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Based on record review, and interview the facility failed to develop, establish, and maintain a comprehensive emergency preparedness (EP) program that identifies all-hazards approach strategies for addressing the facility's vulnerability during emergency events. This affects all staff and residents of the facility. Findings include:

1. Review of the facility EP program on 1/6/2020, showed there was no documentation of a community-based risk assessment for The Ridge Physical Therapy or 19th Lab.

2. During an interview on 1/7/2020 at 2:00 p.m., staff member C stated a community risk assessment including hazard vulnerabilities had not been completed for The Ridge Physical Therapy or 19th Lab.

Based on observation, the facility failed to maintain the fire resistive properties of a two-hour barrier in accordance with NFPA 101-2012, Section 6.1.14.4.1.

Findings include:

1. During an observation on 01/07/2020 at 2:25 p.m., the two-hour doors between MOB 2 and MOB 5 were exercised. The doors would not close and latch under the power of the self-closers.

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.

Findings include:

1. During an observation on 01/07/2020 at 12:06 p.m., the corridor near the two-hour doors was inspected. There were several beds being stored in the corridor taking up over feet of the marked means of egress.

Based on observation, the facility failed to:

a) maintain egress doors with only one releasing operation in accordance with NFPA 101, 2012 Edition, Sections 7.2.1.5., 10.2.;
b) keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Section 7.1.10.1;
c) 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.

Findings include:

1. During an observation on 01/07/2020 at 9:51 a.m., the elevator mechanical room of MOB1 was inspected. The door leading to the corridor was fitted with a deadbolt lock. The interior side of the door leading to the egress did not have a means for unlocking the door if the deadbolt lock was engaged, causing a person to remain locked inside the room.

2. During an observation on 01/07/2020 at 9:53 a.m., room 1C of MOB1 was inspected. The door leading to the corridor was fitted with a lock which required more than one single action to operate the door.

3. During an observation on 01/08/2020 at 6:20 a.m., the EVS closet was inspected. The door would not open a full 90 degrees due to items being stored behind it.

4. During an observation on 01/08/2020 at 7:00 a.m., the financial counselor office was inspected. The door was fitted with a deadbolt lock, separate from the latch set, and required more than one single action to operate the door.

5. During an observation on 01/08/2020 at 7:07 a.m., the endoscopy dictation room was inspected. The door would not open a full 90 degrees due to items being stored behind it.

6. During an observation on 01/08/2020 at 7:09 a.m., the admit/discharge room for the emergency room was inspected. The door would not open a full 90 degrees due to items being stored behind it.

7. During an observation on 01/08/2020 at 7:12 a.m., the emergency room entrance area was inspected. There were illuminated exit signs guiding occupants through double doors into endoscopy to the left, and the ER to the right. Both sets of doors were found to be fitted with electronic magnetic locks. There was no delayed egress set up on the door or access-controlled egress on the doors.

During an an interview on 01/08/2020 at 7:15 a.m., staff member A stated the locks are engaged after hours to keep people from entering endoscopy and the ER without staff knowledge.

8. During an observation on 01/08/2020 at 9:23 a.m., the ICU back exit door was inspected. The door was fitted with a magnetic lock and a push to exit button. This does not satisfy the code regarding access-controlled egress functions.

9. During an observation on 01/08/2020 at 10:30 a.m., the materials management room was inspected. The rear exit door was found to be equipped with a magnetic lock and a "push to exit" button near the door. There was no motion sensor above the door to sense approaching occupants.

10. During an observation on 01/08/2020 at 10:55 a.m., The ED basement egress corridor was inspected. The corridor was found to have a large rack of old computer equipment and boxes of stored computer equipment. Egress corridors cannot have combustible storage in the egress path.

11. During an observation on 01/08/2020 at 11:20 a.m., the service hall for MOB 4, first floor, was found to have storage of combustible materials stored in the corridor.

Based on observation, the facility failed to:

a) maintain egress doors with only one releasing operation in accordance with NFPA 101, 2012 Edition, Sections 7.2.1.5., 10.2.;
b) 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 21.2.1.

Findings include:

1. During an observation on 01/06/2020 at 3:52 p.m., the coding office was inspected. The door leading to the corridor was fitted with a lock which required more than one single action to operate the door.

