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Based on observation and staff interview, the facility did not maintain the proper building structure fire rating based on building height in accordance with NFPA 101, 2012 edition, Sections 19.2.6.2.

Findings include:

On 11/30/2021 at 2:29 PM, observation revealed the floor in the First Floor Dirty Equipment Room 150 of the Surgery Area had two holes - one 2" in diameter and the other 1" in diameter. These holes derated the floor from the original 2 hour rating.

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

Based on observation and staff interview, the facility did not maintain access to exits free of obstructions or impediments in accordance with NFPA 101, 2012 edition, Sections 19.2.1, 7.1.10.1, and 7.13.3.4.

Findings include:

On 11/30/2021 at 11:19 AM, observation revealed the exit door from the Dietary Office 129 to the Corridor was blocked by (3) cardboard boxes, not allowing passage from the Dietary Office and Dietary Kitchen Room 128. Each box measured 8 inches by 10 inches by 16 inches.

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

Based on observation and interview, the facility failed to provide a means of egress in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.2.2.2.4 and 7.2.1.6.2.

Findings include:

1. On 11/30/2021 at 1:02 PM, observation revealed the exit door from the Surgery Corridor 142 to the Corridor adjacent to Room 200 did not open properly. The "push to exit" paddle did not open the locked door. When a person remained still in front of the door, the door would be locked and not open when the panic bar was pushed.

2. On 12/01/2021 at 2:12 PM, observation in the Linen/Equipment Storage Room 190B included access controlled egress locking arrangement but without a manual release device on the egress side. In addition, this 1 hour rated storage room did not include a door closer.

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

Based on observation and interview, the facility failed to provide a means of egress in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.2.2.2.4 and 7.2.1.6.2.

Findings include:

1. On 12/01/2021 at 3:50 PM, observation revealed the double smoke barrier, corridor doors adjacent to First Floor Room 201, included delayed egress but did not include a readily visible and durable sign on the door leaf denoting the egress condition and time delay.

2. On 12/01/2021 at 4:15 PM, observation revealed the double corridor doors, adjacent to First Floor Room 225, included delayed egress but did not include a readily visible and durable sign on the door leaf denoting the egress condition and time delay.

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

Based on observation and interview, the facility did not maintain smoke barrier doors to be self-closing doors or automatic closing devices that released with the fire alarm or local smoke detectors complying with NFPA 101, 2012 edition, Sections 19.2.2.2.7, 7.2.1.8.2, and 8.5.4.4, as well as NFPA 72, 2010 Edition, Section 17.7.5.6.6.1.

Findings include:

On 11/30/2021 at 11:14 AM, observation revealed that the double smoke barrier, corridor doors outside the Dietary Office 129 on the Lower Level, did not have smoke detectors within 5 feet of the doors to activate the fire alarm and release the hold open mechanism of the doors.

This deficient practice was confirmed by Staff GG 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:

1. On 12/1/2021 at 10:46 AM, observation revealed (1) three inch diameter pipe penetration into the corridor above the entry door to Mechanical Room 209 on the Lower Level was not fire stopped. In the same area, a 1 1/2 inch diameter conduit did not include fire stopping.

2. On 12/01/2021 at 5:44 PM, observation revealed that the Chapel, Room 167, was being used for storage of combustible furniture, including (5) mattresses, (8) upholstered chairs, (50) conference room chairs, a wooden desk, and (2) wooded end tables, in addition to the regular wooden furniture, wooden TV stand, and piano used for worship. The corridor door was not self-closing or automatic closing and was not rated. The 20 inch by 40 inch sidelite to the door did not include wired or rated glass within the unrated frame.

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

Based on observation and interview, the facility did not provide occupant notification in accordance with NFPA 101, 2012 edition, Sections 19.3.4.3.1, 9.6.3, and 9.6.1.8, as well as NFPA 72, 2010 edition, Sections 18.5.4.4.5 and 18.6.

Findings include:

1. On 12/01/2021 at 10:20 AM, observation revealed that there was not a visible/audible fire alarm notification device(s) provided inside the Lab Room 186 on the Lower Level.

2. On 12/01/2021 at 10:25 AM, observation revealed that there was not a visible/audible fire alarm notification device(s) provided inside Mechanical Room 189 on the Lower Level.

3. On 12/01/2021 at 10:38 AM, observation revealed that a second visible fire alarm notification device was not provided inside Mechanical Room 216 on the Lower Level. The "L" shape and size of the room requires at least (2) devices.

