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Based on observation and interview, the facility did not protect a hazardous area in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.2.2.2.7, 19.3.2.1, 7.2.1.8.2, and 8.7.1.3. This deficient practice could affect an undetermined number of staff and visitors.

Findings include:

1. On 04/12/2022 at 12:03 PM, observation at the EVS Soiled Utility Room 445 revealed a 1/2 inch diameter hole in the door, adjacent to the door lever.

2. On 04/12/2022 at 12:05 PM, observation at the EVS Clean Laundry Rm 444 revealed (2) 1/2 inch diameter holes in the door, adjacent to the door lever.

3. On 04/12/2022 at 12:07 PM, observation at the EVS Wash Rm 442, a room greater than 50 square feet, revealed a 1/2 inch diameter hole in the door, adjacent to the door lever.

These deficient practices were confirmed by Staff M and HH at the time of discovery.

4. On 04/13/2022 at 9:56 AM, observation in the Patient Room 378 revealed the room was used for the storage of combustibles. The room contained (3) patient mattresses, (1) stretcher mattress, (9) carts and (3) wooden chairs. The walls and the door of the room were not rated for smoke resistance, and door was not equipped with a self-closer or automatic closing hardware.

5. On 04/13/2022 at 12:17 PM, observation in the Lab Break Room revealed the door between the break room and the standard level hazardous Laboratory Room included self-closer or automatic closing hardware but was unable to close due to a chair wedging the door open.

These deficient practices were confirmed by Staff M and FF at the time of discovery.

Based on observation and interview, the facility did not provide operation of fire activating devices in accordance with NFPA 101, 2012 edition, Sections 19.3.4.4, 9.6.1.3, and 9.6.5.2, as well as NFPA 72, 2010 edition, Section 21.8.1 and 21.8.3.

On 04/12/2022 at 3:04 PM, observation revealed that the double smoke barrier doors between the Sleep Study Department Patient Toilet Room and the Emergency Department Soiled Utility Room did not fully close when the fire alarm was enacted.

This deficient practice was confirmed by Staff M and HH at the time of discovery.

Based on record review and interview, the facility did not perform the semi-annual testing and inspections of the fire alarm system in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.4.1, 9.6.1.3, and 9.6.1.5; as well as NFPA 72, 2010 edition, Sections 14.3.1 and 14.4.5.

Findings include:

On 04/12/2022 at 3:53 PM, record review of fire alarm inspection and testing documents revealed that the semi-annual visual inspection of alarm initiating devices for smoke detectors, heat detectors, duct detectors, electromechanical releasing devices (door hold opens), and manual fire alarm boxes (pull stations) was conducted once, on 10/05/2021, by Siemens within the last 12 months.

This deficient practice was confirmed by Staff M at the time of discovery.

Based on observation and interview, the facility did not provide an automatic sprinkler system in accordance with NFPA 101, 2012 edition, Sections 19.3.5.11 and 9.7, as well as NFPA 13, 2010 edition, Sections 8.6.5.2.2 and 8.6.5.2.2.1.

Findings include:

1. On 04/13/2022 at 2:29 PM, observation in the Operating Room Suite Staff Toilet/Shower Room 417A revealed the area inside the shower stall was not sprinkler protected and was blocked from protection of other sprinklers in the room by the privacy shower curtain. The curtain did not include any fabric mesh with openings equal to 70 percent or greater extending a minimum of 22 inches below the ceiling. The space between the ceiling and the top of the solid curtain was 1 inch.

2. On 04/13/2022 at 2:34 PM, observation in the Operating Room Suite Staff Toilet/Shower Room 417B revealed the area inside the shower stall was not sprinkler protected and was blocked from protection of other sprinklers in the room as the privacy shower curtain. The curtain did not include any fabric mesh with openings equal to 70 percent or greater extending a minimum of 22 inches below the ceiling. The space between the ceiling and the top of the solid curtain was 1 inch.

These deficient practices were confirmed by Staff M and FF at the time of discovery.

Based on observation and staff interview, the facility did not maintain corridor doors in accordance with NFPA 101, 2012 edition, Section 19.3.6.3.

Findings include:

On 04/12/2022 at 1:28 PM, observation in the Staff Lounge in the Diagnostics Area revealed that the corridor door to the 311 Room did not close as the door was being held open by an X-Ray Positioning device as a floor wedge.

This deficient practice was confirmed by Staff M and Staff HH at the time of discovery.

Based on observation and interview, the facility did not maintain smoke barriers in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.7.3, 8.5, 8.5.2 and 8.5.6.

Findings include:

1. On 04/12/2022 at 10:07 AM, observation in the OBGYN Dirty Utility Room revealed an (8) smoke barrier ceiling penetrations were not properly fire stopped according to an approved method. These unstopped penetrations included (1) 6 inch diameter low pressure steam pipe, (1) 3 inch diameter condensate pipe, (4) 1/2 inch diameter conduit pipes, and (2) 1/2 inch diameter copper pipes.

2. On 04/12/2022 at 12:09 PM, observation in the Floor Clean Room 440 revealed (3) penetrations were not properly fire stopped according to an approved method. These unstopped penetrations included (1) 1/2 inch diameter electrical conduit and (2) 1/2 inch diameter, insulated copper pipes.

3. On 04/12/2022 at 12:19 PM, observation in the IT Room revealed (4) penetrations to the smoke barrier corridor wall that were not properly fire stopped according to an approved method. These penetrations included (1) 12 inch by 12 inch duct and (3) 4 inch diameter, cable pipes that included 20-30 multi-colored cables in each pipe.

