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Based on observation the facility failed to provide a safe means of egress from the CT room exit to a public way. Failure to provide a clear and unimpeded means of egress could cause harm to the patients and staff in a fire emergency.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10.1 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency." Section 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto egress therefrom, or visibility thereof.

Observations made while on tour on June 1, 2021, revealed a C-arm blocking the exit egress from the CT room emergency exit. Continuing outside the exit door the exit ramp leading away from the facility had a chair and wooden pallets on it.

During the exit conference on June 1, 2021, the above findings were again acknowledged by the management staff.

Based on observation it was determined the the facility failed to prevent an ABC fire extinguisher from being blocked and readily accessible in the disaster/Covid testing area of the facility. Failing to have clear access to a fire extinguisher during an emergency could result in harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1" Section 9.7.4.1 "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable
Fire Extinguishers." NFPA 10, Chapter 7, Section 7.2.2 Periodic inspections or electronic monitoring of fire extinguishers shall include a check of at least the following items: No obstruction to access or visibility.

Findings include:

During a facility tour conducted on June 2, 2021, a portable fire extinguisher located in the disaster/Covid testing area facility was being
blocked by a small table and signage obstructing the fire extinguisher cabinet door from opening.

During the exit conference on June 2, 2021, the above findings were again acknowledged by the management team.

Based on observation it was determined the facility failed to provide protection from electrical shock. Failing to protect energized electrical equipment or wiring can cause a shock or fire. A fire could cause harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1.1 "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2,
"Electrical wiring and equipment installed shall be in accordance with NFPA 70 "National Electrical Code. NEC, 1999, 2011 Edition, Article 110 Requirements for Electrical Installations, "110.12(B) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by
corrosion, chemical action, or overheating."

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1.1 Utilities shall comply with the provisions of Section 9.1., Section 9.1.2
"Electrical wiring and equipment shall be in accordance with NFPA 70, 2011 Edition, "National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction." NEC, 2011 ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment.Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions. Findings Include:

Observations made while on tour on June 2, 2021, revealed the following areas with broken electrical receptacles and/or covers:

1) Medical records office, broken outlet
2) Outside the mail room, broken outlet
3) Hallway between apartments 7 and 8, missing
outlet cover
4) Family waiting room, broken outlet
5) Room A22. missing light switch cover
6) Room C28 IT closet, exposed wiring
7) Room C28 IT closet blocked electrical panel

During the exit conference on June 2, 2021, the above finding was again acknowledged by the management staff.

Based on observation and interview with staff, facility failed to provide a written fire procedure plan for the protection of all patients in time of a fire or emergency. Failure to provide policy, procedures and training to the staff may caused harm to the patients and staff during an emergency.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.1.1 "The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for their evacuation to areas of refuge, and from the evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in
the telephone operator's position or at the security center." 19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan
shall provide for all of the following:

(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for
evacuation
(9) Extinguishment of fire

Findings include:

Based on observation and interview with staff on June 1-3, 2021, the facility was unable to provide a facility fire procedure plan which contained the nine (9) required steps as per NFPA 101 19.7.2.2. A written fire procedure policy was not found or
seen during the survey.

During the exit conference on June 3, 2021, the above finding was again acknowledged by the management staff.