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Based on observation and interview, the facility failed to maintain general requirements not addressed by K-tags, but are deficient, affecting two of two building components.

1. Observation on October 5, 2023, between 10:45 a.m. and 11:30 a.m., revealed the facility failed to obtain required approval from the Department of Health State Plan Review and a granted occupancy from Life Safety Division for the following projects:
A. (10:45 a.m.) The facility was in the process of replacing the roof material on all parts of the component;
B. (11:30 a.m.) A contractor was in the process of finalizing electrical switchgear, main distribution, cabling, loop switches, etc.

Interview with the maintenance director and the fire marshal on October 5, 2023, at 11:30 a.m., confirmed the above projects were being completed without state documentation and inspection.

Based on observation and interview, the facility failed to maintain general requirements not addressed by K-tags, but are deficient, affecting two of two components.

Observation on October 5, 2023, at 11:30 a.m., revealed a contractor was in the process of finalizing electrical switchgear, main distribution, cabling, loop switches, etc. The facility failed to obtain required approval from the Department of Health State Plan Review and a granted occupancy from the Life Safety Division for this project.

Interview with the maintenance director and the fire marshal on October 5, 2023, confirmed the above project was being completed without state documentation and inspection.

Based on observation and interview, the facility failed to maintain doors with self-closing devices for one of one component.

Findings include:

1. Observation on October 5, 2023, between 11:05 a.m. and 11:11 a.m., revealed the following self-closing door deficiencies:
A. (11:05 a.m.) Multiple air handler/mechanical room doors were propped open;
B. (11:11 a.m.) Laundry room 1111 door was removed from the frame.

Interview with the maintenance director and fire marshal on October 5, 2023, at 11:11 a.m., confirmed the self-closing door deficiencies at the time of the survey.

Based on observation and interview, the facility failed to maintain doors with self-closing devices for one of over twenty-five doors with self-closing devices.

Findings include:

Observation on October 5, 2023, at 9:41 a.m., revealed the 2 North 2321 door had a wedge propping the door open.
Interview with the maintenance director and fire marshal on October 5, 2023, at 9:41 a.m., confirmed the door was propped open.

Based on observation and interview, the facility failed to maintain an emergency exit for one of one component.

Findings include:

Observation on October 5, 2023, at 11:08 a.m.., revealed the discharge exit across from the 1118 door did not maintain a hard-packed, all-weather travel surface to a public way.

Interview with the maintenance director and fire marshal on October 5, 2023, at 11:08 a.m., confirmed the exit discharge deficiency.

Based on document review and interview, the facility failed to maintain, inspect, and test emergency lighting for five of five emergency lights.

Findings include:

Document review on October 4, 2023, at 11:25 a.m., revealed the facility lacked documentation that an annual 90-minute test was performed on the emergency lighting.

Interview with the maintenance director and facility safety manager on October 4, 2023, at 11:25 a.m., confirmed the emergency light documentation was unavailable at the time of the survey.

Based on document review and interview, the facility failed to maintain, inspect, and test emergency lighting for five of five emergency lights.

Findings include:

Document review on October 4, 2023, at 11:25 a.m., revealed the facility lacked documentation that an annual 90-minute test was performed on the emergency lighting.

Interview with the maintenance director and facility safety manager on October 4, 2023, at 11:25 a.m., confirmed the emergency light testing documentation was unavailable at the time of the survey.

Based on document review and interview, the facility failed to maintain cooking facilities for one of one main kitchen.

Findings include:

1. Document review on October 4, 2023, at 12:36 p.m., revealed the following kitchen system deficiencies:
A. (12:36 p.m.) The facility could not produce documentation that the semi-annual kitchen exhaust hood/duct cleaning was completed during the most-recent part of the year. The last documented inspection was completed on February 1, 2023;
B. (12:36 p.m.) The last documented hood inspection (dated February 1, 2023) indicated the following deficiencies:
a. "2 furthest north exhaust fans need wire shrink wrap on conduit prior to summers exhaust cleaning;"
b. "Furthest south hood Accuflow sk2-I is not working properly;"
c. "Furthest south hood light flickers periodically above the box oven."

Interview with the maintenance director and facility safety manager on October 4, 2023, at 12:36 p.m., confirmed the kitchen system deficiencies at the time of the survey.

Based on document review, observation, and interview, the facility failed to maintain fire alarm systems for one of one fire alarm system, affecting the entire facility.

