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Based on observation and interview, the facility failed to ensure that doors with self-closing devices were not obstructed from automatically closing.

Findings Include:

On 08/02/18, during a tour of the facility observed the following doors were installed with self-closing devices:
1) LB 125A-1 had a door chalk, holding the door open.
2) Mammography door had a kickstand mounted and engaged to hold the door open.
3) RD 109 had a kickstand mounted and engaged to hold the door open.
4) RD 106A had a kickstand mounted and engaged to hold the door open.
5) Door to the dressing room had a kickstand mounted and engaged to hold the door open.
6) Quiet Room door had a kickstand mounted and engaged to hold the door open.
7) MM 138 had a kickstand mounted and engaged to hold the door open.
8) Door from blood draw area to work room had a kickstand mounted and engaged to hold the door open.

The Maintenance Director confirmed the doors would not operate as designed and acknowledged the deficiency.

NFPA 13
National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, 2010 Edition

6.2.6.2* Painting.
6.2.6.2.1 Sprinklers shall only be painted by the sprinkler manufacturer.
6.2.6.2.2 Where sprinklers have had paint applied by other than the sprinkler manufacturer, they shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

6.2.7 Escutcheons and Cover Plates.
6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.
6.2.7.2* Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly.
6.2.7.3 Cover plates used with concealed sprinklers shall be part of the listed sprinkler assembly.
6.2.8 Guards. Sprinklers subject to mechanical injury shall be protected with listed guards.

8.6.4.1 Distance Below Ceilings.
8.6.4.1.1 Unobstructed Construction.
8.6.4.1.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 inches and a maximum of 12 inches throughout the area of coverage of the sprinkler.

26.1* General
A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained by the property owner or their authorized representative in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.

NFPA 25
National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition

5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)* Loading
5.2.1.1.3* Any sprinkler that has been installed in the incorrect orientation shall be replaced.
5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation.

Based on observation, document review and interview, the facility failed to maintain the automatic fire sprinkler system as required.

Findings include:

1) On 08/02/18 the following sprinklers were missing their escutcheons and/or their escutcheons were loose, exposing the annular space:
a) Recovery Medication Room - the sprinkler was missing its escutcheon.
b) Patient Restroom in the Emergency Department lobby - the sprinkler was missing its escutcheon.
c) DIY Water Housekeeping - the sprinkler was missing its escutcheon.
d) Staff work room - the sprinkler was missing its escutcheon.
e) RD 128 - the sprinkler was missing its escutcheon.
f) CT Room - two missing escutcheons.
g) RD 136 - the sprinkler was missing its escutcheon.
h) Quiet Room - the sprinkler was missing its escutcheon.
i) Pharmacy - the sprinkler in the far back corner was missing its escutcheon.
j) Storage AC 146 - dropped escutcheon.
k) Cafe Corner - the sprinkler was missing its escutcheon.
l) Kitchen - entrance sprinkler was missing its escutcheon, sprinkler in the dry pantry was missing its escutcheon, sprinkler on the kitchen side of the dry pantry had its escutcheon loose and a sprinkler inside the dry pantry was dropped exposing the annular space.
m) Nutrition Services - the sprinkler was missing its escutcheon.
n) Office inside Physical Therapy - the sprinkler was missing its escutcheon.

2) On 08/02/18, the following sprinklers were loaded with foreign material or were rusted/corroded:
a) Kitchen - sprinkler under the wall side of the hood was greenish in color and appeared corroded.
b) Kitchen - the majority of the sprinklers were loaded with dust/debris.
c) Ambulance Entrance - sprinkler had foreign matter hanging on its deflector.

3) On 08/02/18, the following sprinkler deflectors were less than the required one inch from the ceiling:
a) RD 139 - the sprinkler's deflector was approximately 1/8 to 1/4 of an inch from the ceiling.
b) ICU-11 - the sprinkler's deflector was approximately 1/4 of an inch from the ceiling.

4) On 08/02/18, the interstitial space was observed (above the tiled ceiling) at nine locations interspersed throughout the facility. At five of the nine locations, wires were located to be resting on or against the sprinkler pipes.

5) On 08/02/18, the following areas lacked the installation of a sprinkler:
a) The Urinalysis/Drug Testing restroom measured 4 feet 6 inches wide by 5 feet 11 inches deep by 8 feet tall.
b) The Walk-in Refrigerator measured 7 feet 6 inches wide by 7 feet 4 inches deep by 7 feet tall - there was not separation from the building.
c) The Walk-in Freezer measured 5 feet 6 inches by 7 feet 4 inches deep by 7 feet tall - there was not separation from the building.

The Maintenance Director acknowledged the deficiencies at the time of discovery.

Based on staff interview and document review, the facility failed to ensure that the fire watch policies were complete and consistent.

Findings include:

On 08/02/18, a review of the facility's Fire Watch Policy dated 04/2018 documented in part, "...the fire sprinkler system for more than four (4) hours in a twenty-four (24) hour period, the maintenance director shall..."

The Maintenance Director was unaware of the change from four hours to 10 hours and confirmed the deficiency.

National Fire Protection Association (NFPA) 10 (2010) 4-3.2 Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items: (a) Location in designated place, (b) No obstructions to access or visibility, (c) Operating instructions on nameplate legible and facing outward, (d) Safety seals and tamper indicators not broken or missing, (e) Fullness determined by weighing or "hefting", (f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle, (g) Pressure gauge reading or indicator in the operable range or position, (h) (n/a wheeled units), (I) HMIS label in place.

Based on observation and interview, the facility failed to maintain portable fire extinguishers.