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

4. On 04/13/2022 at 10:27 AM, observation above the ceiling in Reading Room 300 revealed a penetration in the smoke barrier wall that was not fire stopped according to an approved method. The corridor wall penetration included an 3/8 inch conduit within an one inch diameter hole.

5. On 04/13/2022 at 10:34 AM, observation above the ceiling in the corridor outside of Room 273 revealed a penetration in the smoke barrier wall that was not fire stopped according to an approved method. The corridor wall penetration included an 1/2 inch conduit within an one inch by 2 inch hole.

These deficient practices were confirmed by Staff M and FF at the time of discovery.

Based on observation and interview, the facility did not maintain doors in smoke barrier doors in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.7.6, 19.3.7.8, 8.2.2.4, 8.5.4, 7.2.1.8 and 7.2.1; as well as NFPA 80, 2010 edition, Section 6.3.1.7.1.

Findings include:

On 04/12/2022 at 2:00 PM, observation revealed that the double smoke doors between the Diagnostic Suite smoke compartment and the East-West Cross Corridor did not fully close leaving greater than a 1/8 inch gap between doors.

This deficient practice was confirmed by Staff M and HH at the time of discovery.

Based on observation and interview, the facility did not ensure the electrical wiring and equipment met the requirements of NFPA 101, 2012 Edition, Sections 19.5.1.1, 9.1.1, and 9.1.2, as well as NFPA 70, edition 2011, Articles 110.3(B), 110.8, 110.27, 210.8(B), and 400.8.

Findings Include:

1. On 04/12/2022 at 1:42 PM, observation in the Diagnostics Exam Room containing the Dexa Bone Density Scanner revealed the grounding wire of the medical device equipment was not properly terminated. The scanner was connected directly to the diagnostic computer terminal. The computer terminal included both a grounded plug connected to the wall receptacle, as well as a separate grounding wire that was affixed to the outside face of the wall receptacle coverplate with only the receptacle coverplate screw.

2. On 04/12/2022 at 2:13 PM, observation in the Office 341 revealed a flexible cord multi-outlet strip device (power strip) powering a space heater without a temperature setting.

These deficient practices were confirmed by Staff M and HH at the time of discovery.

3. On 04/13/2022 at 10:41 AM, observation above the ceiling in the Oncology Manager Office Room 290 revealed a 4 inch by 4 inch electrical junction box missing a cover.

4. On 04/13/2022 at 2:43 PM, observation in the Employee Break Room 416 revealed electrical receptacle NL-2 #1 was located approximately 3-feet from a sink. The facility was not able to confirm that ground-fault circuit-interrupter (GFCI) protection was provided within 6-feet from a sink.

These deficient practices were confirmed by Staff M and FF at the time of discovery.

Based on observation and interview, the facility did not ensure space heating devices were used in accordance with the requirements of NFPA 101, 2012 edition, Section 19.7.8.

Findings include:

1. On 04/12/2022 at 2:15 PM, observation in Office 342 revealed (2) portable space heaters underneath an office desk. The facility did have a space heater policy but was unable to provide documentation that the element of the space heaters did not exceed temperatures of 212 degrees Fahrenheit.

This deficient practice was confirmed by Staff M and HH at the time of discovery.

2. On 04/13/2022 at 11:26 AM, observation in Office 150B revealed a portable space heater underneath an office desk that did not include a facility control number. The facility did have a space heater policy but was unable to provide documentation that the element of the space heaters did not exceed temperatures of 212 degrees Fahrenheit.

3. On 04/13/2022 at 11:32 AM, observation in Office 138 revealed a portable space heater underneath an office desk that did not include a facility control number. The facility did have a space heater policy but was unable to provide documentation that the element of the space heaters did not exceed temperatures of 212 degrees Fahrenheit.

These deficient practices were confirmed by Staff M and FF at the time of discovery.

Based on observation and interview, the facility did not ensure shutoff valves were identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.2.4 and 8.7, as well as NFPA 99, 2012 edition, 5.1.14.3, 5.1.11.2.1, 5.1.11.2.2, 5.2.11.

Findings include:

On 04/13/2022 at 10:02 AM, observation in the corridor between the Vending Rm and Soiled Utility Room in the Patient Wing revealed the labeling, for the gas and vacuum piping, was missing for the zone valves, as well as the area or room served by the piping.

This deficient practice was confirmed by Staff M and FF at the time of discovery.

Based on record review and interview, the facility did not complete maintenance and testing of the emergency generator and transfer switches accordance with the requirements of NFPA 101, 2012 edition, Sections 19.5.1 and 9.1.3; as well as NFPA 110, 2010 edition, Sections 8.3.4, 8.4.2, and 8.4.9.

Findings include:

On 04/12/2022 at 4:11 PM, record review did not reveal evidence that the (1) 350 kW exterior mounted diesel emergency generator had been exercised once every 36 months for at least 4 hours of continuous rated load with at least one test transfer switch operation.

This deficient practice was confirmed by Staff M at the time of discovery.

Based on observation and interview, the facility did not store oxygen cylinders in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.2.4 and 8.7, as well as NFPA 99, 2012 edition, Sections 11.3.1 and 5.1.3.3.2(4).

Findings include:

On 04/12/2022 at 11:41 AM, observation in the Medical Gas Storage Room by the Main Mechanical Room revealed the vinyl wall base was not a noncombustible or limited-combustible material and did not meet the 1-hour fire resistance rated construction requirement for walls, floors, and ceiling.

This deficient practice was confirmed by Staff M at the time of discovery.