2. During an observation on 01/06/2010 at 3:54 p.m., the main entrance door of the same day surgery check-in area was inspected. The door, if equipped with special locking arrangements, 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.

Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 21.2.2.4.

Findings include:

1. During an observation on 01/06/2020 at 4:07 p.m., the exit corridor door to the dirty room in the operating room suite was propped open with a kickdown door stop. The door was fitted with a self-closure.

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 01/07/2020 at 10:01 a.m., the vein clinic area was inspected. The corridor door to the exam room was propped open with a rubber door wedge. The door was fitted with a self-closure.

2. During an observation on 01/07/2020 at 2:34 p.m., the level two supply room in the sleep center was inspected. The corridor door to the room was propped open with a door wedge. The door was fitted with a self-closure.

3. During an observation on 01/08/2020 at 6:49 a.m., the old cath lab office in MOB4 was inspected. The corridor door to the room was propped open with a door wedge. The door was fitted with a self-closure.

4. During an observation on 01/08/2020 at 6:53 a.m., the cath lab biohazard room was inspected. The corridor door to the room was propped open with a door wedge. The door was fitted with a self-closure.

5. During an observation on 01/08/2020 at 9:17 a.m., the clean utility room in the ICU was inspected. The door to the room was fitted with a self-closure and failed to close and positively latch when exercised.

6. During an observation on 01/08/2020 at 9:43 a.m., the nursery documentation room was inspected. The corridor door to the room was propped open with a door wedge. The door was fitted with a self-closure.

7. During an observation on 01/08/2020 at 11:02 a.m., the EVS laundry room was inspected. The corridor door to the room was propped open with a blue disposable glove. The door was fitted with a self-closure.

8. During an observation on 01/08/2020 at 11:04 a.m., the EVS soiled linen room was inspected. The door to the room was fitted with a self-closure and failed to close and positively latch when exercised.

9. During an observation on 01/08/2020 at 11:25 a.m., the cardboard compactor room was inspected. The door to the room was propped open with a door wedge. The door was fitted with a self-closure.

10. During an observation on 01/08/2020 at 11:26 a.m., the cardboard compactor room was inspected. The door to the room was fitted with a self-closure and failed to close and positively latch when exercised.

11. During an observation on 01/08/2020 at 11:27 a.m., the loading dock room was inspected. The door to the room was fitted with a self-closure and failed to close and positively latch when exercised.

Based on observation, the facility failed to maintain exit discharge to the public way with respect to keeping a level walking surface free of obstruction in accordance with NFPA 101, 2012 Edition, Section 7.1.6.2.

Findings include:

1. During an observation on 01/08/2020 at 10:05 a.m., the med-surg and post-partum exit discharges at the end of the corridors were inspected. The exits were found to be obstructed by construction and were lacking an all-weather hard surface egress path to the public way.

Without the available exit discharges leading to the construction area out of each corridor, the travel distances that must be covered to get to another building exit were 495 feet and 435 feet respectively. The cross-corridor doors on both the med-surg and postpartum floors did not come together and latch for both the 495 and 435 feet travel distances.

Based on observation, the facility failed to:

a) where the path of egress was not obvious, 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;
b) ensure proper marking of exit egress was maintained during extensive remodel in accordance with NFPA 101 2012 Edition, Section 43.1.2.1 and 43.6.2.2.

Findings include:

1. During an observation on 01/07/2020 at 10:04 a.m., the corridor outside the vein clinic was inspected. There was no visible exit sign outside the corridor door looking either way, when the smoke doors close upon activation of the fire alarm.

2. During an observation on 01/07/2020 at 1:42 p.m., the exit signage on the 2nd floor at the northwest end of the corridor of MOB 3 going toward the elevator was found to be blocked by hanging lights.

3. During an observation on 01/07/2020 at 2:24 p.m., the 3rd and 4th floor of MOB 4 were undergoing construction. There was no visible illuminated exit signage in the construction areas of the floors.

Based on observation, 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, and 21.2.10.

Findings include:

1. During an observation on 01/06/2020 at 3:56 p.m., the corridor outside the admissions office was inspected. There was no visible exit sign outside the corridor door to the admissions office in F hall.