4. On 12/01/2021 at 12:05 PM, observation revealed that there was not a visible/audible fire alarm notification device(s) provided inside the Soiled Laundry Room 159 on the Lower Level.

5. On 12/01/2021 at 12:11 PM, observation revealed that there was not a visible/audible fire alarm notification device(s) provided inside the Clean Laundry Rm 157 on the Lower Level.

6. On 12/01/2021 at 2:55 PM, observation revealed that there was not a visible/audible fire alarm notification device(s) provided inside the Visitor Lounge Rm 107 on the First Floor.

7. On 12/01/2021 at 3:23 PM, observation revealed that there was not a visible/audible fire alarm notification device(s) provided inside the Patient Waiting Room 130 on the First Floor.

8. On 12/01/2021 at 5:36 PM, observation revealed that there was not a visible/audible fire alarm notification device(s) provided inside each of the Doctor Sleep Rooms 158 and 160 on the First Floor.

These deficient practices were confirmed by Staff GG 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 and 9.6.1.3; as well as NFPA 72, 2010 edition, Sections 14.3.1 and 14.4.5.

Findings include:

On 12/01/2021 at 8:07 AM, record review of fire alarm inspection and testing documents over the past 24 months revealed that the facility's fire alarm vendor, Per Mar, conducted smoke detector sensitivity testing of the fire alarm system on 08/21/2019, greater than 24 months ago. In addition, the testing did not include the acceptable range with the current reading.

This deficient practice was confirmed by Staff GG 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 and 9.6.1.3; as well as NFPA 72, 2010 edition, Sections 14.3.1 and 14.4.5.

Findings include:

On 12/01/2021 at 8:07 AM, record review of the fire alarm inspection and testing documents over the past 24 months revealed that the facility's fire alarm vendor, Per Mar, did conducted smoke detector sensitivity testing of the fire alarm system on 08/21/2019, greater than 24 months ago. In addition, the testing did not include the acceptable range with the current reading.

This deficient practice was confirmed by Staff GG 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, 9.7, as well as NFPA 13, 2010 edition, Section 8.7.5.1.

Findings include:

1. On 11/30/2021 at 11:40 AM, observation in the Lower Level Vending Alcove near the entrance to the Cafeteria Room 126, a sprinkler was located within 2 inches from the corridor wall in the corridor ceiling. The minimum distance from the corridor wall is 4 inches for a pendant sprinkler.

2. On 11/30/2021 at 11:43 AM, observation in the Lower Level Dietary Room 128 at the 'hood over the heat producing appliance,' did not have sprinkler coverage. A sprinkler was missing inside of the hood. In addition, the closest sprinkler was greater than 7.5 feet away and did not provide full coverage under the hood. A sprinkler within 3 inches of the hood was blocked by the hood.

3. On 12/01/2021 at 1:35 PM, observation in Patient Room 184 on the First Floor revealed that 3 inch deep mechanical diffuser was located within 8 inches of the sprinkler head thereby obstructing the pendant discharge towards the exterior wall.

4. On 12/01/2021 at 1:46 PM, observation in Patient Room 188 on the First Floor revealed that 3 inch deep mechanical diffuser was located within 8 inches of the sprinkler head thereby obstructing the pendant discharge towards the exterior wall.

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

Based on record review and interview, the facility did not provide a complete policy addressing when the fire sprinkler systems is out of service in accordance with the requirements of NFPA 101, 2012 edition, 9.6.1.6 and Federal Register Vol. 81, No. 86, page 26886.

Findings include:

On 11/30/2021 at 4:39 PM, record review revealed the fire watch policy did not specify that rounds or tours are to occur with staff in a "continuous or constant" and circulating method throughout the area affected by a fire sprinkler system outage.

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

Based on record review, observation, and interview, the facility did not provide a complete policy or implement a policy addressing when the fire sprinkler systems is out of service in accordance with the requirements of NFPA 101, 2012 edition, 9.6.1.6 and Federal Register Vol. 81, No. 86, page 26886.

Findings include:

1. On 11/30/2021 at 4:39 PM, record review revealed the fire watch policy did not specify that rounds or tours are to occur with staff in a "continuous or constant" and circulating method throughout the area affected by a fire sprinkler system outage.

2. On 12/01/2021 at 1:51 PM observation revealed construction was observed to be underway in Room 183, 184, and 185 on the First Floor. Staff GG noted the sprinkler system was removed from service during this time, but the facility did not implement their fire watch policy.

