Gundersen St Josephs Hospital and Clinics

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment This Condition is not met as evidenced by: 40659 Based on observation, staff interviews, and review of maintenance records between 04/21/2026 through 04/22/2026, the facility did not provide and maintain the building systems to ensure life safety to patients. Findings include: The facility was found to contain the following deficiencies: K0345 Fire Alarm System - Testing and Maintenance K0351 Sprinkler System - Installation K0363 Corridor - Doors K0372 Subdivision of Building Spaces - Smoke Barrier Construction K0521 HVAC K0909 Gas and Vacuum Piped Systems - Information and Warning Signs As a result of these deficiencies, 42 CFR Subpart CFR §485.623 Condition of Participation: Physical Plant and Environment was NOT MET. See K-tags listed above for the specific findings.”

“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: 40659 Based on observation, staff interviews, and review of maintenance records between 04/21/2026 through 04/22/2026, the facility did not provide and maintain the building systems to ensure life safety to patients. Findings include: The facility was found to contain the following deficiencies: K0345 Fire Alarm System - Testing and Maintenance K0351 Sprinkler System - Installation K0363 Corridor - Doors K0372 Subdivision of Building Spaces - Smoke Barrier Construction K0521 HVAC K0909 Gas and Vacuum Piped Systems - Information and Warning Signs As a result of these deficiencies, 42 CFR Subpart CFR §485.623(c) Standard: Life Safety From Fire was NOT MET. See K-tags listed above for the specific findings.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (vi) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. All patient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patients or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of § 483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care. This Standard is not met as evidenced by: 44431 Based on observation, record review and interview, the facility failed to remove expired foods and failed to label and date open foods from 1 (Kitchen) of 3 food storage areas observed. Findings: A review of the facility policy “Food Receiving, Preparation, Holding, and Storage,” #19898346 dated 03/2026 revealed, “Expiration dates of nutrition....products will be reviewed routinely. Expired products will be disposed of...labeling...food labels should include the common name of the food...date...opened, use through date, and initial of employee.” On 04/21/2026 from 9:30 AM to 11:45 AM during a tour and observation of the hospital kitchen with Dietary Manager B the following was observed: On the kitchen counter: - 5 open boxes of breakfast cereal with no open date and inside packages were not sealed In the small refrigerator: - 3 slices of what appeared to be cheese with no date and no label - 1 cup of assorted fresh cut fruit with no date and no label In the small Freezer: None of these following items were in their original packaging: - 1 package of what appeared to be english muffins that were blackened with ice crystals inside the package with no date and no label - 2 packages of what appeared to be french toast with no date and no label - 1 package of what appeared to be pancakes with no date and no label - a large container of homemade individually wrapped cookies with no date and no label In the dry storage area observed the following: - 1 package of coarse sugar with a best by date of 11/28/2025 - 1 open bag of elbow macaroni with no open date - 1 open bag of spaghetti with no open date - 12 bags of sauerkraut with an expiration date of 3/12/2026 - 1 large plastic container of brown rice with a use by date of 3/29/2026 - 1 open roll of club house crackers no date - 5 individual packages of potato chips with a best by date of 4/19/2026 In the large walk in freezer: - 6 packages of open vegetables no date - multiple packages of open food, with no dates and no labels In the large walk in refrigerator: - 2 open mozzarella cheese packages, no date - open sunflower seeds, no date - opened pistachios and chopped peanuts, no date - opened carrots, head lettuce and chopped lettuce, no label and no date On 04/21/2026 at 9:45 AM in an interview with Dietary Manager B when asked if it was an expectation that foods be labeled and dated and expired foods removed, Manager B stated, “Yes, they should be.” 52276”

