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Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in two instance, affecting two of six smoke compartments.

Findings include:

Observation on July 13, 2022, revealed the following hazardous area enclosure deficiencies:

a) 11:25 a.m., revealed the door to the janitor closet that is over 50 square feet containing combustible storage in the long term care hallway, was not equipped with a self -closing device;
b) 11:50 a.m., revealed the self closing device on the door to the storage room in the same day surgery area, had the arm removed, leaving the door unable to close and latch in its frame when tested.


Interview with the Facility COO and the Safety Officer on July 14, 2022, at 12:30 p.m., confirmed the hazardous area enclosure deficiencies.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in five instances, affecting the entire facility.

Findings include:

1. Observation on July 13, 2022, revealed the following sprinkler system deficiencies:

a) 10:46 a.m., there was a gap greater than 1/8 inch around conduit in the ceiling of the soiled instrument room in the OR Suite;
b) 11:15 a.m., there were data wires tied to the sprinkler pipe hanger in two places between the sign to Emergency Services and smoke doors SDD7;
c) 1:17 p.m., there was a gap greater than 1/8 inch around conduit in the ceiling of the janitor closet in the long term care hallway;
d) 1:36 p.m., there were multiple gaps greater than 1/8 of an inch around conduit in the personal laundry room in the long term care hallway.

Interview with the Facility COO and Safety Officer on July 13, 2022, at 12:30 p.m., confirmed the automatic sprinkler system deficiencies.

2.. Observation on July 14, 2022, at 9:30 a.m., revealed visibility of the fire department connection and FDC sign was significantly blocked by water tanks.

Interview with the Facility COO and Safety Officer on July 13, 2022, at 12:30 p.m., confirmed the location of the FDC was obstructed.

Based on observation and interview, it was determined the facility failed to maintain electrical receptacles for one of over 100 receptacles inspected.

Findings include:

1. Observation on July 13, 2022, at 11:470 a.m., revealed an electrical outlet within six feet of a sink in the nursing lounge in acute care was not GFCI protected

Interview with the Facility COO and the Safety Officer on July 14, 2022, at 12:30 p.m., confirmed the outlet was not GFCI protected.