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Based on observation, the facility failed to maintain the means of egress of all obstructions or impediments to full instant use in the case of fire or other emergency per the requirements of:

2012 NFPA 101, 19.2.1, 7.1.10.1, 7.2.1.5.1, and 7.2.1.5.3

This deficiency affects two egress doors.

Findings include:

During a tour of the facility, the surveyor observed in the Gateway Hall Unit:

1. A hasp with a combination padlock was installed on the outside of the Patient Activities Office corridor door

2. A rope was tied around the exterior door handles of the South End's double exit doors, not allowing egress from the building

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain an egress door's releasing mechanism per the requirements of:

2012 NFPA 101, 19.2.2.2.1, and 7.2.1.5.10.1

This deficiency affects one corridor door.

Findings include:

During a tour of the facility, the surveyor observed the Electrical/Mechanical Room's (on the Back Administration Hall) corridor door's releasing mechanism (door handle) was 50" above the finished floor.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the stairway exit enclosure per the requirements of:

2012 NFPA 101, 19.2.2.3, and 7.2.2.5.3.1

This deficiency affects 1 of 4 stairwells.

Findings include:

During a tour of the facility, the surveyor observed the following items being stored at the exit door in the North End stairwell of the Basement/Dietary Hall:

1. One moving platform hand truck/push cart dolly (2' x 5')

2. Two mop buckets with two wringing devices

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and review of documentation, the facility failed to maintain the kitchen hood per the requirements of:

2012 NFPA 101, 19.3.2.5.1, and 9.2.3
2011 NFPA 96, 7.2.3.3, 10.2.6.(4), and 12.1.2.3.1
2009 NFPA 17A, 7.2.2 (7), 7.2.6, 7.3.3.

This deficiency affects the kitchen.

Findings include:

During a tour of the facility, the surveyor observed the following at the kitchen hood:

1. There was a 1 1/2 inch gap between the grease filters on the right side, not making all exhaust air pass through the grease filters

2. One of two blow-off caps was not covering the extinguishing nozzle.

3. The facility failed to provide documentation of a 6 month inspection to the kitchen hood's automatic fire-extinguishing system within the past 6 months. The facility failed to provide documentation of the last inspection.

4. The facility failed to provide an approved method to ensure that appliances that are protected under the kitchen hood are returneded back under the protection (extinguishing nozzle) after they have been moved to be repaired or cleaned under.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the smoke detectors per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, Table 14.3.1(9)(h), and 14.4.5.3.2

This deficiency affects the entire facility

Findings include:

During a tour of the facility, the surveyor observed the following:

1. The facility failed to provide documentation of conducting a semi-annual visual inspection on the smoke detectors within the past 12 months. The facility failed to provide documentation of the last visual inspection on the smoke detectors.

2. The facility failed to provide a smoke detector sensitivity test report completed within the past two years. The facility failed to provide documentation of the last sensitivity test to the smoke detectors, throughout the facility.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to provide information on the automatic sprinkler anti-freeze systems per the requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.1.1(1)
2010 NFPA 13, 7.6.1.4, 7.6.1.5, and TIA 10-2

This deficiency affects the ED ambulance entrance and the Basement Boiler Area.

Findings include:

During a tour of the facility, the facility failed to provide the following:

1. The facility failed to have a placard mounted on the wet system riser feeding the remote antifreeze systems:

This placard shall indicate the number and location of all remote antifreeze systems supplied by that riser.

2. The facility failed to have a placard mounted on the main valves of the antifreeze systems. This placard shall indicate the following:

a. The manufacture type and brand of the antifreeze solution

b. The concentration by volume of anti-freeze used

c. The volume of anti-freeze used in the system

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and review of documentation, the facility failed to maintain the automatic sprinkler system per requirements of:

2012 NFPA 101, 19.3.5.1, 9.7.5, and 9.7.8
2011 NFPA 25, 5.1.1.2, Table 5.1.1.2, 5.3.1.1.1.3, 5.2.4.1, 13.6.2.1, and 5.3.4

This deficiency affects entire facility

Findings include:

During a tour of the facility, the facility failed to provide the following documentation:

1. The 2000 fast-response sprinkler heads that were found in the Basement Boiler Area had been replaced or a representative sample tested within 20 years of installation.

2. The monthly inspections on the wet sprinkler riser gauges.

3. The quarterly automatic sprinkler inspection reports for the last three quarters. The latest quarterly inspection report the facility could provide was dated 07/06/2022.

