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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.

Findings include:

1. During an observation on 4/4/23 at 10:24 a.m., the marked egress exit outside the PT/OT room was inspected. The egress path to the public way was completely obstructed by benches, chairs, and a small temporary fence.

Based on observation, the facility failed to ensure latches or locks were not mounted above acceptable heights on egress doors in accordance with NFPA 101, 2012 Edition, Section 7.2.1.5.10.1, failed to maintain egress doors with only one releasing operation in accordance with NFPA 101, 2012 Edition, Sections 7.2.1.5.10.2, and 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.

Findings include:

1. During an observation on 4/4/23 at 9:26 a.m., the corridor doors to the laundry were inspected. Each door had a dead-bolt lock which was mounted about 60" above the floor. 48 inches in the maximum height for any lock or latch on a door.

2. During an observation on 4/4/23 at 9:57 a.m., the staff locker room was inspected. The door leading to the room was found to be fitted with a lock which required more than one motion to open the door. The room had the capacity to hold three or more people.

3. During an observation on 4/4/23 at 10:19 a.m., the administration hall, dining corridor, was inspected. The corridor was a marked exit, it had a set of cross-corridor doors which were found to be locked with magnetic locks. There was no delayed egress set up on these magnetic locks. There was also an exit sign above the doors. Marked egress pathways cannot be locked, and if they are, they must be set up with special locking arrangements such as delayed-egress or access-controlled egress assemblies.

Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7 and section 19.2.2.2.8.

Findings include:

1. During an observation on 4/4/23 at 9:24 a.m., the corridor door to the maintenance shop was found to have a kick-down device holding the door open. The room is considered a hazardous area and the door to the room had a self-closer which would not close the door when the kick-down device was engaged.

Additionally, many kick-down devices were noted throughout the facility. Corridor doors must be able to be closed by merely pushing or pulling the door. Any corridor doors to hazardous rooms must have self-closers, if the door is held open, it must be on a magnetic releasing device that will operate upon triggering of the fire-alarm system.

Based on record review, the facility failed to provide emergency exit lighting per NFPA 101-2012, Sections 19.2.9.1, 7.10.5.2.1, 7.8.2.2 and 7.9.3.1.1.

Findings include:

1. Review of the facility records for testing of the emergency lighting on 4/4/23 revealed the 30 second monthly and the 90 minute annual test of the emergency exit lighting fixtures with battery-powered backup was not completed 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 4/4/23 at 10:02 a.m., the administration hallway was inspected. The cross-corridor doors going toward the main entrance did not have an illuminated exit sign visible in the corridor. There was only a small printed black and white exit sign taped to the door.

Based on observation, 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 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 4/4/23 at 9:40 a.m., the PPE storage room was inspected. The room was observed being used as a storage area, and it is over 50 square feet. There was no self-closing device on the corridor door as required for storage rooms. Additionally, the corridor door was found to have two large holes in the door.

2. During an observation on 4/4/23 at 10:34 a.m., the clean storage room on the patient wing was inspected. The room is a hazardous room, it was over 50 square feet, and the corridor door did not have a self-closer on the door.

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 4/4/23 at 10:31 a.m., the pharmacy was inspected. There was an ABHR dispenser mounted over a receptacle in the room.

Based on record review and interview, the facility failed to ensure that load voltage tests were conducted on the batteries of the fire alarm control panel (FACP) semi-annually, as required per NFPA 72-2010, Table 7-3.2.

Findings include:

1. During a review of the most recent facility fire alarm inspection on 4/4/23, the fire alarm report was inspected. There was no indication either written on the batteries or in the panel that the six-month voltage test had been completed by the facility.

The last fire alarm system inspection which had been completed by the vendor was June 17, 2022. The voltage test was due in December of 2022.

During an interview on 4/4/23 at 11:00 a.m., staff member A stated it had not been completed.

Based on observation, the facility failed to sprinkle the entire facility in accordance with NFPA 101, Life Safety Code, 2012 Edition, Section 19.3.5.1.

