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Based on observation, record review, and interview, the facility failed to maintain the integrity of the building structure. This was evidenced by unsealed penetrations on the walls and ceilings. This could result in expedited spread of smoke to other areas of the facility. This could have affected 106 of 106 patients, staff, and visitors in Tower 2.

NFPA 101, Life Safety Code, Edition 2012
4.2.2 Structural Integrity. Structural integrity shall be maintained for the time needed to evacuate, relocate, or defend in place occupants who are not intimate with the initial fire development.

Findings:

During a tour of the facility and interview with the Safety Officer, Chief Nursing Officer, and Patient Safety Coordinator on 2/24/25 through 2/28/25, the Tower 2 building construction was observed.

1. On 2/24/25 at 3:37 p.m., in the Intensive Care Unit (ICU) A, there was a penetration on the wall in the Soiled Linen storage closet. The penetration measured approximately one square foot. During a concurrent interview, the Safety Officer stated the facility's plumber removed the drywall to locate a broken drain line.

At 3:38 p.m., the Safety Officer provided a work order dated 2/22/25. The document indicated that drain lines need repair in different areas of ICU A and B. During concurrent interview, the Safety Officer stated that they are planning to start working in the ICU A and then continue with ICU B.

2. On 2/25/25 at 9:51 a.m., in the ICU B, there was a penetration on the wall in the technology storage closet located next to the Nurse Station. The penetration measured approximately one foot by seven feet. There was a cast iron four inch drain pipe behind the drywall. During a concurrent interview, the Chief Nursing Officer confirmed the finding and stated that the facility decided to repair the drain lines sooner than expected.

3. On 2/26/25 at 11:50 a.m., in the ICU B, there was a penetration on the wall next to Room 163. The penetration in the drywall measured approximately eight feet by one foot. During concurrent interview, the Safety Officer stated that they found a drain line that was broken and they had to remove the drywall.

4. On 2/26/25 at 11:57 a.m., in Room 163, the restroom wall had a penetration next to the toilet. The penetration measured approximately three square feet. During a concurrent interview, the Safety Officer confirmed the finding and stated that a drain line was repaired.

5. On 2/26/25 at 11:58 a.m., in Room 163, a ceiling tile was removed. The tile measured two square feet. During a concurrent interview, the Safety Officer stated that the plumber was removing ceiling tiles in order to locate the drain lines.

Based on observation, record review, and interview, the facility failed to maintain the elevators. This was evidenced by the failure to provide elevators in a reliable operating condition, by an elevator fire sign that was not legible, and by the failure to complete corrections identified by a state agency. This could result in a delay to relocate the occupants with special needs during an emergency. This could have affected 106 of 106 patients, staff, and visitors in Tower 2.

NFPA 101, Life Safety Code, Edition 2012
19.5.3 Elevators, Escalators, and Conveyors. Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4.
9.4 Elevators, Escalators, and Conveyors.
9.4.2.2 Except as modified herein, existing elevators, escalators, dumbwaiters, and moving walks shall be in accordance with the requirements of ASME A17.3, Safety Code for Existing Elevators and Escalators.
9.4.2.4 For other than elevators used for occupant-controlled evacuation in accordance with Section 7.14 and other than existing elevators, the elevator corridor call station pictograph specified in 2.27.9 ofASMEA17.1/CSAB44, Safety Code for Elevators and Escalators, shall be provided at each elevator landing.
9.4.3.2 All existing elevators having a travel distance of 25 ft (7620 mm) or more above or below the level that best serves the needs of emergency personnel for fire-fighting or rescue purposes shall conform to the fire fighters' emergency operations requirements of ASMEA17.3, Safety Code for Existing Elevators and Escalators.

ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators
2.27.9 Elevator Corridor Call Station Pictograph. When the building code requires a sign be posted adjacent to hall call fixtures instructing occupants not to use the elevator in case of fire, the sign shown in Fig. 2.27.9 shall be provided. The sign shall include only the wording and graphics shown in Fig. 2.27.9. When the building code specifies a different design, 2.27.9 shall not apply.
8.6.1 General Requirements
8.6.1.1 Maintenance, Repair, and Replacement
8.6.1.1.1 Equipment covered within the scope of this Code shall be maintained in accordance with Section 8.6.
8.6.1.1.2 Maintenance, repairs, replacements, and tests shall conform to Section 8.6 and the applicable
(a) Code at the time of the installation; and
(b) Code requirements at the time of any alteration; and
(c) ASME A17.3 if adopted by the authority having jurisdiction
8.6.2 Repairs. See 8.6.2.1 through 8.6.2.6 for general requirements for repairs.
8.6.2.1 Repair Parts. Repairs shall be made with parts of at least equivalent material, strength, and design (see 8.6.3.1).
8.6.3 Replacements
8.6.3.1 Replacement Parts. Replacements shall be made with parts of at least equivalent material, strength, and design.
8.6.4 Maintenance and Testing of Electric Elevators. The maintenance and testing of electric elevators shall conform to 8.6.1 through 8.6.4.
8.6.4.1 Suspension and Compensating Means
8.6.4.1.1 Suspension and compensating means shall be kept sufficiently clean so that they can be visually inspected.
8.6.4.7 Cleaning of Hoistways and Pits
8.6.4.7.1 Hoistways and pits shall be kept free of dirt and rubbish and shall not be used for storage purposes.

Findings:

During a tour of the facility, record review, and interview with the Safety Officer (SO), Security Staff 1, Deputy Regional Director of Quality, Chief Nursing Officer on 2/24/25 through 2/28/25, elevators #4, #5, and #6 were observed in Tower 2.

1. On 2/24/25 at 1:25 p.m., the facility failed to maintain Elevator #4 in Tower 2 in a reliable operating condition. During a concurrent interview, the SO stated that the Elevator #4 door operator stopped working a week ago due to age. A document titled, "Proposal," dated 2/19/25 and with estimate #7663, indicated a proposal to install a new car door operator equipment.

2. On 2/26/25 at 12:09 p.m., the facility failed to maintain Elevator #5 in Tower 2 in a satisfactory operating condition. A document titled, "Work Order #466783," dated 2/26/25, indicated that Elevator #5 was stuck on the 6th floor. During a concurrent interview, the SO stated that doors to Elevator 5 are bumped by accident and it causes the elevator to get stuck.

On 2/26/25, from 12:09 p.m. to 12:14 p.m., a staff member and a patient were waiting in the lobby for the only functioning elevator at that time, Elevator #6. The staff was transferring the patient to a recovery room upstairs. After waiting for 5 minutes, the security staff had to be summoned to assist with recalling Elevator #6 by using the keyed firefighter's recall switch.

3. On 2/26/25 at 12:20 p.m., the elevator fire sign observed in the first floor lobby of Tower 2 was not legible. The sign would have notified occupants to not use the elevators in case of a fire. During a concurrent interview, the SO confirmed the finding and stated that is was the original fire sign.

4. On 2/28/25 at 1:22 p.m., the preliminary order issued by the state agency responsible for permitting and inspecting elevators listed conditions in need of correction for multipe elevators. During a concurrent interview, the SO confirmed the listed conditions. The preliminary order indicated that the elevators in Tower 1, Tower 2, and in the Administration building had to be compliant by 3/31/25. Conditions were given to elevators with the following state numbers: 045801, 045802, 064018, 066278, 066276 (Elevator #4), 066277 (Elevator #5).

Based on observation, record review, and interview, the facility failed to maintain the electrical equipment. This was evidenced by the failure to connect a refrigerator directly into a wall outlet without the use of an adapter. This could increase the risk of a shock hazard. This could have affected 106 of 106 patients, staff, and visitors in Tower 2.

NFPA 99: Health Care Facilities Code, 2012 Edition
10.5.3 Servicing and Maintenance of Equipment.
10.5.3.1.2 Service manuals, instructions, and procedures provided by the manufacturer shall be considered in the development of a program for maintenance of equipment.

Findings:

During a tour of the facility and interview with the Safety Officer, Third Floor Unit Manager, and Chief Nursing Officer (CNO) on 2/24/25 through 2/28/25, the Tower 2 electrical equipment was observed, and the published service manual was reviewed.

On 2/27/25 at 2:26 p.m., in the third floor Nutrition Room, a refrigerator was plugged directly into a Belkin power strip. The service manual indicated not to plug the appliance into an adapter. Failure to follow the instructions can result in electrical shock. During a concurrent interview, the CNO stated that the power strips were utilized during a power outage two weeks ago and the staff forgot to collect the power strips after the event.