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Based on observation and interview, the facility failed to maintain the wall between the hospital and other occupancies with a construction having a fire resistance rating of at least 2 hour. This deficient practice could affect all patients in the building.

Findings include:

1. On 05/17/2022 at 10:40 am, observation revealed the 2 hour fire wall by the ambulance entrance had a 4 X 4 hole in the wall.

2. On 05/17/2022 at 10:40 am, observation revealed the 2 hour fire wall by the ambulance entrance (between the MOB & ER) had a vent with a only 1 layer of drywall with a 2" hole in it.

3. On 5/17/2022 at 1:00 pm, observation revealed the 2 hour wall in the ED, had 'boarded up' door 4 feet above the floor that is not rated for 2 hours. The door is not usable as a door.

The deficient practice was confirmed by Staff MM and Staff NN at the time of discovery.

Based on observation and staff interview, the facility did not ensure that egress corridors are continuously maintained free of materials or devices that obstruct egress as required per NFPA 101 (2012 edition) sections 19.2.1, 7.1.10.2.1, 7.2.1.6.1.1 (3), and 7.1.3.2(9) The deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings Include:

1. On 05/17/2022 at 09:50 am, observation revealed that the corridor by the EVS room, had 6 EVS carts in the corridor blocking the corridor. The EVS staff was having a meeting and was asked what would the staff do if the fire alarm went off. No one mentioned moving the EVS carts out of the corridor.
2. On 05/17/2022 at 11:05 am, observation revealed that there was no exit out of the ambulance garage. One door was bolt shut and the other had a security code.
3. On 5/17/2022 at 11:50 am, observation revealed that the exit passageway from Stairwell #1, has the boiler room, an unoccupied space, opening up onto it.
4. On 05/17/2022 at 03:45 pm, observation revealed that the corridor to the MRI truck had the "Arm", gurney, housekeeping cart lined up and reducing the width of the corridor.
5. On 05/18/2022 at 6:40 am, observation revealed that chairs, IV stands and other equipment restricted the width of the back aisle in the ED department to 4 feet wide. This is the main pathway for gurneys from the ambulance garage to the ED rooms.


The deficient practice was confirmed at the time of discovery by a concurrent interview with Staff AA (for item 1) , MM and Staff NN. (later in the day for item #5)

Based on observation and interview, the facility failed to provide means of egress in accordance with the requirements of NFPA 101 (2012 edition) Sections 7.2.1.5.1, 7.2.1.5.10, & 7.2.1.5.10.2. This deficient practice could affect all patients and an undetermined number of staff and visitors.

Findings include:

1. On 05/17/2022 at 10:00 am, observation revealed that the exit door from the rehab waiting area would not open.
2. On 05/17/2022 at 11:40 am, observation revealed that the door to the outside from ER waiting can be locked and unable to exit.
3. On 05/17/2022 at 1:20 pm, observation revealed that the door from the main reception area at the main entrance could be locked and prevent the receptions from exiting from the space.
4. On 05/19/2022 at 9:00 am, observation revealed that the door from the MRI patient room labeled as an exit, would not open.

These deficient practices were confirmed at the time of discovery by a concurrent interview with Staff MM and Staff NN.

Based on observation and interview, the facility did not maintain smoke barrier doors to be self-closing doors or automatic closing devices that released with the fire alarm or local smoke detectors complying with NFPA 101, 2012 edition, Sections 19.2.2.2.7, 7.2.1.8.2, and 8.5.4.4, as well as NFPA 72, 2010 Edition, Section 17.7.5.6.6.1.

Findings include:

On 05/17/2022 at 10:41 AM, observation revealed that the door coordinator from the ambulance garage does not allow the double doors to close and latch to the corridor.

This deficient practice was confirmed by Staff MM and Staff NN at the time of discovery.

Based on observation and staff interview, the facility did not ensure that stairways and exit passageway are in accordance with 7.1,7.2, 18.2.2.3,.19.2.2.4, 19.2.2.3 & 19.2.2.4, and 7.1.3.2(9) The deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings Include:

1. On 5/17/2022 at 11:50 am, observation revealed that the exit passageway from Stairwell #1 has the boiler room, an unoccupied space, opening up onto it.

The deficient practice was confirmed at the time of discovery by a concurrent interview with Staff MM and Staff NN.

Based on observation and interview, the facility failed to provide means of egress in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.2.5.2. This deficient practice could affect all patients and an undetermined number of staff and visitors.

Findings include:

1. On 05/17/2022 at 10:30 am, observation revealed that corridor going into the old nursing home from the Med Office B waiting room (2nd fl) has a dead end corridor greater than 30 feet.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff MM and Staff NN.

