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Based on Observationon tour it was determined the facility failed to provide a safe means of egress through the exit pathway at the West Campus . Failure to provide a clear and unimpeded means of egress could cause harm to the patients and staff in a fire emergency.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10.1 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency." Section 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto egress therefrom, or visibility thereof.

Observations on tour on September 22, 2020 revealed the hallway from the dirty side to the clean side in the sterile process room was narrowed to two (2) feet from the required three (3) feet with boxes.

Employees #17 and #88 confirmed during the walkdown and at the exit conference on September 24, 2020 that the hallway from the dirty side to the clean side in the sterile process room was narrowed to two (2) feet from the required three (3) feet with boxes.

Based on observation, it was determined the facility failed to maintain the special locking exit door located on the
2nd floor of the East Campus Kids unit. Failing to provide manual release of the exit doors can cause the door to prevent exit during a fire which likely would result in injury or death to staff or patients.

NFPA 101 Life Safety Court, 2012, Chapter 19, Section, 19.2.2.2.4 "Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side." Exception No. 2 "Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. Section 7.2.1.6.1 "Special Locking Arrangements" " (c) An irreversible process shall release the lock within 15 to 30 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbs nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only."

Findings include:

Observations on tour on September 23, 2020 revealed the kids unit stairwell door would not release when held for 15 seconds. The exit door was tested manually by pushing the panic bar maintenance staff team members made more than three (3) attempts to open the door manually.. The exit door was tested by the alarm company (Climitec) on May 5, 2020 and verified to open during alarm testing.

Employees #17 and #88 acknowledged during the walkdown and at the exit conference on September 24, 2020 that the kids unit stairwell door would not release when held for 15 seconds. The exit door was tested manually by pushing the panic bar maintenance staff team members made more than three (3) attempts to open the door manually. The exit door was tested by the alarm company (Climitec) on May 5, 2020 and verified to open during alarm testing. Maintenance removed the key tumbler so the door would no longer be locked until the latching device could be replaced.

Based on observations conducted September 22, 2020 one (1) of the support builds at the west campus failed to provide emergency lighting in the basement and main and second floor. Failing to install, test and document the battery backup emergency lighting units in case of an emergency or power outage could cause harm to the patients during a power outage.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.9.1 "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " Section 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional Testing shall be conducted monthly with a minimum of 3 weeks and a maximum of 5 weeks between tests. , for not less than 30 seconds except as otherwise permitted by 7.9.3.1.1.(2) The Test interval shall be permitted to be extended beyond 30 days with the approval of authority having jurisdiction.(3) Functional testing shall be conducted annually for a minimum of 1/1/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings include:

Observations on tour on September 22, 2020, revealed that the temporary CM3 building at the west campus did not have emergency lights installed prior to occupying the building.

Employees #17 and #88 acknowledged during the walkdown and at the exit conference on September 24, 2020 that the temporary CM3 building at the west campus did not have emergency lights installed prior to occuping the building.

Based on observations conducted September 22, 2020 one (1) of the support builds at the west campus failed to provide exit lights in the basement and main and second floor. Failing to install, test and document the testing of the exit lights could cause harm to the patients during a power outage.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.2.10.1, Means of egress shall have signs in accordance with Section 7.10 unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4. Chapter 7, Section 7.10.1.2.1, "Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access." Section 7.10.1.5.1, "Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants."


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Findings include:

Observations on tour on September 22, 2020, revealed that the temporary CM3 building at the west campus did not have exit lights installed prior to occupying the building.

Employees #17 and #88 acknowledged during the walkdown and at the exit conference on September 24, 2020, that the temporary CM3 building at the west campus did not have exit lights installed prior to occuping the building.

Based on observation it was determined the facility failed to provide smoke detection in the Cath Lab schedulers office. Missing smoke detectors could prevent or delay the initiating of the fire alarm system in an emergency and this may cause harm to the patients or staff during a fire.


NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.4.1 Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. detection devices, or detection systems.. Chapter 9, Section 9.6.10.1.2 The installation of smoke alarms in sleeping rooms shall be required where required by Chapters 11 through 43. NFPA 72, 2010 Edition, Chapter 13, Section 14.2.2.1, The property or building or system owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system.


Findings include:

Observations while on tour September 22, 2020 revealed the detector portion of the smoke detector in the schedulers office for the Cath Lab had been removed. Only the base was present.

Employees #17 and #88 acknowledged during the walkdown and at the exit conference on September 24, 2020, the detector portion of the smoke detector in the schedulers office for the Cath Lab had been removed. Only the base was present. The scheduler acknowledged the detector had been missing for a few months.

Based on Observation it was determined the facility failed to assure that all parts of the facility were provided sprinkler system coverage. Failing to provide sprinkler coverage in all areas of the facility by blocking the sprinkler heads could result in the sprinkler not controlling the fire which could cause harm to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, 2010 Edition. Chapter 8, Section 8.6.6.1 "The clearance between the deflector and the top of storage shall be 18 in. or greater."

Findings include:

Observations while on tour September 22 and 23, 2020, and during policy review revealed that storage in many areas where within eighteen (18) inches of the sprinkler heads. No areas were observed to have storage in the middle of the rooms but the facility's policy requires all areas maintain a minimum of eighteen (18) inches clearance form the sprinkler heads there were multible areas with this violations. The following areas revealed storage within
eighteen (18) inches of the sprinkler heads:
1. The dry goods storage in the kitchen
2. The main warehouse on the west campus
3. The lab on the west campus
4. Other office and storage rooms west campus

Employees # 17 and 88 acknowledged during the walkdown and at the exit conference on September 24, 2020 that storage in many areas where within eighteen (18) inches of the sprinkler heads. No areas were observed to have storage in the middle of the rooms but the facility's policy requires all areas maintain a minimum of eighteen (18) inches clearance form the sprinkler heads there were multible areas with this violations. The following areas revealed storage within eighteen (18) inches of the sprinkler heads:
1. The dry goods storage in the kitchen
2. The main warehouse on the west campus
3. The lab on the west campus
4. Other office and storage rooms west campus.

Based on record review it was determined that the facility failed to have the five (5) year inspection of the internal automatic sprinkler piping and guages on the west campus EVS room . Failing to conduct the 5 year inspection of the internal automatic sprinkler piping and guages could allow build-up of foreign material which will affect the operation of the automatic sprinklers and may cause harm to patients and staff


NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.1.1.1.3. General "The provisions of Chapter 4, General, shall apply." Chapter 4, Section 4.6.12.3, "Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed." Section 4.6.12.4, "Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. NFPA 13, "Installation of Sprinkler Systems." Chapter 26, Section 26.1, General, "A sprinkler system installed in accordance with this standard shall be properly inspected, tested and maintained by the property owner or their authorized representative in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed." NFPA 25, Chapter 14, Section 14.2 "Internal Inspection of Piping" "Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and be removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material."


NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, "Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems." NFPA 25, 2011 Edition, "Water Based Extinguishment Systems," Chapter 6, Section 6.3.4.1 states "Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge." Chapter 14, Section 14.2.1 states "Except as discussed in 14.2.1 and 14.2.1.4 an inspection of piping and branch lines conditions shall be conducted every 5 years by opening a flushing connection at the the end of one main and by removing a sprinkler toward the endo of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material."



Findings Include:


Observations on tour on September 23, 2020, revealed the sprinkler system in the EVS on the west campus did not have the NFPA required internal piping and guage five (5) year inspection performed.

Employee # 88 acknowledged during the walkdown and at the exit conference on September 24, 2020, that the sprinkler system in the EVS on the west campus did not have the NFPA required internal piping and guage five (5) year inspection performed.

Based on observation it was determined the facility failed to fill penetrations in two (2) of the smoke barriers in the facility. Failing to seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in the time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall , floor or /ceiling assembly constructed as a smoke barrier , or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

Observations on tour on September 22, 2020, revealed the facility failed to maintain the smoke barriers in the hallway outside the surgical unit where recent construction failed to close all penetrations and the cath lab storage area walls where holes were found to be present.