Based on observations, the facility failed to:

a) ensure rooms being used as storage areas 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;
b) ensure fire/smoke barrier doors located in the fire/smoke partitions were maintained per NFPA 101-2012, Section 8.4.3.4 and NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, Section 6.3.1.7.1.

Findings include:

1. During an observation on 01/08/2020 at 7:06 a.m., endoscopy room 4 was inspected. It was found to be used as storage. The room was over 50 square feet and the corridor door was not fitted with a self-closer.

2. During an observation on 01/08/2020 at 9:16 a.m., the storage room in the ICU was inspected. The room measured greater than 50 square feet and was not fitted with the necessary self-closing device.

3.During an observation on 01/08/2020 at 9:22 a.m., the ICU biohazard room was inspected. The door to the room would not close under the power of the self-closer.

4. During an observation on 01/08/2020 at 11:14 a.m., the boiler room doors were exercised. The doors were not tight enough when closed. There was a gap between the doors at the bottom that was at least 3/8" wide. Doors cannot have a gap of more than 1/8" when closed.

Based on observation and interview, the facility failed to ensure piped medical gas zone valves were installed outside the room they are intended to serve in accordance with NFPA 99 Health Care Facilities Code 2012 Edition Section 5.1.4.8.7.

Findings include:

During an observation on 01/06/2020 at 4:07 p.m., the operating room was inspected. The medical gas zone valves for the room were found to be operational and located inside the room itself.

Durin an interview on 01/06/2020 at 4:10 p.m., staff member F stated this was looked at during the last survey in 2014 and they determined they were OK to be there because we were going to be moving out of the building soon.

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 01/07/2020 at 1:39 p.m., the neuroscience center was inspected. There was an ABHR station mounted over a light switch and a thermostat in exam room 4.

2. During an observation on 01/07/2020 at 1:49 p.m., the old radiology waiting room was inspected. There was an ABHR station mounted over a light switch in the room.

3. During an observation on 01/07/2020 at 2:12 p.m. the 5th floor conference room of MOB4 was inspected. There was an ABHR over an outlet in the room.

4. During an observation on 01/08/2020 at 6:10 a.m., operating room 4 was inspected. An ABHR dispenser was observed, installed over an electrical source, the nurse call system button.

5. During an observation on 01/08/2020 at 6:10 a.m., the anesthesia work room was inspected. There was an ABHR station over an outlet in the room.

6. During an observation on 01/08/2020 at 6:52 a.m., cardiac cath lab 2 was inspected. There was an ABHR station mounted over a light switch in the room.

7. During an observation on 01/08/2020 at 6:54 a.m., the cath lab locker room was inspected. An ABHR dispenser was observed, installed over an electrical source.

8. During an observation on 01/08/2020 at 7:35 a.m., the ED triage area was inspected. There was an ABHR station mounted over an ignition source.

9. During an observation on 01/08/2020 at 10:39 a.m., the Sapphire room was inspected. An ABHR dispenser was observed, installed over an electrical outlet.

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 01/07/2020 at 12:42 p.m., the fire alarm pull station on the third floor pediatrics area was found to be blocked from instant access by a chair.

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 01/08/2020 at 6:41 a.m., the fire alarm pull station in the surgical services reception area of MOB4 was found to be blocked from instant access by a trash container.

Based on record review, the facility failed to ensure all test documents related to the fire alarm system was available for review in accordance with NFPA 72 National Fire Alarm and Signaling Code, 2010 Edition, Table 14.4.5.

Findings include:

1. During a review of the facility inspection records on 01/06/2020, it was noted that the facility lacked documentation of any inspection reports for the facilities fire alarm system. Records were requested on 01/06/2020, 01/07/2020, and 01/08/2020.

Based on record review and interview, the facility failed to ensure all test documents related to the fire alarm system was available for review in accordance with NFPA 72 National Fire Alarm and Signaling Code, 2010 Edition, Table 14.4.5.

Findings include:

1. During a review of the facility inspection records on 01/06/2020, it was noted that the facility lacked documentation of any inspection reports for the facilities fire alarm system. Records were requested on 01/06/2020, 01/07/2020, and 01/08/2020.

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, and Section 8.8.4.1.2., and NFPA 101-2012, Section 19.3.5.1.

Findings include:

1. During an observation on 01/08/2020 at 9:40 a.m., the post-partum stairwell was inspected. The room was found to have a sprinkler head that was obstructed by a ceiling mounted light fixture.