Findings include:

On 08/02/18 at 10:45 AM during a tour of the facility, observed portable fire extinguishers with annual tags dated 06/06/18 and monthly inspections documented for July and August 2018. The Maintenance Director expressed they do not conduct a monthly heft test for each fire extinguisher. The Maintenance Director was unaware of this requirement.

Based on observation and interview, the facility failed to ensure smoke barrier construction was properly sealed at points of penetration.

Findings include:

On 08/02/18 during a tour of the facility, the following smoke barriers were not properly sealed to prevent the passage of smoke:
1) The roof access room had a penetration in the smoke barrier wall.
2) Interstitial space had a rigid conduit with a green wire inside that was not sealed.
3) Interstitial space in the corridor outside the Operating Room had a two inch by four inch hole that was not sealed.
4) Interstitial space near Radiology:
a) a bundle of Category (CAT) 5 wires running through the barrier wall without fire caulk.
b) approximately two inch by 10 inch hole was located in the barrier wall and was not sealed.
c) approximately one inch by 3 inch hole was located in the barrier wall and was not sealed.
5) Interstitial space near the Radiology waiting room had one flexible conduit and one rigid conduit running through the barrier wall and was not sealed.

The Maintenance Director confirmed the penetrations at the time of discovery.

Article 400 - Flexible Cords and Cables
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
1) As a substitute for the fixed wiring of a structure
2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
3) Where run through doorways, windows, or similar openings
4) Where attached to building surfaces
Exception to 4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
6) Where installed in raceways, except as otherwise permitted in the Code
7) Where subject to physical damage

Article 408.4 Field Identification Required
(A) Circuit Directory of Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include an approved degree of detail that allows each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard and at each switch or circuit breaker in a switchboard or switchgear. No circuit shall be described in a manner that depends on transient conditions of occupancy.

Based on observation and interview, the facility failed to ensure electrical wiring and equipment complied with the National Electric Code, National Fire Protection Association (NFPA) 70.

Findings include:

1) On 08/02/18, the following relocatable power taps (RPT) were located in the facility:
a) A refrigerator was plugged into a RPT in the manager's office.
b) A refrigerator was plugged into a tan colored extension cord in Respiratory Therapy.

2) On 08/02/18, the following electrical panelboards revealed the following panelboards had inaccurate panelboard directories:
a) Panelboard EN - breakers 36, 38, 40 and 42 were documented as "Blank" in the directory, however, each breaker was in the "on" position.
b) Panelboard XR - breakers 14, 16, 18, 20, 25, 27, 29, 32, 34, 38, 40 and 42 lacked documented evidence of what they were scheduled for on the directory. All breakers were in the "on" position.
c) Panelboard P2 - breakers 1, 3, 5, 7, 9, 11, 13, 15, 17, 19, 21, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36 were missing on the directory. Each breaker was in the "off" position.
d) Panelboard P1 - breakers 19, 21, 23, 25, 27, 29, 31, 33 and 35 were missing documentation on the directory and were in the "off" position. Breaker 32 wasn't listed on the directory and was a blank on the panelboard. Breaker 42 wasn't listed on the directory and was in the "off" position.

The Maintenance Director acknowledged the deficiencies at the time of discovery.

Based on documentation review and interview, the facility failed to ensure fire drills were conducted at varying times.

Findings include:

On 08/03/18, the facility's following third shift fire drills were not conducted a varying times:

a) 01/24/18 at 4:25 AM.
b) 04/26/18 at 4:15 AM.
c) 07/24/18 at 4:05 AM.
d) 09/21/17 at 6:05 AM.

Additionally, the facility failed to provide documented evidence of a fire drill conducted during the third shift in the fourth quarter of 2017.

On 08/03/18 at 7:45 AM, the Maintenance Director confirmed the findings.

Based on observation and interview, the facility failed to prohibit the use of space heating devices.

Findings include:

On 08/02/18 the following space heaters were discovered:

- Nurse's station in Obstetrics (OB).
- Business Office.
- Informatics Office.

On 08/02/18, the Maintenance Director confirmed the space heating devices and was unable to provide the required specification information.

Based on document review and interview, the facility failed to test its essential electrical system (EES) under load 12 times a year and weekly inspections.

Findings include:

On 08/03/18, the facility failed to provide documented evidence of weekly inspections from August 2017 through July 2018.

Additionally, the facility failed to provide documented evidence the generator was exercised under load in 20-40 day intervals for the the following:

- The generator was exercised under load on 09/29/17 then was exercised under load again on 10/11/17, less than the required 20 day interval.
- The generator was exercised under load on 10/11/17 then not until 11/30/17, beyond the required 40 day interval.

On 08/03/18, the Maintenance Director confirmed the documentation and was unaware of the required load testing intervals. The Maintenance Director expressed conducting weekly inspections, however, they were unable to provide the documented evidence of the inspections.

National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 Edition

11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 feet), shall be displayed on each door or gate of the storage room or enclosure.
11.3.4.2 The sign shall include the following wording as a minimum
CAUTION:
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

Based on observation and interview, the facility failed to display the precautionary sign on the storage room doors.

Findings include:

On 08/02/18, during a tour of the facility, observed of medical gas (oxygen) storage areas revealed the following:

- Emergency Supply Storage Room contained six E-sized oxygen cylinders. The exterior of the door lacked documented evidence of the required signage.

- Storage Room AC 124-2 contained six full E-sized oxygen cylinders. The exterior of the door lacked documented evidence of the required signage.

On 08/02/18, the Maintenance Director confirmed each door lacked signs stating oxygen was stored. The Maintenance Director confirmed from a separate employee, these room were used as oxygen storage.