“NURSING SERVICES CFR(s): A registered nurse or, where permitted by State law, a physician assistant, must supervise and evaluate the nursing care for each patient, including patients at a SNF level of care in a swing-bed CAH. This Standard is not met as evidenced by: 52395 Based on record review and interview staff failed to complete pain assessments and reassessments for 1 of 6 (Patient #11) patients in a total universe of 23 medical records reviewed. Findings Include: Review of the facility’s policy titled, “Pain Assessment and Management” last revised on 10/2025, revealed “...Ongoing Pain Assessment/Reassessment- Reassessment is defined as pain assessment after an intervention... Reassessment will occur within 60 minutes for the following: 1. Oral medication 2. Intravenous medication. 4. Intramuscular medication.” A review of Patient #11’s medical record revealed he was admitted on 4/17/2026 with acute appendicitis (inflammation of the appendix) and a current patient. Medication ordered in the chart included Morphine 2 mg intravenous (IV) every 2 hours as needed for severe pain (7 or greater). On 4/18/2026 at 1:08 PM 2 mg of Morphine IV was documented as given for severe pain with no reassessment of pain after intervention until 5:36 PM (4 hours and 28 minutes). On 4/19/2026 at 3:17 AM 2 mg of Morphine IV was documented as given for severe pain with no pain reassessment after intervention until 8:17 AM (5 hours). On 4/19/2026 at 10:23 AM 2 mg of Morphine IV was documented as given for severe pain with no pain reassessment after intervention until 1:15 PM (2 hours and 15 minutes). On 4/19/2026 at 11:36 PM 2 mg of Morphine IV was documented as given for severe pain with no pain reassessment after intervention until 7:44 AM on 4/20/2026 (9 hours and 8 minutes). During an interview on 4/22/2026 at 2:45 PM with Professional Development RN QQ during record review, when asked when pain reassessments are to be completed, educator NN stated “an hour after the medication is given.” Professional Development RN QQ confirmed pain reassessments were not completed according to policy in Patient #11’s medical record.”

“NURSING SERVICES CFR(s): §485.635(d)(3) All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. This Standard is not met as evidenced by: 53566 Based on record review and interview, facility staff failed to collect a urine sample and obtain a physician order for restarting a blood transfusion for 1 of 1 patient (Patient #23) with a transfusion reaction in a total sample of 23 medical records reviewed. Findings: A review of the facility’s policy titled “Blood Transfusion Reaction” last revised 03/2023 revealed, “...The transfusion will be halted immediately... if any of the following symptoms appear: A. Hemolytic/Febrile...7. Chest pain...If transfusion reaction is suspected:...F. Order “Transfusion Reaction Work-up”...I. Obtain patient urine sample, label it...and send it to the lab...L. If the blood bank reports “No laboratory evidence of a hemolytic transfusion reaction”...1. Review vital signs and patient status...Obtain provider approval to restart blood...” A review of Patient #23’s medical record revealed the following: Patient #23 experienced a possible transfusion reaction. The blood transfusion was stopped. No post-transfusion reaction urine sample was collected and there was no physician order to restart the blood transfusion per facility policy. During an interview on 4/22/2026 at 8:15 AM, Professional Development RN QQ reviewed Patient #23’s medical record and confirmed there was no order for a post-transfusion reaction urine sample and stated, “[The urine sample] should have been collected following Path C of the transfusion reaction protocol.” Professional Development RN QQ also confirmed there was no provider order to restart Patient #23’s blood transfusion and stated she would expect to see this order in Patient #23’s chart per facility policy.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 44431 Based on record review, observation and interview, facility staff failed to terminally clean a patient room per policy in 1 out of 1 (Med Surg) terminal cleaning observed; failed to perform hand hygiene per policy for 6 staff out of 46 (Housekeeper II, Laboratory Tech L, Laboratory Tech M, Dietary Aide C, Dietary Aide D and Dietary Aide E) observations of hand hygiene; failed to follow policy in handling ready to eat foods for Dietary Staff in 1 of 2 dietary staff observations of food preparation observed; failed to keep nourishment room hospital refrigerator food separate from food brought in from outside the hospital per policy in 1 out of 1 (Med Surg/ED) nourishment refrigerators; failed to keep dirty instruments damp after usage and before being picked up in 1 of 1 dirty utility rooms. Findings include: Example of incomplete terminal room cleaning: A review of facility “Inpatient Room Discharge” cleaning list revealed, “...Wipe down high touch surfaces (...Doorknob...)...Wipe down under mattress...” Further review revealed no evidence of when or how often to clean the vinyl window blinds in patient rooms. A review of facility policy titled, “Hand Hygiene and Glove Use,” #19894492 last revised 03/2026 revealed, “...Proper Hand Hygiene ...Use vigorous friction on the surfaces of the lathered fingers, fingertips, areas between the fingers, under the nails, hands and arms for at least 10 to 15 seconds...Hand washing is to occur as noted below: 1. Before and after wearing or changing gloves...7. After handling trash, sweeping or picking up items from the floor. 