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Based on observation, the facility failed to prevent the use of an enclosed exit stairway for storage purposes per NFPA 101-2012, Sections 7.1.3.2.3 and 7.2.2.5.3.

Findings include:

1. During an observation on 4/19/23 at 12:17 p.m., stairwell number 1041 was inspected. There were two combustible cubical panels being stored in the stairwell.

Based on record review, the facility failed to provide emergency lighting per NFPA 101-2012, Sections 19.2.9.1 and 7.9.3.1.1.

This affects all locations where the battery powered emergency light fixtures were utilized.

Findings include:

1. Review of the facility records for testing of the emergency lighting on 4/19/23 showed a lack of supporting documentation for the 90 minute annual test within the last year.

Based on observation, the facility failed to ensure all egress pathways had illuminated exit signage in accordance with NFPA 101 2012 Edition, Section 7.10.5.

Findings include:

1. During an observation on 4/19/23 at 12:05 p.m., the imaging suite was inspected. The north hallway in the suite lacked a second illuminated exit sign to guide patients and staff to an alternative exit, where that way may not be apparent when the current illuminated exit pathway may be blocked in a fire.

2. During an observation on 4/19/23 at 12:55 p.m., the north end patient hall going into the ICU lacked an illuminated exit sign designating an alternate route through the ICU to another exit if the currently marked and illuminated exit sign is blocked by a fire.

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.

Findings include:

1. During an observation on 4/19/23 at 11:51 a.m., the cafeteria dining room was inspected. There was a marked exit with a pull station in the room. The pull station was located above a counter top with items such as a rack and serving utensils stored on it. There was also a high top table and chairs placed near the counter, obstructing clear access to the pull station.

Based on observation the facility 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.

Findings Include:

1. During an observation on 4/19/23 at 12:50 p.m., room 2002-1, a housekeeping closet was inspected. A ceiling mounted light fixture was found to be obstructing a sprinkler head within the room. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

2. During an observation on 4/19/23 at 1:08 p.m., soiled utility room 2041-1 was inspected. A ceiling mounted light fixture was found to be obstructing a sprinkler head within the room. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

Based on observation, the facility failed to maintain spare sprinklers in accordance with NFPA 101 Life Safety Code 2012 Edition Section 4.2.3, 4.6.12.3., and NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.5.

Findings include:

1. During an observation on 4/19/23 at 11:53 a.m., the standpipe was inspected, the spare sprinkler box contained only pendant sprinkler heads, it did not contain any spare directional heads. During the walk-through, there were directional heads noted in place in the business occupancy.

Based on observation, the facility failed to:

a) continuously maintain automatic fire sprinklers in reliable operating condition including examination of the heads per NFPA 25-2011, Sections 5.2.1.1.2.;

b) maintain spare sprinklers 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

c) maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1.;

Findings include:

1. During an observation on 4/19/23 at 11:39 a.m., the boiler room was inspected. There was a sprinkler head totally covered in fire retardant spray that was applied to the ceiling in the room.

2. During an observation on 4/19/23 at 11:53 a.m., the standpipe was inspected. The spare sprinkler box contained an array of pendant sprinkler heads. It did not contain any spare directional heads. During the walk-through, a directional head was noted in place in the IT room.

3. During an observation on 4/19/23 at 1:02 p.m., both isolation rooms, 2027 and 2028 were inspected. Both rooms were found to have sprinkler heads missing escutcheon rings.

Based on observation, the facility failed to install portable fire extinguishers in accordance with NFPA 101 Life Safety Code 2012 Edition, Sections 39.3.5, 9.7.4.1, and NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.8.1.

Findings include:

1. During an observation on 4/19/23 at 1:19 p.m., there was a portable extinguisher mounted on the wall greater than 60" from the floor.

Based on observation, the facility failed to maintain the electrical system in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-12(B).

Findings include:

1. During an observation on 4/19/23 at 11:49 a.m., the kitchen outlets were inspected. There was an outlet cover in the room which was cracked and broken.