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Based on observation, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Sections 7.1.10.1 and 18.2.3.4(5).

Findings include:

1. During an observation on 04/05/2023 at 6:49 a.m., the Med-Surg hallway was inspected. Various medical equipment was observed, being stored on both sides of the hallway. This medical equipment could impede egress in the corridor during a fire.

2. During an observation on 04/05/2023 at 7:53 a.m., the emergency department hallway was inspected. Various medical equipment was observed, being stored on both sides of the hallway. This medical equipment could impede egress in the corridor during a fire.

Based on observation, the facility failed to ensure doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side in accordance with NFPA 101-2012, Section 7.2.1.5.3 and 7.2.1.6.2, access-controlled egress door assemblies.

Findings include:

1. During an observation on 04/05/2023 at 7:17 a.m., the hospital main entrance was inspected. Two power-operated sliding doors were observed, marked as an emergency exit. Both sliding doors were found to be locked upon inspection. A key was required for the doors to unlock and allow egress from inside the hospital .

Based on observation, the facility failed to ensure doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 18.2.2.2.7 and section 18.2.2.2.8.

Findings include:

1. During an observation on 04/05/2023 at 6:05 a.m., the door leading to room 1525 was exercised. The door would not close and latch under the power of the self-closure.

2. During an observation on 04/05/2023 at 6:13 a.m., the elevator control room was inspected. The door to the room was found to be chocked open by a metal device and unable to close under the power of the self-closer.

3. During an observation on 04/05/2023 at 6:38 a.m., the Med Surge medication room was inspected. The door to the room was found to be chocked open by a garbage can and unable to close under the power of the self-closer.

Based on observation, the facility failed to assure hazardous rooms had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 18.3.2.1 and 18.3.2.1.3.

Findings include:

1. During an observation on 04/05/2023 at 6:53 a.m., room 212 was inspected. The room was observed being used as a storage area, and it is over 50 square feet. There was no self-closing device on the corridor door as required for storage rooms.

Based on observation, the facility failed to ensure accessibility to a manual fire alarm box in accordance with NFPA 101, 2012 Edition, Section 9.6.2.7

Findings include:

1. During an observation on 04/05/2023 at 7:18 a.m., the fire alarm pull station located in the hospital main entrance was observed, it was blocked from easy access by a wheelchair being stored in front of it.

Based on observation the facility failed to ensure sprinkler piping shall be substantially supported from a builidng structure in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 9.2.1.3.1.

Findings Include:

1. During an observation on 04/05/2023 at 6:26 a.m., the third level was inspected. Several sprinkler pipes greater than ten feet in length were observed. The pipes were swaying and were not supported.

Based on observation and record review, the facility failed to:

a) make records available for all inspections, tests, and maintenance of the facilities wet and dry sprinkler system per NFPA 25-2011, Section 4.3.1.;
b) maintain the weekly and monthly gauge readings on all of the sprinkler risers per NFPA 25-2011, Sections 5.2.4.1 and 5.2.4.2;
c) maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1.; and
d) ensure sprinkler pipes were free of external loads in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2


Findings include:

1. During a review of the facility inspection records on 04/04/23, it was noted that the facility lacked documentation of the five- year inspection reports for the facilities wet and dry sprinkler systems.

2. Review of facility documentation for the dry and wet sprinkler systems on 04/05/2023 reflected that facility did not have written documentation showing the weekly and monthly pressure gauges for the wet and dry sprinkler system had been recorded.

3. During an observation on 04/05/2023 at 7:02 a.m., the cafeteria was inspected. The pop machine in the room was observed to be stored within 18 inches of the sprinkler head above it.

4. During an observation on 04/05/2023 at 8:08 a.m., the server room was inspected. Several blue lines were observed, resting upon the sprinkler pipe within the room.

Based on observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1.

Findings include:

1. During an observation on 04/05/2023 at 6:11 a.m., the elevator control room was inspected. The portable extinguisher in the room was found to have various items stored in front of it.

