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Based on observation, the facility failed to ensure fire/smoke barrier doors located in the fire/smoke partitions were maintained per NFPA 101-2012, Section 19.3.7.8.

This deficiency affects 2 of 2 smoke compartments.

Findings include:

1. During an observation on 8/11/2021 at 10:08 a.m., the right leaf of the 3 hour rated fire doors leading to the North Hall failed to latch upon being exercised twice.

Based on observations, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Sections 7.1.10.1. This deficiency affects 1 of 2 smoke compartments.

Findings include:

1. During an observation on 8/11/21 at 11:53 a.m., the ED-Lab corridor was found to be lined with stored items. There were 2 chairs, a large crib, 2 beds, and a rolling storage rack in the corridor.

Based on observations, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Sections 7.1.10.1. This deficiency affects 1 of 6 smoke compartments.

Findings include:

1. During an observation on 8/11/21 at 12:50 p.m., the generator hallway was found to be partially blocked with stored items, such as seed spreaders, large rolling bins, and miscellaneous boxes.

Based on observation, the facility failed to ensure doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side in accordance with NFPA 101-2012, Section 7.2.1.5.3, 7.2.1.5.10, and 7.2.1.6. Facilities can only lock doors and gates in the case of clinical need such as a special care unit. This deficiency affects the entire facility.

Findings include:

1. During an observation on 8/11/21 at 11:34 a.m., the ED access doors to Imaging was inspected. The doors were magnetically locked. They would unlock with activation by staff using a card swipe or fob-type access mechanism. There was also a green button on the Imaging side of the doors. It appeared as a "push to exit" button as one would find with special locking arrangements such as access-controlled egress doors, but was lacking the motion sensor on the egress side. Further inspection revealed the button is actually the releasing mechanism for delayed egress locking system. There was no signage on the door or near the button to explain how the delayed egress system worked.

In an interview on 8/11/21 at 2:00 p.m., non-staff member A stated the doors in the facility with the special locking arrangements to not unlock with the facility fire alarm system being activated either. He stated the latching system utilized by the crash bar was not actually latching the door, the magnets were the locking system, with the single release point being the green button.

The facility must decide which type of special locking arrangement they want to utilize throughout the facility, either delayed egress, or access-controlled egress and then apply all the features the code requires in NFPA 101-2012 Section 7.2.1.6. The locked doors in the lighted path of egress must also unlock and be open to occupants in the event the sprinkler or fire detection systems are activated.

Based on observation, the facility failed to maintain egress doors to unlock in accordance with NFPA 101, 2012 Edition, Sections 7.2.1.5.3 and 7.2.1.5.10.1.

This deficiency affects 1 of 7 smoke compartments in the facility.

Findings include:

1. The oxygen storage room off the main corridor to the front entrance from the nurses station was inspected. The corridor door had a keyed dead bolt located 60" from the floor. The maximum height of any releasing mechanism is no more than 48 inches from the floor.

2. During an observation on 8/11/21 at 1:37 p.m., the med surge utility room was inspected. The room had a dead bolt which could not be operated from the egress side of the room.

Based on observation, the facility failed to ensure storage room doors were able to close, and latch under the power of a self-closing device in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3. The deficiency affects 1 of 1 smoke compartment on the floor.

Findings include:

1. During an observation on 8/11/2021 at 10:16 a.m., the area behind the nurses station was inspected. The area is open to the corridor, there are no doors on the room. It was being used as a storage area for linens and other items.

Based on observation, the facility failed to ensure storage room doors were able to close, and latch under the power of a self-closing device in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3. The deficiency affects 1 of 2 smoke compartments.

Findings include:

1. During an observation on 8/11/2021 at 10:37 a.m., the pediatric storage room was inspected. The corridor door would not close and latch under the power of the self-closer.

Based on observation, the facility failed to ensure storage room doors were able to close, and latch under the power of a self-closing device in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3. The deficiency affects 1 of 3 smoke compartments.

Findings include:

1. During an observation on 8/11/2021 at 10:18 a.m., the South wing storage room was inspected. The room was greater than 50 square feet, there was no self-closer on the door to the room.

