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Based on observation and interview, the facility failed to maintain egress doors with only one releasing operation in accordance with NFPA 101, 2012 Edition, Section 7.2.1.5.10.2. and failed to to maintain egress doors in accordance with NFPA 101, 2012 Edition, Sections 7.2.1.5.1 and 7.2.1.5.3.

Findings include:

1. During an observation on 8/14/19 at 12:41 p.m., the seventh-floor sleep rooms were inspected. The doors were fitted with deadbolt locks, separate from the latchset, and required more than one single action to operate the doors.

2. During an observation on 8/14/19 at 12:42 p.m., the seventh-floor sleep room bathrooms were inspected. The doors were fitted with deadbolt locks, separate from the latchset, and required more than one single action to operate the doors.

3. During an observation on 8/14/19 at 1:31 p.m., the southwest exit door out of ortho-neuro on the fourth floor was found to be mag-locked with no delayed egress or access-controlled egress available to get out of the door.

Based on observation, the facility failed to keep egress doors arranged to be opened readily from the egress side whenever the building is occupied, in accordance with NFPA 101, 2012 Edition, Sections 7.2.1.5.3, 7.2.1.5.5.1, and 19.2.2.2.4.

Findings include:

1. During an observation on 8/13/19 at 9:26 a.m., the main entrance door of the walk-in clinic was inspected. The door, if not equipped with special locking arragements, needs to have signage stating, "This door to remain unlocked when the building is occupied," in letters not less than 1 inch high on a contrasting background.

2. During an observation on 8/13/19 at 9:28 a.m., the northeast door out of occupational health was found to be locked with an electronic magnet, there was a "Push to Exit" button on the wall, there was no delayed egress or a motion detector which would sense an approaching occupant and release the magnet upon egress.

3. During an observation on 8/13/19 at 9:37 a.m., the south ortho/receiving was found to be locked with an electronic magnet, there was a "Push to Exit" button on the wall, there was no delayed egress or a motion detector which would sense an approaching occupant and release the magnet upon egress.

Based on observation, the facility failed to maintain egress doors in accordance with NFPA 101, 2012 Edition, Section 7.2.1.6.1.1 and 19.2.2.2.4.

Findings include:

1. During an observation on 8/14/19 at 10:25 a.m., the employee wellness center was inspected. The marked exit door by the restrooms was found to be locked via a magnetic lock with a "push to exit" button to get out.

Based on observation, the facility failed to maintain egress doors in accordance with NFPA 101, 2012 Edition, Section 7.2.1.6.1.1, 19.2.2.2.4, and 7.2.1.4.5.1.

Findings include:

1. During an observation on 8/13/19 at 12:41 p.m., the marked exterior exit door out of the morgue was inspected. The door required more than 30 pounds of force to set the door in motion upon egress. The door was sticking on the bottom of the frame.

2. During an observation on 8/13/19 at 1:25 p.m., the employee fitness gym was inspected. The door was found to be locked via a magnetic lock with a "push to exit" button to get out.

3. During an observation on 8/13/19 at 1:42 p.m., the north center stairwell egress door was inspected. It was found to be locked by an electromagnetic lock. The only way to get out of the door was to have a badge to unlock the magetic lock.

Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7.

Findings include:

1. During an observation on 8/13/19 at 12:20 p.m., the kitchen door leading to the corridor was inspected. The door was fitted with a self-closure and failed to close and positively latch when exercised.

Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7.

Findings include:

1. During an observation on 8/13/19 at 7:59 a.m., the exit corridor door to the medical oncology office was propped open with a wooden wedge. The door was fitted with a self-closure.

2. During an observation on 8/13/19 at 8:10 a.m., the exit corridor door leading from the boardroom to the Administration area was inspected. The door was propped open with a rubber wedge. The door was fitted with a self-closure.

Based on observation, the facility failed to prevent the use of enclosed exit stairway for storage purposes per NFPA 101-2012, Sections 7.1.3.2.3 and 7.2.2.5.3.

Findings include:

1. During an observation on 8/13/19 at 10:26 a.m., the back stairwell enclosure by the big breakroom was inspected. The stairwell enclosure contained a stored massage table and another long item. Enclosures shall not be used as storage areas.

