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Based on observation, and staff interview, the facility failed to maintain fire-resistive construction in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly maintain fire-resistive construction could result in the spread of smoke and fire, resulting in injury or death. The deficiency affected a 2-hour fire barrier and has the potential to affect all residents, staff, and visitors.

The findings were:

Observation on 08/24/2023 at 12:36 PM revealed that the facility failed to maintain fire-resistive construction. Observation above the ceiling at the cross corridor doors located on the north end of the LDRP area revealed a large penetration of cables that were not properly firestopped. Observation and document review revealed that the wall was part of a 2-hour fire barrier. Fire-resistive construction shall be continuously maintained.

Interview with the plant operations manager at the time of the observation acknowledge the deficiency, and indicated that they were aware of the requirement.

Interview with the chief executive officer at the time of exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.1.1.1.3, 4.6.12.1

Based on observation and staff interview, the facility failed to properly lock doors in the means of egress in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly lock doors in the means of egress could result in the delay of egress in an emergency, resulting in injury or death. The deficiency affected the corridor open to the emergency department waiting area and has the potential to affect all patients, staff, and visitors in the area.

The findings were:

Observation on 08/24/2023 at 11:38 AM revealed a door located at the end of the corridor that is open to the emergency department waiting area, and opens into another corridor. Observation of the door revealed that was was locked and could only be unlocked using a staff badge. Interview with the plant operations manager revealed that an exit sign had been removed from in front of the door, and the door had been locked for security concerns. Locking of the door created a dead-end corridor of greater than 30 feet and eliminated one of the two means of egress from the corridor, leaving only an exterior exit available. The corridor is adjacent to the emergency department suite and is part of the means of egress from the suite. Doors within a required means of egress shall not be quipped with a latch or lock that requires the use of a tool or key from the egress side unless permitted by the LSC.

Interview with the plant operations manager at the time of the observation acknowledge the deficiency, and indicated that they were unaware of the requirement.

Interview with the chief executive officer at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.2.2.2.4, 19.2.4.3, 19.2.5.2

Based on observation and staff interview, the facility failed to protect hazardous areas in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly protect hazardous areas could result in the spread of smoke and fire which could result in injury or death. The deficiency affected the receiving area and has the potential to affect all staff and visitors in the area.

The findings were:

Observation on 08/24/2023 at 11:48 AM revealed a room located in the receiving area. Observation of the room revealed it contained a large amount of combustible storage and was over 50 sq. ft. in size. It was observed that the door that opens into the storage room was not equipped with a self- or automatic- closer. Storage rooms greater than 50 sq. ft. in size and containing combustible materials shall be separated from other spaces by smoke partitions and the doors shall be self or automatic closing.

Interview with the plant operations manager at the time of the observation acknowledge the deficiency, and indicated that they were aware of the requirement.

Interview with the chief executive officer at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.3.2.1.2, 19.3.2.1.3

Based on document review and staff interview, the facility failed to test and maintain the fire alarm system in accordance with the 2012 NFPA 101, Life Safety Code, and 2010 NFPA 72, National Fire Alarm and Signaling Code. Failure to properly test and maintain the fire alarm system could result in a failure of the system, resulting in injury or death in the event of a fire. The deficiency affected the fire alarm system and has the potential to affect all patients, staff, and visitors.

The findings were:

Document review on 08/24/2023 starting at 1:30 PM revealed that the facility failed to conduct semi-annual, and monthly testing of the fire alarm system. At the time of the survey no documentation was available to demonstrate that the fire alarm system had been activated every month in the last twelve months. Document review revealed that the system was being activated typically once a quarter as part of the fire drills but no additional testing was being conducted. Also, document review revealed that the inspection and load voltage testing of the fire alarm system batteries was conducted only once in the last twelve months.

Interview with plant operations manager at the time of the observation acknowledge the deficiency, and indicated that they were aware of the requirement.

Interview with the chief executive officer at the time of the exit acknowledge the deficiency.