Based on observations, the facility failed to ensure hazardous rooms had doors which were able to close, and latch under the power of a self-closing device in accordance with NFPA 101, 2012 Edition, Sections 18.3.2.1.3 and 18.3.2.1.5. These deficiencies affect 1 of 6 smoke compartments.

Findings include:

1. During an observation on 8/11/21 at 1:06 p.m., the soiled linen room off the OR locker room corridor would not latch under the power of the self-closing device.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8).

This deficiency affects 1 of 2 smoke compartments.

Findings include:

1. During an observation on 8/11/21 at 12:15 p.m., ED room 12 was inspected. There was an ABHR dispenser mounted over the low voltage IT outlet in the room.

Based on observation, the facility failed to ensure accessibility to a manual fire alarm box in accordance with NFPA 101, 2012 Edition, Section 9.6.2.7

This deficiency affects 1 of 3 smoke compartments in the facility.

Findings include:

1. During an observation on 8/11/21 at 12:49 p.m., the materials warehouse was inspected. The pull station by the back exit door was found to be blocked and hidden from view by several boxes stacked up around it.

Based on observation, the facility failed to properly install a sprinkler head in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, Section 8.6.4.1.1.1. and failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

These deficiencies affect 1 of 2 smoke compartments.

Findings Include:

1. During an observation on 8/11/2021 at 11:58 a.m., the electrical room off the ED back corridor did not have a drop-in ceiling at the level of the current sprinkler head. And there was no sprinkler head up higher within 12 inches of what is the current ceiling.

2. During an observation on 8/11/21 at 12:11 p.m., the decontamination shower room off the ED was inspected. The ceiling mounted light in the room was blocking the sprinkler head next to it.

Based on observation, the facility failed to sprinkle an alcove in the rehab area, in accordance with NFPA 101, Life Safety Code, 2012 Edition, Section 19.3.5.1. The deficiency affects 1 of 2 smoke compartments.

Findings include:

1. During an observation on 8/11/2021 at 10:52 a.m., the alcove near the hydrocollator was inspected. There was no sprinkler head covering the alcove. There was a sprinkler head near the alcove, but there was also a 12" header separating the alcove from the corridor. The sprinkler head would not cover the entire alcove.

Based on interview and record review, the facility failed to ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1.

These deficiencies affect 1 of 2 smoke compartments.

Findings include:

1. During an observation on 8/11/21 at 10:37 a.m., the pediatric storage room was inspected. There was a ceiling tile out of the drop-down ceiling.

2. During an observation on 8/11/21 at 10:39 a.m., the rehab housekeeping closet was inspected. There was a large hole in the sheet rock in the ceiling in the closet.

Based on interview and record review, the facility failed to ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1.

This deficiency affects 1 of 3 smoke compartments.

Findings include:

1. During an observation on 8/11/21 at 10:19 a.m., the crutch and walker storage room was inspected. There was a ceiling tile out of the drop-down ceiling.

Based on observation and interview, the facility failed to continuously maintain automatic fire sprinklers in reliable operating condition including examination of the heads for debris per NFPA 25-2011, Sections 5.2.1.1.2.

These deficiencies affect 1 of 2 smoke compartments.

Findings include:

1. During an observation on 8/11/21 at 11:24 a.m., the sprinkler heads in the imaging corridor were inspected. There was one head in the corridor which appeared to be corroded, from maybe a small leak.

Based on observation and record review, the facility failed to:

a) document the monthly gauge readings on the sprinkler systems per NFPA 25-2011, Section 5.2.4.1.,
b) complete the 5-year internal inspection of all of the automatic sprinkler systems on campus per NFPA 25-2011, Section 14.2.1; and Table 8.6.5.1.1;
c) maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition Section 6.2.7.1 and NFPA 101-2012 and NFPA 25-2011, Section 5.2.1.1

These deficiencies affect 1 of 9 smoke compartments of the facility.

Findings include:

1. Review of facility records reflected the facility was not documenting monthly pressure readings on the wet system, and weekly pressure readings on the dry system.