Findings include:

1. During an observation on 4/4/23 at 9:32 a.m., the old electrical room was inspected. There was no sprinkler head in the room.

2. During an observation on 4/4/23 at 10:26 a.m., the newly remodeled FACP room was inspected. The room was found to be missing a sprinkler head.

Based on observation, the facility failed to:
a) maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1.;

b) 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.;

c) 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(3), and;

d) failed to ensure sprinkler heads over 50 years old had been tested or replace in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protections Systems, Table 5.1.1.2, Sections 5.3.1.1.1, 5.3.1.2, and 5.3.1.3.

Findings include:

1. During an observation on 4/4/23 at 9:25 a.m., the laundry was inspected. The sprinkler head in the room was observed, missing its escutcheon ring.

2. During an observation on 4/4/23 at 9:36 a.m., the boiler room was inspected. The new boilers had two large intake stacks which were found to be suspended via cables from the sprinkler pipes in the room.

3. During an observation on 4/4/23 at 9:45 a.m., there was a sprinkler head missing the escutcheon ring in the corridor outside the liquid oxygen room.

4. During an observation on 4/4/23 at 9:55 a.m., the large OB room was inspected. There was a large 4"x 4" hole in the ceiling tile just outside the room.

5. During a review of facility sprinkler reports on 4/4/23, it was found the vendor stated the sprinkler heads in the crawl space were over 50 years old. This was on a report from 3/3/20. The facility had not had any of the heads sampled and tested at the time of the survey. Sampling must include a minimum of 4 heads or 1% of the total in the space, whichever is greater.

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 6.1.3.3.1.

Findings include:

1. During an observation on 04/04/2023 at 10:21 a.m., the the PT/OT room was inspected. There was a portable extinguisher in the room which was mounted over the top of a counter top. This is obstructive to people of smaller stature to be able to remove the extinguisher from the wall.

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.

Findings include:

1. During an observation on 4/4/23 at 10:51 a.m., the cross-corridor doors between the ER and Imaging were inspected. When closed, the doors had a gap between them of about 1/4". Wood doors, when closed, cannot have a gap greater than 1/8".

2. During an observation on 4/4/23 at 10:51 a.m., the cross-corridor doors between Imaging and the waiting area were inspected. When closed, the doors had a gap between them of about 1/4". Wood doors, when closed, cannot have a gap greater than 1/8".

Based on record review, 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 and 19.7.2.2.

Findings include:

1. During a review of facility fire drills on 4/4/23, it was determined the facility had not completed fire drills for the NOC shift of the first quarter of 2023.

2. During a review of the facility fire drills on 4/4/23, the facility failed to communicate to the staff that an actual phone call must be placed (simulated during a planned drill) to 911 or the area dispatch to let the fire department know that it is indeed a fire and where it is in the building. Staff must be trained to read the fire alarm control panel FACP, and be able to understand what it is saying.

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 smoke compartments.

Findings include:

1. Review of the fire safety maintenance records on 4/4/23, 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 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 4/4/23 at 10:06 a.m., the kitchen mechanical room outlets were inspected. There was an outlet cover in the room which was cracked and broken.

Based on interview and record review, the facility failed to have evidence that the generator was being exercised under load 12 times a year for 30 minutes in accordance with NFPA 110 Standard for Emergency and Standby Power Systems, 2010 Edition, Section 8.4.2.4.

Findings include:

Record review of the facility generator logs on 4/4/23 revealed that the natural gas generator was not being run for 30 minutes under the available load on a monthly basis. It was only being run annually under load. Spark-ignited gensets do not have the allowance to only be load-tested annually only.

In an interview on 4/4/23 at 9:00 a.m., staff member A stated that there are several transfer switches and they were not sure how it could be tested monthly. The vendor from TW enterprises was at the facility during the survey and stated that it could be done, it would take a couple hours to show facility staff how to do it.