Deficiency
Atlas
Atlas
Physical Environment & Life Safety · CMS 2567 Analysis
A data-driven analysis of deficiencies most critical to ASC design, derived from CMS Form 2567 survey records across 5,886 licensed ASC facilities nationwide. 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 — Operational & staffing tags excluded
+ Top Architectural Deficiency Tags
Tag 130 · NFPA 25 · FGI §1.2-8.5
2,799
Sprinkler System
Spare head cabinet absent, gauge calibration lapsed, heads obstructed, external loads on piping
Tag 51 · NFPA 72 · FGI §1.2-8.1
2,316
Fire Alarm System
Unreported troubles, monitoring connection failures, smoke detector sensitivity not tested
Tag 29 · NFPA 101 · FGI §1.2-8.3
1,827
Hazardous Area Separation
Self-closing doors inoperative, not latching, rooms not properly rated
Tag 114 · NFPA 101 · FGI §1.2-8.3
1,460
Fire-Rated Penetrations
Unsealed conduit ends, open pipe sleeves, gaps at wall-to-deck interface
Tag 46 · NFPA 101 §7.9 · FGI §2.1-8.6
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
FGI Cross-Reference — Fire & Life Safety
FGI §1.2-8 requires that all ambulatory surgery facilities comply with NFPA 101 for fire and life safety systems, including sprinkler systems (§1.2-8.5), fire alarm systems (§1.2-8.1), and hazardous area separation (§1.2-8.3). FGI does not relax these CMS minimums — in many cases it adds documentation and commissioning requirements. Sprinkler systems must be designed, installed, and commissioned per NFPA 25, with a compliant inspection and testing record maintained from day one of occupancy.
FGI §1.2-8.1 through §1.2-8.5 · NFPA 101 §21.3 · NFPA 25
Construction Administration: Fire-rated wall continuity must extend uninterrupted from slab to structural deck. Above-ceiling inspections during CA consistently reveal unsealed conduit and pipe penetrations. Confirm in CDs and verify during field walkthroughs.
OR Ventilation Requirements — CMS & FGI
20 ACH
Total Air Changes — Operating Room
CMS minimum per ASHRAE 170 Table 7.1. Supply from ceiling only, exhaust at floor level only. 4 ACH must be outdoor air.
CMS Tag 101 · ASHRAE 170 Table 7.1
FGI Requirement — OR Air Changes
FGI Table 2.1-2 also requires a minimum of 20 total ACH for ORs, consistent with ASHRAE 170. FGI additionally requires that at least 4 ACH be outdoor air, that all supply air be introduced from ceiling-level diffusers, and that exhaust/return air be at or near floor level. FGI further requires that air quantities be verified by a commissioned TAB report before occupancy.
FGI Table 2.1-2 · FGI §2.1-8.2.1
+0.01"
Positive Pressure to Corridor
Minimum differential. Magnehelic gauges required at OR entry. Verified by current TAB report on file.
CMS Tag 101 · ASHRAE 170 §7.1
FGI Requirement — Pressure Relationships
FGI Table 2.1-2 requires ORs to be maintained at positive pressure relative to all adjacent spaces including corridors, substerile rooms, and workrooms. The pressure cascade — OR (+) → Corridor (neutral) → Soiled Utility (−) — must be designed in and verified during commissioning. Pressure relationships must be maintained continuously during occupied hours, not just at survey.
FGI Table 2.1-2 · FGI §2.1-8.2.2
30–60%
Relative Humidity — OR
834 citations for humidity out-of-range. Daily monitoring logs with documented corrective actions required.
CMS Tag 101 · ASHRAE 170
FGI Requirement — Humidity
FGI Table 2.1-2 requires OR relative humidity to be maintained between 20% and 60% — a slightly wider band than the legacy 30–60% threshold still referenced in many CMS surveys. However, many AHJs continue to enforce 30–60%. Design to the more stringent 30–60% range to ensure survey compliance.
FGI Table 2.1-2 · ASHRAE 170 Table 7.1
68–75°F
Temperature Range — OR
939 citations for non-compliance. HVAC must be sized to hold range under full surgical heat loads.