2. During an observation on 01/08/2020 at 6:57 a.m., the stairwell by the facilities office was inspected. There was a light ballast mounted next to a sprinkler head, the ballast and cover was lower than the head and would be blocking the spray pattern of the sprinkler head.

3. During an observation on 01/08/2020 at 9:31 a.m., the shower room next to patient room 235 was inspected, the deflector of the sprinkler head was less than one inch below the ceiling.

4. During an observation on 01/08/2020 at 9:31 a.m., the shower room next to patient room 231 was inspected, the deflector of the sprinkler head was less than one inch below the ceiling, and nearly up inside the escutcheon ring.

5. During an observation on 01/08/2020 at 10:01 a.m., the first-floor hospital EVS closet was inspected. The sprinkler head in the closet was found to be blocked by a light.

6. During an observation on 01/08/2020 at 7:40 a.m., electrical room 212 was inspected. There was no visible sprinkler head in the room. There was also a wire that was zip-tied to the sprinkler pipe in the room.

7. During an observation on 01/08/2020 at 7:42 a.m., electrical room 214 was inspected. There was no ceiling in the room and inspection revealed there was no upright head up near the roof deck above.

Based on observation, the facility failed to:

a) maintain the sprinkler system by installing sprinkler heads too close to walls in accordance with NFPA 13 Standard for Automatic Sprinkler Systems, 2010 Edition, Section 8.5.5.2.2.;
b) ensure sprinkler heads were installed with the proper distance between the heads in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.7.3.4.

Findings include:

1. During an observation on 01/06/2020 at 3:48 p.m., the admissions office was inspected. There was a sprinkler head in the room that was installed less than 4 inches from the wall in the room.

2. During an observation on 01/06/2020 at 3:49 p.m., the satellite office was inspected. A sprinkler head in the room was found to be installed less than four inches from the wall in the room.

3. During an observation on 01/06/2020 at 3:50 p.m., the general break room was inspected. Both sprinkler heads located in the room were observed to be installed less than six feet apart from each other.

4. During an observation on 01/06/2020 at 3:50 p.m., the admin break room was inspected. There was a sprinkler head less than four inches from the wall in the room.

Based on observation the facility failed to:

a) maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1.;
b) 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.;
c) ensure proper sprinkler maintenance in accordance with NFPA 101-2012 and NFPA 25-2011, Sections 5.1.1.1 and Table 5.1.1.2.

Findings include:

1. Review of facility sprinkler inspection reports reflected the five-year internal inspection, and calibration/replacement of the standpipe gauges for MOB4 had not taken place every five years. The five-year internal inspection and calibration/replacement of the sprinkler gauges for the facility were conducted in 2013, and completed again on 11/11/2019, exceeding the five-year requirement.

2. Review of facility sprinkler inspection reports reflected the five-year internal inspection, and calibration/replacement of the standpipe gauges had not taken place every five years. The five-year internal inspection and calibration/replacement of the sprinkler gauges for the hospital were conducted in 2013, and completed again on 11/11/2019, exceeding the five-year requirement.

3. Review of the facility sprinkler maintenance reports on 01/06/2020 showed the facility failed to have the sprinkler system for MOB4 inspected every ninety days, with a ten-day grace period. The 2019 second quarter inspection was conducted on 04/23/19 and the next inspection did not occur until 08/19/19.

4. Review of the facility sprinkler maintenance reports on 01/06/2020 showed the facility failed to have the hospital sprinkler system inspected every ninety days, with a ten-day grace period. The 2019 second quarter inspection was conducted on 04/23/19 and the next inspection did not occur until 08/19/19.

5. During an observation on 01/07/2020 at 1:58 p.m., the level six mechanical room of MOB4 was inspected. Orange wires were observed attached to the sprinkler pipe within the room.

6. During an observation on 01/07/2020 at 2:11 p.m., the level five center hall bathroom of MOB4 was inspected. The sprinkler head in the room was observed to be missing its escutcheon ring.

7. During an observation on 01/07/2020 at 2:38 p.m., the pulmonary function lab linen closet in MOB4 was inspected. Items were observed being stored within 18 inches of the sprinkler head within the room.

