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Based on observation and interview, the facility failed to provide separation between the hospital and the medical office building by construction having not less than 2-hour fire resistance-rated construction, in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.1.3.4.1. This deficient practice could affect all patients and an undetermined number of staff and visitors.

Findings include:

On 07/19/2022 at 3:20 PM, observation revealed that the door to the retail eye clinic was fire rated at 45 minutes. Doors in a two hour building separation wall are required to be 90 minutes.

These deficient condition were confirmed at the time of discovery by a interview with Staff A.

Based on observation and interview, the facility failed to provide means of egress in accordance with the requirements of NFPA 101 (2012 edition) Sections 7.2.1.5.1, 7.2.15.2, 7.2.1.5.10, & 7.2.1.5.10.2. This deficient practice could affect all patients and an undetermined number of staff and visitors.

Findings include:

1. On 07/19/2022 at 10:05 am, observation revealed that all of the corridor exit doors from the emergency department did not open when pushed. There was a magnetic lock preventing them from opening. {Note: On the wall next to the doors, there was a "push to exit" button that unlocked the door.}

2. On 07/19/2022 at 10:30 am, observation revealed that the fire doors to the ambulance garage from the Emergency Department did not latch.

These deficient practices were confirmed at the time of discovery by a concurrent interview with Staff A and Staff B.

Based on observation and interview, the facility did not protect a hazardous area in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.2.1.3 and 19.3.2.1.5.

Findings include:

On 07/19/2022 at 2 pm, observation revealed that room 508 was being used for storage of combustible material, including cardboard boxes and poster boards in quantities consider to be hazardous. The corridor door was not self-closing or automatic closing.

These deficient practices were confirmed by Staff A at the time of discovery.

Based on observation and interview, the facility did not protect a hazardous area in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.2.1.3 and 19.3.2.1.5.

Findings include:

On 07/19/2022 at 3:30 pm, observation revealed that the gift shop room door did not have a closer on it. It is a rated fire door and the gift shop was being used for storage of combustible material in quantities consider to be hazardous.

These deficient condition were confirmed at the time of discovery by a interview with Staff A.

Based on observation and staff interview, the facility did not provide a sprinkler system as required by the code; with all spaces sprinkler protected in accordance with NFPA 101 (2012 edition) sections 19.3.5, and NFPA 13 (2010 edition) sections 8.1, 8.5.5.2.1, 8.6.5.2.2, 8.6.5.2.2.1, 8.7 & 8.10.7.3.2. 8.15.7.5 This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 07/19/2022 at 1:47 pm, observation In the ceiling of the 400 wing corridor by the nurse station, that a sprinkler was located above the ceiling and did not provide sprinkler coverage.

2. On 07/19/2022 at 2:30 pm, observation In the ceiling of the closet of room 405, revealed that sprinkler was 'too high in the ceiling'. The ceiling was blocking the development of water spray pattern. In addition, the sprinkler was missing the metal ring (echon).

These deficient conditions were confirmed at the time of discovery by a interview with Staff A.

Based on observation and staff interview, the facility did not provide a sprinkler system as required by the code; with all spaces sprinkler protected in accordance with NFPA 101 (2012 edition) sections 19.3.5, and NFPA 13 (2010 edition) sections 8.1, 8.5.5.2.1, 8.6.5.2.2, 8.6.5.2.2.1, 8.7 & 8.10.7.3.2. 8.15.7.5 This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings include:

On 07/19/2022 at 10:20 am, observation under the canopy of the Emergency Department, two trash barrels where located there. This is combustible storage under the canopy. There were no sprinklers located there.

These deficient conditions were confirmed at the time of discovery by a interview with Staff A.

Based on observation and staff interview, the facility failed to provide proper ventilation in accordance with NFPA 101, 2012 edition, Sections 19.5, ASHRAE Standard 170 Part 6 Table 7-1, (FGI guidelines for Healthcare Facilities 2014 version), and CDC guidelines. This deficient practice had a potential of contamination of air in clean spaces with undesirable contaminants.

Findings Include:

On 07/20/2022 at 8:30 am, observation in the Clean Storage room of the Surgery area, had the airflow going from the hallway (dirty) to the clean room. Airflow is required to be from clean to dirty.

