Warren General Hospital

“General Requirements - Other CFR(s): NFPA 101 General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 43722 Based on document review and interview, the facility failed to maintain general requirements of the Life Safety Code that are not addressed by specific K-tags, but are still deficient for two of two building components. Findings include: Document review on December 30, 2025, at 11:02 a.m., revealed the facility failed to obtain required approval from the Department of Health State Plan Review and a granted occupancy from the Life Safety Division for the replacement of four elevators, two in Penthouse #4 and two in Penhouse #5. Interview with the facilities director on December 30, 2025, at 11:02 a.m., confirmed the facility could not provide Plan Review documents at the time of the survey.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 49939 Based on observation and interview, the facility failed to maintain doors with self-closing devices, affecting one of over five doors. Findings include: Observation on December 30, 2025, at 11:25 a.m., revealed the first floor corridor’s self-closing door, located near the environmental suite, failed to close and properly latch in the frame. Interview with the maintenance supervisor on December 30, 2025, at 11:25 a.m. confirmed the door failed to latch in the frame.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 49939 Based on observation and interview, the facility failed to meet fire alarm system maintenance and testing requirements for one of one fire alarm panel. Findings include: Observation on December 30, 2025, at 11:35 a.m., revealed the fire alarm panel had a trouble signal present at the time of the survey. Interview with the maintenance supervisor on December 30, 2025, at 11:35 a.m., confirmed the trouble signal and explained that it was due to the abatement of the 3B north wing.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 42642 Based on observation and interview, the facility failed to maintain portable fire extinguishers for three of over twelve months. Findings include: Observation on December 30, 2025, between 10:02 a.m. and 11:25 a.m., revealed the following fire extinguisher deficiencies at the time of the survey: A. (10:02 a.m.) Lab extinguisher 116 was missing monthly inspections for May, June, and July; B. (11:20 a.m.) Nuclear medicine extinguisher 26 was missing May, June, and July monthly inspections; C. (11:25 a.m.) ER, near room 3, was missing May, June, and July monthly inspections. Interview with the maintenance supervisor on December 30, 2025, at 11:25 a.m. confirmed the monthly inspections were missing for the fire extinguishers.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 42642 Based on document review and interview, the facility failed to maintain fire drills for four of four quarters. Findings include: Document review on December 30, 2025, at 12:00 p.m., revealed the facility had signatures for specific departments that participated in a fire drill each quarter. Based on interview with the maintenance supervisor it was determined staff were educated yearly and participate within their department quarterly for fire drills. However, the facility was unable to provide documentation of all staff participation at the time of the survey.The drill logs had insufficient amount of signatures at the time of the survey. Interview with the maintenance supervisor on December 30, 2025, at 12:00 pm. confirmed the documentation was limited at the time of the survey.”

“Combustible Decorations CFR(s): NFPA 101 Combustible Decorations Combustible decorations shall be prohibited unless one of the following is met: o Flame retardant or treated with approved fire-retardant coating that is listed and labeled for product. o Decorations meet NFPA 701. o Decorations exhibit heat release less than 100 kilowatts in accordance with NFPA 289. o Decorations, such as photographs, paintings and other art are attached to the walls, ceilings and non-fire-rated doors in accordance with 18.7.5.6(4) or 19.7.5.6(4). o The decorations in existing occupancies are in such limited quantities that a hazard of fire development or spread is not present. 19.7.5.6 This Standard is not met as evidenced by: 49939 Based on observation and interview, the facility failed to maintain combustible decorations for one of one building component. Findings include: Observation on December 23, 2025, at 12:12 p.m., revealed the main entrance lobby had a Christmas tree that had no documentation of fire, flame, or smoke-proofing at the time of the survey. Interview with the maintenance supervisor on December 23, 2025, at 12:12 p.m., confirmed the combustible decoration deficiency.”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations 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 (NFPA 99) This Standard is not met as evidenced by: 42642 Based on document review and interview, the facility failed to maintain one of one piped-in gas and vacuum system. Findings include: Document review on December 30, 2025, at 10:10 a.m., revealed the following boiler room deficiencies at the time of the survey: A. (10:10 a.m.) No source valve; B. (10:10 a.m.) Main line vacuum switch not present; C. (10:10 a.m.) Main line vacuum gauge not present; D. (10:10 a.m.) No lag alarm; E. (10:10 a.m.) System not monitored at master alarm panel. Interview with the maintenance supervisor on December 30, 2025, at 10:10 a.m. confirmed the corrective documentation was unavailable at the time of the survey.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 49939 Based on observation and interview, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, for two of more than twenty receptacles. Findings include: Observation on December 23, 2025, at 11:52 a.m., revealed the first floor main laboratory circuits 4 and 6 and the P262 break room had non-protected GFCI receptacles located within six feet of water basins. Interview with the maintenance supervisor on December 23, 2025, at 11:52 a.m., confirmed the electrical system deficiencies.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 42642 Based on document review and interview, the facility failed to maintain one of two monthly essential electric maintenance requirements. Findings include: Document review on December 30, 2025, at 10:00 a.m., revealed the facility failed to provide documentation for the monthly conductance testing of the generators at the time of the survey. Interview with the maintenance supervisor on December 30, 2025, at 10:00 a.m. confirmed the documentation was unavailable at the time of the survey.”