8. During an observation on 01/08/2020 at 6:59 a.m., the women's bathroom leading to the emergency room was inspected. The sprinkler head within the room was observed to be loaded with dust particles.

9. During an observation on 01/08/2020 at 9:18 a.m.., the ICU med room was inspected. A sprinkler head was observed, covered in white paint.

10. During an observation on 01/08/2020 at 9:26 a.m.., the labor and delivery room # 3 bathroom was inspected. A sprinkler head was observed, covered in white paint.

11. During an observation on 01/08/2020 at 9:35 a.m.., the shower room by room #226 was inspected. A sprinkler head was observed, missing its escutcheon ring.

12. During an observation on 01/08/2020 at 9:39 a.m.., room 223 was inspected. A sprinkler head was observed, covered in white paint.

13. During an observation on 01/08/2020 at 9:41 a.m.., the post-partum stairwell was inspected. A sprinkler head was observed, covered in white paint.

14. During an observation on 01/08/2020 at 10:08 a.m.., the opening to rooms 120/121 was inspected. A sprinkler head was observed, covered in white paint.

15. During an observation on 01/08/2020 at 10:16 a.m., the respiratory therapy locker room was inspected. A sprinkler head was observed, obstructed by various items that were placed within 18 inches of the sprinkler head.

16. During an observation on 01/08/2020 at 10:41 a.m., the Meadowlark storage closet was inspected. A ceiling tile was observed to be missing from the ceiling within the room.

17. During an observation on 01/08/2020 at 10:30 a.m., the cafeteria serving area was inspected. There was one sprinkler head loaded with lint.

Based on observation, interview and record review, the facility failed to:
a) maintain the sprinkler system with quarterly inspections in accordance with NFPA 101 2012 Edition, Section 9.7.5 and 4.6.12.3;
b) failed to ensure sprinkler pipes were free of external loads, and 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, Sections 5.2.2.2, and 5.4.1.5.

Findings include:

1. During a record review of facility sprinkler inspections, all documentation provided by the facility revealed the sprinkler system was only being inspected annually, not quarterly. There was one inspection done on 08/19/19, and prior to that, it was done on 09/17/18.

During an interview on 01/06/2020, the sprinkler vendor stated the facility was a class B occupancy and only needed to be done annually.

2. During an observation on 01/07/2020 at 1:04 p.m., the loading dock room was inspected. A white IT data line was observed lying across the sprinkler pipe within the room.

3. During an observation on 01/07/2020 at 1:05 p.m., the spare sprinkler box was inspected. There were only 5 heads in the box. A minimum of 6 heads must be kept for spares.

Based on record review, the facility failed to make records available for all inspections, tests, and maintenance of the facilities wet sprinkler system per NFPA 25-2011, Section 4.3.1.

Findings include:

1. During a review of the facility inspection records on 01/06/2020, it was noted that the facility lacked documentation of any inspection reports for the facilities wet sprinkler system. Records were requested on 01/06/2020, 01/07/2020, and 01/08/2020.

Based on record review and interview, the facility failed to make records available for all inspections, tests, and maintenance of the facilities wet sprinkler system per NFPA 25-2011, Section 4.3.1.

Findings include:

1. During a review of the facility inspection records on 01/06/2020, it was noted that the facility lacked documentation of any inspection reports for the facilities wet sprinkler system. Records were requested on 01/06/2020, 01/07/2020, and 01/08/2020.

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 01/07/2020 at 10:23 a.m., the compliance hallway was inspected. The portable fire extinguisher in the hallway was found to be blocked from instant access by a chair being stored 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.

Findings include:

1. During an observation on 01/07/2020 at 3:37 p.m., the PT area in The Ridge was inspected. The portable fire extinguisher in the room was found to be blocked from instant access by a therapy table.

Based on observation, the facility failed to:

a) maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1.;
b) 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 01/07/2020 at 9:48 a.m., the elevator mechanical room for MOB 3 was inspected. The portable fire extinguisher in the room was found to be blocked from instant access by a large box, paint supplies, and a gallon of paint being stored in front of it.

2. During an observation on 01/07/2020 at 2:44 p.m., the level one lab was inspected. The portable fire extinguisher in the room was found to be blocked from instant access by a cart with medical supplies stored on top of it.

