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Based on observation, the facility failed to ensure doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side in accordance with NFPA 101-2012, Section 7.2.1.5.3.

Findings include:

1. During an observation on 5/3/22 at 3:54 p.m., the outpatient exit door was inspected. The door was equipped with an access-controlled egress locking system. It was not equipped with all the parts of this type of special locking arrangement. It had the electomagnetic lock and the "push to exit" button, but the motion detector was not mounted where it could detect the motion of an approaching occupant and unlock the door.

Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7 and section 19.2.2.2.8.

Findings include:

1. During an observation on 5/3/22 at 3:39 p.m., the housekeeping room was inspected. The room was more than 50 square feet and was used to house combustible storage. The door was chocked open and would not close under the power of the self-closer.

2. During an observation on 5/3/2022 at 3:45 p.m., the two-hour fire door on the hold-open by IT was exercised. The door would not close and latch under the power of the self-closer.

Based on observation the facility failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures 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:

1. During an observation on 5/3/22 at 7:55 a.m., the basement IT corridor was inspected. The row of ceiling mounted lights in the corridor were blocking the sprinkler heads next to them. The heads were within 12 inches of the lights, and the lights were lower than the deflectors on the sprinkler heads.

Based on observation, the facility failed to maintain automatic fire sprinklers in reliable operating condition including examination of the heads per NFPA 25-2011, Sections 5.2.1.1.2., maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1.

Findings include:

1. During an observation on 5/3/22 at 3:10 p.m., the service hall corridor was inspected. There was a pendant type sprinkler head in the corridor which had some type of corrosion running down from above. The sprinkler head will need to be cleaned or replaced and the source of the corrosion needs to be addressed.

2. During an observation on 5/3/22 at 3:33 p.m., the clean side of the laundry was inspected. There were several painted sprinkler heads in the room.

3. During an observation on 5/3/22 at 3:36 p.m., the soiled side of the laundry was inspected. There were several painted sprinkler heads in the room.

4. During an observation on 5/4/22 at 7:45 a.m., the ER was inspected. There was a sprinkler head over a cabinet which had items stacked on top within 18" of the sprinkler head.

Based on observation, the facility failed to maintain portable fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers 2010 edition, Section 6.1.3.4., failed to install portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.8.1, and failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1. This deficiency affects 1 of 8 smoke compartments.

Findings include:

1. During an observation on 5/3/22 at 3:19 p.m., the biohazard storage room was inspected. There was a portable fire extinguisher sitting on a shelf in the room, it was not properly mounted to the wall.

2. During an observation on 5/3/22 at 3:43 p.m., the basement air handling room was inspected. There was a portable extinguisher mounted on the wall at 65 inches to the top of the handle.

3. During an observation on 5/3/22 at 4:19 p.m., the radiology department was inspected. There was a portable extinguisher blocked by a tall cabinet in the area.

4. During an observation on 5/3/22 at 4:25 p.m., the MRI corridor was inspected. There was a portable extinguisher blocked by a table placed in front of it.

5. During an observation on 5/4/22 at 7:38 a.m., the ER waiting room was inspected. There was a portable extinguisher blocked by a chair placed in front of it.

6. During an observation on 5/4/22 at 7:40 a.m., the ER was inspected. There was a portable extinguisher blocked by a cabinet placed in front of it.

7. During an observation on 5/4/22 at 7:40 a.m., the ER ambulance bay was inspected. There was a portable extinguisher mounted on the wall at 69 inches to the top of the handle.

Based on observation, the facility failed to ensure fire/smoke barrier doors located in the fire/smoke partitions were maintained per NFPA 101-2012, Section 8.4.3.4 and NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, Section 6.3.1.7.1.

Findings include:

1. During an observation on 5/3/22 at 4:16 p.m., the smoke doors between acute care and administration were exercised. The doors were not tight enough when closed. The gap between the doors was at least 1/4" wide. Doors cannot have a gap of more than 1/8" when closed.

Based on observation and interview, the facility failed to adhere to provisions set forth for hospital ground level helipads in accordance with NFPA 101, 2012 Edition, Section 9.7.4, NFPA 10, Standard for Portable Fire Extinguishers, 2011 Edition, Section 5.6.1, and NFPA 418 Standards for Helipads, 2011 Edition, Section 9.2 and 4.6.2

Findings include:

1. During an observation on 5/3/22 at 4:00 p.m., the helipad was inspected. There was no portable fire extinguisher in the immediate area of the helipad.

2. During an observation on 5/3/22 at 4:00 p.m., the helipad was inspected. There were not any "no smoking" signs at the access and egress points to the helipad.

Based on record review, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6.

Findings include:

1. Review of facility documents regarding fire drills for the last year reflected there was no documentation for a completed drill for:

-Evening shift for the 4th quarter of 2021;
-NOC shift for the 3rd quarter of 2021.

Based on observations, the facility failed to maintain the electrical system in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110.27.

Findings include:

1. During an observation on 5/3/22 at 4:03 p.m., the infusion room was examined. There were two clock boxes on the wall in one of the partitions. The clocks had been removed. The clocks were of the hard-wired type. The 110 volt wires were left open to the room inside the mounting boxes where they could accidentally be contacted by anyone in the room.