These deficient practice was confirmed by Staff A at the time of discovery.

Based on record review and interview the facility failed to conduct fire drills in accordance with, the requirements of NFPA 101 - 2012 edition, Sections 4.7.1, 4.7.6, 19.7.1, 19.7.1.4 and 19.7.2.1.2. This deficient practice could affect all inpatients, outpatients, staff and visitors.

Findings include:

On 06/27/2022 at 11:30 am, in the Kitchen, Staff V was asked about what s/he would do about a grease fire on the grill where the automatic extinguishing system did not work. Staff V knew RACE, but did take a while to find the fire alarm pull station and the 'emergency manual' to confirm his/her answerers.

This finding was confirmed at the time of discovery by an interview with Staff V and Staff A observing.

Based on observation and staff interview, the facility failed to provide hanging ceiling decoration in the office of the admitting area a in accordance with NFPA 101 - 2012 edition, section 19.7.5.6. This deficient practice had a potential of fire hazard or serious burns.

Findings Include:

On 07/19/2022 at 3:35 PM, observation revealed that in the admitting area office, 6 combustible hanging decoration were suspended from the ceiling. These decorations were not fire treated.

These deficient practices were confirmed by Staff A at the time of discovery.

Based on observation and staff interview, the facility failed to provide wall decoration on the walls in the nurse station of the patient area in accordance with NFPA 101 - 2012 edition, section 19.7.5.6.. This deficient practice had a potential of fire hazard or serious burns.

Findings Include:

1. On 07/19/2022 at 1:55 PM, observation revealed that in the nurse station, approximately 50% of the wall was covered in paper. The paper was not fire treated.

2. On 07/19/2022 at 2:10 PM, observation revealed that in the stairwell in the 400 wing, there was a bulletin board cover in paper. This paper was not fire treated.

These deficient practices were confirmed by Staff A at the time of discovery.

Based on observation and interview, the facility failed to store soiled linen and trash receptacles in accordance with the requirements of NFPA 101 (2012 edition), sections 19.7.5.7.1. This deficient practice could affect all patients, staff and visitors.

Findings include:

On 07/19/2022 at 10:00 AM, observation in the emergency department, rooms 1,3 & 4, revealed a 32 gallon waste linen container and a 16 gallon trash contain next to each other. This exceeds the limit of 32 gallons in a 64 square foot area.

These deficient conditions were confirmed at the time of discovery by a interview with Staff A and Staff B

Based on observation and interview, the facility failed to store soiled linen and trash receptacles in accordance with the requirements of NFPA 101 (2012 edition), sections 19.7.5.7.1. This deficient practice could affect all patients, staff and visitors.

Findings include:

On 07/19/2022 at 1:24 pm, observation in the the on call room, 425, revealed two 32-gallon trash containers next to each other. This exceeds the limit of 32 gallons in a 64 square foot area.

These deficient conditions were confirmed at the time of discovery by a interview with Staff A.

Based on observation and interview, the facility failed to store soiled linen and trash receptacles in accordance with the requirements of NFPA 101 (2012 edition), sections 19.7.5.7.1. This deficient practice could affect all patients, staff and visitors.

Findings include:

On 07/19/2022 at 3:10 PM, observation in the CT, revealed five 12 gallon waste linen containers next to each other. This exceeds the limit of 32 gallons in a 64 square foot area.

These deficient condition were confirmed at the time of discovery by a interview with Staff A.

Based on observation and staff interview, the facility failed to ensure safety to patients due to lack of clear working space in front of electrical equipment and switches in accordance with NFPA 101, 2012 edition, 19.5.1, 9.1.2, NFPA 70 Sections 110.34(A), 110.26, (312.11), and 408.4(A). The deficiency had the potential to affect all patients and undetermined number of staff in the facility.

Findings include

1. On 07/19/2022 at 10:50 am, observation in the clean room of the ED, revealed that access to the electrical panel was less than the minimum required 3'-0" clearance. A clean storage was stored in front of the electrical panel.

2. On 07/19/2022 at 3:15 PM observation in the Retail Pharmacy Office that access to the electrical panel was less than the minimum required 3'-0" clearance. A chair, computer and trash bin was stored in front of the electrical panel.

The above findings were confirmed by interview with Staff A at the time of discovery.