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Based on observation during the survey walk-through, the means of egress from occupied spaces is not maintained in accordance with Code requirements. Failure to maintain means of egress for all spaces can result in confinement of occupants in a building during required evacuation.

Findings include:

On 09/13/2023, while in the company of the DM, it was observed that the Exit doors required excessive force to open and lacked positive latching to comply with Section 19.2.1, 7.2.1.4.5, and 7.2.1.5. Locations observed:

A. At 9:05 am, Stair # 1

B. At 9:10 am, Stair # 2

Based on observation, not all designated fire barriers are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors on the building because fire could pass between adjacent fire compartments if fire barriers are not properly constructed.

The finding is:

On 09/13/23 at 10:45 am, while in the company of the DM, a designated 2-hour fire barrier is incomplete due to the pair of cross corridor fire rated doors which do not close to a latched position to comply with 8.3.5.7. Location observed: 1st floor fire barrier doors at hallway near the Admin Suite.

Based on document review and staff interview, emergency lighting is not tested and maintained. This deficient practice could affect patients, staff and visitors if failure to test and maintain the installed emergency lighting system can result in failure of the system to perform when needed during loss of normal power.

The finding is:

On 09/12/2023 at 12:45 pm, while in the company of the DM during document review battery powered emergency lighting annual testing for the 1.5-hour duration was not conducted and recorded to comply with 7.9.3.1.1 (3).

Based on observation smoke detectors are not located as required for a compliant fire alarm system installation. Failure to locate devices accordingly may result in failure or delay of alarm initiation during an emergency. If devices do not function properly, then building occupants may not be alerted to an emergency in a timely manner.

Findings include:

On 09/13/2023, while in the company of the DM, it was observed at various locations that smoke detectors are located where airflow may prevent normal operation of the device as written in 2010 Edition of NFPA 72, Section 17.7.4.1. Locations observed:

A. At 9:24 am, a smoke detector was observed within 3'-0" of an HVAC supply/return register at Hallway near 2nd floor Specialty Clinic Reception.

B. At 10:02 am, a smoke detector was observed within 3'-0" of an HVAC supply/return register at Hallway near 1st floor Stair # 1.

C. At 10:40 am, a smoke detector was observed within 3'-0" of an HVAC supply/return register at Hallway near 1st floor Gift Shop.

Based on observation the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

On 09/13/2023, while in the company of the DM, missing ceiling tiles were observed. This condition can delay activation of a sprinkler head by allowing heat and combustive materials to bypass the sprinkler. This condition does not comply with 2010 Edition of NFPA 13, Section 8.6.4.1. Locations observed:

A. At 9:17 am, 2nd floor Soiled Holding.

B. At 10:50 am, 1st floor ER Nurse Station.

Based on observation and document review, the sprinkler system is not being inspected, tested and maintained in accordance with Code requirements. Failure to properly inspect, test and maintain the sprinkler system can result in failure of the system to operate as required when needed to control a fire event.

Findings include:

On 09/12/2023, while in the company of the DM, it was observed that the following documentation are not available for review:

A. At 2:20 pm, documentation for the Annual Sprinkler System Inspection as required by 2011 Edition of NFPA 25, Section 5.2.1, is not available for review.

B. At 2:25 pm, documentation for the Weekly Fire Pump Visual Inspection as required by 2011 Edition of NFPA 25, Section 8.2, and Table 8.1.1.2, is not available for review.

C. At 2:28 pm, documentation for the Monthly Fire Pump Churn Test as required by 2011 Edition of NFPA 25, Section 8.3.1, is not available for review.

D. At 2:30 pm, documentation for the Annual Fire Pump Inspection & Flow Test as required by 2011 Edition of NFPA 25, Section 8.3.3, is not available for review.

E. At 2:33 pm, documentation for the 5-Year Fire Sprinkler Pressure Gauges Calibration/ Replacement as required by 2011 Edition of NFPA 25, Table 5.1.1.2, is not available for review.

F. At 2:35 pm, documentation for the 5-Year Fire Department Connection (FDC) Hydrostatic Piping Test as required by 2011 Edition of NFPA 25, Section 6.3.1, Section 6.3.2.1 and Table 13.8.1, is not available for review.

Based on document review and staff interview, the facility failed to document / conduct fire drills as required. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills.

Findings include:

On 09/12/2023 at 12:30 pm during document review in the company of the DM, Facility fire drill documentation for the past 12 months did not indicate the following to comply with Section 19.7.

A. Documentation was not available to confirm fire dills are conducted quarterly of each shift.

B. Documentation was not available to confirm fire dills are conducted at varying times.

C. Documentation of acknowledgment regarding transmission of a signal and signal receipt by the Fire Department or monitoring agency is not available.

Based on observation and document review, fire and smoke doors are not maintained in accordance with Code requirements. Failure to conduct and document fire and smoke door inspection and maintenance can compromise the safety of any building occupants if the door assemblies are not maintained as intended to restrict the spread of fire & smoke during a fire emergency.

The finding is:

On 09/12/2023, at 3:15 pm while in the company of the DM, it was observed that the documentation for Annual Fire and Smoke Door Inspections in accordance with Section 21.7.6, 8.3.3.1, 7.2.1.15, and 2010 Edition of NFPA 80, Section 5.2.4.2 was not performed per code requirements.

Based on observation during the survey walk-through, ground fault circuit interruption (GFCI) is not provided in accordance with Code requirements. If GFCI protection is not provided, the circuit remains an electrical shock hazard and electrical burns to occupants. This deficient practice could affect the safety of patients, staff, and visitors.

The finding is:

On 09/13/2023, at 10:00 am while in the company of the DM, it was observed that two electrical receptacles are within 6'-0" of sink at Lab and is not provided with GFCI protection in accordance with 2011 Edition of NFPA 70, Section 210.8(B)(5).

Based on staff interview/document review, required essential electrical equipment inspection and testing is not being conducted. This deficient practice could affect patients, staff and visitors during a utility outage or fire event.

Findings include:

On 09/12/2023, while in the company of the DM, it was observed that the following documentation are not available for review:

A. At 3:30 pm, documentation for the Annual Diesel Fuel Quality Test as required by 2010 Edition of NFPA 110, Section 8.3.8, is not available for review.

B. At 3:32 pm, documentation for the 3-Year 4-Hour Generator Load Test as required by 2010 Edition of NFPA 110, Section 8.4.9, is not available for review.