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Based on observation and interview, the facility failed to ensure that egress exit doors were properly marked.

Findings include:

On 05/05/21, the acute corridor exit door was considered a confused exit as it was observed to be marked with both an exit sign and a "STOP" sign.

On 05/05/21 at 2:26 PM, the Maintenance Supervisor was present at discovery and promptly removed the "STOP" sign.

NFPA 13
National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, 2010 Edition

6.2.7 Escutcheons and Cover Plates.
6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.
6.2.7.2* Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly.
6.2.7.3 Cover plates used with concealed sprinklers shall be part of the listed sprinkler assembly.
6.2.8 Guards. Sprinklers subject to mechanical injury shall be protected with listed guards.

8.6.4.1 Distance Below Ceilings.
8.6.4.1.1 Unobstructed Construction.
8.6.4.1.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 inch and a maximum of 12 inches throughout the area of coverage of the sprinkler.

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
National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition

5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)* Loading
5.2.1.1.3* Any sprinkler that has been installed in the incorrect orientation shall be replaced.
5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation.

Based on observation, document review and interview, the facility failed to maintain the automatic fire sprinkler system as required.

Findings include:

1) On 05/05/21 at 2:15 PM, a tour of the facility revealed a gap between the escutcheon and ceiling at the Emergency Room nurses' station.
2) On 05/05/21, during a tour of the facility, painter's tape was observed on the escutcheon in the bathroom of Room 202.
3) On 05/05/21, during a tour of the facility, the sprinkler in Room 204 was loaded with dust.
4) On 05/05/21 at 3:01 PM, two sprinklers in the entrance canopy had dropped escutcheons.

The Maintenance Supervisor confirmed the findings at the time of discovery.

National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers, 2010 Edition

6.1.3.3 Visual Obstructions.
6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.
6.1.3.3.2* In large rooms and in certain locations where visual obstructions cannot be completely avoided, means shall be provided to indicate the extinguisher location.
6.1.3.4* Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:
(1) Securely on a hanger intended for the extinguisher
(2) In the bracket supplied by the extinguisher manufacturer
(3) In a listed bracket approved for such purpose
(4) In cabinets or wall recesses

6.1.3.8 Installation Height.
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.
6.1.3.8.2 Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 31?2 ft (1.07 m) above the floor.
6.1.3.8.3 In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm).
6.1.3.10 Cabinets.
6.1.3.10.1 Cabinets housing fire extinguishers shall not be locked, except where fire extinguishers are subject to malicious use and cabinets include a means of emergency access.

Based on observation and interview, the facility failed to 1) ensure all portable fire extinguishers (PFE) were not obstructed or obscured from view, and 2) install and maintain fire extinguishers as required by National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers, 2010 Edition.

Findings include:

1) On 05/05/21, in the Employee Kitchen, a mop bucket was parked in front of a portable fire extinguisher (PFE).

On 05/05/21, the Maintenance Supervisor was present at discovery.

2) On 05/05/21 at 11:25 AM, a PFE was observed in a locked cabinet in the Administration corridor. At the time of discovery, the Coordinator of Policy and Procedure verbalized the cabinet should not be locked.

On 05/05/21 at 12:45 AM, the Maintenance Supervisor verbalized the PFE cabinet locked automatically when the door was closed. The Maintenance Supervisor removed the lock from the PFE cabinet immediately after becoming aware the lock was non-compliant.

NFPA 70; 2011 Edition

Article 314 - Outlet, Device, Pull, and Junction Boxes; Conduit bodies; Fittings; and Handhole Enclosures
314.28(c) Pull and Junction Boxes and Conduit Bodies.
(c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110.

422.51 Cord-and-Plug-Connected Vending Machines.
Cord-and-plug-connected vending machines manufactured or remanufactured on or after January 1. 2005. shall include a ground-fault circuit interrupter as an integral part of the attachment plug or be located within 300 mm (12 in.) of the attachment plug. Older vending machines manufactured or remanufactured prior to January 1, 2005, shall be connected to a GFC1-protected outlet.
Informational Note: For further information, see ANS1/UL 541 -2(X)5, Standard for Refrigerated Vending Machines, or ANSI/UL 751 -2005, Standard for Vending Machines.

Based on observation and interview, the facility failed to ensure electrical wiring and equipment complied with the National Electric Code, National Fire Protection Association (NFPA) 70.

Findings include:

1) On 05/05/21 at 2:01 PM, the vending machine in Admitting was plugged into a receptacle with a missing cover. The receptacle cover was hanging on the vending machine cord.
2) On 05/05/21 at 2:01 PM, the vending machine in Admitting was plugged into a non-GFCI receptacle.

On 05/05/21, the Maintenance supervisor was present at each discovery.

Based on observation, document review and interview, the facility failed to conduct fire drills at unexpected times under varying conditions at least once per shift per quarter.

Findings include:

On 05/06/21, the facility's fire drill logs revealed the following night shift (6:00 PM to 6:00 AM) fire drills were not conducted at unexpected times:

a) 03/11/21 at 5:00 AM.
b) 05/03/21 at 5:00 AM.

On 05/06/21, the Maintenance Supervisor was made aware of the deficiency at the exit interview.