Based on observation, the facility failed to ensure exit signs are illuminated either internally or externally in accordance with NFPA 101, 2012 Edition, Section 7.10.5.1.

Findings include:

1. During an observation on 8/13/19 at 12:23 p.m., the center corridor of the finance suite was inspected for egress. There was no visible exit sign in the center corridor.

2. During an observation on 8/13/19 at 12:27 p.m., the east end of the finance suite was inspected for egress. There was no visible exit sign in the area.

3. During an observation on 8/13/19 at 12:46 p.m., the egress door G058 of the finance suite was inspected for egress. There was no visible exit sign over the door.

Based on observation, the facility failed to ensure exit signs are illuminated either internally or externally in accordance with NFPA 101, 2012 Edition, Section 7.10.5.1.

Findings include:

1. During an observation on 8/14/19 at 8:29 a.m., the remodel space on the fourth floor was inspected for egress. There was no visible exit sign within the entire space.

Based on observation, the facility failed to ensure illuminated exit signs were clearly visible in accordance with NFPA 101, 2012 Edition, Section 7.10.1.5.2.

Findings include:

1. During an observation on 8/14/19 at 3:01 p.m., the CDV pod in the emergency department was found to have an exit sign obstructed by a building header. It was not visible from the other end of the corridor.

Based on observations, where the path of egress was not obvious, the facility failed to mark the path of egress by approved exit or directional exit signs in accordance with NFPA 101, 2012 Edition, Section 7.10.1.2.2, and 7.10.1.5.2.

Findings include:

1. During an observation on 8/13/19 at 9:44 a.m., the orthopedic office area was inspected. The area lacked an illuminated exit sign where the path of egress was not obvious.

2. During an observation on 8/13/19 at at 10:02 a.m., the outpatient surgery center was inspected for egress. The west exit cheveron pointed to a mag locked door as well as an exterior exit through a storage corridor.

3. During an observation on 8/13/19 at 10:10 a.m., the outpatient surgery recovery area was inspected. The souith end of the area lacked an illuminated exit sign where the path of egress was not obvious.

4. During an observation on 8/13/19 at 10:49 a.m., the rheumatology hall was inspected. The area lacked an illuminated exit sign where the path of egress was not obvious.

5. During an observation on 8/13/19 at 10:53 a.m., the infusion waiting room was inspected. The area lacked an illuminated exit sign where the path of egress was not obvious, as well as out in the hall through the egress doors, guiding occupants to the next illuminated sign.

Based on observation, the facility failed to maintain continuous illumination for all exit signs in accordance with NFPA 101, 2012 Edition, Section 7.10.5.1 and 7.10.5.1. and failed to ensure illuminated exit signs were clearly visible in accordance with NFPA 101, 2012 Edition, Section 7.10.1.5.2.

Findings include:

1. During an observation on 8/13/19 at 7:52 a.m., the exit sign in the infusion suite was inspected. The exit sign was not illuminated and had both bulbs burned out.

2. During an observation on 8/13/19 at 7:56 a.m., the exit sign leading to the elevator corridor was blocked from view by a "restroom/dressing room" sign hanging from the ceiling.

Based on observation, a vertical opening between floors was not protected per NFPA 101, 2012 Edition, Section 19.5.4.1,

Findings include:

1. During observation on 8/14/19 at 1:00 p.m., the linen chute door on the 6th floor by the NICU, was exercised. The door would not close and latch under the power of the self-closer.

Based on observation, a vertical opening between floors was not protected per NFPA 101, 2012 Edition, Section 19.5.4.1, This deficiency affects all smoke compartments in the tower the chute serves.

Findings include:

1. During observation on 8/14/19 at 9:10 a.m., the rubbish chute door in room 333, soiled utility, was exercised. The door would not close and latch under the power of the closers.

Based on observations, the facility failed to ensure hazadous 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 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 8/13/19 at 12:57 p.m., the clean side and soiled side of the laundry was inspected. Both of the corridor doors out of each side of the laundry were exercised. Both doors failed to close and latch under the power of the self-closer.

Based on observations, the facility failed to ensure rooms being used as storage 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 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 8/14/19 at 9:03 a.m., rooms 304 and 306 were being used as storage rooms. Both rooms were greater than 50 square feet and were not fitted with the necessary self-closing device.