4. The annual backflow preventer test. The only documentation the facility could provide was dated 2018.

5. The annual, indicating the existing antifreeze solution had been drained and the new premixed antifreeze solution had been put into the systems.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain corridor doors per the requirements of:

2012 NFPA 101, 19.3.6.3.2 (2), and 19.3.6.3.10

This deficiency affects 3 corridor doors.

Findings include:

During a tour of the facility, the surveyor observed the following corridor door deficiencies:

1. The facility failed to provide a smoke resistive corridor door for the Nutrition Room on the Golden Years Hall. The door had the following unsealed holes that penetrated the door:

a. 1/2" below the door handle

b. 1/4" below the door handle

2. The following corridor doors on the Administration Front Hall were impeded from closing:

a. The Intake corridor door was being held open by a wooden wedge

b. The Rehab corridor door was being held open by a 10 lb. dumbbell

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to conduct fire drills per the requirements of:

2012 NFPA 101, 19.7.1.6, 4.7.2, 4.7.4, and 4.7.6

This deficiency affects all fire drills.

Findings include:

During a tour of the facility, the facility failed to provide documentation to confirm fire drills were conducted as per the following code requirements:

1. Drills shall be conducted quarterly on each shift

2. Ensure participation of all persons subject to drills (e.g., sign-in sheets)

3. Drills are held at expected and unexpected times and under varying conditions

4. A written record of each drill shall be completed and maintained in an approved manner

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the fire doors per the requirements of:

2012 NFPA 101, 19.7.6, 4.6.12, and 8.3.3.1
2010 NFPA 80, 5.2, and 5.2.3
S&C 17-38-LSC

This deficiency affects 2 of 2 fire doors.

Findings include:

During a tour of the facility, the facility failed to provide documentation of its annual fire door inspection and testing for the past 12 months for the following doors:

1. The 1.5 hour rated roll-up door between the Kitchen and the corridor

2. The 3 hour rated double, cross-corridor doors on the Administration/Med-Surg Front Hall near the stairwell

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the piped medical gas per the requirements of:

2012 NFPA 99, 5.1.14.2.1, 5.1.14.2.2, and 5.1.15

This deficiency affects the complete piped medical gas system.

During a tour of the facility, the facility failed to provide documentation of the annual inspection for the piped medical gas system for the past 12 months. The last documentation was on 03/2022.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the testing of the emergency generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3, 6.5.4.2, and 6.4.4.2
2010 NFPA 110, 8.3.7.1, 1.3, 8.4.2, 8.4.2.3, 8.3.8, 8.4.1, and 8.4.9

This deficiency affects 1 of 1 generator.

Findings include:

During a tour of the facility, the facility failed to provide documentation for the following:

1. Performing monthly conductance testing on the facility's emergency generator maintenance-free batteries for the past 12 months.

2. Testing the diesel generator:

i. Once monthly for a minimum of 30 minutes under one of the following conditions:

a. Operating temperature conditions at not less than 30% of the nameplate kW rating

b. Loading that maintains the minimum exhaust gas temperature

OR

ii. Provide an annual 1.5-hour supplemental load test at not less than 50% of the EPS nameplate kW rating for 30 continuous minutes and at not less 75% of the EPS nameplate KW rating for one continuous hour for a total test duration of not less than 1.5 continuous hours

3. A fuel quality test performed within the past 12 months using tests approved by ASTM standards

4. Exercising under load at least monthly, if the facility choses option (2) (ii) above

5. Having a Level 1 EPSS four hour load test conducted within the past 36 months

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the oxygen cylinders per the requirements of:

2012 NFPA 99, 11.6.2.3 (11), 11.3.2.3 and 11.6.5.4

This deficiency affects 19 of 19, 24 cu. ft. oxygen cylinders.

Findings include:

During a tour of the facility, the surveyor observed the following:

1. One 24 cu. ft. oxygen cylinder on the floor in the Maintenance Office:
a. Unsecured
b. Within 1" of combustibles

2. Eighteen, 24 cu. ft. oxygen cylinders secured within a wooden rack located in the outside Emergency Department Gas Storage area (up against the building) (within 1" of combustibles)


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3. Failed to protect both outside oxygen cylinder storage areas, against continuous exposure to direct rays of the sun where extreme temperatures prevail.

A member of the maintenance staff was present when this deficiency was identified.