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Based on interview and record review the facility failed to implement the initial and annual training of the EP program to all staff members, consistent with each team members' expected roles during an emergency or a disaster.

Findings include:

Record review of the facility EP plan and training documents on 9/4/24 revealed, the facility did not have documentation that staff training for the EP plan was conducted initially for new staff and every other year for all current staff.

During an interview on 9/4/24 at 8:30 a.m., staff member A stated he did not have documentation of staff who have completed emergency preparedness training upon hire and every two years after.

Based on observation and interview, the facility failed to provide emergency lighting per NFPA 101-2012, Sections 39.2.9.1, and 7.9.2.7.

Findings include:

During an observation and interview on 9/4/24 at 12:30 p.m. the emergency light in the ortho suite by the nurse's station was observed. The light was making a low buzzing sound. Staff member C stated the light has been buzzing like that for a while and does not work when the power goes out. Staff member C stated, "it's pitch black in here when there is no power."

Based on observation and interview, the facility failed to maintain exit signage illuminated in accordance with NFPA 101, 2012 Edition, Section 7.10.5.1, 7.10.5.2, and 7.10.5.2.1.

Findings include:

During an observation on 9/4/24 at 12:26 p.m. the ortho suite was observed. The marked exit by the nurse's station was not internally illuminated.

During an observation and interview on 9/4/24 at 12:30 p.m. the emergency light in the ortho suite by the nurse's station was observed. The light was making a low buzzing sound. Staff member C stated the light has been buzzing like that for a while and does not work when the power goes out. Staff member C stated, "it's pitch black in here when there is no power."

Based on an observation and interview, the facility failed to assure hazardous rooms/areas had doors which were able to close and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1, 19.3.2.1.3 and 19.3.2.1.5 (6) (7).

Findings include:

1. During an observation and interview on 9/4/24 at 10:20 a.m., the soiled work room was inspected. The room was over 50 square feet and was used to store dirty linen. The self-closure had been removed from the door. Staff member B stated the room was used to store dirty linen.

2. During an observation on 9/4/24 at 11:42 a.m., the ER equipment storage room was inspected. The room was over 50 square feet, used as storage, and would not close and latch under the power of the self-closure.

Based on observation, the facility failed to ensure an alcohol-based hand rub (ABHR) dispenser was not mounted within 1 inch of an ignition source in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8 b).

Findings include:

1. During an observation on 9/4/24 at 11:30 a.m., room six in the ER was inspected. A hand sanitizer pump was installed within one inch of an ignition source.

2. During an observation on 9/4/24 at 11:40 a.m., room three in the ER was inspected. A hand sanitizer pump was installed within one inch of an ignition source.

Based on record review and interview, the facility failed to ensure that load voltage tests were conducted on the batteries of the fire alarm control panel (FACP) semi-annually, as required per NFPA 72-2010, Table 14.4.5 (6).

Findings include:

A record review on 9/4/2024 of the most recent facility fire alarm inspection, indicated the fire alarm system was inspected on 9/26/23. There was no documentation the semi-annual voltage test had been completed by the facility.

During an interview on 9/4/24 at 1:14 p.m., staff member B stated a 6-month voltage test had not been completed.

Based on record review and interview, the facility failed to ensure that load voltage tests were conducted on the batteries of the fire alarm control panel (FACP) semi-annually, as required per NFPA 72-2010, Table 14.4.5 (6).

Findings include:

During a review of the most recent facility fire alarm inspection on 9/4/24, the fire alarm system was inspected on 9/26/23. There was no documentation the semi-annual voltage test had been completed by the facility.

During an interview on 9/4/24 at 1:14 p.m., staff member B stated the 6-month voltage test had not been completed.

Based on an observation the facility failed to ensure a sprinkler head was installed clear of a ceiling mounted fixture in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

Findings Include:

During an observation on 9/4/24 at 12:04 p.m. the kitchen janitor closet was inspected. A sprinkler head was obstructed by a ceiling mounted light fixture.

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:

During an observation on 9/4/24 at 11:14 a.m., the data closet in outpatient surgery was inspected. There were IT cords through the ceiling tiles causing unsealed perforations in the ceiling tiles.

Based on observation the facility failed to:

a) failed to ensure sprinkler piping was fee from external loads in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2.,

b) Maintain escutcheon rings in accordance with NFPA 13, 2010 Edition, Section 6.2.7.1,

c) 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)., and

d) ensure sprinkler head pendants are unobstructed from the ceiling in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.4.1.1.1

Findings include:

1. During an observation on 9/4/24 at 12:08 p.m., the clinic IDF room was inspected. There were IT cords zip tied to the sprinkler piping.

2. During an observation on 9/4/24 at 12:10 p.m., the work room was inspected. A ceiling tile was removed.

3. During an observation on 9/4/24 at 12:12 p.m., exam room three was inspected. An escutcheon ring was missing on a sprinkler head.