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

Based on observation and staff interview, the facility failed to maintain corridor doors in accordance with NFPA 101, 2012 edition, Sections 19.3.6.3.

Findings include:

1. On 11/30/2021 at 11:46 AM, observation revealed that the corridor door to the Dining Room 127 'Serving Line Area' did not positively latch after three attempts.

2. On 12/01/2021 at 12:01 PM, observation revealed that the double door from the Cart Prep Area Rm 128 to the corridor did not positively latch after three attempts.

These deficient practices were confirmed by Staff GG 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 21.3.7.5, 8.5.2 and 8.5.6.

1. On 11/30/2021 at 11:03 AM, observation in the ceiling above the double smoke barrier doors in the corridor adjacent to Dietary Office Room 129 on the Lower Level, revealed penetrations in the 2-hour fire barrier separation wall that were not fire stopped according to an approved method. A bundle of low voltage cable 2 inch diameter had the fire caulk falling out of the wall. In addition, a 3 inch diameter pipe was not properly fire stopped.

2. On 11/30/2021 at 11:30 AM, observation in the ceiling above the double smoke barrier doors in the corridor adjacent to Cart Prep Area of Kitchen 128, revealed penetrations in the 2-hour fire barrier separation wall that were not fire stopped according to an approved method. A 1 1/2 inch diameter hole was not properly fire stopped.

3. On 12/01/2021 at 10:07 AM, observation above the ceiling between the corridor and the Draw Room 182 on the Lower Level revealed penetrations in the 1-hour fire barrier separation wall that were not fire stopped according to an approved method. (2) 1/2 inch diameter conduits and (2) 1/2 inch diameter copper pipe for medgas were not properly fire stopped.

4. On 12/01/2021 at 10:13 AM, observation above the ceiling between the Corridor and Lab 186 on the Lower Level revealed penetrations in the 1-hour fire barrier separation wall that were not fire stopped according to an approved method. The 6 inch by 12 inch hole existed on the corridor side of the wall was not properly fire stopped.

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

Based on observation and staff interview, the facility did not ensure the electrical wiring and equipment met the requirements of NFPA 101, 2012 Edition, Sections 6.3.2.1 , 19.5.1.1, and 9.1.2, as well as NFPA 70, edition 2011, Sections 110.08, 110.27, and Article 210.8(B).

Findings Include:

1. On 12/01/2021 at 3:05 PM, observation in Office Rm 123 and 125 revealed a hospital grade electrical receptacle was located approximately 3 feet from the sink. The facility was not able to confirm that ground-fault circuit-interrupter (GFCI) protection was provided within 6 feet from a sink.

2. On 12/01/2021 at 3:15 PM, observation in the First Floor Corridor adjacent to Patient Room 125 revealed an electrical breaker box, in a publically accessible space, that was not secured.

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

Based on observation and staff interview, the facility did not ensure the electrical wiring and equipment met the requirements of NFPA 101, 2012 Edition, Sections 6.3.2.1 , 19.5.1.1, and 9.1.2, as well as NFPA 70, edition 2011, Sections 110.08, 110.27, and Article 210.8(B).

Findings Include:

On 12/01/2021 at 5:25 PM, observation in the Emergency Room adjacent to Patient Room 208 revealed an electrical breaker box, in a publically accessible space, that was not secured.

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

Based on observation and staff interview, the facility failed to provide proper ventilation in several rooms in accordance with ASHRAE Standard 170 Part 6 Table 7-1, AIA Guidelines for Design and Construction of Health Care Facilities, and CDC guidelines. This deficient practice had a potential of contamination of air in clean spaces with undesirable contaminants.

Findings Include:

1. On 11/30/2021 at 11:35 AM, observation in the kitchen ceiling return air plenum, revealed there was a combustible plastic blue/gray 'dish/silverware collection pail' located above the ceiling, possibly collecting dripping water from a duct. Combustible items with a flame spread rating greater than 50 and smoke rating greater than of 25 are not allowed in a return air plenum ceiling.

2. On 11/30/2021 at 1:25 PM, observation in the Clean Room 146 of the Surgery Area revealed air was moving from the 'dirty' Corridor 170 into the Clean Room 146. Airflow is required to be from clean to dirty.

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

Based on observation and staff interview, the facility did not install the linen chute per NFPA 101, 2012 edition, Section 19.5.4.1 and 9.5.2, as well as NFPA 82, 2009 edition, Sections 5.2.3.2.