3. During an observation on 01/08/2020 at 6:12 a.m., operating room #5 was inspected. The two portable fire extinguishers in the room were found to be blocked from instant access by a chair and a computer station being stored in front of them.

4. During an observation on 01/08/2020 at 6:14 a.m., operating room #6 was inspected. The two portable fire extinguishers in the room were found to be blocked from instant access by a computer station being stored in front of them.

5. During an observation on 01/08/2020 at 10:23 a.m., the decontamination 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.

6. During an observation on 01/08/2020 at 10:26 a.m., the portable extinguisher in the sterile processing department was inspected. The portable extinguisher lacked documentation which showed that the monthly maintenance inspection was performed during the months of November 2019 and December 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 01/08/2020 at 7:50 a.m., the film library office corridor door was exercised. It didn't close tight to where it would be resistant to the passage of smoke, and the door did not have any latch, it was free-swinging.

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 8.4.3.4 and NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, Section 6.3.1.7.1

Findings include:

1. During an observation on 01/07/2020 at 12:11 p.m., the engineering room fire rated doors were exercised. The doors were not tight enough when closed. The gap between the doors was at least 3/8" wide. Doors cannot have a gap of more than 1/8" when closed.

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 8.4.3.4 and NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, Section 6.3.1.7.1.

Findings include:

1. During an observation on 01/07/2020 at 10:05 a.m., the smoke doors between MOB 2 and MOB 3 were exercised. The gap between the doors was at least 3/8" wide. Doors cannot have a gap of more than 1/8" when closed.

Based on observation, the facility failed to:

a) maintain proper clearances between smoke doors in accordance with NFPA 101, 2012 Edition, Section 8.4.3.4 and NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, Section 6.3.1.7.1.;
b) 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 01/07/2020 at 9:20 a.m., the cross-corridor doors by the open stairwell were exercised. When closed, the gap between the doors was greater than 3/8".

2. During an observation on 01/08/2020 at 9:14 a.m., the double doors leading to the ICU failed to close and latch when exercised. The doors were interfaced with the fire alarm control panel.

3. During an observation on 01/08/2020 at 9:34 a.m., the double doors in the post-partum wing failed to close and latch when exercised. The doors were interfaced with the fire alarm control panel.

4. During an observation on 01/08/2020 at 1:25 p.m., the double doors in the med/surg wing failed to close and 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 01/08/2020 at 7:15 a.m., the emergency room waiting 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 and interview, the facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, section 21.7.1.6.

Findings include:

1. Record review of facility documents regarding fire drills on 01/06/2020, showed there was no documentation for completed fire drills for the facility.

During an interview on 01/06/2020 at 11:01 a.m., staff member A stated that all fire drills for the facility were located at the facility.

During a tour of the facility on 01/06/2020 at 3:40 p.m., staff member A stated he was not able to get access to the fire drills.

Fire drill documentation was again requested by the survey team on 01/07/2020 and at 8:00 a.m. on 01/08/2020. No documentation was provided by the facility showing that the facility had conducted any fire drills prior to 01/08/2020.

Based on record review and interview, the facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, section 39.7.2.

Findings include:

1. Record review of facility documents regarding fire drills on 01/06/2020, showed there was no documentation for completed fire drills for the facility.

During an interview on 01/06/2020 at 11:01 a.m., staff member A stated that all fire drills for the facility were located at the facility and would be produced on 01/07/2020.

During a tour of the facility on 01/07/2020 at 7:40 a.m., staff member A stated he was not able to get access to the fire drills because they were locked in a filing cabinet and he did not have the key.

Fire drill documentation was again requested by the survey team at 8:00 a.m. on 01/08/2020. No documentation was provided by the facility showing that the facility had conducted any fire drills prior to 01/08/2020.

Based on record review, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6.

Findings include:

1. Review of facility documents regarding fire drills on 01/06/2020, showed there was no documentation for completed fire drills for the PM shift during the second quarter of 2019 for MOB4.

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 01/07/2020 at 10:09 a.m., the main floor mechanical room was inspected. The electrical panel in the room was blocked from easy access by a portable air conditioning unit being stored 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 01/07/2020 at 12:14 p.m., the fifth-floor mechanical room was inspected. The electrical panel in the room was blocked from easy access by four boxes being stored in front of it.