Based on observations, the facility failed to ensure rooms being used as storage of large quanities of soiled linen 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 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 8/13/19 at 7:35 a.m., the garage in the basement was inspected. The room is considered a hazardous area due to large soiled linen bins being kept in the room, the room was not fitted with the necessary self-closing device.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8).


Findings include:

1. During an observation on 8/14/19 at 12:43 p.m., room 7159 was inspected. The room contained an ABHR dispenser which was installed over an electrical outlet.

2. During an observation on 8/14/19 at 12:44 p.m., room 7127 was inspected. The room contained an ABHR dispenser which was installed over an electrical outlet.

3. During an observation on 8/14/19 at 12:45 p.m., room 7128 was inspected. The room contained an ABHR dispenser which was installed over an electrical outlet.

4. During an observation on 8/14/19 at 12:48 p.m., room 7125 was inspected. The room contained an ABHR dispenser which was installed over a light switch.

5. During an observation on 8/14/19 at 12:55 p.m., the clean utility room on the sixth floor was inspected. The room contained an ABHR dispenser which was installed over a light switch.

6. During an observation on 8/14/19 at 2:02 p.m., room 2425 was inspected. The room contained an ABHR dispenser which was installed over an electrical outlet.

7. During an observation on 8/14/19 at 2:02 p.m., the emergency room entrance area was inspected. The room contained two ABHR dispensers which were installed over electrical outlets.

8. During an observation on 8/14/19 at 2:58 p.m., the sexual assault exam room was inspected. The room contained an ABHR dispenser which was installed over an electrical outlet.

9. During an observation on 8/14/19 at 1:17 p.m., rooms 5105, 5121, and 5113 on the fifth floor were inspected. The rooms contained ABHR dispensers which were installed over a light switch.

10. During an observation on 8/14/19 at 2:10 p.m., interventional room 14019 was inspected. The room contained an ABHR dispenser which was installed over a light switch.

11. During an observation on 8/14/19 at 2:15 p.m., the MRI control room contained an ABHR dispenser mounted over a light switch.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8).

Findings include:

1. During an observation on 8/14/19 at 7:44 a.m., room 827 was inspected. The room contained an ABHR dispenser which was installed over a light switch.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8).

Findings include:

1. During an observation on 8/13/19 at 1:16 p.m., the second floor therapy gym was inspected. There was an ABHR dispenser mounted over an outlet in the room.

2. During an observation on 8/13/19 at 1:35 p.m., exam room 9 of wound care was inspected. The room contained an ABHR dispenser which was installed over a light switch.

3. During an observation on 8/13/19 at 1:52 p.m., room 205 was inspected. The room contained an ABHR dispenser which was installed over a light switch.

4. During an observation on 8/13/19 at 2:03 p.m., dining room prep room 279 was inspected. The room contained an ABHR dispenser which was installed over a light switch.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8).

Findings include:

1. During an observation on 8/13/19 at 8:47 a.m., nephrology exam rooms 1-4 were inspected. Each exam room contained an ABHR dispenser which was installed over light switches within each room.

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

Findings include:

1. During an observation on 8/13/19 at 2:07 p.m., the fire alarm pull station near the pain clinic reception exit was found to be blocked from instant access by a large plant being stored in front of it.

2. During an observation on 8/13/19 at 2:30 p.m., the basement exit by the clark room was inspected. The fire alarm pull station by the exit door was observed to be blocked from instant access due to items being stored in front of it.

Based on observation the facility failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

Findings include:

1. During an observation on 8/14/19 at 8:33 a.m., the room 406, outside the vascular access bathroom, was inspected. A sprinkler head was observed, obstructed by a light fixture on the ceiling.

2. During an observation on 8/14/19 at 9:03 a.m., room 340 was inspected. A sprinkler head was observed, obstructed by a light fixture on the ceiling.

3. During an observation on 8/14/19 at 9:06 a.m., room 328 was inspected. A sprinkler head was observed, obstructed by a light fixture on the ceiling.

4. During an observation on 8/14/19 at 9:58 a.m., the first floor housekeeping closet was inspected. A sprinkler head was observed, obstructed by a light fixture on the ceiling.

Based on observation the facility failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

Findings include:

1. During an observation on 8/13/19 at 10:29 a.m., the obstetrics checkout area was inspected. A sprinkler head was observed, obstructed by a light fixture on the ceiling.

