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Based on observation and interview, it was determined that the facility failed to maintain the means of egress, free of obstructions, on one of four levels.

Findings include:

1. Observation on June 16, 2022, between 10:19 a.m. and 10:23 a.m., revealed the following egress door deficiencies:
A. (10:19 a.m.) Basement medical records storage cage was configured with a two-step locking arrangement that could delay egress during an emergency;
B. (10:23 a.m.) Basement medical records storage room door was configured with hardware that could be locked from the outside, but could not be unlocked from inside of the room.

Interview with the maintenance supervisor on June 16, 2022, at 10:23 a.m., confirmed the above egress door deficiencies.

Based on observation and interview, it was determined that the facility failed to maintain doors with self-closing devices on two of four building levels.

Findings include:

1. Observation on June 16, 2022, between 10:11 a.m. and 12:00 p.m., revealed the following self-closure deficiencies:
A. (10:11 a.m.) Basement hot room had a self-closing door propped open with a wedge;
B. (10:15 a.m.) Basement paint room had a self-closing door propped open with a wedge;
C. (10:18 a.m.) Basement laundry room had a self-closing door propped open with a wedge;
D. (10:23 a.m.) Basement shop storage door had the arm mechanism removed from the self-closing apparatus;
E. (11:22 a.m.) First floor kitchen office self-closing door, leading to the corridor, did not positively latch in the frame.
F. (12:00 p.m.) Third floor pharmacy had a smoke barrier door lacking a closure arm.

Interview with the maintenance supervisor and building services director on June 16, 2022, at 12:00 p.m., confirmed the above door self-closure deficiencies.
2. Observation on June 17, 2022, at 10:54 a.m., revealed the second floor marketing supply room was propped open with a wedge.
Interview with the maintenance supervisor and administrator of Warren Medical Group on June 16, 2022, at 10:54 a.m., confirmed the above self-closing door was propped open.

Based on document review and interview, the facility failed to meet emergency lighting requirements for three of twelve months.

Findings include:

Document review on June 16, 2022, at 10:44 a.m., revealed the emergency lighting in the delivery room, OR 1, OR 2, OR 3, and OR 4 were not tested in January, February, and March of 2022.

Interview with the building services supervisor on June 16, 2022, at 10:44 a.m., confirmed the lack of emergency lighting testing documentation for January, February, and March of 2022.


43721

Based on observation and interview, the facility failed to maintain emergency lighting on two of four building levels.

Findings include:

1. Observation on June 16, 2022, between 10:09 a.m. and 12:08 p.m., revealed the following battery pack emergency lighting units did not illuminate when the test button was pushed:
A. (10:09 a.m.) Basement maintenance shop cage had one bulb not functioning on the unit;
B. (10:38 a.m.) First floor hyperbaric oxygen storage room emergency lighting unit did not illuminate;
C. (12:08 p.m.) First floor operating room corridor, next to anesthesiology office, emergency lighting unit did not illuminate;

Interview with the maintenance supervisor on June 16, 2022, at 12:08 p.m., confirmed the above battery-pack emergency lighting units were not functioning.

Based on observation and interview, it was determined the facility failed to maintain emergency lighting on one of one level.

Findings include:

Observation on June 16, 2022, at 12:27 p.m., revealed the MRI mechanical room battery back-up emergency light unit did not illuminate when the test button was pushed.

Interview with the maintenance supervisor and administrator of Warren Medical Group on June 16, 2022, at 12:27 p.m., confirmed the above emergency light deficiency.

Based on document review and interview, the facility failed to maintain fire alarm system maintenance requirements for one of one facility.

Findings include:

Document review on June 16, 2022, at 10:02 a.m., revealed the fire alarm system inspection, dated February 11, 2022, identified a heat detector in the morgue that was untestable and had to be installed lower.

Interview with the building services supervisor on June 16, 2022, at 10:02 a.m., confirmed the above fire alarm system deficiency had not been corrected at the time of the survey.


43721

Based on observation and interview, the facility failed to meet requirements, per NFPA 72, for one of one fire alarm system.

Findings include:

Observation on June 16, 2022, at 10:37 a.m., revealed the fire alarm annunciator panel, located in the housekeeping breakroom, indicated a trouble signal for the supply duct O.R. control - smoke detector.

Interview with the maintenance supervisor and administrator of Warren Medical Group on June 16, 2022, at 10:37 a.m., confirmed the fire alarm panel indicated a trouble mode.

Based on document review and interview, the facility failed to maintain sprinkler system requirements for one of two systems.

Findings include:

Document review on June 16, 2022, at 10:22 a.m., revealed the backflow prevention device, dated May 23, 2022, was unable to be tested due to a recommended rebuild.

Interview with the building services supervisor on June 16, 2022, at 10:22 a.m., confirmed the backflow rebuild documentation was not available at the time of the survey.

Based on document review and interview, the facility failed to maintain sprinkler system requirements for one of two systems.

