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The inspector observed, while accompanied by the Risk Management Director during the hours of the inspection from 1:00 pm to 4:30 pm on 08/30/2022 that there were the following issues: Documentation was not available showing that Records are maintained of fire-rated door assemblies and certain other doors in the means of egress shall be tested annually or per an accepted performance-based evaluation schedule approved by the authority having jurisdiction per NFPA 80, 2010, Ch. 5.2. A written record of the inspections and testing shall be signed and kept for inspection by the authority having jurisdiction. NFPA101, 7.2.1.15

The inspector observed, while accompanied by the Risk Management Director during the hours of the inspection from 1:00 pm to 4:30 pm on 08/30/2022 that there were the following issues. In the kitchen storage room and in the lab storage room the following requirement was not being met for clearance under sprinkler heads. "The clearance between the deflector and the top of storage shall be 18 inches or greater." - NFPA 13, 2010: 8.5.6.1.

The inspector observed, while accompanied by the Risk Management Director during the hours of the inspection from 1:00 pm to 4:30 pm on 08/30/2022 that there were the following issues. The following was missing. One sprinkler wrench as specified by the sprinkler manufacturer shall be provided in the cabinet for each type of sprinkler installed to be used for the removal and installation of sprinklers in the system. - NFPA 13, 2010, 6.2.9.6

The inspector observed, while accompanied by the Risk Management Director during the hours of the inspection from 1:00 pm to 4:30 pm on 08/30/2022 that there were the following issues: Documentation was available showing that fire drills are being conducted. However, these documents did not include the required signatures of the participants of the fire drills.

The inspector observed, while accompanied by the Risk Management Director during the hours of the inspection from 1:00 pm to 4:30 pm on 08/30/2022 that there were the following issues. Documentation was not available to review for flame spread ratings for Draperies, Curtains, and Loosely Hanging Fabrics.

The inspector observed, while accompanied by the Risk Management Director during the hours of the inspection from 1:00 pm to 4:30 pm on 08/30/2022 that there were the following issues: Documentation was not available to review for flame spread ratings for Upholstered Furniture and Mattresses.

The inspector observed, while accompanied by the Risk Management Director during the hours of the inspection from 1:00 pm to 4:30 pm on 08/30/2022 that there were the following issues: Documentation was not available showing that Records are maintained of Risk Assessment: Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel, see Chapter 4 (NFPA 99). The facility must define its risk assessment methodology, implement the methodology, and document the results in relation to the risk categories contained in the NFPA99 Health Care Facilities Code. No particular risk assessment procedure is required. The facility will determined the procedure that most meets their needs within the requirement of the NFPA code. For additional information see the appendix of NFPA 99, A4.1 and A4.2.

The inspector observed, while accompanied by the Risk Management Director during the hours of the inspection from 1:00 pm to 4:30 pm on 08/30/2022 that there were the following issues. Not all cylinders were properly secured in the outdoor storage area per the following requirement. "Design and Construction. Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements: (7) They shall be provided with racks, chains, or other fastening to secure all cylinders from falling, whether connected, unconnected, full, or empty." - NFPA 99, 2012: 5.1.3.3.2

The inspector observed, while accompanied by the Risk Management Director during the hours of the inspection from 1:00 pm to 4:30 pm on 08/30/2022 that there were the following issues. Items were improperly being stored in the electrical rooms per the following requirement. "Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage." - NFPA 70, 2012, 110.26(E)

The inspector observed, while accompanied by the Risk Management Director during the hours of the inspection from 1:00 pm to 4:30 pm on 08/30/2022 that there were the following issues: For patient care receptacles, documentation was not available showing that records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99).