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Based on observation, the facility failed to ensure access-controlled egress door assemblies met the requirements of NFPA 101, 2012 Edition, Section 7.2.1.6.2.

Findings include:

1. During an observation on 9/16/25 at 3:42 p.m., the laboratory area was inspected. There was a set of cross-corridor doors leaving the lab area going to the ER, and the doors were magnetically locked. The door was fitted with an access-controlled egress system, complete with a manual release device with was mounted farther than 60 inches from the secured door opening.

Based on observation and interview, the facility failed to ensure magnetic locking device 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 Edition, Section 7.2.1.6.2.

Findings include:

1. During an observation on 9/16/25 at 2:42 p.m., the surgical suite was inspected. In a corridor near some offices, there was a magnetically locked door going from the urgent care to the ER. The door was fitted with an access-controlled egress system, complete with a badge-in type unlocking system on the outside, and the motion sensing device and the push-to-exit button on the inside. The motion-sensing device was turned up toward the ceiling so it could not detect an approaching occupant. The motion-sensing device was also turned off and would not cut the power to the magnets, which kept the door shut.

During an interview on 9/16/25 at 2:42 p.m., staff member B stated the motion device was opening the door every time it sensed a person, and it caused disruption to those working in the offices.

Based on observation, the facility failed to ensure that all exit discharges were provided with a hard surface path to the public way. Per NFPA 101, 2012 Edition, Section 7.7.1.

The findings include:

1. The exit discharge from the North Hall exit was inspected on 9/16/25 at 2:04 p.m. The discharge from the landing for the door had approximately 1.5 feet of concrete surface, and then ended, there was no hard surface path to the public way.

Based on observation the facility failed to maintain fire doors fully functioning in accordance with NFPA 101, 2012 Edition, Section 18.7.9 and NFPA 80, 2010 Edition Section 6.3.1.7.1.

Findings include:

During an observation on 9/16/25 at 2:43 p.m., the two-hour steel doors between the new surgical suite and the old hospital/endoscopy area were inspected. The gap between the two doors was approximately 1/4" when the doors were closed. The maximum allowable gap between fire doors in 1/8".

Based on observation, the facility failed to ensure a hazardous area was separately maintained to prevent the passage of smoke from the hazardous area in accordance with NFPA 101-2012, Sections 19.3.2.1 and 19.3.2.1.2.

Findings include:

1. During an observation on 9/16/25 at 2:44 p.m., the environmental services supply room was inspected. There was black tubing and black wiring going through an unsealed hole in the ceiling in two places.

Based on record review, the facility failed to maintain the wet chemical extinguishing system for the kitchen hood in accordance with NFPA 17A, 2009 Edition, Section 7.5.1.

Findings include:

1. Review of the maintenance records on 9/16/25 showed the last hydro test on the main cylinder for the kitchen hood was completed in 2012 and was due in 2024.

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 9/16/25 at 3:48 p.m., the lab employee breakroom was inspected. An ABHR dispenser was installed within one inch over an ignition source (light switch).

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 9/16/25 at 4:29 p.m., the reception area for the pain management clinic on the second story was inspected. An ABHR dispenser was installed within one inch over an ignition source (electrical outlet).

Based on observation, the facility failed to maintain all fire alarm systems in accordance with the standards of NFPA 72-2010, Section 10.5.5.2.1 - 10.5.5.2.4.

Findings include:

1. During an observation on 9/16/25 at 2:55 p.m., the new fire alarm control panel (FACP) was inspected. The location of the electrical panel and breaker serving the FACP were not identified on the FACP. The two breakers identified in red were the old FACP and were labeled identifying the origin of the power.

Based on observation and record review, the facility failed to ensure proper sprinkler maintenance in accordance with NFPA 101-2012 and NFPA 25-2011, Sections 5.1.1.1 and Table 5.1.1.2.

Findings include:

1. During an observation on 9/16/25 at 4:20 p.m., the ICU/Swing bed building was inspected. There was a sprinkler head near the storage room, which was choked with debris.

Based on observation, the facility failed to ensure proper sprinkler maintenance in accordance with NFPA 101-2012 and NFPA 25-2011, Sections 5.1.1.1 and Table 5.1.1.2.

Findings include:

During an observation on 9/16/25 at 3:37 p.m., the emergency department was inspected. Room A contained a sprinkler head near the storage room, which was found to be choked with debris.

Based on observation, the facility failed to 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).

Findings include:

1. During an observation on 9/16/25 at 1:57 p.m., the obstetrics supply room was inspected. A ceiling tile was left propped open for access to the attic.

Based on observation, the facility failed to maintain spare sprinklers in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.4.

Findings include:

1. During an observation on 9/16/25 at 2:51 p.m., the standpipe located in the housekeeping closet on the maintenance hallway was inspected. The spare sprinkler box contained three spare sprinkler heads. There should be a minimum of six spare sprinklers.

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 7.3.3.2.

Findings include:

1. During an observation on 9/16/25 at 2:09 p.m., the north inpatient hall was inspected. There was a portable extinguisher in the corridor which was found to be missing the verification collar. The collar is required for all extinguishers which have undergone maintenance. The extinguisher had an initial manufacture date of 2006, so it has undergone several required maintenance dates.

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 7.3.3.2.

Findings include:

1. During an observation on 9/16/25 at 2:52 p.m., the endoscopy area was inspected. There was a portable extinguisher in the corridor, which was found to be missing the verification collar. The collar is required for all extinguishers which have undergone maintenance. The extinguisher had an initial manufacture date of 1996, so it has undergone several required maintenance dates.

Based on observation, the facility failed to maintain corridor doors in accordance with NFPA 101-2012, Section 7.2.1.4.1, and failed to maintain corridor doors to ensure a means suitable for keeping the doors closed in accordance with NFPA 101, 2012 Edition, Section 19.3.6.3.1 and 19.3.6.3.5.

Findings include:

1. During an observation on 9/16/25 at 2:48 p.m., the main corridor door to the soiled linen room was exercised. The latch on the door was malfunctioning and would not catch the strike plate to latch the door.

Based on interview and record review, the facility failed to document fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6.

Findings include:

1. During a review of facility fire drills on 9/16/25 at 11:00 a.m., fire drill records reflected a missing NOC shift fire drill for the last quarter of 2024.

2. During an interview on 9/16/25 at 4:58 p.m., staff member B stated "we don't have a 4th quarter fire drill for NOC shift."

Based on interview and record review, the facility failed to document fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6.

Findings include:

1. During a review of facility fire drills on 9/16/25 at 11:00 a.m., fire drill records reflected a missing NOC shift fire drill for the last quarter of 2024.

2. During an interview on 9/16/25 at 4:58 p.m., staff member B stated "we don't have a 4th quarter fire drill for NOC shift."

Based on observation, the facility failed to keep trash receptacles greater than 32 gallons in an area protected as hazardous in accordance with NFPA 101, 2012 Edition, Section 19.7.5.7.1.

Findings include:

1. During an observation on 9/16/25 at 4:00 p.m., the two corridors were inspected. There was a large paper shred bin, which was greater than 32-gallons capacity, left in the corridor. Receptacles greater than 32-gallon capacity must be stored in a room with a self-closing door.

Based on 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, Sections 8.4.1 and 8.4.2.4.

This deficiency affects the entire facility.

Findings include:

1. Review of the emergency generator inspection records on 9/16/25, the generator documentation showed the monthly load tests were incomplete as some were missing from the record. As the generator is diesel, the facility may also use the option of performing an annual load test, in lieu of monthly tests. The last annual load test on the generator was in 2023.