Findings include:

Document review on June 16, 2022, between 10:22 a.m. 10:30 a.m., revealed the following sprinkler system deficiencies:
A. (10:22 a.m.) Backflow prevention device, dated May 23, 2022, was unable to be tested due to a recommended rebuild;
B. (10:24 a.m.) Clean agent suppression system did not reach the 10-minute hold time for its room integrity for hazard rooms 3300A and 3301, resulting in a poor seal (noted May 18, 2022);
C. (10:30 a.m.) Report, dated May 18, 2022, noted a dirt trap should be added to the piping under the clean agent suppression system deficiency list.

Interview with the building services supervisor on June 16, 2022, at 10:30 a.m., confirmed the above sprinkler system deficiency corrective documentation was unavailable at the time of the survey.


43721

Based on observation and interview, the facility failed to maintain fire sprinkler heads for two of over 100 fire sprinkler heads.

Findings include:

Observation on June 16, 2022, at 9:50 a.m., revealed the basement emergency exit corridor, behind the chiller, had two ceiling tiles removed, which may delay the nearby sprinkler head activation.

Interview with the maintenance supervisor on June 16, 2022, at 9:50 a.m., confirmed the above ceiling tiles were removed.

Based on observation and interview, it was determined that the facility failed to maintain smoke barrier construction on one of four levels.

Findings include:

1. Observation on June 16, 2022, between 10:52 a.m. and 11:20 a.m., revealed the following:
A. (10:52 a.m.) First floor, above the pediatric rehab door, had an unsealed penetration around a section of electrical conduit;
B. (11:20 a.m.) First floor smoke barrier doors, outside materials management, did not latch in the frame with the attached latching hardware.

Interview with the maintenance supervisor and administrator of Warren Medical Group on June 16, 2022, at 11:20 a.m., confirmed the above deficiencies.

Based on observation and interview, it was determined that the facility failed to maintain smoke barrier construction on one of one level.

Findings include:

Observation on June 16, 2022, at 12:33 p.m., revealed the emergency room registration smoke barrier walls had a penetration around data cables.

Interview with the maintenance supervisor and administrator of Warren Medical Group on June 16, 2022, at 12:33 p.m., confirmed the above deficiency.

Based on observation and interview, the facility failed to maintain, inspect, and test fire doors, in accordance with regulations, affecting two of over ten fire doors.

Findings include:

Observation on June 16, 2022, between 10:55 a.m. and 12:11 p.m., revealed the following fire-rated door deficiencies:
A. (10:55 a.m.) First floor fire doors to rehab failed to positively latch in the frame;
B. (11:35 a.m.) First floor south-side elevator fire doors failed to positively latch in the frame;
C. (12:04 p.m.) Third floor fire door 3318 was warped and failed to close in the frame;
D. (12:11 p.m.) Third floor south smoke barrier door failed to positively latch in the frame.

Interview with the maintenance supervisor, building services director, and administrator of Warren Medical Group on June 16, 2022, at 12:11 p.m., confirmed the above fire-rated door deficiencies.
Based on document review and interview, the facility failed to maintain fire and smoke door requirements for three of over twenty doors.

Findings include:

Document review on June 16, 2022, at 9:44 a.m., revealed the following fire and smoke door deficiencies:
A. (9:44 a.m.) A south stairwell door label was painted over;
B. (9:44 a.m.) Door 1041 label was painted over;
C. (9:44 a.m.) No label on loading dock supply closet.

Interview with the building services director on June 16, 2022, at 1:30 p.m., confirmed the facility was unable to provide documentation that the above fire and smoke door deficiencies listed had been corrected at the time of the survey.

Based on document review and interview, the facility failed to maintain gas and vacuum piped systems throughout the facility.

Findings include:

Document review on June 16, 2022, between 11:02 a.m. and 11:05 a.m., revealed the following gas and vacuum piped system deficiencies listed on the March 25-29, 2022 report:
A. (11:02 a.m.) 3 mega S deficient source systems;
B. (11:02 a.m.) 55 deficient outlets/inlets;
C. (11:03 a.m.) 5 deficient master alarm systems;
D. (11:04 a.m.) 12 deficient area alarms;
E. (11:05 a.m.) 10 deficient zone valves.

Interview with the building services supervisor on June 16, 2022, at 11:05 a.m., confirmed the correction documentation for the above deficiencies was not available at the time of the survey.

Based on document review and interview, the facility failed to maintain gas and vacuum piped systems throughout the facility.

Findings include:

Document review on June 16, 2022, between 11:02 a.m. and 11:05 a.m., revealed the following gas and vacuum piped system deficiencies listed on the report dated March 25-29, 2022:
A. (11:02 a.m.) 3 mega S deficient source systems;
B. (11:02 a.m.) 55 deficient outlets/inlets;
C. (11:03 a.m.) 5 deficient master alarm systems;
D. (11:04 a.m.) 12 deficient area alarms;
E. (11:05 a.m.) 10 deficient zone valves.

Interview with the building services supervisor on June 16, 2022, at 11:05 a.m., confirmed corrective documentation was unavailable for the above gas and vacuum piped system deficiencies.

Based on observation and interview, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, on two of four levels.