Findings include:

1. Document review on October 4, 2023, between 10:40 a.m. and 12:17 p.m., revealed the following fire alarm deficiencies:
A. (10:40 a.m.) The facility could not produce documentation that the required semi-annual visual inspection was completed;
B. (10:47 a.m.) The facility could not produce documentation that the required two-year smoke detector sensitivity test was completed.
C. (12:17 p.m.) The last documented fire inspection report (dated May 4, 2023) listed three functional failures pertaining to rated doors properly closing. The facility could not produce documentation that the noted items were corrected;

Interview with the maintenance director, maintenance manager, and facility safety manager on October 4, 2023, at 12:17 p.m., confirmed the fire alarm documentation was not on-site during the survey.

Based on document review, observation, and interview, the facility failed to maintain fire alarm systems for one of one fire alarm system, affecting the entire facility.

Findings include:

1. Document review on October 4, 2023, between 10:40 a.m. and 12:17 p.m., revealed the following fire alarm deficiencies:
A. (10:40 a.m.) The facility could not produce documentation that the required semi-annual visual inspection was completed;
B. (10:47 a.m.) The facility could not produce documentation that the required two-year smoke detector sensitivity test was completed;
C. (12:17 p.m.) The last documented fire inspection report (dated May 4, 2023) indicated three functional failures pertaining to rated doors properly closing. The facility could not produce documentation that the noted items were corrected.

Interview with the maintenance director, maintenance manager, and facility safety manager on October 4, 2023, at 12:17 p.m., confirmed the fire alarm documentation was not on-site during the survey.

Based on document review and interview, the facility failed to maintain and test the fire sprinkler suppression system for two of two sprinkler systems.

Findings include:

1. Document review on October 4-5, 2023, between 11:01 a.m. and 11:45 a.m., revealed the following sprinkler system deficiencies:
A. (11:01 a.m.) The last documented fire inspection report, dated August 8, 2023, listed thirteen device deficiencies. The majority of these involved control valves on the report since 2021. The most-recent inspection identified an additional deficiency, stating, "Flow switch may not be intended or UL listed for fire sprinkler systems. Hospital has (5) installed." Furthermore, the report listed the following general deficiencies:
a. "FDC check valve near fire pump room is leaking by slowly and back out of the FDC connection. Advising replacing and repairing check valve ASAP;"
b. "Internal pipe exams are required every 5 years. Advise completing asap;"
c. "Gauges are required to be replaced every 5 years. Advise completing asap;"
d. "Standpipe system requires a 5 year flow test. Advise completing asap;"
e. "Both fire department connections are due for a 5 year hydrostatic test. Advise performing asap;"
f. "1966 Grimes 155" head found in basement room 016. Advise replacing ASAP;"
g. "Caps are missing on hose valves, advise installing correct caps."
B. (11:45 a.m.) The five-year internal valve and pipe inspection was not completed.

Interview with the maintenance director and the facility safety manager on October 4, 2023, at 11:45 a.m., confirmed the sprinkler system deficiencies at the time of the survey.

2. Observation and interview on October 5, 2023, at 11:32 a.m., revealed the facility had four of five gauges replaced on the system. One of the gauges exceeded the required time for replacement or calibration.

Interview with the maintenance director and the facility safety manager on October 5, 2023, at 11:32 a.m., confirmed the sprinkler system deficiency at the time of the survey.

Based on document review and interview, the facility failed to maintain and test the fire sprinkler suppression system for two of two sprinkler systems.

Findings include:

1. Document review on October 4-5, 2023, between 11:01 a.m. and 11:45 a.m., revealed the following sprinkler system deficiencies:
A. (11:01 a.m.) The last documented fire inspection report, dated August 8, 2023, listed thirteen device deficiencies. The majority of these involved control valves that were on the report since 2021. The most-recent inspection noted an additional deficiency stating, "Flow switch may not be intended or UL listed for fire sprinkler systems. Hospital has (5) installed." Furthermore, the report listed the following general deficiencies:
a. "FDC check valve near fire pump room is leaking by slowly and back out of the FDC connection. Advising replacing and repairing check valve ASAP;"
b. "Internal pipe exams are required every 5 years. Advise completing asap;"
c. "Gauges are required to be replaced every 5 years. Advise completing asap;"
d. "Standpipe system requires a 5 year flow test. Advise completing asap;"
e. "Both fire department connections are due for a 5 year hydrostatic test. Advise performing asap;"
f. "1966 Grimes 155" head found in basement room 016. Advise replacing ASAP;"
g. "Caps are missing on hose valves, advise installing correct caps."
B. (11:45 a.m.) The five-year internal valve and pipe inspection was not completed.

Interview with the maintenance director and the facility safety manager on October 4, 2023, at 11:45 a.m., confirmed the sprinkler system deficiencies at the time of the survey.