Employees # 88 acknowledged during the walkdown and at the exit conference on September 24, 2020, that the facility failed to maintain the smoke barriers in the hallway outside the surgical unit where recent construction failed to close all penetrations and the cath lab storage area walls where holes were found in the barrier.

Based on Record Review and Interview the facility failed to properly document weekly generator testing of the generator battery at the East campus. Failure to test the emergency generator under load, inspect weekly, and document time from normal power to emergency power could result in harm to patients during emergency system failures.

NFPA 101 Life Safety Code, 2012, Chapter19, Section 19.7.6 "Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 8.4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 8, Section 8.4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...

Findings Include:

Observations on tour on September 23 and 24, 2020, revealed the East campus failed to document the continuity or conductivity tests on the generators at the East campus. The West campus has forms that showed this testing was completed but these forms were not used at the East campus.

Employees # 88 and #89 acknowledged during the exit conference on September 24, 2020, that the East campus failed to document the continuity or conductivity tests on the generators at the East campus. The West campus has forms that showed this testing was completed but these forms were not used at the East campus.

Based on Observation it was determined the facility allowed the use of power strips and extension cords. multi plug adaptors and did not use the wall outlet receptacles for appliances. The improper use of portable electrcal devices could result in an electrical over load and fire.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

Observations on tour on September 22, 23 and 24, 2020, revealed the following locations with power strips plugged into power strips (Daisy Chained). Use of extension cords as permanent equipment or heavy load drawing appliance (refrigerators, microwaves and large printers) plugged into power strips.
1. The ASC had power strip into UPS at the front desk, and three power strips plugged into a multi plug adaptor.
2. The Wellness center had a heater plugged into a UPS power strip.
3. The CM3 building have a coffee maker plugged into an extension cord.
4. The East campus had power strip into a power strip (daisy chained), a refrigerator plugged into a power
strip in BIO Med, a power strip into a UPS device third (3rd) floor training, a large printer plugged into a power
strip second (2nd) floor A pod and daisy chained power strips in the IT room first (1st) floor
5. The West campus Multi plug power adaptor in the lab area, a refridgerator plugged into a power strip fourth (4th) floor nursing office, daisy chained power strips second (2nd) floor resource room and daisy chained UPS in the mingus room.
6. Multiple other locations had examples of the above listed items but were removed on the spot.

A policy review revealed the facility has a policy against the use of power strips and multi plug adaptors and clear direction on the use of extention cards and all other electrcal devices.

Employee #17, #88, and #89 confirmed during the exit conference and findings review on September 24, 2020 the improper use of power strips, extension cords and multi plug adaptors without surge protection.

Based on Observation the facility failed to secure two medical gas Nitrous Oxide cylinders in a stand or cart. Failing to secure compressed medical gas cylinders could cause harm to the patients and staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."

Findings include:

Observations while on tour September 22, 2020 revealed nine (9) unsecured Nitrous Oxide cylinders and 12 Helium cylinders in the Medical Gas storage room at the west campus.

Employees # 17 and #88 acknowledged during the walkdown and exit conference on September 24, 2020 the existence of nine (9) unsecured Nitrous Oxide cylinders and 12 Helium cylinders in the Medical Gas storage room at the west campus.

Based on interview and program review it was determined the facility failed to provide programs for continuing education and periodic review of safety guidelines and usage requirements for medical gases and oxygen cylinders. Failing to provide programs and periodic review of safety guidelines of oxygen cylinders or liquid oxygen could cause harm to the patients and staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.5.2.1" Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment.

Findings include:

Observations while during the program interview on September 23 and 24, 2020 revealed that none of the facilities had a continuing oxygen risk training program. The facility does provide initial training to staff.

Employees #17 and #88 confirmed during the exit conference on September 24, 2020, that the none of the facilities had a continuing oxygen risk training program. The facility does provide initial training to staff.