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Based on observation and staff interview, the facility failed to Maintain Egress Doors in accordance with (NFPA 101 / NFPA 99), (Life Safety Code / Health Care Facilities Code), Section 19.2.2.2.4. This deficient practice could affect (36 of patient).
Findings include:
On a facility tour between the hours of (9-3pm) on 12/3/2019, it was revealed that the delayed egress doors, in the Med/Surge pods for stairwells C and E did not have a delayed egress sign stating "PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS".

This deficient practice was verified by the Facility Maintenance Director at the time of discovery.

Based on observation and staff interview, the facility failed to Maintain Hazardous Areas - Enclosure in accordance with (NFPA 101 / NFPA 99), (Life Safety Code / Health Care Facilities Code), Section 19.3.2.1, 19.3.5.9. This deficient practice could affect 36 of patient.
Findings include:
On a facility tour between the hours of (9-3pm) on 12/3/2019, it was revealed that Room 23 Vendor Room is over 100 square feet in size with a self-closing door that was wedged open.

This deficient practice was verified by the Facility Maintenance Director at the time of discovery.

Based on observation and staff interview, the facility failed to Maintain Fire Alarm System - Installation in accordance with (NFPA 101 / NFPA 99), (Life Safety Code / Health Care Facilities Code), Section 19.3.4.1, 9.6, 9.6.1.8. This deficient practice could affect 36 of patients.
Findings include:
On a facility tour between the hours of (9-3pm) on 12/3/2019, it was revealed that the Sterile Supply Room had a smoke detector that was within 36 inches of an air plenum.

This deficient practice was verified by the Facility Maintenance Director at the time of discovery.

Based on observation and staff interview, the facility failed to Maintain Spinkler System - Installation in accordance with (NFPA 101 / NFPA 99), (Life Safety Code / Health Care Facilities Code), Section 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1). This deficient practice could affect 36 of patients.
Findings include:
On a facility tour between the hours of (9-3pm) on 12/3/2019, it was revealed that the following:

1) The EMS Quarters Suite had 2 sprinkler heads that were approximately 3 feet from each other.
When questioned about the installation, one senior paramedic stated that wall was removed during a remodel. 12/02/2019

2) Room 23 Vendor Room had storage within 18 inches from the sprinkler head deflector. The storage racks all had signs stating

3) The 1st floor dry sprinkler riser closet did not have a sprinkler head protecting the space.

This deficient practice was verified by the Facility Maintenance Director at the time of discovery.

Based on (observation or document review) and staff interview, the facility failed to Maintain Corridors - Construction of Walls in accordance with (NFPA 101 / NFPA 99), (Life Safety Code / Health Care Facilities Code), Section 19.3.6.2, 19.3.6.2.7. This deficient practice could affect 36 of patients.
Findings include:
On a facility tour between the hours of (9-3pm) on 12/3/2019, it was revealed that the smoke barrier outside Room 23 Vendor Room and surgery suite had penetrations through the smoke barrier wall, above the double doors.

This deficient practice was verified by the Facility Maintenance Director at the time of discovery.

Based on (observation or document review) and staff interview, the facility failed to Maintain Smoke Barrier Construction in accordance with (NFPA 101 / NFPA 99), (Life Safety Code / Health Care Facilities Code), Section 19.3.7.3, 8.6.7.1(1) . This deficient practice could affect 36 of patients.
Findings include:
On a facility tour between the hours of 9-3pm on 12/3/2019, it was revealed that the corridor smoke/fire door near 2C Nurses Station did not positively latch when closed.

This deficient practice was verified by the Facility Maintenance Director at the time of discovery.

Based on (observation or document review) and staff interview, the facility failed to Maintain Power Cords and Extension Cords in accordance with (NFPA 101 / NFPA 99), (Life Safety Code / Health Care Facilities Code), Section 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 . This deficient practice could affect 36 of patients.
Findings include:
On a facility tour between the hours of 9-3pm on 12/3/2019, it was revealed that a power strip was observed in Staff Area Room 205. There was two coffee makers plugged into this power strip.

This deficient practice was verified by the Facility Maintenance Director at the time of discovery.