4. During an observation on 9/4/24 at 12:15 p.m., ortho suite two was inspected. A sprinkler pendent did not have the minimum clearance of 1 inch from the ceiling.

5. During an observation on 9/4/24 at 12:25 p.m., ortho suite hall was inspected. Four sprinkler pendants did not have the minimum clearance of 1 inch from the ceiling.

6. During an observation on 9/4/24 at 12:32 p.m., OBGYN Dr.'s Office was inspected. There was a missing escutcheon ring on the sprinkler head.

Based on observation the facility failed to:

a) Maintain cover plates for concealed sprinklers in accordance with NFPA 13, 2010 Edition, Section 6.2.7.1, 6.2.7.3,

b) Maintain escutcheon rings in accordance with NFPA 13, 2010 Edition, Section 6.2.7.1, and

c) 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).

d) ensure sprinkler head pendants are unobstructed from the ceiling in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.4.1.1.1

Findings include:

1. During an observation on 9/4/24 at 10:07 a.m., room 201 in med surge was inspected. Two concealed sprinkler heads were missing cover plates.

2. During an observation on 9/4/24 at 10:24 a.m., the nurse call closet was inspected. There were two perforations in the ceiling tiles, and the sprinkler head was missing an escutcheon ring.

3. During an observation on 9/4/24 at 10:39 a.m. the nursery work room was inspected. There was a loose escutcheon ring, causing gapping around the sprinkler head which could interrupt activation time if there were a fire.

4. During an observation on 9/4/24 at 10:41 a.m. the OB janitor closet was inspected. There was a loose escutcheon ring, causing gapping around the sprinkler head which could interrupt activation time if there were a fire.

5. During an observation on 9/4/24 at 10:43 a.m. the admin IDF closet was inspected. There were multiple cords running through the ceiling tiles resulting in unsealed penetrations in the ceiling tiles.

6. During an observation on 9/4/24 at 11:28 a.m., ultrasound room two was inspected. The sprinkler deflector and the ceiling did not have the minimum clearance of 1 inch.

7. During an observation on 9/4/24 at 11:48 a.m., the ED entrance was inspected. A ceiling tile was pushed up causing gapping in the ceiling tiles.

Based on an observation the facility failed to:

a) install a portable fire extinguisher in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Sections 6.1.3.4, 6.1.3.6, 6.1.3.7, and

b) maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1.


Findings include:

1. During an observation on 9/4/24 at 1:04 p.m., the light room was inspected. Seven fire extinguishers were stored on a shelf free standing. They must be secured with a listed bracket.

2. During an observation on 9/4/24 at 1:05 p.m., the welding shop was inspected. A portable fire extinguisher was observed to be obstructed by storage of various items.

Based on observation, the facility failed to install portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.8.1.

Findings include:

1. During an observation on 9/4/24 at 11:07 a.m., the health information office was inspected. A portable fire extinguisher was mounted 69 inches from the handle to the floor.

2. During an observation on 9/4/24 at 12:00 p.m., the kitchen was inspected. The portable K-type fire extinguisher was mounted 69 inches from the handle to the floor.

Based on observations, the facility failed to maintain egress doors in accordance with NFPA 101-2012, Sections 7.2.1.4.1 and 7.2.1.4.5.1.

Findings include:

During an observation on 9/4/24 at 11:26 a.m., the soiled work room was inspected. The egress door was prevented from fully opening by boxes stored behind the door.

Based on observation, the facility failed to ensure smoke barriers were maintained to prevent the potential for smoke to spread in accordance with NFPA 101-2012, Section 19.3.7.3.

Findings include:

During an observation on 9/4/24 at 10:16 a.m., the smoke barrier on med surge was inspected. A blue wire was passing though the smoke barrier that was not properly sealed.

Based on observation, the facility failed to ensure latching fire/smoke barrier doors were maintained per NFPA 101-2012, Section 19.3.7.8., 4.2.3, and 4.6.12.1.

Findings include:

1. During an observation on 9/4/24 at 10:11 a.m. the med surge fire/smoke doors were exercised. The doors failed to latch under the power of the self-closer after being exercised twice.

2. During an observation on 9/4/24 at 11:02 a.m. the fire/smoke doors located by the chapel were exercised. The doors failed to latch under the power of the self-closer after being exercised twice.

Based on record review the facility failed to ensure an annual diesel fuel supply quality test was conducted at least annually per NFPA 101 2012 Edition, Section 9.1.3.1 and NFPA 110, Section 8.1.1, 8.3.1, and 8.3.8

Findings include:

Review of facility documents on 9/4/24 indicated the annual diesel fuel quality test conducted on 1/3/24 failed as reported on the certificate of analysis.