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Cotton Architecture + Design
CMS Deficiency Analysis
CMS 2567
Analysis · 2023
Analysis · 2023
Deficiency
Atlas
Atlas
Physical Environment & Life Safety
A data-driven analysis of deficiencies most critical to ASC design, derived from CMS Form 2567 survey records. Operational, documentation, and staffing citations excluded. Expand each section below to explore the full findings.
147K
Total citations analyzed
5,886
ASC facilities surveyed
36,255
Architectural citations
13
Deficiency tag types
Physical Environment · Life Safety · Building Systems Only
+ Top Architectural Deficiency Tags
Tag 130 · NFPA 25
2,799
Sprinkler System
Spare head cabinet absent, gauge calibration lapsed, heads obstructed, external loads on piping
Tag 51 · NFPA 72
2,316
Fire Alarm System
Unreported troubles, monitoring connection failures, smoke detector sensitivity not tested
Tag 29 · NFPA 101
1,827
Hazardous Area Separation
Self-closing doors inoperative, not latching, rooms not properly rated
Tag 114 · NFPA 101
1,460
Fire-Rated Penetrations
Unsealed conduit ends, open pipe sleeves, gaps at wall-to-deck interface
Tag 46 · NFPA 101
1,366
Emergency Lighting
On wall-switch circuits, burned-out lamps, battery not sustaining 90-min load
Tags 47+64+70+75
3,401
Additional LSC Items
Exit signs, fire extinguisher service, portable space heaters, oversized waste receptacles
Construction Administration: Fire-rated wall continuity must extend uninterrupted from slab to structural deck above. Above-ceiling inspections during CA consistently reveal unsealed conduit and pipe penetrations. Confirm in CDs and verify during field walkthroughs.
OR Ventilation Requirements · ASHRAE 170
20 ACH
Total Air Changes — Operating Room
Minimum per ASHRAE 170 Table 7.1. Supply from ceiling only, exhaust at floor level only. 4 ACH must be outdoor air.
ASHRAE 170 · FGI §3.7-3.3
+0.01"
Positive Pressure to Corridor
Minimum pressure differential. Magnehelic gauges required at OR entry. Verified by current TAB report on file.
ASHRAE 170 §7.1
30–60%
Relative Humidity — OR
834 citations for humidity out-of-range. Must be monitored and logged daily with documented corrective actions.
ASHRAE 170
68–75°F
Temperature Range — OR
939 citations for non-compliance. HVAC must be sized to hold range under full surgical heat loads.
ASHRAE 170
10 ACH
Sterile Processing / Decontamination
Decontam: negative to clean assembly. Clean assembly: positive to decontam. Unidirectional dirty-to-clean airflow.
ASHRAE 170
MERV-14
Final Filtration — OR Supply Air
Minimum MERV-14 in gasketed, sealed housings. No filter bypass permitted. Document in commissioning records.
ASHRAE 170 · FGI §A8.3
Pressure Cascade Design: OR (+) → Corridor (neutral) → Soiled Utility (−) → Outside. Door-opening infiltration must be factored into HVAC sizing. Final TAB report and ongoing monitoring records required for CMS compliance.
Most Cited Sub-Category
1,726
Floor Surface Failures
Damaged, cracked, non-seamless, or carpet in procedure areas. Cove base missing or cracked. Grout joints in ORs.
1,238
Wall Surface Failures
Peeling paint, holes from former equipment, exposed CMU, horizontal ledges accumulating debris.
592
Rust & Uncleanable Equipment
Rust on IV poles, OR tables, carts. Adhesive residue creating porous, uncleanable surfaces.
466
Ceiling Deficiencies
Open plenum accessible from OR, lay-in tiles without gasketed frames, unsealed penetrations at fixtures.
Design Implications
OR Floors:Seamless sheet vinyl or polished sealed concrete. 4" radius coved base. No grout joints, no carpet anywhere in the procedure suite.
OR Ceilings:Monolithic, non-shedding surface. Gasketed, sealed light fixtures. No lay-in tiles without sealed frames. Plenum not accessible.
OR Walls:Smooth, non-porous finish. No horizontal ledges. Equipment attachment penetrations fully sealed when relocated.
Equipment:Specify stainless or non-corrosive finishes. Remove adhesive labels from all cylinder surfaces before placing in sterile areas.
Rooms Most Frequently Cited — NFPA 101 §21.3.2
572
Storage Rooms
Doors not self-closing or latching; room >50 sf not properly rated
315
Soiled Utility
Self-closer inoperative or door fails to fully latch in frame
230
Mechanical Rooms
Wall penetrations unsealed; door hardware failed or removed
173
Boiler Rooms
Combustible storage present; door not properly rated
118
Electrical Rooms
Unsealed conduit penetrations in rated walls
106
Janitor Closets
Door propped open or no positive-latch hardware
Design Implication: Specify surface-mounted or concealed door closers and positive-latching hardware on all hazardous area doors. Confirm door ratings in door schedule. Verify during CA that no closers have been removed or disabled.
Tag 104 · 61.5%
1,953
Combustibles Near Oxygen
Materials within 5 ft of oxygen outlets, regulators, or storage
Tag 76 · 28.7%
913
Oxygen Storage Room
Non-compliant storage room design or shared with general storage
Tag 923 · 9.8%
310
Unsecured Cylinders
Compressed gas cylinders not restrained per NFPA 99 §11.6.2
Citation Distribution by Tag
Tag 104 — Combustibles Near Oxygen
5-ft Exclusion Zone Required
NFPA 99 §8-3 requires no combustible materials within 5 feet of any oxygen outlet, regulator, or storage. Most common violation: paper products, linens, and alcohol-based cleaners stored near wall outlets and portable oxygen staging areas.