2. During an observation on 8/13/19 at 10:04 a.m., the janitor's closet in the outpatient surgery center was found to have a sprinkler head blocked by a ceiling mounted light fixture.

Based on observation the facility failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

Findings include:

1. During an observation on 8/13/19 at 12:24 p.m., the kitchen cooler was inspected. A sprinkler head was observed, obstructed by a light fixture on the ceiling.

2. During an observation on 8/13/19 at 1:39 p.m., the housekeeping closet across from exam room 4 in the wound clinic was inspected. A sprinkler head was observed, obstructed by a light fixture mounted on the ceiling.

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

a) 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.
b) failed to ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1(3)
c) maintain spare sprinklers in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.5
d) failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.
e) maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1.

Findings include:

1. During an observation on 8/13/19 at 12:31 p.m., the chiller room of air handler 10 was inspected. There was a ground wire fixed to the sprinkler pipe in the room.

2. During an observation on 8/13/19 at 12:57 p.m., the clean side of the laundry was inspected. There were several ceiling tiles out of place or missing in the room.

3. During an observation on 8/13/19 at 12:57 p.m., the soiled side of the laundry was inspected. There were several ceiling tiles out of place or missing in the room.

4. During an observation on 8/13/19 at 1:05 p.m, room G119, storage/mechanical room was inspected. There were several yellow brackets fixing copper pipes to the sprinkler pipes in the room.

5. During an observation on 8/13/19 at 1:15 p.m., the spare sprinkler box at the standpipe was inspected. It lacked any of the white quick-response heads which were prevalent throughout the building served by the standpipe.

6. During an observation on 8/13/19 at 1:32 p.m., the housekeeping room number 234 was inspected. There was a sprinkler head found to be obstructed by a ceiling mounted light fixture.

7. During an observation on 8/13/19 at 12:23 p.m., the kitchen cooler was inspected. A box containing food was observed being stored within six inches of the sprinkler head.

Based on observation, the facility failed to

a) maintain proper distances of storage from sprinkler heads in accordance with NFPA 13-2010 Standard for the Installation of Sprinkler Systems, Section 8.5.6.1. This deficiency affects 3 of 3 smoke compartments.
b) maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1.
c) failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.
d) failed to ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1(3).

These deficiencies affect 5 smoke compartments on three floors.

Findings include:

1. During an observation on 8/14/19 at 1:44 p.m., the sprinkler head was blocked by several containers of vegetable broth in the walk-in cooler in the kitchen. At least an 18 inch distance must be maintained under the sprinkler.

2. During an observation on 8/14/19 at 10:08 a.m., room 1014 was inspected. Cords were observed resting on the sprinkler pipe within the room.

3. During an observation on 8/14/19 at 10:10 a.m., the exit sign on the first floor by the information desk was found to be blocking a sprinkler head.

4. During an observation on 8/14/19 at 10:19 a.m., the IT room number 1075B was inspected. There were ceiling tiles left out of the ceiling in the room.

5. During an observation on 8/14/19 at 10:24 a.m., the care coordination office storage room was inspected. A ceiling tile was observed, removed from the ceiling fixture within the room.

6. During an observation on 8/14/19 at 10:50 a.m., the conference room storage human resources room was inspected. A ceiling tile was observed, removed from the ceiling fixture within the room

Based on observation, the facility failed to inspect and maintain the sprinkler system in accordance with NFPA 13, 2010 Edition, Section 6.2.7.2.

Findings include:

1. During an observation on 8/13/19 at 3:43 p.m., supply room 3 was inspected. The sprinkler head in the room was observed missing its escutcheon ring.

2. During an observation on 8/13/19 at 3:44 p.m., the area outside operating room 4 was inspected. The sprinkler head in the room was observed missing its escutcheon ring.

Based on observation, the facility failed to maintain spare sprinklers in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.5

Findings include:

1. During an observation 8/13/19 at 9:00 a.m., the spare sprinkler head box was found to be missing quick response sprinkler heads. The facility had many quick response heads throughout the facility.

Based on observation, the facility failed to maintain spare sprinklers in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.5 and failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

Findings include:

1. During an observation 8/13/19 at 7:29 a.m., the spare sprinkler head box was found to be missing quick response sprinkler heads. The facility had many quick response heads throughout the facility.