CMS Tag 101 · ASHRAE 170
FGI Requirement — Temperature
FGI Table 2.1-2 requires OR temperature to be maintained between 68°F and 75°F (20°C–24°C). The HVAC system must be sized to hold this range under peak surgical heat loads — including equipment, lighting, and occupancy — not just at ambient conditions. Documented temperature monitoring is required under both CMS and FGI.
FGI Table 2.1-2 · ASHRAE 170 Table 7.1
10 ACH
Sterile Processing / Decontamination
Decontam: negative to clean assembly. Clean assembly: positive to decontam. Unidirectional dirty-to-clean airflow.
CMS · ASHRAE 170
FGI Requirement — Sterile Processing
FGI Table 2.1-2 requires decontamination rooms to be negative pressure to the clean workroom, with a minimum of 10 ACH. The clean assembly/sterile storage area must be positive pressure to the decontamination area. FGI also requires these spaces to have dedicated exhaust systems that are not recirculated.
FGI Table 2.1-2 · FGI §2.1-8.2.3
MERV-14
Final Filtration — OR Supply Air
Minimum MERV-14 in gasketed, sealed housings. No bypass permitted. Document in commissioning records.
CMS · ASHRAE 170 · FGI §A8.3
FGI Requirement — Filtration
FGI §2.1-8.2 and Appendix A8.3 require a minimum of MERV-14 final filters on all air-handling units serving ORs and procedure rooms. Filters must be installed in gasketed, sealed housings with no bypass. FGI requires filter installation to be confirmed in the commissioning record prior to occupancy.
FGI §2.1-8.2 · FGI Appendix A8.3 · ASHRAE 170 §6.4
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 both CMS and FGI 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 — CMS & FGI Requirements
OR Floors:
Seamless sheet vinyl or polished sealed concrete throughout the procedure suite. No grout joints, no carpet. Cove base required at all floor-wall intersections.
FGI Requirement — Floor Cove Base
CMS surveys have cited 4" cove base as insufficient in OR and sterile processing areas. FGI §2.1-7.2.1 requires a minimum 6" integral coved base at all floor-wall intersections in operating rooms, procedure rooms, and sterile processing areas. The base must be the same material as the floor or a compatible seamless material — not a separate vinyl strip. This is a common design gap between general construction standards and healthcare FGI compliance.
FGI §2.1-7.2.1 · FGI §3.1-7.2.1
OR Ceilings:
Monolithic, non-shedding surface. Gasketed, sealed light fixtures. No exposed lay-in tiles without sealed frames. Plenum must not be accessible from within the OR.
FGI Requirement — OR Ceilings
FGI §2.1-7.2.2 requires a monolithic, non-perforated ceiling in operating rooms and Class B and C procedure rooms. Lay-in acoustic tile ceilings are not permitted unless installed in a gasketed, sealed grid system that prevents air infiltration to the plenum. All penetrations through the ceiling plane — light fixtures, sprinkler escutcheons, medical gas outlets — must be sealed with gasketed, tight-fitting trim rings.
FGI §2.1-7.2.2 · FGI §3.1-7.2.2
OR Walls:
Smooth, non-porous, washable finish. No horizontal ledges or recesses that trap debris. Equipment attachment penetrations must be fully sealed when equipment is relocated.
FGI Requirement — Wall Finishes
FGI §2.1-7.2.3 requires wall surfaces in ORs and procedure rooms to be smooth, non-porous, and washable to a height of at least 48 inches — and to the ceiling in wet areas and sterile processing. Exposed CMU, textured paint, and any surface that creates recesses or ledges is not permitted. All wall openings — including conduit, plumbing, and equipment connections — must be sealed to prevent air infiltration.
FGI §2.1-7.2.3
Equipment:
Specify only stainless or non-corrosive material finishes for all equipment used in sterile areas. Remove adhesive labels from all cylinder and equipment surfaces before placing in sterile areas.
Rooms Most Frequently Cited · NFPA 101 §21.3.2 · FGI §1.2-8.3
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
FGI Requirement — Hazardous Area Separation
FGI §1.2-8.3 requires hazardous areas in ambulatory surgery facilities to be separated from the remainder of the building by a 1-hour fire-rated construction or by automatic sprinkler protection where the building is fully sprinklered. All doors in hazardous area separations must be self-closing, positive-latching, and rated consistent with the wall assembly. FGI also requires soiled workrooms, soiled linen rooms, and clean supply storage to be separated from each other and from procedure areas by construction and pressure relationships — going beyond the basic CMS door-closer requirement.