Findings include:

1. Observation on June 16, 2022, between 9:46 a.m. and 10:37 a.m., revealed the following electrical deficiencies:
A. (9:46 a.m.) Basement boiler room had a missing cover on a transition section of the conduit body;
B. (9:49 a.m.) Basement chiller room had a missing cover on a junction box;
C. (9:55 a.m.) East basement electrical room had multiple electrical disconnects that were obstructed or blocked from access;
D. (9:59 a.m.) Basement boiler room had a partially-removed cover on a transition section of the conduit body;
E. (10:00 a.m.) Basement boiler room, next to the entrance to the tunnel, had a junction box with a missing cover;
F. (10:12 a.m.) Basement hot room had two electrical panels that were blocked from access;
G. (10:12 a.m.) Basement hot room had a missing cover on a transition section of the conduit body;
H. (10:18 a.m.) Basement medical records storage room had a missing cover on a junction box;
I. (10:37 a.m.) First floor housekeeping breakroom, breaker panel "H" had an open breaker slot in breaker numbers 21, 23, and 25.

Reference: NFPA 70-314.17, NFPA 70-408.7, NFPA 70-314.28(C), and NFPA 70-110.26(a)

Interview with the maintenance supervisor on June 16, 2022, at 10:37 a.m., confirmed the above electrical system deficiencies existed.

2. Observation on June 17, 2022, at 10:07 a.m., revealed panel "EP-CR" had an open breaker slot in breaker numbers 14, 16, and 18.

Reference: NFPA 70-408.7

Interview with the maintenance supervisor and administrator of Warren Medical Group on June 17, 2022, at 10:07 a.m., confirmed the above electrical system deficiency existed.

Based on document review and interview, the facility failed to maintain essential electric system testing and maintenance requirements for one of two generators.

Findings include:

Document review on June 16, 2022, between 10:36 a.m. 10:39 a.m., revealed the following essential electric system deficiencies:
A. (10:36 a.m.) Louvre motor had broken free and had one bent mounting bracket (June 4, 2022 Kohler generator report);
B. (10:38 a.m.) One battery was junk with no DC volts possible due to an internal short (June 4, 2022 Kohler generator report);
C. (10:39 a.m.) Facility lacked documentation for an annual 90-minute load bank test;
D. (10:39 a.m.) Facility lacked documentation for a three-year, four-hour load test;
E. (10:39 a.m.) Facility lacked documentation to show the diesel fuel was tested in the two generators in the past year.

Interview with the building services supervisor on June 16, 2022, at 10:39 a.m., confirmed the above essential electric documentation was unavailable at the time of the survey.

Based on document review and interview, the facility failed to maintain essential electric system testing and maintenance requirements for one of two generators.

Findings include:

Document review on June 16, 2022, between 10:36 a.m. and 10:39a.m., revealed the following essential electric system deficiencies:
A. (10:36 a.m.) Louvre motor had broken free and had one bent mounting bracket (June 4, 2022 Kohler generator report);
B. (10:38 a.m.) One battery junk, with no DC volts possible due to an internal short (June 4, 2022 Kohler generator report);
C. (10:39 a.m.) Facility lacked documentation for its annual 90-minute load bank test;
D. (10:39 a.m.) Facility lacked documentation for a three-year, four-hour load test;
E. (10:39 a.m.) Facility lacked documentation that the diesel fuel quality test was performed for the two generators within the past year.

Interview with the building services supervisor on June 16, 2022, at 10:39 a.m., confirmed the above essential electric documentation was unavailable at the time of the survey.

Based on observation and interview, the facility failed to maintain electrical power cords for one of over fifty rooms.

Findings include:

Observation on June 16, 2022, at 12:23 p.m., revealed the "Seneca Sleep Disorders Center" room had a coffee pot and microwave plugged into a surge protector.

Interview with the maintenance supervisor and administrator of Warren Medical Group on June 16, 2022, at 12:23 p.m., confirmed the above power cord deficiency.

Based on observation and interview, the facility failed to maintain electrical power cords for three of over 100 rooms.

Findings include:

Observation on June 16, 2022, between 10:05 a.m. and 12:06 p.m., revealed the following electrical power cord deficiencies:
A. (10:05 a.m.) Basement Johnson Control air dryer was plugged into an extension cord;
B. (11:43 a.m.) First floor physicians lounge had a coffee pot and toaster plugged into a surge protector;
C. (12:06 p.m.) First floor operating room had a hospital-grade extension cord with damaged insulation.

Interview with the maintenance supervisor and administrator of Warren Medical Group on June 16, 2022, at 12:06 p.m., confirmed the above power cord deficiencies.

Based on observation and interview, it was determined that the facility failed to maintain medical gas cylinder storage on one of four levels.

Findings include:

Observation on June 16, 2022, at 10:21 a.m., revealed the first floor oxygen storage had an unsecured acetylene tank stored with multiple oxygen tanks.

Interview with the maintenance supervisor on June 16, 2022, at 10:21 a.m., confirmed the above gas cylinder storage deficiency.