2. During an observation on 8/13/19 at 7:28 a.m., room 009 in the basement was inspected. There was a sprinkler head blocked by a large electrical conduit.

3. During an observation on 8/13/19 at 7:28 a.m., the elevator mechanical room was inspected. There was a sprinkler head blocked by a light in the room.

Based on observation and interview, the facility failed to inspect portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 7.2.1.2.

Findings include:

1. During an observation on 8/13/19 at 3:40 p.m., operating room 3 was inspected. The fire extinguisher in the room lacked a monthly maintenance check for the month of February of 2019

Based on observation and interview, the facility failed to:

a) inspect portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 7.2.1.2
b) 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 8/13/19 at 12:29 p.m., the dining area was inspected. The fire extinguisher in the room lacked a monthly maintenance check for the month of June of 2019.

During an interview on 8/13/19 at 12:30 p.m., staff member A stated the facility maintenance staff performs monthly checks on all extinguishers throughout the facility. He stated the fire extinguisher missed its monthly inspection in June of 2019.

2. During an observation on 8/13/19 at 1:51 p.m., the pharmacy was inspected. The fire extinguisher in the room lacked a monthly maintenance check for the month of March of 2019.

3. During an observation on 8/13/19 at 1:51 p.m., the pharmacy was inspected. The portable fire extinguisher located by the door leading to the corridor was observed to be blocked from easy access by multiple items being stored in front of it.

4. During an observation on 8/13/19 at 2:08 p.m., the pain clinic was inspected. The fire extinguisher in the room was observed, blocked from easy access due to a large chair being stored in front of it.

5. During an observation on 8/13/19 at 2:35 p.m., the plastic surgery nursing station was inspected. The fire extinguisher in the room was observed, blocked from easy access due to a variety of items being stored in front of it.

6. During observations on 8/13/19 at 12:16 p.m, it was determined that all the portable extinguishers in the finance area had not been checked for the month of July 2019.

Based on observation, interview and record review, 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 8/14/19 at 2:29 p.m., the soiled laundry room was inspected. The portable fire extinguisher in the room was found to be blocked from instant access by several items being placed in front of it.

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, and failed to ensure a placard was appropriately placed with the K extinguisher in the kitchen, directing staff to its proper use per NFPA 10-2010, Section 5.5.5.3.

Findings include:

1. During an observation on 8/14/19 at 7:46 a.m., the eighth-floor kitchen area was inspected. The portable fire extinguisher in the room was found to be blocked from instant access by several items being placed in front of it.

2. During an observation on 8/14/19 at 8:02 a.m., the sixth-floor kitchen area was inspected. The portable fire extinguisher in the room was found to be blocked from instant access by several items being placed in front of it.

3. During an observation on 8/14/19 at 10:12a.m., elevator equipment room 1001A area was inspected. The portable fire extinguisher in the room was found to be blocked from instant access by several items being placed in front of it.

4. During an observation 8/14/19 at 10:59 a.m., the instructional placard for the K extinguisher was not observed hanging above or near the K extinguisher in the kitchen.

5. During an observation on 8/14/19 at 2:29 p.m., the soiled laundry room was inspected. The portable fire extinguisher in the room was found to be blocked from instant access by several items being placed in front of it.

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, Sections 6.1.3.3.1 and 7.2.1.2.

Findings include:

1. During an observation on 8/13/19 at 9:22 a.m., the waiting room of the walk-in clinic was inspected. The portable fire extinguisher in the room was observed, blocked from easy access by items being stored directly in front of it.

2. During an observation on 8/13/19 at 9:25 a.m., the laboratory was inspected. There was a portable extinguisher blocked from instant access by some waiting chairs.

3. During an observation on 8/13/19 at 10:21 a.m., the women's health suite was inspected. The portable fire extinguisher in the room was observed, blocked from easy access by items being stored directly in front of it.

4. During an observation on 8/13/19 at 10:40 a.m, the portable extinguisher at the roof access of MOB 4 was found to have not been marked as inspected for the month of July 2019.

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 8/13/19 at 7:31 a.m., the elevator room was inspected. The portable fire extinguisher in the room was observed, blocked from easy access by items being stored directly in front of it.