FGI §1.2-8.3 · NFPA 101 §21.3.2 · FGI §2.1-2.6
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 — NFPA 99 §8-3
Tag 76 · 28.7%
913
Oxygen Storage Room
Non-compliant room design or shared with general storage — NFPA 99 §8-3.1
Tag 923 · 9.8%
310
Unsecured Cylinders
Cylinders not restrained per NFPA 99 §11.6.2 — chains, racks, or straps required
Citation Distribution by Tag
Tag 104 — Combustibles Near Oxygen · NFPA 99 §8-3
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.
FGI Requirement — Medical Gas Zone Separation
FGI §2.1-8.8 requires that medical gas zones be clearly identified on the construction documents and that no combustible storage be permitted within 5 feet of any medical gas outlet. FGI further requires zone valve boxes to be accessible and labeled, and that the design indicate the location of all shutoffs. The 5-foot exclusion zone must be shown on the floor plan and confirmed in the O&M documents provided at occupancy.
FGI §2.1-8.8 · NFPA 99 §8-3
Tag 76 — Oxygen Storage Room · NFPA 99 §8-3.1 · FGI §2.1-8.8.2
Dedicated Room Requirements
Requires: dedicated ventilation to exterior, no combustible materials, proper door rating with self-closing hardware, and integral cylinder restraint systems. Must not be shared with general storage.
FGI Requirement — Oxygen Storage Room
FGI §2.1-8.8.2 requires a dedicated oxygen storage room when bulk or manifold oxygen systems are used. The room must have: (1) mechanical ventilation to the exterior — not recirculated — at a minimum rate that prevents oxygen concentration buildup; (2) a minimum 1-hour fire-rated enclosure; (3) a self-closing, positive-latching door; (4) no combustible materials or finishes; (5) required cylinder restraint systems; and (6) compliant signage per NFPA 99. The room must appear as a labeled, distinct room type on the floor plans — not an unnamed closet or shared storage.
FGI §2.1-8.8.2 · NFPA 99 §8-3.1 · NFPA 99 §11.6.2
Design Note: Coordinate the oxygen storage room as a named, dedicated room type on the floor plan from schematic design forward. Do not combine with clean utility. Confirm ventilation, door rating, restraint systems, and signage 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 approved submittal
✓ Compliant
Pipe Collar Sealed
Intumescent firestop collar installed at pipe penetration through rated assembly
FGI Requirement — Firestop Systems
FGI §1.2-8.3 requires that all penetrations through fire-rated wall and floor-ceiling assemblies be protected with UL-listed firestop systems installed in accordance with the manufacturer's instructions for the specific assembly type. FGI requires firestop submittals to be included in the construction document package and approved by the AHJ prior to construction. FGI also requires a firestop inspection log documenting each penetration by location, firestop system used, installer, and inspection date — this log must be included in the project closeout documents. Empty conduit ends through rated assemblies must be sealed regardless of whether wire is present.
FGI §1.2-8.3 · NFPA 101 §21.3.7 · UL Fire Resistance Directory
CA Action
Above-Ceiling Inspection
Required at all fire-rated walls. Empty conduit ends must be sealed even if no wire is present.
CA Action
Firestop Submittals
Review and approve before construction. UL-listed systems required. Document product, installer, and inspection date.
CA Action
Closeout Documentation
FGI requires a firestop inspection log in project closeout documents — confirm this is included in CA scope.
Key Insight: 764 of 1,460 citations relate specifically to conduit or pipe penetrations — a clear construction sequence failure. Both CMS and FGI require penetrations to be sealed. The 34 citations noting "above ceiling" suggest the real number is far higher.
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
FGI Requirement — Sprinkler Systems
FGI §1.2-8.5 requires that all new ambulatory surgery facilities be fully sprinklered throughout, including above ceilings, in interstitial spaces, and in all mechanical and electrical rooms. FGI requires the system to be designed and installed per NFPA 13 and inspected, tested, and maintained per NFPA 25. FGI requires a current NFPA 25 inspection and testing record to be provided at occupancy. The spare head cabinet — often the most-cited single deficiency — must be specified in the construction documents and its location shown on the drawings.