Based on observation and interview, the facility failed to provide means of egress in accordance with the requirements of NFPA 101 (2012 edition) Sections 7.7, 7.1.7. and 19.2.7 This deficient practice could affect MRI patients and an undetermined number of staff and visitors.

Findings include:

1. On 05/19/2022 at 9:01 am, observation revealed that the door from the MRI patient room labeled as an exit, when opened, there was approximately three foot drop off to the pavement below.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff MM and Staff NN.

Based on observation and interview, the facility failed to provide means of egress in accordance with the requirements of NFPA 101 (2012 edition) Sections 7.8 and 19.2.8 This deficient practice could affect MRI patients and an undetermined number of staff and visitors.

Findings include:

1. On 05/19/2022 at 9:15 am, observation revealed that the emergency lights in the MRI suite did not work when tested.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff MM and Staff NN.

Based on observation and interview, the facility failed to provide means of egress in accordance with the requirements of NFPA 101 (2012 edition) Sections 7.10 and 19.2.10.17 This deficient practice could affect MRI patients and an undetermined number of staff and visitors.

Findings include:

1. On 05/19/2022 at 9:05 am, observation revealed that the door from the MRI patient room labeled as an exit, but did not have an illuminated exit sign.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff MM and Staff NN.

Based on observation and interview, the facility failed to maintain all Stairways, elevator shafts,ventilation shafts chutes and other vertical opening between floor are enclosed with construction having a fire resistance rating of at least 1 hour. This deficient practice could affect all patients, staff and visitors in the building.

Findings include:

On 05/17//2022 at 10:25 am, observation revealed a fire cabinet and Stair HVAC cabinet were recessed into the walls of the 2 hr wall between the nursing home and the hospital (fire cabinet), and in the fire rated stairwell wall (HVAC). These cabinets were not rated for the wall that they were in.

The deficient practice was confirmed by Staff MM and Staff NN at the time of discovery.

Based on observation and interview, the facility failed to maintain the fire rating of fire rated door in accordance with the requirements in NFPA 101, 2012 edition section 8.3.3.1 and NFPA 80, This deficient practice could affect all patients, staff and visitors in the building.

Findings include:

On 05/17/2022 at 9:15 am, observation revealed fire rated elevator doors and an fire rated biohazard room door had combustible signs on the door. No combustibles are permitted on fire rated doors..

The deficient practice was confirmed by Staff MM and Staff NN at the time of discovery.

Based on observation and interview, the facility did not provide a second branch of emergency power or normal power in a critical care area per NFPA 99, 6.3.2.2.1.2. This deficient practice could potentially affect an undermined number of patients.

Findings include:

1. On 05/17/2022 at 2:49 pm, observation revealed that there was no normal power or 2nd branch of emergency power in Operating Room 2 and 1.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff MM and Staff NN.

Based on observation and interview, the facility did not provide occupant notification in accordance with NFPA 101, 2012 edition, Sections 19.3.4.3.1, 9.6.3, and 9.6.1.8, as well as NFPA 72, 2010 edition, Sections 19.5.4.4.5 and 19.6.

Findings include:

1. On 05/18/2022 at 1: 40 pm observation revealed that there was not a visible/audible fire alarm notification device(s) provided inside the ED provider sleep room.
2. On 05/18/2022 at 2:18 pm, observation revealed that there was not a visible/audible fire alarm notification device(s) provided inside the Hospitalist Office (sleeping room).
3. On 05/19/2022 at 9:10 am, observation revealed that the remote MRI "suite" did not have a fire alarm system installed in the 'trailer'.

These deficient practices were confirmed at the time of discovery by a concurrent interview with Staff MM and Staff NN.

Based on record review and interview, the facility did not perform the semi-annual testing and inspections of the fire alarm system in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.4 and 9.6.1.3; as well as NFPA 72, 2010 edition, Sections 14.3.1 and 14.4.5.

Findings include:

On 05/18/2022 at 8:15 am, record review of fire alarm inspection and testing documents over the past 24 months revealed that the facility's fire alarm vendor, conducted smoke detector sensitivity testing of the fire alarm system. The testing did not include the acceptable range with the current reading.

This deficient practice was confirmed by Staff MM and NN at the time of discovery.

Based on observation and staff interview, the facility did not provide a sprinkler system as required by the code; with all spaces sprinkler protected in accordance with NFPA 101 (2012 edition) sections 19.3.5, and NFPA 13 (2010 edition) sections 8.1, 8.5.5.2.1, 8.6.5.2.2, 8.6.5.2.2.1, 8.7 & 8.10.7.3.2. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 05/17/2022 at 2:40 pm, observation in the shower in surgery area that 18" of clearance down from the sprinkler was not maintained and did not have proper water spray coverage.

