk with an ASTM listing was used to seal penetrations. b.) Above the ceiling tiles of the ER smoke wall contained two unsealed penetrations around conduits. c.) Above the ceiling tiles of the main hall smoke wall contained 10 unsealed screw size holes. d.) Above the ceiling tiles of the OB smoke wall contained an unsealed penetration around wires. Based on records review at 2:30 p.m., there was no documentation provided to show the firestop rating of the blue caulk. Based on interviews at 2:10 p.m. and 2:30 p.m., the Facilities Services Coordinator agreed there were smoke walls with unsealed penetrations and penetrations sealed with a blue caulk with an unknown ASTM listing. The findings were reviewed with the Administrator and The Maintenance Director during the exit conference at 3:10 p.m.”

“Emergency Officials Contact Information CFR(s): §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: 34653 Based on record review and interview, the facility failed to ensure the Emergency Preparedness Plan (EPP) includes (2) Contact information for the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance in accordance with 485.625(c)(2) This deficient practice could affect all occupants. Findings include: Based on records review with the Emergency Preparedness Coordinator on 06/10/25 at 10:43 a.m., the EPP did not include Federal, State, tribal, regional, and other sources of assistance contact information. Based on an interview at 10:43 a.m., the Emergency Preparedness Coordinator stated the contact information for Federal, State, tribal, regional, and other sources of assistance contact information could not be found. This finding was reviewed with the President, Facilities Services Coordinator, Emergency Preparedness Coordinator, and Maintenance Tech II during the exit conference at 3:10 p.m.”

“EP Training Program CFR(s): §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: 34653 Based on record review and interview, the facility failed to conduct training for the Emergency Preparedness Program (EPP). *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and. This deficient practice could affect all staff and patients in the facility. Findings include: Based on records review with the Emergency Preparedness Coordinator on 06/10/25 at 10:55 a.m., documentation of EEP initial training for new staff and training for existing staff every two years including demonstration of knowledge of the EPP was not available for review. Based on an interview at 11:50 a.m., the Emergency Preparedness Coordinator stated the EPP training for staff including demonstration of knowledge was not conducted within the last two years. This finding was reviewed with the President, Facilities Services Coordinator, Emergency Preparedness Coordinator, and Maintenance Tech II during the exit conference at 3:10 p.m.”