FGI §1.2-8.5 · NFPA 13 · NFPA 25
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
FGI Requirement — Essential Electrical System
FGI §2.1-8.6 requires a Type 1 Essential Electrical System for all ambulatory surgery facilities containing operating rooms. The EES must consist of three branches: Life Safety, Critical, and Equipment. The Critical Branch must restore power within 10 seconds of outage. FGI also requires the remote annunciator to be located at a continuously attended location outside the generator room — this is a design-phase decision that must be coordinated with the floor plan. FGI requires EES branch assignments to be shown on the electrical drawings and confirmed in the commissioning record. FGI further requires a generator load test report to be provided at occupancy.
FGI §2.1-8.6 · NFPA 99 §517 · NFPA 110
EES Branch Assignment — Required by FGI §2.1-8.6 & NFPA 99
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, sterilizers
⚠ C-arms must be on Equipment Branch — not Life Safety Branch. Cited deficiency in ASC surveys. Coordinate branch assignments on electrical drawings and confirm during commissioning.
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. FGI requires the location to be shown on the drawings.
400 SF
Min. OR Floor Area
General ORs. Ortho/cardiac: 600 sf. Endo/minor procedure: 200 sf. Exclusive of fixed equipment alcoves.
CMS · 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. No reversed flow.
CMS Tag 101 · ASHRAE 170 · FGI Table 2.1-2
+
Positive Pressure
ORs positive to all adjacent spaces. Design pressure cascade from OR outward to soiled utility. Verify with TAB at occupancy.
CMS · ASHRAE 170 §7.1 · FGI Table 2.1-2
MERV 14
Final Filtration
Minimum MERV-14 in gasketed, sealed housings. No bypass. Confirmed in commissioning record.
CMS · ASHRAE 170 · FGI §2.1-8.2 / Appendix A8.3
IPS
Isolated Power System
Required in wet procedure locations (Class 1 ORs). LIM alarm required and functional. IPS panelboard location coordinated in CDs.
CMS · NFPA 99 §517-63 · FGI §2.1-8.6
8 ft
Min. Ceiling Height
In procedure areas. Higher preferred for surgical booms. FGI requires additional height clearance when ceiling-mounted equipment is present.
FGI §3.7-3.2.3
Additional Requirements — CMS & FGI Cross-Reference
Seamless floor — no grout joints, no carpet
CMS: non-porous, cleanable surface required. FGI §2.1-7.2.1: seamless sheet vinyl or sealed concrete, with a minimum 6" integral coved base at all floor-wall intersections (not a separate vinyl strip). Note: 4" cove base does not meet FGI in ORs and sterile processing.
No recessed fixtures without sealed trim rings
CMS: cleanable surfaces required. FGI §2.1-7.2.2: monolithic ceiling required in ORs — all ceiling penetrations must be sealed with gasketed trim rings to maintain plenum integrity.
Written pressure / temp / humidity monitoring logs
CMS: monitoring logs required at survey. FGI §2.1-8.2: continuous monitoring system with documented corrective action protocol must be in place — design the monitoring infrastructure in from day one.
Scrub sink at each OR — hands-free activation
CMS: hand hygiene facilities required. FGI §3.7-3.4.1: minimum one scrub station per OR, located in the corridor immediately outside the OR entry, with hands-free (sensor or knee-operated) faucet activation. Scrub stations must not be located inside the OR.
Magnehelic gauges at each OR entry
CMS: positive pressure must be verified at survey. FGI §2.1-8.2.2: pressure-indicating devices (Magnehelic or equivalent) must be installed at each OR entry and be readable from the corridor without entering the OR. Location must be shown on drawings.
Substerile room between adjacent ORs (where provided)
FGI §3.7-3.5.1: where a substerile room is provided between ORs, it must be positive pressure to both adjacent ORs and equipped with a pass-through sterilizer. Substerile rooms must have a dedicated exhaust and must appear as a labeled room type on the floor plan.
OR size exclusive of fixed equipment alcoves
FGI §3.7-3.2.1: the minimum 400 sf net clear floor area is measured exclusive of fixed equipment alcoves, column projections, and areas used for storage. A room that meets 400 sf gross but less than 400 sf clear floor area does not comply. Confirm net clear area on floor plan with furniture and equipment shown.