Based on observation, the facility failed to maintain corridor doors and to ensure a means suitable for keeping the doors closed in accordance with NFPA 101, 2012 Edition, Section 19.3.6.3.1 and 19.3.6.3.5.

Findings include:

1. During an observation on 8/14/19 at 1:51 p.m., the corridor door to room 2175 in the ambulatory care unit was exercised. The door would not close and positively latch with a nominal amount of force placed on it.

2. During an observation on 8/14/19 at 1:53 p.m., the corridor door to room 2168 in the ambulatory care unit was exercised. The door would not close and positively latch with a nominal amount of force placed on it.

Based on observation, the facility failed to maintain corridor doors in accordance with NFPA 101-2012, Section 19.3.6.3.4.

Findings include:

1. During an observation on 8/14/19 at 8:37 a.m., the door to the 4th floor reconstruction room was found to have a gap at the bottom of the door exceeding one inch.

2. During an observation on 8/14/19 at 8:12 a.m., resident room 566 was inspected. The door to would not close and positively latch when exercised.

Based on observation, the facility failed to ensure smoke barriers were maintained to prevent the potential for smoke to spread in accordance with NFPA 101-2012, Section 19.3.7.3.

Findings include:

1. During an observation on 8/14/19 at 2:37 p.m., the 90-minute rated fire barrier doors in the emergency room entrance were inspected. The doors failed to close and positively latch when exercised.

2. During an observation on 8/14/19 at 2:46 p.m., the RME 90-minute rated fire barrier doors in the emergency room were inspected. The doors failed to close and positively latch when exercised.

Based on observation, the facility failed to ensure fire/smoke barrier doors located in the fire/smoke partitions were maintained per NFPA 101-2012, Section 19.3.7.8.

Findings include:

1. During an observation on 8/14/19 at 8:40 a.m., the left leaf of the fire/smoke doors at the entrance to the pharmacy failed to latch when exercised. The doors were interfaced with the fire alarm control panel.

2. During an observation on 8/14/19 at 11:02 a.m., the double doors by the Rejuvenation Center failed to latch when exercised. The doors were interfaced with the fire alarm control panel

Based on observation, the facility failed to ensure the installation of a direct vent fireplace met all regulatory criteria in accordance with NFPA 101 2012 Edition, Section 19.5.2.3 and 9.8.

Findings include:

1. During an observation on 8/13/19 at 8:11 a.m., the main lobby area was inspected. There was a direct vent fireplace installed in the room. There was no electronically supervised carbon monoxide detector installed in the room with the fireplace.

Based on record review, the facility failed to ensure piped oxygen shutoff valves were properly labeled in accordance with NFPA 99 Healthcare Facilities Code 2012 Edition, Section 5.3.11.2.

Findings include:

1. During an observation on 8/14/19 at 2:48 p.m., the piped oxygen shutoff valves were found to be mislabled. The label on the valve, did not match the room it went to.

Based on observation, the facility failed to maintain electrical rooms 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 8/13/19 at 9:42 a.m., the storage hydraulic room in the family practice area was inspected. The electrical panel in the room was blocked from easy access by various items being placed in front of it.

Based on observation, the facility failed to maintain electrical rooms 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 8/14/19 at 8:15 a.m., the fifth-floor equipment depot room was inspected. The electrical panel in the room was blocked from easy access by various items being placed in front of it.

2. During an observation on 8/14/19 at 10:30 a.m., the infection prevention storage room was inspected. The electrical panel in the room was blocked from easy access by various items being placed in front of it.

3. During an observation on 8/14/19 at 10:44 a.m., the air handling room below the lab was inspected. The electrical panel in the room was blocked from easy access by various items being placed in front of it.

Based on observation, the facility failed to maintain electrical rooms 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 8/14/19 at 12:57 p.m., room 6175 was inspected. The electrical panel in the room was blocked from easy access by various items being placed in front of it.

2. During an observation on 8/14/19 at 12:59 p.m., room 6130 was inspected. The electrical panel in the room was blocked from easy access by various items being placed in front of it.

3. During an observation on 8/14/19 at 1:52 p.m., room 2132 was inspected. The electrical panel in the room was blocked from easy access by various items being placed 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 8/13/19 at 7:37 a.m., room 256 was inspected. The electrical panel in the room was observed to be blocked from easy access by a garbage can, a vacuum, and a cart being stored in front of it.