2. During an observation on 01/07/2020 at 12:14 p.m., the third-floor electrical room was inspected. The electrical panel in the room was blocked from easy access by various items being stored in front of it.

3. During an observation on 01/07/2020 at 1:18 p.m., room 3F was inspected. The electrical panel in the room was blocked from easy access by a broom and boxes being stored in front of it.

4. During an observation on 01/07/2020 at 1:21 p.m., the third-floor electrical room was inspected. The electrical panel in the room was blocked from easy access by several boxes and various items being stored in front of it.

5. During an observation on 01/07/2020 at 1:36 p.m., room 2F was inspected. The electrical panel in the room was blocked from easy access by several large boxes being stored 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 01/07/2020 at 7:44 a.m., the main Information Technology room was inspected. The electrical panel in the room was blocked from easy access by various items being stored in front of it, including a green ladder and a large cardboard box.

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 01/07/2020 at 9:30 a.m., the water chemistry room of MOB1 was inspected. Two electrical panels in the room were blocked from easy access by a large table with various items being stored on top of, and on the bottom shelf of the table.

2. During an observation on 01/07/2020 at 9:33 a.m., the finance room of MOB1 was inspected. The electrical panel in the room was blocked from easy access by a large ivory colored bag with unknown contents.

3. During an observation on 01/07/2020 at 1:34 p.m., the room 2F Information Technology closet of MOB3 was inspected. The electrical panel in the room was blocked from easy access by various items being stored in front of it.

4. During an observation on 01/07/2020 at 2:47 p.m., the level one lab of MOB4 was inspected. An electrical panel in the room was blocked from easy access by a large black cart with boxes stored on top of it.

5. During an observation on 01/08/2020 at 7:27 a.m., room 2E was inspected. The electrical panel in the room was blocked from easy access by a chair and a large trash can being stored in front of it.

6. During an observation on 01/08/2020 at 7:40 a.m., room 2D was inspected. The electrical panel in the room was blocked from easy access by a large black cart with several contents being stored in front of it.

7. During an observation on 01/08/2020 at 7:43 a.m., the radiology hall was inspected. The electrical panel in the hallway was blocked from easy access by various items being stored in front of it.

8. During an observation on 01/08/2020 at 11:20 a.m., the electrical room in MOB4 was inspected. The electrical panel in the room was blocked from easy access by various items being stored in front of it.

9. During an observation on 01/07/2020 at 2:16 p.m., the 5th floor electrical room next to the service elevator in MOB4 was inspected. The electrical panel in the room was blocked from easy access by various items 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 01/08/2020 at 11:06 a.m., the water treatment room 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 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 01/06/2020 at 4:37 p.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 per NFPA 99-2012, Health Care Facilities Code, Section 10.2.4 and failed to ensure power strips complied with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-Life Safety Code (LSC).

Findings include:

1. During an observation on 01/07/2020 at 12:10 p.m., the engineering room was inspected. An orange extension cord was observed, which was plugged into the outlet on the wall and a battery charger which was stored on a shelf within the room. The use of the extension cord was not attended by a staff member of the facility.

2. During an observation on 01/07/2020 at 1:40 p.m., the lab exit was inspected. There was a power strip observed, dangling from the wall. The power strip was not supported or mounted to the wall or floor within the room.

Based on observation, the facility failed to ensure that power strips were used per NFPA 99-2012, Health Care Facilities Code, Section 10.2.4.

Findings include:

1. During an observation on 01/07/2020 at 9:40 a.m., the nurse managers office in MOB1 was inspected. A surge protector was observed in the room, unsecured and hanging from the wall.

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 01/06/2020 at 4:35 p.m., the outside oxygen storage room was inspected. Three k-tanks were observed, unsecured, sitting on the floor within the room.

Based on observation, the facility failed to ensure proper signage was posted on the gate going to the bulk liquid oxygen tank, in accordance with NFPA 99 2012 Edition, Section 5.1.3.9.

Findings include:

1. During an observation on 01/07/2020 at 1:04 p.m., the bulk oxygen tank was inspected. The tank was behind a fenced area with two gates. One gate had the required signage regarding smoking or open flame, the other gate did not have any warning signage.

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 01/07/2020 at 8:06 a.m., the clean utility room was inspected. An e-tank was observed, unsecured, sitting on the floor within the room.