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Based on record review and interview, the facility failed to conduct exercises to test the emergency plan at least twice a year. Findings:

1. The facility records were reviewed 06/28/2022. The administrator assistant provided an emergency preparedness packet that was reviewed and did not meet the training and testing requirements for the comprehensive emergency program. No documentation was found to show the facility had participated in a second full-scale community based exercise or a tabletop in the past 12 months.

2. The administrator assistant was interviewed during the record review and she stated the facility had only conducted one full scale exercise for the year.

Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke. Findings:

1. A tour of the facility was conducted on 06/28/2022. The door to the Pharmacy had a Dutch door. When the two leafs of the door was closed, there was an approximately quarter inch gap between the doors.


2. The director of maintenance was present during the tour of the facility and acknowledged the problem with the door. He stated he would make the repairs as soon as possible.

Based on observation and interview, the facility failed to maintain smoke barrier walls to resist the passage of smoke. Findings:

1. A tour of the facility was conducted on 06/28/2022. The smoke wall, located on the new edition hall, had one penetration in the wall.

2. The director of maintenance was present during the tour of the facility and he acknowledged the unsealed penetration in the smoke wall.

Smoke barriers shall be constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels and steel frames.
8.3, 19.3.7.3, 19.3.7.5

Based on record review and staff interview, the facility failed to properly maintain and test the generator as required by NFPA 99. Findings:


1. Record review was conducted on 06/28/2022. It was noted the monthly load test was being performed on the Zero wing generator. However, it was only being tested for 25 minutes and not the required 30 minutes.

2. The director of maintenance was interviewed on 06/28/2022, and stated the generator was being tested but was unaware of the 30 minute requirement.

Based on observation and staff interview, the facility failed to provide safe storage for each oxygen cylinder as required by NFPA 99. Findings:

1. A tour of the facility was conducted on 06/28/2022.

It was observed in the oxygen room, located on the Obstetrician hall, that the full "E" oxygen cylinders were not separated from the empty "E" oxygen cylinders in the rack.

2. The director of maintenance was present during the tour of the facility and acknowledged the oxygen cylinders were not separated.

NFPA Standard: NFPA 99, 4-3.5.2.2 (b) 2, states that if stored within the same enclosure, empty oxygen cylinders shall be separated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. Also, this section states that cylinders shall be secured from falling or mechanical shock.