“Means of Egress Requirements - Other CFR(s): NFPA 101 Means of Egress Requirements - Other List in the REMARKS section any LSC Section 18.2 and 19.2 Means of Egress requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. 18.2, 19.2 This Standard is not met as evidenced by: 49939 Based on observation and interview, the facility failed to maintain evacuation diagrams in one of two components. Findings include: Observation on February 12, 2025, between 10:59 a.m. and 11:09 a.m., revealed the evacuation diagrams did not contain a notation showing the location of the viewer on the diagram. Ref: NFPA 170 - 11.2.4 & 11.3.2 Interview with the maintenance supervisor on February 12, 2025, at 11:09 p.m., confirmed the above deficiency existed.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 49939 Based on observation and interview, the facility failed to maintain building rehabilitation requirements on one of three building levels. Findings include: Observation on February 12, 2025, at 10:22 a.m., revealed in the basement morgue laboratory room had been converted into a storage room containing combustible materials. This room does not meet hazardous area requirements. The facility changed the use of the room without the approval of State Plan Review and a granted occupancy from the Division of Life Safety. Interview with the maintenance supervisor on February 12, 2025, at 10:22 a.m., confirmed the room had changed use without submitted plans to designate the rooms as hazardous storage areas.”

“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: 49939 Based on observation and interview, was determined that the facility failed to maintain smoke barrier construction on one of four levels. Findings include: Observation on February 12, 2025, at 11:37 a.m., revealed the first floor loading dock area, near door 1500, had grid work that needed repaired, as well as four missing ceiling tiles, allowing the passage of smoke. Interview with the maintenance supervisor on February 12, 2025, at 11:37 a.m., confirmed the above smoke barrier deficiencies.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 49939 Based on observation and interview, the facility failed to maintain, inspect, and test smoke barrier doors, in accordance with regulations, on one of four levels. Findings include: Observation on February 12, 2025, at 12:44 p.m., revealed the facility failed to maintain the 3B north wing smoke barrier door. The door had a gap of 3/8”, exceeding the 1/8” maximum allowance. Ref: NFPA 80 6.3.1.7 Interview with the maintenance supervisor on February 12, 2025, at 12:44 p.m., confirmed the above smoke barrier door deficiency.”

“Electrical Systems - Receptacles CFR(s): NFPA 101 Electrical Systems - Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 43722 Based on observation and interview, the facility failed to maintain electrical outlets, to comply with Life Safety Code requirements and electrical safety policies, for two of two hydrocollators. Findings include: Observation on February 12, 2025, at 1:00 p.m., revealed the first floor physical therapy room had two hydrocollators that were not plugged into a ground fault circuit interrupter (GFCI) outlet. Interview with the facilities manager on February 12, 2025, at 1:00 p.m., confirmed the above hydrocollators did not have GFCI protection. 49939 Based on observation and interview, the facility failed to maintain electrical receptacles in five of over twenty rooms. Findings include: Observation on February 12, 2025, between 10:35 a.m. and 12:32 p.m., revealed the facility failed to ensure ground fault circuit interrupter (GFCI) protection in the following areas: A. (10:35 a.m.) Basement maintenance shop, receptacle within six feet of the sink; B. (11:45 a.m.) First floor, outside of the men’s locker room, near OR suite, receptacle within six feet of the sink; C. (12:15 p.m.) First floor main lab, near the eye wash station, receptacle; D. (12:30 p.m.) Third floor C wing laundry, washing machine receptacle; E. (12:32 p.m.) Third floor soiled utility room, receptacle within six feet of the sink. Interview with the maintenance supervisor on February 12, 2025, at 12:32 p.m., confirmed the electrical outlet deficiencies.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 43722 Based on observation and interview, the facility failed to install and maintain the emergency generator, per NFPA 110-5.6.5.6, for two of two emergency generators. Findings include: Observation on February 12, 2025, at 1:15 p.m., revealed the east and west emergency generators lacked a remote emergency shut off button on the exterior of the generator building. Interview with the facilities manager on February 12, 2025, at 1:15 p.m., confirmed the emergency generators lacked a remote emergency shut off button on the exterior of the generator building.”

“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: 49939 Based on observation and interview, the facility failed to maintain gas equipment storage requirements in one of two storage areas. Findings include: Observation on February 12, 2025, at 10:45 a.m., revealed the first-floor oxygen storage room, near the loading dock, had oxygen cylinders that were unsegregated and not labeled as full or empty. Interview with the maintenance supervisor on February 12, 2025, at 10:45 a.m., confirmed the oxygen cylinder deficiencies existed.”