Based on observation, the facility failed to maintain corridor doors to ensure a means suitable for keeping the doors closed in accordance with NFPA 101, 2012 Edition, Section 18.3.6.3.5.

Findings include:

1. During an observation on 04/05/2023 at 6:42 a.m., the corridor door to patient room 202 was exercised. The door would not close and positively latch.

Based on observation and interview, the facility failed to utilize portable space heaters in a health care occupancy in accordance with NFPA 101, 2012 Edition, Section 18.7.8.

Findings include:

1. During an observation on 04/05/2023 at 6:47 a.m., the room 2018 was inspected. A portable space heater was observed plugged into the wall. The room is located in a patient care area, and portable space heaters are not permitted.

2. During an observation on 04/05/2023 at 7:09 a.m., the gift shop was inspected. A portable space heater was observed plugged into a white extension cord that was plugged into a surge protector, which was plugged into the wall.

3. During an observation on 04/05/2023 at 7:11 a.m., room 1011 was inspected. A portable space heater was observed plugged into the wall.

4. During an observation on 04/05/2023 at 7:13 a.m., the business office was inspected. A total of nine space heaters were observed, plugged into the outlets throughout the room.

During an interview on 04/05/2023 at 7:10 a.m., staff member A stated the facility did not have documentation showing the space heaters being used in the facility did not exceed 212 degrees Fahrenheit.


Actual Code: NFPA 101, 2012 Edition, Section 18.7.8: Portable space heating devices are prohibited in health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212 degrees Fahrenheit. If a facility is utilizing space heaters, the facility must maintain documentation/policies consistent with the Life Safety Code.

Based on observations, the facility failed to maintain areas with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d).

Findings include:

1. During an observation on 04/05/23 at 7:31 a.m., the HIM office area was inspected. An electrical panel was observed with a large wooden desk being stored in front of it.

2. During an observation on 04/05/23 at 7:41 a.m., the Emergency Department was inspected. An electrical panel was observed with a black chair being stored in front of it.

3. During an observation on 04/05/23 at 7:42 a.m., the Emergency Department entrance was inspected. An electrical panel was observed with a large, black animal crate being stored in front of it.

Based on observation, the facility failed to maintain the electrical system in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-12(B).

Findings include:

1. During an observation on 04/05/2023 at 6:12 a.m., the elevator control room was inspected. There was an electrical outlet missing its protective cover plate observed on the wall within the room.

Based on record review, the facility failed to ensure an annual diesel fuel supply quality test was conducted at least annually per NFPA 110, Section 8.3.8.

Findings include:

1. Review of the emergency generator inspection records on 04/05/2023, revealed there was no documentation of an annual diesel fuel supply quality test conducted within the last year. The last diesel fuel quality test was performed on 01/29/2022.

Based on observation, the facility failed to:

a) ensure that power strips were used per NFPA 99-2012, Health Care Facilities Code, Section 10.2.4.; and
b) ensure extension cords were not used in the facility per NFPA 99-2012, Health Care Facilities Code, Section 10.2.4.

Findings include:

1. During an observation on 04/05/2023 at 6:44 a.m., the Quality Program Manager Compliance Specialist office was inspected. There was an unsecured surge protector observed, dangling from the wall behind the desk.

2. During an observation on 04/05/2023 at 7:10 a.m., the gift shop office was inspected. There was a white extension cord observed, plugged into a surge protector and a space heater.

Based on observation, the facility failed to ensure non-medical appliances that have hot surfaces shall not be permitted within oxygen-delivery equipment or within the site of intentional expulsion per NFPA 99 Section 11.5.1.1.4.

Findings include:

1. During an observation on 04/05/2023 at 7:33 a.m., room 1612 was inspected. A scentsy candle wax warmer was observed, plugged into the wall and hot to the touch. The warmer was placed on a table directly next to a portable oxygen tank and directly below a wall oxygen supply.