“A Life Safety Code Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 485.623(c). Survey Date: 06/10/25 Facility Number: 005097 Provider Number: 151300 AIM Number: 100269320A At this Life Safety Code survey, Community Hospital of Bremen was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR 485.623(c). Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC). The Community Hospital of Bremen was built in 2006 and is a single-story fully sprinklered building of Type II (111) construction with a fire alarm system with smoke detection in the corridors and spaces open to the corridors. The facility was surveyed with Chapter 19, Existing Health Care Occupancies of the Life Safety Code. The hospital provides overnight care, surgical services, and maintains an Emergency Department. The facility has 24 certified beds. At the time of the survey, the census was 7. Quality Review completed on 06/19/25”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 34653 Based on observation and interview, the facility failed to provide an approved method for returning cooking appliances to the designed and installed positions for 1 of 1 kitchen hood extinguishing system. NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations Section 2011 Edition Section 12.1.2.2, states cooking appliances requiring protection shall not be moved, modified, or rearranged without prior re-evaluation of the fire-extinguishing system by the system installer or servicing agent, unless otherwise allowed by the design of the fire extinguishing system. Section 12.1.2.3 states the fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations, and any disconnected fire-extinguishing system nozzles attached to the appliances are reconnected in accordance with the manufacturer’s listed design manual. Section 12.1.2.3.1 states an approved method shall be provided that will ensure that the appliance is returned to an approved design location. The deficient practice affects staff, visitors, and patients in the cafeteria. Findings include: Based on observation with Maintenance Tech II on 06/10/25 at 1:20 p.m., the cooking equipment in the kitchen was covered by the fire suppression system, but the kitchen was not provided with an approved method that would ensure that the appliances were returned to an approved design location after they had been moved for maintenance and cleaning. Based on an interview at 1:20 p.m., Maintenance Tech II agreed the kitchen was not provided with an approved method that would ensure that the appliances were returned to an approved design location after they had been moved for maintenance and cleaning. This finding was reviewed with the President, Facilities Services Coordinator, Emergency Preparedness Coordinator, and Maintenance Tech II during the exit conference at 3:10 p.m.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 34653 Based on observation, records review, and interview, the facility failed to ensure the penetrations caused by the passage of wires and/or conduits through 4 of 6 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier with a proper firestop system. LSC Section 19.3.7.5 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. LSC Section 8.5.2.1 requires smoke barriers to be continuous from an outside wall to an outside wall, from a floor to floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. 8.5.6.2 requires penetrations for cables, cable trays, conduits, pipes, tubes, 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 smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the movement of smoke. LSC 8.2.3.1 states the fire resistance of structural elements and building assemblies shall be determined in accordance with test procedure set forth in ASTM E 119, Standard Test Methods for Fire Tests of Building Construction and Materials, or ANSI/UL 263, Standard for Fire Tests of Building Construction and Materials; other approved test methods; or analytical methods approved by the AHJ. The AHJ requires penetrations in smoke barriers to be sealed with a firestop system or device tested in accordance with ASTM E 814. This deficient practice could affect all occupants in the facility Findings include: Based on observation with the Facilities Services Coordinator and Maintenance Tech II on 06/10/25 between 2:10 p.m. and 2:30 p.m., the following smoke walls had unsealed penetrations or a firestop system not meeting ASTM E 814: a.) Above the ceiling tiles of the lab smoke wall, blue caulk with an ASTM listing was used to seal penetrations. b.) Above the ceiling tiles of the ER smoke wall contained two unsealed penetrations around conduits. c.) Above the ceiling tiles of the main hall smoke wall contained 10 unsealed screw size holes. d.) Above the ceiling tiles of the OB smoke wall contained an unsealed penetration around wires. Based on records review at 2:30 p.m., there was no documentation provided to show the firestop rating of the blue caulk. Based on interviews at 2:10 p.m. and 2:30 p.m., the Facilities Services Coordinator agreed there were smoke walls with unsealed penetrations and penetrations sealed with a blue caulk with an unknown ASTM listing. The findings were reviewed with the Administrator and The Maintenance Director during the exit conference at 3:10 p.m.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 34653 Based on observation and interview, the facility failed to ensure 5 of 6 receptacles within 6 feet from a sink or located in a wet location were provided with ground fault circuit interrupter (GFCI) protection against electric shock. LSC 19.5.1.1 requires utilities comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code. NFPA 70, NEC 2011 Edition at 210.8 Ground-Fault Circuit-Interrupter Protection for Personnel, states, 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. (B) Other Than Dwelling Units. All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in 210.8(B)(1) through (8) shall have ground-fault circuit-interrupter protection for personnel. (1) Bathrooms, (2) Kitchens, (3) Rooftops, (4) Outdoors, (5) Sinks - where receptacles are installed within 1.8 m (6 ft.) of the outside edge of the sink. (6) Indoor wet locations, (7) Locker rooms with associated showering facilities, (8) Garages, service bays, and similar areas where electrical diagnostic equipment, electrical hand tools. NFPA 70, 517-20 Wet Locations, requires all receptacles and fixed equipment within the area of the wet location to have GFCI protection. Note: Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could staff in the lab. Findings include: Based on observations with the Facilities Services Coordinator and Maintenance Tech II on 06/10/25 at 1:28 p.m., by each of the three work-sinks in the lab had two receptacles 3 feet from a water source. One receptacle was GFCI protected but the other five receptacles were not GFCI Protected. Based on an interview at 1:28 p.m., the Facilities Services Coordinator agreed there were receptacles by each work-sink in the lab that were not GFCI protected. This finding was reviewed with the President, Facilities Services Coordinator, Emergency Preparedness Coordinator, and Maintenance Tech II during the exit conference at 3:10 p.m.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 34653 Based on observation and interview, the facility failed to ensure 2 of 2 flexible cords were not used as a substitute for fixed wiring including providing power to equipment with a high current draw. NFPA-70/2011, 400.8 state unless specifically permitted in 400.7 flexible cords and cables shall not be used for (1) as a substitute for fixed wiring. This deficient practice could affect all occupants in the main lobby. Findings include: Based on observations with Maintenance Tech II on 06/10/25 at 11:46 a.m. and at 1:18 p.m., a refrigerator and a microwave (high power draw equipment) were plugged into and supplied power by a power strip in the Anesthesia office, and an extension cord powered a radio in the Gift Shop. Based on interviews at 11:46 a.m. and 1:18 p.m., Maintenance Tech II agreed that a power strip was supplying power to high power draw equipment and an extension cord was powering a radio. This finding was reviewed with the President, Facilities Services Coordinator, Emergency Preparedness Coordinator, and Maintenance Tech II during the exit conference at 3:10 p.m.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet 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.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 34653 Based on observation and interview, the facility failed to ensure 1 of 1 piped oxygen storage room doors were provided with a precautionary sign stating “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING,” that is readable from 5 feet. This deficient practice could affect staff by the oxygen storage room. Findings include: Based on observations with Maintenance Tech II on 06/10/25 at 1:00 p.m., the door to the main oxygen storage room containing piped oxygen tanks was not provided with a precautionary sign stating “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Based on an interview at 1:00 p.m., the Maintenance Director stated the door to the storage room was recently replaced and the new door was not provided with a precautionary sign that indicates storage of oxygen stating “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” This finding was reviewed with the President, Facilities Services Coordinator, Emergency Preparedness Coordinator, and Maintenance Tech II during the exit conference at 3:10 p.m.”