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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 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 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, 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 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 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 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 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 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, 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 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, 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 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 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 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