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Based on observations, the facility failed to maintain the means of egress.

The findings included:

1. Observation on 05/07/2019 at 2:19 PM, revealed dead bolt style latches and positive latching hardware installed on the doors to Endoscopy Lab 1 and 2 resulting in more than 1 releasing operation. NFPA 101, 19.3.1 (2012 Edition) NFPA 101, 7.2.1.5.10.2 (2012 Edition)

2. Observation on 05/07/2019 at 2:37 PM, revealed dead bolt style latches and positive latching hardware installed on the door to room 161 resulting in more than 1 releasing operation. NFPA 101, 19.3.1 (2012 Edition) NFPA 101, 7.2.1.5.10.2 (2012 Edition)

The Area Director of Facilities was present when these deficiencies were identified and the Area Regional Director of Facilities acknowledged these deficiencies during the exit conference on 05/07/2019.

Based on observation and document review, the facility failed to maintain the sprinkler system.

The findings included:

1. Observation on 05/07/2019 at 1:02 PM, revealed 2 flex conduits zip tied to the fire sprinkler pipe above ceiling over the administration/ HR office on the 2nd floor.
NFPA 101, 19.3.5.1 (2012 Edition), NFPA 101,9.7.1.1 (2012 Edition), NFPA 13, 26.1 (2010 Edition), NFPA 25, 5.2.2.2 (2011 Edition)

2. Observation on 05/07/2019 at 1:38 PM, revealed a bent sprinkler in the clean supply room on the 2nd floor.
NFPA 101, 19.3.5.1 (2012 Edition), NFPA 101,9.7.1.1 (2012 Edition), NFPA 13, 26.1 (2010 Edition),
NFPA 25, 5.2.1.1.2 (2011 Edition)

3. Observation on 05/07/2019 at 1:47 PM, revealed a bent sprinkler in the janitors closet by therapy treatment center on the 2nd floor.
NFPA 101, 19.3.5.1 (2012 Edition), NFPA 101,9.7.1.1 (2012 Edition), NFPA 13, 26.1 (2010 Edition),
NFPA 25, 5.2.1.1.2 (2011 Edition)

4. Document review on 05/07/2019 between 3:00 PM and 3:45 PM, revealed no documentation for the dry sprinkler pendant test within the last 10 years.
NFPA 101, 19.3.5.1 (2012 Edition), NFPA 101, 9.7.1.1 (2012 Edition), NFPA 13, 26.1 (2010 Edition),
NFPA 25, 5.3.1.1.1.6 (2011 Edition)

The Facilities Manager was present when these deficiencies were identified and the Area Regional Director of Facilities acknowledged these deficiencies during the exit conference on 05/07/2019.

Based on observation and document review, the facility failed to maintain the sprinkler system.

The findings included:

Document review on 05/07/2019 between 3:00 PM and 3:45 PM, revealed no documentation for the dry sprinkler pendant test within the last 10 years.
NFPA 101, 19.3.5.1 (2012 Edition), NFPA 101,9.7.1.1 (2012 Edition), NFPA 13, 26.1 (2010 Edition),
NFPA 25, 5.3.1.1.1.6 (2011 Edition)

The Facilities Manager was present when these deficiencies were identified and the Area Regional Director of Facilities acknowledged these deficiencies during the exit conference on 05/07/2019.

Based on observations, the facility failed to ensure Portable space heating devices shall be prohibited in all health care occupancies.

The findings include:

Observation on 05/07/2019 at 1:41 PM revealed 2 portable electric space heater behind the registration desks in the front lobby. NFPA 101, 19.7.8 (2012 Edition)

The Facilities Manager was present when these deficiencies were identified and the Area Regional Director of Facilities acknowledged these deficiencies during the exit conference on 05/07/2019.