2. Record review and observation reflected the sprinkler system had not had the 5 year internal inspection completed.

3. During an observation on 8/11/21 12:36 p.m., the janitor's closet in the kitchen was inspected. The sprinkler head in the room was missing the escutcheon ring.

4. During an observation on 8/11/21 at 12:38 p.m., the kitchen office was inspected. There was a sprinkler head in the room missing the escutcheon ring, creating a large annular ring around the sprinkler head.

5. During an observation on 8/11/21 at 12:54 p.m., the main electrical room was inspected. The sprinkler head in the room was missing the escutcheon ring.

Based on observations, the facility failed to maintain the automatic sprinkler system with regard to the protective caps per NFPA 13, 2010 Edition, Section 8.3.1.5. This deficiency affects 1 of 6 smoke compartments.
Findings include:

1. During an observation on 8/11/21 at 1:08 p.m., the clean linen storage room was inspected. The two sprinkler heads in the rooms still had the protective caps over the bulbs.

Based on observation, the facility failed to install portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.8.1. The deficiency could affect 1 of 1 basement smoke compartment.

Findings include:

1. During an observation on 8/11/21 at 12:54 p.m., the portable extinguisher in the main electrical room was found to be mounted at 63" high, 3 inches higher than the maximum height of 60".

Based on observation, the facility failed to maintain corridor doors without openings or transfer grilles in accordance with NFPA 101, 2012 Edition, Section 19.3.6.4.1. This deficiency affects 1 of 2 smoke compartments.

Findings include:

1. During an observation on 8/11/21 at 10:43 a.m., the IT closet in the rehab area was found to be equipped with a transfer grill in the corridor door. Transfer grills are only allowed in auxiliary spaces that do not contain flammable and combustible materials.

Based on observation, the facility failed to ensure fire/smoke barrier doors located in the fire/smoke partitions were maintained per NFPA 101-2012, Section 8.4.3.4 and NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, Section 6.3.1.7.1

This deficiency affects 1 out of 2 smoke compartments.

Findings include:

1. During an observation on 8/11/21 at 11:04 a.m., two sets of smoke/fire cross-corridor doors in the main corridor to the main entrance had gaps larger than 1/4' when closed. Smoke/fire doors shall not have gaps larger than 1/8".

Based on record review and interview, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6. This deficiency affects the entire facility.

Findings include:

1. Review of facility documents regarding fire drills on 8/11/21 reflected the facility failed to perform fire drills during the NOC shift of the second quarter of 2021.

Based on record review, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report). This deficiency affects all of the fire/smoke compartments.

Findings include:

1. Review of the fire safety maintenance records on 8/11/21, reflected the lack of the annual fire door assembly testing documentation. The facility must identify the required fire/smoke barriers, as well as electronically controlled doors and doors with special locking arrangement in the building and show inspections of all components of the doors in those barriers.

Based on record review, the facility failed to maintain the receptacles in patient areas. The deficient practice affected the entire facility.

Findings include:

Record review on 8/11/2021 revealed non-hospital grade receptacles located in resident rooms throughout the facility did not have annual retention testing as required by sections 6.3.4.1.2 and 6.3.4.1.3 in NFPA 99, Health Care Facilities Code.

Actual NFPA Standard: NFPA 99 (2012), 6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Based on record review and interview the facility failed to fix the problems identified in the annual med gas report in accordance with NFPA 99 Health Care Facilities Code.

This deficiencies affect all areas of the building with piped oxygen.

Findings include:

1. Review of the annual med gas report, dated 12/15/2020, reflected a number of issues with the piped oxygen system. None of the issues identified had been fixed by the vendor or the facility.

In an interview on 8/11/2021 at 9:00 a.m., staff member A stated he had been meaning to get to the fixes, but had not been able to get them done.

Based on observation, the facility failed to store oxygen cylinders in from tipping over per NFPA 99, 2012 Edition, Sections 11.3.3 and 11.6.2.3. The deficiency affects 1 of 2 smoke compartments.

Findings include:

1. During an observation on 8/11/21 at 12:05 p.m., there were 27 E-sized oxygen tanks found to be stored in the open in the emergency department. Only 12 tanks are allowed to be stored in the open in a smoke compartment.