8. After using cleaners or chemicals...Proper Glove Use:...Wash hands after removing gloves...” During an observation on 4/22/2026 starting at 8:11 AM, Housekeeper II complete a terminal cleaning in a patient med surg room after discharge. While cleaning the bed, the middle of the base of the bed was never cleaned and when finished with the bed, there was evidence of blood still on the base of the bed. After completing the room cleaning, Housekeeper II did not wipe down the door handles on the bathroom door, the door handles on the entrance door, the stethoscope hanging in the room or the blinds in the room. During observation on the medical surgical floor of a terminal room cleaning after patient discharge on 4/22/2026 at 8:11 AM, Housekeeper II observed terminally cleaning a patient room after discharge. When mopping the floor, Housekeeper II failed to wear gloves while mopping the floor and removed the dirty mop head with her ungloved hands and placed a new mop head on the mop. She continued mopping the room and when done mopping, again removed the dirty mop head from the mop with ungloved hands. She then finished and left the room without sanitizing or washing her hands. During an interview on 4/22/2026 at 9:00 AM, Housekeeper II stated, “I don’t have a clue who cleans the blinds. I have never cleaned them.” She stated that she should be cleaning the door handles and stated, “That’s something I forget about.” Housekeeper II also confirmed and agreed that the items observed not cleaned during the terminal clean should have been. When asked about touching the mop head, Housekeeper II stated, “Yes, I touched the dirty mop head. I probably should be wearing gloves.” Examples of hand hygiene and food preparation in the Kitchen: A review of the facility policy #19894492 last revised 03/2026 titled, “Hand Hygiene and Glove Use,” revealed, “It is the policy of the Food Services department to practice proper hand-washing and glove usage to protect patients and employees from contagious and foodborne illnesses...Proper Hand Hygiene...hand washing is to occur...for at least 10-15 seconds...before and after wearing and changing gloves...all ready to eat foods handled during tray line operation will require the use of a tongs or serving utensil...if gloves are used, they may only be used for handling of the ready to eat food item and nothing else to avoid cross contamination.” During a tour and observation of food preparation in the kitchen on 04/21/2026 from 10:49 AM through 11:59 AM observed 10 hand washing opportunities completed by Dietary Aides C, D and E. 9 of the 10 hand washing opportunities were completed in less than 10 seconds. During an observation of food preparation in the kitchen on 04/21/2026 at 11:00 AM observed Dietary Aide E put on gloves, touch a food container, then touch the counter, then reach into a bag of ready-to-eat lettuce with the contaminated, gloved hand and place the lettuce in a dish then on a tray to be served. Dietary Aide E was not observed to use a tongs or serving utensil as per the facility policy. In an interview on 04/21/2026 at 11:05 AM when Dietary Aide C was asked how long they were to wash their hands. Dietary Aide C stated, “15 seconds.” In an interview on 04/21/2026 at 11:14 AM when Dietary Aide E was asked how long they were to wash their hands. Dietary Aide E stated, “1 to 1.5 minutes.” On 04/21/2026 at 11:20 AM an interview was conducted with Dietary Manager B. Dietary Manager B stated, “Hands should be washed for 20 seconds.” When asked if it was acceptable to touch ready-to-eat food with a gloved hand, Dietary Manager B stated, “No, they should be using a utensil.” Example of food storage: A review of facility policy titled, “Food Receiving, Preparation, Holding, and Storage” last revised on 3/2026 revealed, “...The use of home cooked foods will be discouraged. When patients insist on food from an outside source, the following guidelines will be followed... B. Food storage in nursing units 1. Food will not be stored in a refrigerator used to store medications, chemicals, or specimens. 2. Only floor stock food items and hospital provided food belonging to a hospital patient are allowed in nourishment room refrigerators...” During observation of the refrigerator in the nourishment room in Medical Surgical and Emergency Department shared space on 4/21/2026 at 09:50 AM, found contents to include staff food, and a patient labeled Pyrex container in the patient refrigerator. During an interview on 4/21/2026 at 09:55 PM with Medical Surgcal Manager R, Med Surg Manager R stated, “We only have this one nourishment refrigerator and have no other place to store patient food.” Example of dirty instruments: A review of facility policy titled, “Transportation of Contaminated Instruments” last revised 09/2025 revealed, “...If contaminated items do not have a direct route to the decontamination area at the time of use, a pretreatment product