Ref: 2010 NFPA 72 Table 14.4.5(24), Table 14.3.1(3)(d), Table14.4.5(6)(3)

Based on observation and staff interview, the facility failed to install the fire sprinkler system in accordance with the 2010 NFPA 13, Installation of Sprinkler Systems. Failure to properly install the fire sprinkler system could result in the system working improperly, which could allow the spread of smoke and fire, resulting in injury or death. The deficiency affected a corridor and has the potential to affect all patients, staff, and visitors.

The findings were:

Observation on 08/24/2023 at 10:31 AM revealed a sprinkler head in the corridor leading from the main entrance area to the patient wing. Observation of the sprinkler head revealed that it was positioned approximately six (6) inches from a receiver that projected down approximately eight (8) inches from the ceiling. It was observed that the next closest sprinkler in the direction of the receiver was approximately fifteen (15) feet which created an unprotected area of the corridor due to the receiver obstructing the sprinkler head. Obstructions that project more than eight (8) inches down from the ceiling shall be located at least 3 feet from any sprinkler heads.

Interview with the plant operations director at the time of the observation acknowledge the deficiency, and indicated that they were aware of the requirement.

Interview with the chief executive officer at the time of the exit acknowledge the deficiency.

Ref: 2010 NFPA 13 8.6.5.1.2

Based on observation and staff interview, the facility failed to maintain opening protection at smoke barriers in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly maintain opening protections could result in delays to egress, which could result in injury or death. The deficiency affected two (2) of multiple smoke barriers, and has the potential to affect all patients, staff, and visitors.

The findings were:

Observation on 08/24/2023 at 12:11 PM revealed a smoke barrier that runs adjacent to the operating room waiting area and down the corridor that leads to imaging and the emergency department. Observation of multiple cross corridor doors revealed the panic release bar associated with them were labeled as "panic hardware". Smoke barrier doors are required to have fire rated door assemblies that are equipped with labeled fire door hardware. Observation of the cross corridor doors revealed that they were labeled as 90 minute fire rated doors.

Interview with the plant operations manager at the time of the observation acknowledge the deficiency, and indicated that they were unaware of the requirement.

Interview with the chief executive officer at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.3.7.3, 8.3.3, 2010 NFPA 80 7.4.3

Based on document review, and staff interview, the facility failed to conduct fire drills in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly conduct fire drills could result in an improper response by staff to an emergency, resulting in injury or death. The deficiency has the potential to affect all residents, staff, and visitors.

The findings were:

Document review on 08/24/2023 starting at 1:30 PM revealed that the facility failed to conduct fire drills as required. No documentation was available at the time of the survey to demonstrate that fire drills were being conducted once a quarter on every shift. Document review revealed that the first shift for the facility had fire drills conducted every quarter for the last 12 months, however, there was no documentation that the facility's second shift had any fire drills conducted during the last 12 months.

Interview with the plant operations manager at the time of the observation acknowledge the deficiency, and indicated that they were aware of the requirement.

Interview with the chief executive officer at the time of exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.7.1.6

Based on observation and staff interview, the facility failed to protect wet procedure locations in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to properly protect wet procedure locations could result in electrical malfunction, resulting in injury or death. The deficiency affected the operating rooms and has the potential to affect all patients receiving procedures in these areas.

The findings were:

Observation on 08/24/2023 at 1:05 PM revealed the operating rooms were not provided with special protection against electrical shock. Observation of the operating rooms revealed that an isolated power system (IPS) was not provided, and observation of all electrical outlets revealed that they were not equipped with ground-fault circuit interruption. Operating rooms are considered wet procedure locations unless a risk assessment is conducted to determine otherwise. A risk assessment was available at the time of the survey, however, it was incomplete and appeared to have been completed by plant operations rather than facility administration and operating room staff.

Interview with the plant operations manager at the time of the observation acknowledge the deficiency, and indicated that they were unaware of the requirement.

Interview with the chief executive officer at the time of exit acknowledge the deficiency.

Ref: 2012 NFPA 99 6.3.2.2.8.4, 6.3.2.2.8.7