2. On 05/17/2022 at 04:15 pm, observation in the Bone Density room revealed that the curtains had too small of holes to allow sprinkler water through.

3. On 05/18/2022 at 01:22 pm, observation in the Pharmacy, revealed storage rack did not have the 18" vertical clearance from the sprinkler head which obstructed the sprinkler.

4. On 05/18/2022 at 01:50 pm, observation in the IV Prep room, the Air Conditioner on the wall obstructs the wall flow from the side wall sprinkler.

5. On 05/18/2022 at 02:40 pm, observation in the chapel pastors office, there was no sprinkler coverage. There was no sprinkler.


These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff MM and Staff NN.

Based on observation and staff interview, the facility failed to maintain corridor doors in accordance with NFPA 101, 2012 edition, Sections 19.3.6.3.

Findings include:

1. On 05/17/2022 at 11:19 am, observation revealed that the corridor door to east end of the ER did not positively latch.

2. On 05/17/2022 at 11:25 am, observation revealed that the door to the vending room from the corridor did not positively latch.

3. On 05/18/2022 at 1:25 pm, observation revealed that the Dutch door (Upper door) to the pharmacy from the corridor did not positively latch.

These deficient practices were confirmed by Staff MM and Staff NN at the time of discovery.

Based on observation and staff interview, the facility did not ensure the electrical wiring and equipment met the requirements of NFPA 101, 2012 Edition, Sections 6.3.2.1 , 19.5.1.1, and 9.1.2, as well as NFPA 70, edition 2011, Sections 110.08, 110.27, and Article 210.8(B).

Findings Include:

1. On 05/17/2022 at 11:30 am observation in the ER (Panel "GNA" ) revealed an electrical breaker box, in a publicly accessible space, that was not secured. In addition, the spare breaker were not labeled.

2. On 05/17/2022 at 3:15 PM, observation in the First Floor Corridor adjacent to Patient Room 125 revealed an electrical breaker box, in a publicly accessible space, that was not secured.

These deficient practices were confirmed by Staff MM and NN at the time of discovery.

Based on observation and interview, the facility did not provide a ventilation system in accordance with NFPA 101 (2012 ed.), 19.5.2.1, 9.2 and NFPA 90A, (2012 ed.) 4.3.12 with corridor used as a portion of a supply, return, or exhaust air system. This deficient practice could affect all inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 05/19/2022 at 3:00 pm , it was observed that the corridor within the Med/Surg wing [First floor] of the hospital was being used as a return air plenum for the patient and ancillary rooms along this corridor.
2. On 05/19/2022 at 2:30 pm, it was observed that the East and West wing [First floor] of the hospital patient rooms did not have any air changes provided from the ventilation system. No supply air is being provided to these rooms as well.
3. On 05/19/2022 at 10:35 pm, it was observed that Storage room G4, a hazardous area, did not have a fire damper in the transfer grill.

This finding was confirmed at the time of discovery by an interview with Staff MM and Staff NN. Staff MM & NN stated that this issue has been investigated and there is no ceiling height available to install new ductwork to alleviate this code violation. He also stated that the HVAC system shuts down upon the activation of the fire alarm system.

Based on record review and interview the facility failed to conduct fire drills in accordance with, the requirements of NFPA 101 - 2012 edition, Sections 4.7.1, 4.7.2, 4.7.6, 19.7.1, 19.7.1.4 and 19.7.1.6. This deficient practice could affect all inpatients, outpatients, staff and visitors.

Findings include:

1. On 05/17/2022 at 3:55 pm, in the radiology department, staff OO was asked about what s/he would do about the oxygen supply in the radiology room in case there was a fire. S/he did not know where the med gas (oxygen) shut off valve was located.

2. On 05/18/2022 at 6:50 am at the inpatient nurse station, Staff LL was asked what s/he would do if there was smoke coming out of the patient room. She looked at two different 'safety' manuals at the nurse station. In reading the two "safety" manuals, one said to rescue the patient first, the other said to initiate the fire alarm first.

3. On 5/18/2022 at 7:05 am at ED nurse desk, Staff NW was asked what s/he would do if smoke was coming out of a patient room. S/he remember "RACE" after a few moments, but then could not find a record/paper copy of the emergency plan and stated it would take a few minutes to confirm it (find it) on the computer. S/he did eventually find it on the computer and showed it to me.

This finding was confirmed at the time of discovery by an interview with Staff OO, LL, and W with staff MM and Staff NN observing item one only.