should be applied to the item and placed in the properly labeled closed container for transportation. The pretreatment will prevent the formation of biofilm and prevents the risk of corrosion.” A review of facility policy titled, “Universal Instrument Pre-Cleaning Process, last revised 5/2023 revealed, “...4. Gently pour or place instruments into the larger biohazard collection bin and saturate with enzymatic spray. At end of day, add Brawny paper towel dampened with sterile or distilled water to maintain humidity.” During observation on in the Emergency Department/Medical Surgical dirty utility room on 4/21/2026 at 11:14 AM, 2 biohazard bins were observed to contain dry, dirty/used instruments covered with dry paper towels. During an interview on 4/21/2026 at 11:16 AM with Emergency Department Manager U, Emergency Department manager U stated she was unsure how long the instruments were in the bins. 50644 52395 53566”

“A standard Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 04/21/2026 through 04/22/2026. Gundersen St. Joseph Hospital and Clinics was found out of compliance with the following applicable regulations for hospital participation in Medicare-Medicaid: 42 CFR 485.623 Condition of Participation: Physical Environment was NOT MET 42 CFR 485.623(d) Standard: Life Safety from Fire was NOT MET NFPA 101 (2012 edition) Life Safety Code was NOT MET Gundersen St. Joseph Hospital and Clinics, a Critical Access Hospital, is a two-story structure built in 2020, with Type II (1,1,1) construction. The upper story contains surgery suites, business offices and clinic spaces for the hospital and a rural health clinic. All of these spaces are contained in the hospital building. No buildings are attached to the hospital building. The facility is fully sprinklered with one wet pipe sprinkler and has one 750 kW 480V 3 Ph (937.5 KVA @ pf=0.8) emergency generator. The facility contained five smoke compartments, three on the lower story, two on the upper story. One atrium located at the main entry is separated from the corridor with glass and concealed sprinklers. Gundersen St. Joseph Hospital and Clinics is licensed for 25 beds, with a census of 13 inpatients on 04/21/2026 and 13 inpatients on 04/22/2026 at the time of the survey. The facility was surveyed under the 42 CFR Subpart 485.625 for hospitals. Six (6) federal deficiencies of the Life Safety Code were cited.”

“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: 40659 Based on record review, observation, and interview, the facility did not test and maintain the fire alarm system as required in NFPA® 101 Life Safety Code® 2012 Edition, Sections 9.6, 9.6.1.3, and 19.3.4.1; NFPA® 72, National Fire Alarm and Signaling Code, 2010 edition, Sections 14.4.2.2, 14.4.2.2(5), 14.4.5, 14.4.5(5), and 14.6.2; NFPA® 70, National Electrical Code®, 2011 edition, article 760. This deficient practice could affect 13 of 13 inpatients. Findings include: 1. On 04/21/2026 at 11:00 AM, record review revealed the Ban Koe annual fire alarm inspection report dated 02/17/2026 did not include semi-annual battery testing. 2. On 04/21/2026 at 11:10 AM, record review revealed the Ban Koe annual fire alarm inspection report dated 02/17/2026 did not include smoke detector sensitivity range and measured sensitivity. 3. On 04/21/2026 at 3:21 PM, observation revealed at the Fire Alarm Control Panel (FACP), FACP displayed 11:49:18 at 3:21 PM. 4. On 04/21/2026 at 3:24 PM, observation revealed at CKT LL1A-42, CKT LL1A-42 was not red. These findings were confirmed at the time of discovery by a concurrent interview with Staff GG.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 NEW Buildings are to be protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state and local regulations prohibit sprinklers. Listed quick-response or listed residential sprinklers are used throughout smoke compartments with patient sleeping rooms. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed six square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 18.3.5.1, 18.3.5.4, 18.3.5.5, 18.3.5.6, 9.7, 9.7.1.1(1), 18.3.5.10 This Standard is not met as evidenced by: 40659 Based on observation and interview, the facility did not provide an approved automatic sprinkler system in accordance with NFPA 13, Standard for Installation of Sprinkler Systems as required in NFPA® 101 Life Safety Code® 2012 Edition, Sections 9.7, 9.7.1.1(1), 19.3.5, 19.3.5.1, and 19.3.5.4; NFPA® 13 Standard for the Installation of Sprinkler Systems 2010 edition Sections 7.1 and 8.6.5.1.2; NFPA® 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition sections 5.2 and 5.2.1.1. This deficient practice could affect 3 of 13 inpatients. Findings include: On 04/22/2026 at 9:33 AM, observation revealed at emergency room corridor door HIL1299J, one center-of-tile concealed sprinkler was obstructed by one center-of-tile 16 inch full dome mirror. This finding was confirmed at the time of discovery by a concurrent interview with Staff GG.”

