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Based on observation and interview, the facility failed to maintain the corridor means of egress per the requirements of:

2012 NFPA 101, 19.2.3.4 (4)

This deficiency could affect all occupants.

Findings include:

On 04/23/2019, during a tour of the facility from 8:30 am to 3:00 pm, the surveyors observed the following:
1. A table and cart were located in the corridor by the Doctor's Office at the second floor GI Lab; these were not moved during the entire survey from 8:00 am to 3:00 pm.


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2. Med Carts were located in the corridor at the third floor Nurses' Station; these med carts were observed plugged in for charging and were not moved during the entire survey from 8:00 am to 3:00 pm.
3. The facility failed to provide a fire safety plan and training program that addressed relocating wheeled equipment in the corridor during a fire or similar emergency

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain the required means of egress per the requirements of:

2012 NFPA 101, 19.2.10.1, 7.10.1.2.1, 7.10.1.3, and 7.10.1.5.1

Findings include:

On 04/24/2019, during a tour of the facility from 8:15 am to 1:30 pm, the surveyor observed the ER's southeast required exit door had signage on the door "not an exit", and "stop no exit", this required exit had an exit sign above the door.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain the stairway exit enclosure per the requirements of:

2012 NFPA 101, 19.3.1, and 19.3.1.1

This deficiency could affect 25 occupants.

Findings include:

On 04/23/2019, during a tour of the facility from 8:30 am to 3:00 pm, the surveyor observed an unsealed approximately 3/4" red pipe penetrating the stairway exit enclosure wall on the second floor near the Lab. entrance.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain the hazardous rooms per the requirements of:

2012 NFPA 101, 19.3.2.1, 19.3.5.9, and 19.3.2.1.3
42 CFR 482.41 (b)(1)(ii)

Findings include:

On 04/23/2019, during a tour of the facility from 8:30 am to 3:00 pm, the surveyor observed the following in nonsprinklered hazardous rooms:

1. The Primary Mechanical Room with fueled fired equipment was observed with two penetrations sealed with an orange unapproved, nonfire rated fire stop material.

2. The Linen Storage Room's door failed to close tight in the frame and positive latch; this room was 220 sq. ft. with combustible materials and was located on the first floor inside the Linen Room.

A member of maintenance staff was present when the facility was identified
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Based on the observation and interview, the facility failed to maintain the smoke detectors per the requirements of:

2012 NFPA 101, 9.6.1.3
2010 NFPA 72, Table 14.4.2.2 (14)(g)(1), and 10.3.2

On 04/24/2019, during a tour of the facility from 8:15 am to 1:30 pm, the surveyor observed the smoke detectors in OR 1 and OR 2 failed to activate the fire alarm system.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain an automatic sprinkler per the requirements of:

2012 NFPA 101, 9.7.5
2011 NFPA 25, 5.2.6, 5.2.4.1, 6.2.1 and Table 6.1.1.2

Findings include:

On 04/23/2019, during a tour of the facility from 8:30 am to 3:00 pm, the surveyor observed the following:

1. The hydraulic tag on the second floor stand pipe was not legible
2. The facility failed to provide documentation on the monthly inspections for the wet gauges
3. The facility failed to provide documentation on the annual inspections of the 2016 Standpipe Hoses

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain a corridor door to resist the passage of smoke per the requirements of:

2012 NFPA 101, 19.3.6.3.5
42 CFR 482.41 (b)(1)(ii)

Findings include:

On 04/23/2019, during a tour of the facility from 8:30 am to 3:00 pm, the surveyor observed Room 202's corridor door failed to close tight and positive latch in the frame.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3, 8.5.1, and 8.5.6.2

This deficiency could affect 25 occupants.

Findings include:

On 04/23/2019, during a tour of the facility from 8:30 am to 3:00 pm, the surveyor observed the following in smoke barriers:

1. An 1/2 unsealed pipe at the Rehab entrance door
2. An 3/4 unsealed pipe at the ICU Nurses' Station
3. An unsealed penetration on the third floor by Admissions
4. Unapproved orange fire caulk through out facility

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain the electrical wiring and equipment per the requirements of:

2012 NFPA 101, 19.5.1.1, and 9.1.2
2011 NFPA 70, 314.28(3)(C)

Findings include:

On 04/23/2019, during a tour of the facility from 8:30 am to 3:00 pm, the surveyor observed a 4x4 electrical junction box was missing it's cover at the smoke barrier near the Lab.

A member of the maintenance staff was present when this deficiency was identified.
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Based on review of documentation and interview, the facility failed to maintain the testing of the diesel generator per the requirements of:

2012 NFPA 99, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 1.3, 8.4.2, and 8.4.2.3

Findings include:

On 04/24/2019, during a tour of the facility from 8:15 am to 1:30 pm, based on review of documentation and interview the facility failed to test the diesel generator once monthly for a minimum of 30 minutes under loading that maintains the minimum exhaust gas temperature OR under operating temperature conditions at not less than 30% of the nameplate kW rating OR provide an annual 1.5 hour supplemental load test at not less than 50% of the EPS nameplate kW rating for 30 continuous minutes and at not less 75% of the EPS nameplate KW rating for one continuous hour for a total test duration of not less than 1.5 continuous hours.

A member of the maintenance staff was present when this deficiency was identified.