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Based on record review the facility failed to plan and implement a provision of subsistence needs for the patients. This affects all occupants in the facility.

Findings include:

1. Review of the EP plan, policies, and procedures on 07/25/23, reflected the facility lacked a complete system for determining subsistence needs for patients, particularly what life safety systems will remain online in the event of a power failure.

Based on record review, the facility failed to develop policies and procedures related to the emergency and standby power systems for the EP plan. The record review showed insufficient information about the role of the emergency generator meeting care needs of the patients, the other occupants, as well as the building's needs based on the facility's safety and hazard vulnerability assessment. This deficiency affects all of the occupants in the facility.

Findings Include:

1. Review of the EP plan on 07/25/23 reflected a lack of specific details about the emergency generator and what kind of services could be supported by the onsite emergency generator, i.e., the building temperatures, daily kitchen functions, safe food storage, illumination of the exit halls and exit signs, and the fire alarm, extinguishing and detection systems in the building.

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.

Findings include:

1. During an observation on 07/25/23 at 12:19 p.m., the OR suite was inspected. There were two sets of doors that were magnetically locked. They would unlock with activation by staff using a card swipe access mechanism. There was also a green button on the egress 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 to automatically unlock the door to an approaching occupant on the egress side.

Whatever type of special locking arrangement they want to utilize throughout the facility, either delayed egress, or access-controlled egress, the facility must 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 properly post mandatory signage regarding the locks on the exit doors as required by the code in accordance with NFPA 101, 2012 Edition, Sections 39.2.2.2.2 and 7.2.1.5.5.

Findings include:

1. During an observation on 07/25/23 at 1:47 p.m., the marked exit pathway to the rear exit door lacked the verbiage, "This door to remain unlocked when the business is occupied."

Based on observation, the facility failed to ensure all exit passageways were marked in accordance with NFPA 101 2012 Edition, Section 7.10.1.2.2.

Findings include:

1. During an observation on 07/25/23 at 1:42 p.m., the east exit passage in Pintlar Family Medicine 2 was inspected. The exit passageway lacked a visible sign where the means of egress was not obvious.

Based on observation, the facility failed to assure hazardous rooms/areas 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 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 07/25/23 at 11:40 a.m., the basement corridor was inspected. There were several beds being stored in the corridor, creating a hazardous area. Combustible items must be stored in a room with a self-closing door.

2. During an observation on 07/25/23 at 11:42 a.m., the basement storage room was inspected. The room has a set of double doors at the corridor opening. The gap between the doors was approximately 1/4", making it non-resistant to the passage of smoke.

Based on record review, the facility failed to ensure piped oxygen shutoff valves were accessible in accordance with NFPA 99 Healthcare Facilities Code 2012 Edition, Section 5.1.4.8.4

Findings include:

1. During an observation on 07/25/23 at 12:20 p.m., the "sterile core" area of the OR suite was inspected. The zone valves for OR 2 and OR 4 were blocked by the rolling shelving units in the core. Occupants could not readily see the shutoffs, or get to them easily in an emergency.

Based on record review, the facility failed to maintain the kitchen hood extinguishing system in accordance with NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition, Section 11.2.1.

Findings include:

1. Record review of the kitchen hood system cleaning records reflected a lack of documentation to show the contractor had performed services on a semi-annual basis. The last recorded inspection of the hood extinguishing system was September of 2022. The hood system was due to be inspected again in March of 2023.

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).

Findings include:

1. During an observation on 07/25/23 at 12:35 p.m., LDR 2 was inspected. There was an ABHR dispenser mounted over a light switch in the area.

Based on observation, the facility failed to:

a) ensure spare sprinklers were available in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.5, and NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition, Section 6.7.4.; and
b) ensure sprinkler pipes were free of external loads in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2.

Findings include:

1. During an observation on 07/25/23 at 1:11 p.m., the old main hospital standpipe and its accessory items were inspected. The spare sprinkler box was found to be missing directional sprinkler heads. Directional heads were in use on the system fed by the standpipe.

2. During an observation on 07/25/23 at 1:20 p.m., the MRI suite was inspected. In the electrical room, a bundle of copper pipes were found to be supported by a wire wrapped around the over-head sprinkler pipe.

Based on observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.2.1.2 and Table 6.2.1.1.

Findings include:

1. During an observation on 07/25/23 at 1:02 p.m., the portable extinguisher in the lab was found to be blocked from easy access by items being stored in front of it.

Based on observation, the facility failed to maintain corridor door openings in accordance with NFPA 101, 2012 Edition, Section 7.2.1.4.1.

Findings include:

1. During an observation on 07/25/23 at 12:50 p.m., the clean room on B hall was inspected. The door to the room was found to be blocked from opening fully due to the room having items stored behind the door. The door would only open half-way.

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.

Findings Include:

1. During an observation on0 7/25/23 at 12:46 p.m., the cross-corridor fire doors on B hall were exercised twice. Both of the doors failed to securely latch under the power of the self-closer.

2. During an observation on 07/25/23 at 1:05 p.m., the cross-corridor doors in the main hall by the conference room were exercised. One side of the doors failed to close and latch under the power of the self-closer.

Based on observation, the facility failed to assure that a fire-rated door, protecting the linen chute, closed and latched with the efforts of the self-closing device per NFPA 101 2012 Edition, Sections 9.5, 8.3, and 7.2.1.8.1, and NFPA 80 Standard for Fire Doors and Other Opening Protective's 2010 Edition, Sections 6.1.4.2.1 and 6.1.4.3.1.

Findings include:

1. During an observation on 07/25/23 at 12:25 p.m., the linen chute in the OR suite was inspected. Upon first look, the door to the chute was not latched. It was exercised twice and failed to close and latch both times.