“Corridor - Doors CFR(s): NFPA 101 Doors protecting corridor openings shall be constructed to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have self-latching and positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 18.3.6.3.6 are permitted. 18.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatic closing devices, etc. This Standard is not met as evidenced by: 40659 Based on observation and interview, the facility did not protect corridor door openings as required in NFPA® 101 Life Safety Code® 2012 Edition, Sections 19.3.6.3 and 19.3.6.3.5. This deficient practice could affect 3 of 13 inpatients. Findings include: On 04/22/2026 at 9:22 AM, observation revealed at the Flex Hil1356 automatic-closing corridor door, the automatic-closing corridor door did not close and latch after three attempts. This finding was confirmed at the time of discovery by a concurrent interview with Staff GG.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 NEW Smoke barriers shall be constructed to provide at least a one hour fire resistance rating and constructed in accordance with 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations of fully ducted HVAC systems. 18.3.7.3, 18.3.7.4, 18.3.7.5, 8.3 Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 40659 Based on observation and interview, the facility did not provide smoke barriers constructed to a 1/2-hour fire resistance rating as required in NFPA® 101 - 2012 edition, Sections 8.5, 8.6.7.1(1), and 19.3.7.3; NFPA® 70®, National Electrical Code®, 2011 edition, Sections 300.21 and 800.26. This deficient practice could affect 3 of 13 inpatients. Findings include: 1. On 04/21/2026 at 10:37 AM, observation revealed at the lab smoke barrier, one 4 inch diameter sch 40 Poly Vinyl Chloride (PVC) Drain Waste Vent (DWV) pipe penetration did not have a listed penetration firestop assembly tested with 4 inch diameter PVC DWV. W-L-2342 label shown was for Poly Vinyl Chloride (PVC) pipe nom. 2 in. diameter (or smaller). W-L 2377 label shown was for Chlorinated Poly Vinyl Chloride (CPVC) pipe nom. 2 in. diameter (or smaller). 2. On 04/21/2026 at 2:05 PM, observation revealed at the clinic compartment smoke barrier, two Metal Clad (MC) electrical cables through one 1 ½ inch diameter hole did not have a listed penetration firestop assembly. These findings were confirmed at the time of discovery by a concurrent interview with Staff GG.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 40659 Based on observation and interview, the facility did not provide operating rooms with two low sidewall return grilles spaced at opposite corners as required in NFPA® 101 Life Safety Code® 2012 Edition, Sections 9.2 and 19.5.2.1; ANSI/ASHRAE/ASHE Standard 170-2017, Ventilation of Health Care Facilities section 7.4. This deficient practice could affect 3 of 13 inpatients. Findings include: On 04/21/2026 at 2:45 PM, observation revealed at Orthopedic Operating Room 1 (OR1), one low sidewall return grille was obstructed by one robotic assisted surgery robot. There was no marking and identification to provide clearance in front of the HVAC low sidewall return grilles. This finding was confirmed at the time of discovery by a concurrent interview with Staff GG.”

“Gas and Vacuum Piped Systems - Information an CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Information and Warning Signs Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. 5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99) This Standard is not met as evidenced by: 40659 Based on observation and interview, the facility did not label piping identifying the gas or vacuum system as required in NFPA® 101 - 2012 edition, Sections 8.7 and 19.3.2.4; NFPA® 99, 2012 edition, Sections 5.1, 5.1.11, 5.1.11.1, 5.1.11.1.2, 5.1.14.3, and 5.1.14.3.1. This deficient practice could affect 3 of 13 inpatients. Findings include: 1. On 04/21/2026 at 11:23 AM, observation revealed at emergency smoke barrier, one1 inch diameter copper medical gas piping with concealed green label was not labeled as oxygen. 2. On 04/21/2026 at 2:26 PM, observation revealed in the procedure room corridor, one ½ inch diameter copper piping medical gas label was not present. These findings were confirmed at the time of discovery by a concurrent interview with Staff GG.”