Based on document review, observation, and interview, the facility failed to maintain fire/ smoke damper inspections, affecting the entire facility.

Findings include:

Document review on October 4, 2023, at 10:05 a.m., revealed the last documented inspection/exercise, dated March 27, 2023, listed dampers in need of repair, but no documentation was provided to indicate the dampers were repaired. Additionally, there was no tracking method available to identify which dampers were inspected, exercised, and repaired.

Interview with the maintenance director, maintenance manager, and facility safety manager on October 4, 2023, at 10:05 a.m., confirmed the deficiencies listed.

Based on document review, observation, and interview, the facility failed to maintain fire/ smoke damper inspections, affecting the entire facility.

Findings include:

Document review on October 4, 2023, at 10:05 a.m., revealed the last documented inspection/exercise, dated March 27, 2023, listed dampers in need of repair, but there was no documentation to indicate the dampers were repaired. Additionally, there was no tracking method available to identify which dampers were inspected, exercised, and repaired.

Interview with the maintenance director, maintenance manager, and facility safety manager on October 4, 2023, at 10:05 a.m., confirmed the deficiencies listed.

Based on observation and interview, the facility failed to maintain the requirements for fire doors for two of over five rated doors.

Findings include:

Observation on October 5, 2023, between 11:22 a.m. and 11:25 a.m., revealed the following fire door deficiencies:
A. (11:22 a.m.) South wing fire doors lacked positive latching;
B. (11:25 a.m.) East wing fire doors (198) lacked positive latching.

Interview with the maintenance director and fire marshal on October 5, 2023, at 11:25 a.m., confirmed the fire door deficiencies.

Based on observation and interview, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, in one of over 100 rooms.

Findings include:

Observation on October 5, 2023, at 9:35 a.m., revealed the 3 North 3421 door had a breaker panel with two open breaker slots.

Reference: NFPA 70-408.7

Interview with the maintenance director and fire marshal on October 5, 2023, at 9:35 a.m., confirmed the breaker panel had two open breaker slots.

Based on observation and interview, the facility failed to maintain electrical receptacles in two of over fifty rooms.

Findings include:

1. Observation on October 5, 2023, between 10:01 a.m. and 11:45 a.m., revealed the following electrical receptacle deficiencies:
A. (10:01 a.m.) 2 North 2304 door had an outlet located next to a sink not protected by a ground fault circuit interrupter (GFCI) receptacle;
B. (11:45 a.m.) 3 North 3402 door had an outlet located next to a sink not protected by a ground fault circuit interrupter (GFCI) receptacle.

Interview with the maintenance director and fire marshal on October 5, 2023, at 11:45 a.m., confirmed the receptacle deficiencies.

Based on document review and interview, the facility failed to maintain essential electric system maintenance and testing, affecting four of four emergency generators.

Findings include:

1. Document review on October 4, 2023, between 10:45 a.m. and 11:03 a.m., revealed the following emergency generator testing and inspection deficiencies:
A. (10:45 a.m.) The facility lacked documentation the monthly battery voltage check was being completed;
B. (11:03 a.m.) The facility lacked results from the most-recent annual fuel quality testing and no documentation was present for results from the previous year.

Interview with the maintenance director and facility safety manager on October 4, 2023, at 11:03 a.m., confirmed the generator testing and inspection results were unavailable at the time of the survey.

Based on document review and interview, the facility failed to maintain essential electric system maintenance and testing, affecting four of four emergency generators.

Findings include:

1. Document review on October 4, 2023, between 10:45 a.m. and 11:03 a.m., revealed the following emergency generator testing and inspection deficiencies:
A. (10:45 a.m.) The facility lacked documentation the monthly battery voltage check was being completed;
B. (11:03 a.m.) The facility lacked results from the most-recent annual fuel quality testing, and there was no documentation detailing results from the previous year.

Interview with the maintenance director and facility safety manager on October 4, 2023, at 11:03 a.m., confirmed the generator testing and inspection results were unavailable at the time of the survey.

Based on observation and interview, the facility failed to maintain electrical power cords in two of over 50 rooms.

Findings include:

1. Observation on October 5, 2023, between 9:45 a.m. and 9:54 a.m., revealed the following electrical equipment deficiencies:
A. (9:45 a.m.) 2 North staff development classroom 2330 door had an air conditioning unit and microwave plugged into a surge protector;
B. (9:54 a.m.) 2 North staff development office 2306 door had a coffee pot and refrigerator plugged into a multiport extension cord.

Interview with the maintenance technician and fire marshal on October 5, 2023, at 9:54 a.m., confirmed the power cords were not in compliance.