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Based on observation and interview, the facility failed to properly dispose of oil-soaked rags, as required by 18.1 and 19.1. This deficient practice could affect all occupants in the event of a fire emergency.

Findings Include:
On May 18, 2022, at approximately 10:41 AM, observation revealed oil-soaked rags in a coffee can in the B-Elevator mechanical room. This deficient practice could result in a fire by spontaneous combustion of the oil-soaked rags.

The Plant Engineering Director Environmental of Care and Hospital Vice President confirmed these findings during interview at the time of observation.

Based on observation and interview, the facility failed to ensure aisles, passageways, corridors, exit discharges, exit locations and accesses are in accordance with Chapter 7, and continuously maintained free of all obstructions to full use in case of an emergency as required by 19.2.1 and 7.1.10.1. This deficient practice could affect all occupants in the event of a fire emergency requiring occupants to evacuate.

Findings Include:
A. On May 18, 2022, at approximately 9:54 AM, observation revealed overhead cross-corridor fire barrier at the first-floor elevator adjacent to the out-patient service corridor is obstructed by an electrically powered scooter.

B. On May 18, 2022, at approximately 10:10 AM, observation revealed egress corridor from the basement Physical Therapy track parallel to the elevator is obstructed by a coat rack, a wooden bench, and a large wheelchair.

The Plant Engineering Director Environmental of Care and Hospital Vice President confirmed these findings during interview at the time of observation.

Based on observation, record review and interview, the facility failed to ensure the automatic sprinkler and standpipe systems are inspected, tested and maintained in accordance with NFPA 25, and records are readily available as required by 9.7.5, 9.7.7, 9.7.8 and NFPA 25. This deficient practice could affect all occupants in the event of a fire emergency and activation of the sprinkler system.

Findings Include:
A. On May 18, 2022, between 9:30 AM - 10:45 AM, record review revealed the facility failed to provide documentation at the time of survey the required quarterly flow test of the automatic sprinkler system was completed during the last 12 months. Per the Director Environmental of Care, the flow test are completed the morning after third shift fire drill.

B. On May 18, 2022, at approximately 9:58 AM, observation revealed two concealed sprinkler heads with missing escutcheon rings in the out-patient service entrance.

C. On May 18, 2022, at approximately 10:22 AM, observation revealed ceiling tile missing in the pulmonary rehabilitation storage room.

D. On May 18, 2022, at approximately 11:11 AM, observation revealed stock items stored within eighteen inches of sprinkler deflector in basement activities storage room.

E. On May 18, 2022, at approximately 1:25 PM, observation revealed dirty sprinkler heads at the emergency department nurse station.

The Plant Engineering Director Environmental of Care and Hospital Vice President confirmed these findings during interview at the time of observation.

Based on observation and interview, the facility failed to ensure smoke barriers were constructed to a minimum 1/2-hour fire resistance rating in accordance with 8.5, as required by 19.3.7.3 and 8.6.7.1(1). This deficient practice could affect all occupants in the event of fire emergency.

Findings Include:
On May 18, 2022, at approximately 10:55 AM, observation revealed fire barrier penetration at the 8-inch water pipe in the basement PT sump room.

The Plant Engineering Director Environmental of Care and Hospital Vice President confirmed these findings during interview at the time of observation.

Based on observation and interview, the facility failed to ensure equipment using gas or gas-related piping complies with NFPA 54, and electrical wiring and equipment complies with NFPA 70, as required by 19.5.1.1, 9.1.1 and 9.1.2. This deficient practice could affect all occupants in the event of a fire emergency.

Findings Include:
A. On May 18, 2022, at approximately 10:49 AM, observation revealed electric stove in PT restorative area is not equipped with a power lockout device.

B. On May 18, 2022, at approximately 10:53 AM, observation revealed electric dryer in physical therapy restorative area equipped with unauthorized foiled paper vent duct.

C. On May 18, 2022, at approximately 10:57 AM, observation revealed stock items in the form of rolls of vinyl flooring and carpet stored within three feet of the electrical panel in the basement PT storage room.

The Plant Engineering Director Environmental of Care and Hospital Vice President confirmed these findings during interview at the time of observation.

Based on observation and interview, the facility failed to ensure portable space heating devices shall be prohibited in all health care occupancies. Unless used in non-sleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit as required by 18.7.8, 19.7.8. This deficient practice could affect all occupants in the event of a fire emergency.

Findings Include:
A. On May 18, 2022, at approximately 10:16 AM, observation revealed unauthorized space heater at the basement physical therapy reception desk.

B. On May 18, 2022, at approximately 12:10 PM, observation revealed unauthorized space heater plugged into a surge protector in the Rural Health Clinic back nurse station.

The Plant Engineering Director Environmental of Care and Hospital Vice President confirmed these findings during interview at the time of observation.

Based on observation and interview, the facility failed to ensure storage of nonflammable gasses meet all requirements of 11.3.1 through 11.3.4 and 11.6.5 of NFPA 99. This deficient practice could affect all occupants in the event of a fire emergency.

Findings Include:
A. On May 18, 2022, at approximately 10:23 AM, observation revealed oxygen cylinders being stored in the basement pulmonary rehabilitation storage room, not safely stored with signage indicating "Full" or "Empty".

B. On May 18, 2022, at approximately 12:01 PM, observation revealed Nitrogen cylinder in the Rural Health Clinic clean utility not properly secured to prevent tip over.

The Plant Engineering Director Environmental of Care and Hospital Vice President confirmed these findings during interview at the time of observation.