Based on observation, and interview, the facility failed to install a ground fault interrupter circuit for electrical sources to close to a water source as required in NFPA 70, 2011 Edition, Article 210.8(B)(5).

Findings include:

1. During an observation on 8/13/19 at 8:17 a.m., the med spa salon was inspected. There was a receptacle within four feet of the hair washing basin, it was not equipped with a ground fault circuit interrupter.

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 8/14/19 at 9:04 a.m., room 326 was inspected. There was a low voltage outlet missing a protective cover plate observed on the wall of the room.

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 8/13/19 at 12:31 p.m., the Joseph room was inspected. There was a low voltage outlet missing a protective cover plate observed on the wall of the room.

2. During an observation on 8/13/19 at 12:41 p.m., the projection room was inspected. There was a low voltage outlet missing a protective cover plate observed on the wall of the room.

Based on observation and interview, the facility failed to ensure a labeled remote manual stop station for the generator was installed in accordance with NFPA 110-2010, Section 5.6.5.6 and 5.6.5.6.1.

Findings include:

1. During an observation on 8/13/19 at 1:21 p.m., the generator was inspected. The generator lacked a labeled manual stop station at a remote location on the outside of the prime mover, of a type in order to prevent inadvertent or unintentional operation of the generator in an emergency.

Based on observation, the facility failed to ensure a labeled remote manual stop station for the generator was installed in accordance with NFPA 110-2010, Section 5.6.5.6 and 5.6.5.6.1.

Findings include:

1. During an observation on 8/13/19 at 7:36 a.m., the generator was inspected. The generator lacked a labeled manual stop station at a remote location outside of the room housing the prime mover, of a type in order to prevent inadvertent or unintentional operation of the generator in an emergency.

Based on observation, the facility failed to ensure extension cords were not used in the facility and that power strips were used per NFPA 99-2012, Health Care Facilities Code, Section 10.2.4.

Findings include:

1. During an observation on 8/14/19 at 1:51 p.m., room 2155 was inspected. An surge protector was observed in the room, unsecured and hanging from the wall.

Based on observation, the facility failed to 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 8/14/19 at 11:16 a.m., the project management office was inspected. An extension cord was observed, which was plugged into the outlet on the wall.

Based on observation, the facility failed to 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 8/13/19 at 10:30 a.m., the urology 2035 office was inspected. An extension cord was observed, which was plugged into the outlet on the wall.

Based on observation, the facility failed to 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 8/13/19 at 8:52 a.m., the medical director office was inspected. An extension cord was observed, which was plugged into the outlet on the wall.

Based on observation, the facility failed to 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 8/13/19 at 7:48 a.m., the infusion clinic reception area was inspected. A brown extension cord was observed, which was plugged into the outlet on the wall.

2. During an observation on 8/13/19 at 7:55 a.m., office room 522 was inspected. A white extension cord was observed, which was plugged into the outlet on the wall.

Based on observation, the facility failed to ensure that the oxygen storage locations were maintained in accordance with NFPA 99-2012 Edition, Sections 5.1.3.3.2 (10), 11.3.4.1 and 11.3.4.2.

Findings include:

1. During an observation on 8/14/19 at 9:06 a.m., the oxygen storage room on the third floor was inspected. The oxygen storage area was located indoors and lacked a cautionary oxygen sign. The sign must include the following wording as a minimum:
CAUTION:
OXIDIZING GAS(ES) STORED
NO SMOKING

Based on observation, the facility failed to maintain oxygen cylinders per NFPA 99-2012, Section 11.6.2.3.

Findings include:

1. During an observation on 8/14/19 at 1:29 p.m., an E size oxygen cylinder was free standing in the ICU southwest oxygen storage room.

2. During an observation on 8/14/19 at 2:51 p.m., the oxygen storage room near the door to the ambulance bay was inspected. The door to the room was not lockable, and the light switch in the room was mounted 48 inches from the floor, it shall be at 60 inches.

3. During an observation on 8/14/19 at 2:55 p.m., the oxygen storage room in the ambulance bay was inspected. The light switch in the room was mounted at 48 inches, it shall be at 60 inches.