Findings include:

On 12/01/2021 at 11:15 AM, observation revealed the bottom of the trash chute, within the Lower Level trash chute room, did not have a fire rated assembly protecting the bottom of the chute. The chute discharge door was on a hold open, but it did not include a fusible link.

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

Based on observation and interview, the facility did not eliminate combustible decorations in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.7.5.6 and 10.2.5.3.

Findings include:

On 11/30/2021 at 12:17 PM, observation in Room 172 (Tonia's office), revealed that the wall had (10) combustible decorations and (20) pictures without glass coverage that exceeded 30% of the wall area. No listing information was provided for the combustible material.

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

Based on observation and interview, the facility did not eliminate combustible decorations in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.7.5.6 and 10.2.5.3.

Findings include:

On 12/01/2021 at 3:55 PM, observation in the Corridor adjacent to Room 204 revealed nine combustible decorations covering more than 50 percent of two wall surfaces. These included (7) 24 x 26 paintings and (2) 4 foot by 8 foot fabric panels on one wall and (5) 24 x 26 paintings on the adjacent wall. Application of flame retardant or treatment of a fire retardant coating was not apparent or could not be confirmed by interview with Staff GG at the time of discovery.

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

Based on observation and staff interview, the facility did not store trash collection receptacles greater than 32 gallons capacity in a properly separated hazardous storage area as required by NFPA 101, 2012 edition, Section 19.7.5.7.

Findings include:

On 11/30/2021 at 2:12 PM, observation revealed (1) 20 gallon size trash receptacle, (1) 20 gallon size soiled linen receptacle and (1) 20 gallon recycle receptacle were stored together in Recovery Room 147. These two trash and soiled linen receptacles together exceeded 32 gallons capacity in a 64 square foot area.

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

Based on observation and staff interview, the facility did not maintain zone valves access and operability from a standing position in the corridor on the same floor they serve as required by NFPA 99, 2012 edition, Section 5.1.4.8.1.

Findings include:

On 12/1/2021 at 4:51 PM, observation in the Emergency Room revealed the zone valve box, adjacent to Room 220, was not readily accessible. One (1) 20 gallon garbage and one (1) 20 gallon linen container were stored in front of the zone valve box.

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

Based on record review and interview, the facility did not have records of testing electrical receptacles in accordance with the requirements of NFPA 99, 2012 edition, Sections 6.3.3.1, 6.3.3.2, 6.3.4, and 6.3.4.2.

Findings include:

On 12/01/2021 at 9:28 AM, record review revealed no annual documentation for the review of non-hospital grade electrical outlets in patient care rooms for voltage and impedance measurements. In addition, testing of new or replaced hospital grade electrical outlets in patient care areas was not documented for physical integrity, continuity of ground in circuits, polarity or retention force.

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

Based on observation and interview, the facility did not maintain the indoor generator room in accordance with requirements of NFPA 101, 2012 edition, Sections 19.5.1 and 9.1.3, as well as NFPA 110, 2010 edition, Section 7.11.

Findings include:

On 12/01/2021 at 12:20 PM, observation in Boiler Room 165 revealed a hazardous room containing an existing boiler and an existing generator. However, the room also was used for storage of combustible materials, thereby using the room for other purposed that are not directly related to the emergency power supply. Items stored included (2) cardboard boxes of 24 inches by 24 inches by 6 inches in size, (1) cardboard box of 24 by 18 by 30 inches in size, (1) cardboard box of 24 inches by 24 inches by 24 inches in size, (2) 30 gals carts full of combustible materials.

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

Based on observation and interview, the facility failed to maintain a clear working space in front of and label circuits within electrical panels in accordance with NFPA 101, 2012 edition, Section 19.5.1, 9.1.2 and NFPA 70, 2011 edition, Sections 110.26, 312.11, and 408.4 (A).

Findings include:

1. On 11/30/2021 at 12:05 PM, observation in Room 172 (Tonia's office), revealed that access to the electrical disconnect was less than the minimum required 3'-0" clearance. Two storages cart were stored in front of the disconnect.

2. On 12/1/2021 at 10:31 AM, observation in Mechanical Room 189 Electrical Closet on the Lower Level revealed that not all circuits were permanently labeled within electrical Panels 3, 3A, and K. Some labels were made with duct tape and adhered to the panel but were not include within a panel card directory on the face or inside of the panel door.

3. On 12/1/2021 at 3:40 PM, observation in the first floor X-Ray Room revealed that not all circuits were permanently labeled within electrical isolation panel. Some labels were made with duct tape and adhered to the panel but were not include within a panel card directory on the face or inside of the panel door.

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