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Based on observation and interview, the facility did not maintain the means of egress door in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.2.2.2.4 , 7.2.1.5.1, 7.2.1.5.3 , 7.2.1.5.10, 7.2.1.5.10.2 & 7.2.1.6.1.1(4). This deficiency had the potential to affect an undetermined number of inpatients, staff and visitors.

Findings include:

On 7/24/2019 at 11:15 am, observation revealed in the second floor OR suite, that the OR suite door was equipped with separate a dead bolt locking system that required more than one operation to unlock it, and was not readily openable from the egress side.

This deficient practice was confirmed by Staff D at the time of discovery.

Based on observation and interview, the facility failed to provide a reliable source of illumination at exit discharges in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.2.8, 19.2.9.1, 19.7.3, 7.8, 7.8.1, 7.8.2, 7.8.2.1, 7.9, 7.9.1 and 7.9.1.1. This deficiency had the potential to affect an undetermined number of inpatients, staff and visitors.

Findings include:

On 7/23/19 at 2:51 PM, observation revealed that the exterior sidewalk at the discharge from the first floor dining room did not have any exterior lighting to provide the minimum required amount of illumination for the exit discharge path.

This deficient practice was confirmed by Staff D at the time of discovery.

Based on observation and interview, the facility failed to provide protection of the vertical floor opening in accordance with NFPA 101 (2012 edition) Sections 19.3.1, 8.6., and 8.6.2; NFPA 90A (2012 edition) Sections 5.3.2 and 5.4. This deficiency had the potential to affect an undetermined number of inpatients, staff and visitors.

Finding include:

On 7/23/19 at 1:45 PM, observation revealed in the first floor laundry room that there was a 2'-0" x 1'-0" duct penetration thru the floor above without the proper fire-stopping. Staff D was not able to confirm whether that duct was enclosed in a shaft or not and there was no fire damper at the two hour rated floor penetration.

This deficient practice was confirmed by Staff D at the time of discovery.

Based on observation and interview, the facility did not maintain a hazardous area in accordance with the requirements of NFPA 101 - 2012 edition, sections 19.3.2.1, 19.3.2.1.2, 19.3.2.1.3 and 8.4. This deficiency had the potential to affect an undetermined number of inpatients, staff and visitors.

Findings include:

On 7/23/2019 at 1:35 PM, observation revealed in the first floor soiled linen room that the hazardous room was protected with a sprinkler system but was not smoke tight. There was a 2 inch diameter hole in the wall.

This deficient practice was confirmed by Staff D at the time of discovery.

Based on observation, interview & record review, the facility did not provide battery powered emergency lights in an anesthetizing location in accordance with the requirements of NFPA 101 (2012 edition), Section 19.3.2.3 , NFPA 99 (2012 edition), Section 6.3.2.2.11.1, 6.3.2.2.11.2, 6.3.2.2.11.3, 6.3.2.2.11.4 & 6.3.2.2.11.5. These deficiencies had the potential to affect an undetermined number of inpatients, staff and visitors.

Findings include:

1. On 7/23/2019 at 12:45 PM, during review of the facility emergency light testing records it was discovered that tests were not conducted for the emergency lights located inside second floor operating rooms for a minimum of 30 seconds each month and 30 minutes annually within the last year.

2. On 7/24/2019 at 11:25 am, observation revealed in the 2nd floor operating room that the operating room OR-A and OR-B were used to administer general anesthesia and deep sedation, and one or more battery powered lighting units were not provided inside these operating rooms.

These deficient practices were confirmed by Staff D at the time of discovery.

Based on observation and interview, the facility did not maintain the automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 19.3.5 and 9.7.5, and NFPA 25 - 2011 edition, Sections 4.4, 5.2.1 & 5.2.1.1.1. This deficiency had the potential to affect an undetermined number of inpatients, staff and visitors.

Findings include:

On 7/24/2019 at 10:50 am, observation revealed in the second floor story-2, room 141 that the lose sprinkler head escutcheon ring came out of the ceiling.

This deficient practice was confirmed by Staff D at the time of discovery.

Based on observation and interview, the facility failed to install and maintain the portable fire extinguishers as required by NFPA 101 (2012 edition), Sections 19.3.5.12 and 9.7.4.1, and NFPA 10 (2010 edition) Section 6.1.3.8.3. This deficiency had the potential to affect an undetermined number of inpatients, staff and visitors.

Findings include:

On 7/23/2019 at 2:05 PM, observation revealed in first floor emergency generator room that two ABC type fire extinguishers were kept on the floor and the the clearance between the bottom of the hand portable fire extinguishers and the floor were less than 4 inches.

This deficient practice was confirmed by Staff D at the time of discovery.

Based on observation and interview, the facility failed to provide corridor spaces separated by corridor walls and doors that meet the requirements of NFPA 101 (2012 edition), 19.3.6.1, 19.3.6.2 and 19.3.6.3. This deficiency had the potential to affect an undetermined number of inpatients, staff and visitors.

Findings include:

On 7/23/19 at 3:00 PM, observation revealed that the first floor reception area was not properly separated from the exit egress corridor by wall or door construction. The room had a 48 inch high by 60 inch wide pass through window. The window had a manually operated vertical shutter that did not have positive self-latching. The area did not satisfy all of the requirements for an exception for spaces open to the corridor. The space did not have a smoke detector, nor was it arranged and located to allow direct supervision by the facility staff from the nurses' station or similar location.

This deficient practice was confirmed by Staff D at the time of discovery.

Based on interview and observation, the facility failed to provide an emergency electrical generator with a remote stop and to ensure the correct clearance in front of the electrical panels in accordance with the requirements of NFPA 101 - 2012 edition, Sections 9.1.3.1, 9.2.1; NFPA 110 - 2010 edition, Sections 7.2.1, 7.2.1.1 and 7.2.1.2; NFPA 90A - 2012 edition, Sections 5.3.1 & 5.3.1.1; NFPA 70 (2011 edition), section 110.26. These deficiencies had the potential to affect an undetermined number of inpatients, staff and visitors.

Findings include:

1. On 7/23/2019 at 2:05 pm, observation revealed in the first floor emergency generator room that there was a 2'-0" x 2'-0" duct penetration without any fire damper. Also, 2 bags of salt were stored inside the emergency generator room.

2. On 7/24/2019 at 1:30 pm, observation revealed in the second floor clean linen room 224, that access to the electrical panels E2A and L2A were less than the minimum required 3'-0" clearance. Large linen carts were stored in front of the main electrical panels.

These deficient practices were confirmed by Staff D at the time of discovery.