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Based upon observations made in the presence of the facility manager on 02-23-2022, it was determined that the facility did not continuously maintain the means of egress and exits to the public way at all times in accordance with NFPA 101: 20.2.1, 7.1.10.1

This deficiency affected all fire door openings.

Findings include:
1-During the record review the facility failed to provide the documentation for the identification for the annual testing of the fire doors test and maintenance of the fire doors in accordance with NFPA 80 5.2, NFPA 105

Based upon observations made during the facility tour in the presence of the facility manager on 02-23-2022 it was discovered that the facility did not maintain the means of egress, Exit discharge in accordance with NFPA 101 19.2.11, 19.2.1, 7.1.10.1.

This deficiency affected 2 of the fire exit stairwells

Findings include:
1-During the facility tour it was discovered that there was storage of 7 chairs, 2 cribs, 4 folding tables in exit discharge stairwells, these finding were confirmed with the facility manager.

Based on observations made it the presence of the facility manager on 02-23-2022 it was determined that the facility did not maintain egress doors in the required means of egress, egress doors shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the special locking arrangements per. NFPA 101 19.2.2.2.5.1, 19.2.2.2.6, 19.2.2.2.5.2, TIA 12-4

This deficiency affected all chain link storage areas in the basement.

Findings include:
During the facility tour it was observed that the storage areas in the basement has segregated storage areas by fencing them with 6 ft. chain link fence and framed chicken wire fencing and had pad locks that were not operable in the direction of egress when secured, estimated 3 each, 2 of the purchasing department and 1 of the dietary department.

Based upon observations made in the presence of the facility manager on 02-23-2022 it was determined that the facility did not provide an emergency lighting system in accordance with NFPA 101 19.2.9.1, 20.2.9existing and 7.9)

This deficiency affected all emergency lights.

Findings include:
During the record review it was observed that the facility failed to provide the documentation for the identification for the annual and monthly testing of the emergency lights with battery backup, in accordance with NFPA 101 7.9.3.

Based upon observations made in the presence of the facility manager on 02-23-2022, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1.

This deficiency affected

Findings include:
1-During the facility tour it was observed that the door to housekeeping storage room in the basement was being held open with a wooden wedge. The door is required to be self-closing or automatic closing to the latch position in accordance with NFPA 101 19.3.2.1.
2-During the facility tour it was observed that the door to housekeeping storage room by medical records was being held open with a wooden wedge. The door is required to be self-closing or automatic closing to the latch position in accordance with NFPA 101 19.3.2.1.

Based upon observations made in the presence of the facility manager on 02-23-2022, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

This deficiency affected several GFIC outlets.

Findings include
1-During the facility tour it was observed that the outlet at the RT office hand wash sink was not GFIC protected and was observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
2- During the facility tour it was observed that the outlet in central sterile at the sink was not GFIC protected and was observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
3- During the facility tour it was observed that the outlet in the new Post anesthesia care unit storage room at the sink was not GFIC protected and was observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
4- During the facility tour it was observed that the outlet in the pharmacy at the sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
5- During the facility tour it was observed that the 4 outlets in the kitchen pot and pan wash sink area and 1 outlet by the roll up serving window that was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
6- During the facility tour it was observed that the 2 outlets in the old dirty utility room at the sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
7- During the facility tour it was observed that the outlets in the ER exam rooms 1,2 and 3 at the sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
8- During the facility tour it was observed that the outlet in the ER housekeeping closet at the sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
9- During the facility tour it was observed that the 2 outlets in X RAY room 143 at the sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
10- During the facility tour it was observed that there were several outlets "normal power and emergent power" in the lab area at the sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
11- During the facility tour the electrical panel in the cafeteria stairwell was observed to be unlocked allowing unauthorized access to unqualified persons not in accordance with NFPA 70,110-31 (D)
12- During the facility tour the electrical panel in the central sterile hallway was observed to be unlocked allowing unauthorized access to unqualified persons not in accordance with NFPA 70,110-31 (D)

Based upon observations made during the record review in the presence of the facility manager on 02-23-2022, it was determined that the facility did not conduct fire drills or training related to the current fire plan, they must be held at unexpected times under varying conditions at least quarterly on each shift in accordance with NFPA 101 19.7.1.4. Through 19.7.1.7. (ASC 21.7.1.4 through 21.7.1.7)

This deficiency affected 5 of 12 fire drills.

Findings include:
During the record review the facility failed to provide documentation of the required 12 fire drills and or a documented orientation training program. The missing drills were the 1st quarter 3rd shift, 2nd quarter 1st shift, 3rd quarter 1st and 2nd shift and the 4th quarter 1st shift. Drills shall be held at unexpected time under varying conditions at least quarterly on each shift in accordance with NFPA 101 19.7.1.4. Through 19.7.1.7.

Based upon observations made in the presence of the facility manager on 02-23-2022, it was determined that the facility did not test the Line Isolation Monitors in accordance with NFPA 99 6.3.4.1.4, 6.3.3.3.2

The deficiency affected 2 of 2 isolation monitor.

Findings include:
1-During the facility tour it was discovered that the line isolation monitors in 2 of the operating rooms had not be tested. Line Isolation Monitors shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). The affected rooms were Operating Rooms 3 and 4, Operating room #4 "Endo" had an old LIM that did not have a functional alarm or trouble light in the OR room to alert the medical staff of hazardous conditions, the panel was in the central sterile corridor.
For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators, the system was not in accordance with NFPA 99 6.3.4.1.4, 6.3.2.6.3

Based upon observations made in the presence of the facility manager on 02-23-2022, it was determined that the facility did not maintain medical gas storage in accordance with NFPA 99 5.1.3.3.2.

This deficiency affected 1 of the stored cylinders.

Findings include:
1-During the facility tour with the facility manager it was discovered that there was a CO2 cylinder in the Dornoch room that was not secured and not in accordance with NFPA 99 5.1.3.3.2 (7)