Based on observation and interview, the facility failed to store soiled linen and trash receptacles in accordance with the requirements of NFPA 101 (2012 edition), Sections 19.7.5.7.1. and 19.7.5.7.2 (4). This deficient practice could affect all patients, staff and visitors.

Findings include:

1. On 05/17/2022 at 2:50 pm, observation in the OR 2 revealed a 32-gallon trash and a 32 gallon linen containers next to each other. This exceeds the limit of 32 gallons in a 64 square foot area.
2. On 05/17/2022 at 4:30 pm, observation in the Lab, 2' X 2' X 2' biohazard storage container. This exceeds the limit of 32 gallons in a 64 square foot area. The lab is not enclosed in 1 hour walls.
3. On 05/18/2022 at 6: 30 am, observation in the ED, revealed two 32 gallon trash containers next to each other. This exceeds the limit of 32 gallons in a 64 square foot area.
4. On 05/18/2022 at 2:31 pm, observation in the Administrative suite, revealed a secured paper waste bin greater than 32 gallon. The container was not labeled and listed as meeting the requirements of FM Approval Standard 9621 Container for Combustible Waste..

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff MM and Staff NN.

Based on record review and interview, the facility did not perform the annual inspection and testing of fire doors and recording the information in accordance with NFPA 80.

Findings include:

On 05/18/2022 at 8:35 am, record review of fire door inspection and testing documents did not show that all of the fire doors were tested.

This deficient practice was confirmed by Staff MM and NN at the time of discovery.

Based on observation and interview, the facility did not maintain the proper distance from a building and the bulk oxygen tank per NFPA 99 5.1.3.5.12.2 and NFPA 55 Table 9.3.2 (2) & (7) Minimum Separation Distance Between Bulk Liquid Oxygen Systems and Exposure Hazards

Findings include:

On 05/18/2022 at 11:45 am, observation revealed that the MRI truck was within 15 feet of the bulk liquid oxygen tank. Buildings of type III, IV, V and areas occupied by nonambulatory patients as measured from the primary pressure relief device discharge vent, and from filling and vent connections are required to be 50 feet away

This deficient practice was confirmed by Staff MM and NN at the time of discovery.

Based on observation and interview, the facility did not provide a second branch of emergency power or normal power in a critical care area per NFPA 99, 6.3.2.2.1.2, 6.3.2.1, and NFPA 70. This deficient practice could potentially affect an undermined number of patients, staff and visitors.

Findings include:

1. On 05/17/2022 at 1:50 pm, observation revealed that there was no normal power or 2nd branch of emergency power in the procedure room of the surgery area, a critical care area.
2. On 05/17/2022 at 2:20 pm, observation revealed in the ED ice room, that the ice machine cord has been cut and installed inside a surface mounted steel electrical box connected to a 'light' switch. The cord was then plugged into a receptacle.
3. On 05/18/2022 at 11:00 am, observation revealed in the emergency panel room, that Staff MM and NN could not state what emergency branches were served by QEM, LEM, SEM, and CEM; and.there was no other identification available.

These deficient practices were confirmed at the time of discovery by a concurrent interview with Staff MM and Staff NN.

Based on observation and interview, the facility failed to maintain a clear working space in front of electrical disconnects in accordance with NFPA 101 (2012 edition) Section 9.1.2; NFPA 70 (2011 edition) Sections 110.26 , 110.34 & 408.4(A). The deficient practice could affect an undetermined number of patients, staff and visitors

Findings include:

1. On 05/18/2022 at 1:14 pm, observation in the Respiratory Therapist Office revealed that access to the electrical panel was less than the minimum required 3'-0" clearance due to storage in from of it.
2. On 05/18/2022 at 2:15 pm, observation in the corridor by 127, revealed that access to the electrical panel was less than the minimum required 3'-0" clearance due to a cart in from of it.
3. On 05/18/2022 at 2:30 pm, observation in the adminstration suite, revealed that access to the electrical panel was less than the minimum required 3'-0" clearance due to a cart in from of it.

The deficient practices were confirmed at the time of discovery by a concurrent interview with Staff MM and Staff NN.

Based on observation and interview, the facility failed to maintain proper storage of an oxygen cylinder in accordance with NFPA 101 (2012 edition) Section 19.3.2.4; NFPA 99 (2011 edition) Sections 11.6.2. The deficient practice could affect an undetermined number of patients, staff and visitors

Findings include:

1. On 05/18/2022 at 1:15 pm, observation in the respiratory therapist office revealed that an
E size osygin cylinder was free standing and not sucured to anything.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff MM and Staff NN.