Tag 76 — Oxygen Storage Room
Dedicated Room Requirements
Requires: dedicated exterior ventilation, no combustibles, proper door rating with self-closing hardware, and integral cylinder restraint systems. Must not be shared general storage. Do not combine with clean utility.
Tag 923 — Unsecured Cylinders
Restraint Systems Required
All compressed gas cylinders must be secured. NFPA 99 §11.6.2 requires chains, racks, or straps at all storage and use locations. Design must include integral wall-mounted cylinder restraints. Specify in interior details.
Design Note: Oxygen storage rooms must be designed as a dedicated room type — not shared storage. Coordinate on floor plan, section, and interior details. Confirm compliance during CA.
Penetration Conditions — Compliant vs. Non-Compliant
✗ Not Compliant
Unsealed Conduit
Open conduit end through fire-rated wall — no firestop material installed
✗ Not Compliant
Open Pipe Sleeve
Oversized sleeve left open — annular gap around pipe not sealed
✓ Compliant
Firestop Sealed
UL-listed intumescent or caulk firestop system installed and documented per submittal
✓ Compliant
Pipe Collar Sealed
Intumescent firestop collar installed at pipe penetration through rated assembly
CA Action
Above-Ceiling Inspection
Required at all fire-rated walls. Empty conduit ends must be sealed even if no wire is currently present.
CA Action
Firestop Submittals
Review and approve before construction. UL-listed systems required. Document product, installer, and inspection date.
CA Action
Substantial Completion Punch
Penetration sealing must be confirmed. Include above-ceiling walkthroughs at all rated walls in CA scope.
Key Insight: 764 of 1,460 citations relate specifically to conduit or pipe penetrations — a clear construction sequence failure. Empty conduit ends must be sealed regardless of whether wire is present. Confirm in CDs; verify during CA.
Top Failure Modes · NFPA 25
01
Spare head cabinet absent or incomplete
~780
02
Gauge calibration >5 years lapsed
~600
03
Storage obstructing 18" clearance below heads
~510
04
External loads attached to sprinkler piping
~385
05
Painted, corroded, or physically damaged heads
~300
06
Coverage gaps — unsprinklered spaces
~224
NFPA 25 §2-4.1.4: Minimum 6 spare heads of each type and temperature rating, plus a head wrench, in a cabinet on premises — required from day one of occupancy. Specify cabinet location in construction documents.
Tag 144 · NFPA 110
1,821
Generator Testing Records
Missing monthly logs, insufficient run time (<30 min), or load not documented
Tag 147 · NFPA 70
1,469
Junction Boxes & Wiring
Open junction boxes and missing cover plates in OR suites and above ceilings
Tag 106 · NFPA 99
805
Remote Annunciator
Inoperative lamps, no audible alarm, panel not at regularly attended station
EES Branch Assignment — Design Requirement
Life Safety Branch
Exit lights, egress lighting, fire alarm, nurse call
Critical Branch
OR lighting, anesthesia alarms, PACU monitoring, patient monitoring — transfers within 10 seconds
Equipment Branch
Anesthesia machines, C-arms, surgical imaging equipment
⚠ C-arms must be on Equipment Branch — not Life Safety Branch. Cited deficiency in ASC surveys.
NFPA 99 §3-4.1.1.15: The remote annunciator must be battery-powered, located at a regularly attended workstation outside the generator room, with both visual and audible alarm. Annunciator location is a design-phase decision — coordinate with floor plans during CDs.
400 SF
Min. OR Floor Area
General ORs. Ortho/cardiac: 600 sf. Endo/minor procedure: 200 sf. Exclusive of fixed equipment alcoves.
FGI §3.7-3.2.1
20 ACH
Total Air Changes
4 ACH must be outdoor air. Supply from ceiling diffusers only. Exhaust at floor level only.
ASHRAE 170 Table 7.1
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Positive Pressure
ORs positive to all adjacent spaces. Design pressure cascade from OR outward to soiled utility.
ASHRAE 170 §7.1
MERV 14
Final Filtration
Minimum MERV-14 in gasketed, sealed housings. No bypass. Document in commissioning records.
ASHRAE 170 · FGI §A8.3
IPS
Isolated Power System
Required in wet procedure locations (Class 1 ORs). LIM alarm required. Panelboard location coordinated in CDs.
NFPA 99 §517-63
8 ft
Min. Ceiling Height
In procedure areas. Higher preferred for surgical booms. Verify with equipment consultant early in design.
FGI §3.7-3.2.3
Additional OR Requirements
No recessed fixtures without sealed trim rings
Any ceiling penetration must be sealed to maintain negative plenum above OR.
Seamless floor — no grout joints, no carpet
Cove base 4" radius minimum. Sheet vinyl or polished sealed concrete only.
Written pressure/temp/humidity logs required
CMS surveys cite missing or incomplete monitoring logs — design monitoring infrastructure in from day one.
Scrub sink at each OR — hands-free activation
Sensor or knee-operated faucets. Located outside OR entry, not inside the OR.
Magnehelic gauges at each OR entry
Required to verify positive pressure differential. Must be readable from corridor without entering the OR.
OR suite restricted to essential personnel
Physical barriers, not just policy — door hardware and layout must support restriction.