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Based upon observation and interview, it was determined that the facility failed to maintain an unobstructed means of egress in two instances, affecting two out of two floors.

Findings include:

1. Observation on September 5, 2019, revealed the following:

a) 8:05 a.m., there were tables and signs being stored in the stairwell between the first floor dialysis suite and the second floor office space;
b) 8:40 a.m., there were multiple large picture frames being stored in the stairwell (B) between the first floor cardiac suite and the second floor outpatient care area.

Interview with the Chief Operating Officer and Maintenance Director on September 5, 2019, at 9:30 a.m., confirmed the stairwell deficiencies.

Based upon document review, observation and interview, it was determined that the facility failed to maintain the automatic sprinkelr system in three instances, affecting the entire facility.

Findings include:

1. Document review on September 5, 2019, at 8:00 a.m., revealed the fire pump had been deficient throughout the last four quarterly inspections and had not been repaired by the time of survey. Documentation shows the pump packing gland leaks severely, threatening the function of the pump as noted by the sprinkler inspection contractor.

Interview with Facility Administrator and Maintenance Director on September 5, 2019, at 8:00 a.m., confirmed the fire pump deficiency.

2. Observation on September 5, 2019 revealed the following:

a) 8:25 a.m., there was an unsealed gap in the drop ceiling in the cardiac suite janitors closet;
b) 8:35 a.m., there were two missing ceiling tiles in the cardiac suite soiled utiltiy room.

Interview with the Facility Administrator and Maintenance Director on September 5, 2019, at 9:30 a.m., confirmed the automatic sprinkler system deficiencies.

Based upon document review, observation and interview, it was determined that the facility failed to maintain the automatic sprinkler system in three instances, affecting the entire facility.

Findings include:

1. Document review on September 4, 2019, at 10:30 a.m., revealed the fire pump had been deficient throughout the last four quarterly inspections and had not been repaired by the time of survey. Documentation shows the pump packing gland leaks severely, threatening the function of the pump as noted by the sprinkler inspection contractor.

Interview with Chief Operating Officer and Maintenance Director on September 4, 2019, at 10:30 a.m., confirmed the fire pump deficiency.

2. Observation on September 4, 2019 revealed the following:

a) 12:41 p.m., the shower curtain in the echo sleep lab lacked a minimum of 22 inches of mesh opening and obstructed the spray pattern of the sprinkler head;
b) 2:30 p.m., there was a ceiling light fixture in exam room 4 of the Emergency Room department that was attached to the sprinkler pipe.

Interview with Chief Operating Officer and Maintenance Director on September 5, 2019, at 9:30 a.m., confirmed the automatic sprinkler system deficiency.

Based upon observation and interview, it was determined that the facility failed to maintain portable fire extinguishing equipment in five instances, for five out of over fifty fire extinguishers inspected.

Findings include:

1. Observation on September 4, 2019 revealed the following:

a) 1:00 p.m., there was a fire extinguisher in the surgical suite operating area, outside of the procedure room, that was not completely charged to the required operating pressure;
b) 1:20 p.m., the fire extinguishers in the surgical suite operating area did not contain the minimum required Class A rating, resulting in a travel distance of greater than seventy five feet to the next closest appropriate fire extinguisher;
c) 1:40 p.m., there was a fire extinguisher in the generator room that was sitting on the ground and not mounted on an approved bracket;
d) 1:42 p.m., there was a fire extinguisher in the generator electrical control room that was sitting on the ground and not mounted on an approved bracket;
e) 1:55 p.m., there was a fire extinguisher in the mechanical room that was sitting on the ground and not mounted on an approved bracket.

Interview with the Chief Operating Officer and Maintenance Director on September 5, 2019, at 9:30 a.m., confirmed the fire extinguisher deficiencies.

Based upon observation and interview, it was determined that the facility failed to maintain portable fire extinguishing equipment in one instance, for one out of over twenty five fire extinguishers inspected.

Findings include:

1. Observation on September 5, 2019, at 8:15 a.m., revealed a fire extinguisher in elevator room #4 that had not been serviced since September 2017.

Interview with the Chief Operating Officer and Maintenance Director on September 5, 2019, at 9:30 a.m., confirmed the fire extinguisher deficiency.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in three instance, affecting three of four smoke compartments.

Findings include:

1. Observation on September 4, 2019, revealed the following:

a) 1:10 p.m., There were multiple unsealed conduit penetrations in the smoke barrier wall above the smoke barrier doors between the mailroom and electrical closet eight;
b) 1:20 p.m., There was an unsealed wire penetration in the smoke barrier wall, above the smoke barrier doors near electrical closet six;
c) 2:00 p.m. There were two unsealed MC cable penetrations in the smoke barrier wall in the Clinical Educator Office.

Interview the Chief Operating Officer and Maintenance Director on September 5, 2019, at 9:30 a.m., confirmed the unsealed conduit penetrations.

Based upon observation and interview, it was determined that the facility failed to maintain fire doors in one instance, affecting one out of over over twenty-five fire doors inspected.

Findings include:

1. Observation on September 4, 2019, at 1:50 p.m., revealed the fire door between the generator room and the adjacent electrical room did not positively latch upon testing. Observation revealed the latching and locking hardware had been removed from the door.

Interview with the Chief Operating Officer and Maintenance Director on September 5, 2019, at 9:30 a.m., confirmed the fire door deficiency.

Based upon observation and interview, it was determined that the facility failed to maintain clearance in front of medical gas panels in one instance, out of over ten medical gas panels inspected.

Findings include:

1. Observation on September 5, 2019, at 8:50 a.m., revealed the medical gas shut off valve in the second floor specialty services suite, next to room S-2, was obstructed by medical equipment.

Interview with the Chief Operating Officer and Maintenance Director on September 5, 2019, at 9:30 a.m., confirmed the medical gas panel deficiency.

Based upon observation and interview, it was determined that the facility failed to maintain electrical receptacles in three instances, out of over five hundred receptacles inspected.

Findings include:

1. Observation on September 4, 2019, revealed the following:

a) 12:45 p.m., there were two receptacles in the surgical suite pre-op area, within six feet of a sink, that were not GFCI protected;
b) 12:50 p.m., there was one receptacle in the surgical suite soiled utility room, within six feet of a sink, that was not GFCI protected.

Interview with the Chief Operating Officer and Maintenance Director on September 5, 2019, at 9:30 a.m., confirmed the electrical receptacle deficiencies.

Based upon observation and interview, it was determined the facility failed to install a remote emergency stop switch for one of one emergency generators, affecting the entire facility.

Findings include:

1. Observation on September 4, 2019, at 1:45 p.m., revealed the facility lacked a remote manual stop station located outside of the generator enclosure.

Interview with the Chief Operating Officer and Maintenance Director on September 5, 2019, at 9:30 a.m., confirmed the generator deficiency.

Based upon observation and interview, it was determined the facility failed to install a remote emergency stop switch for one of one emergency generators, affecting the entire facility.

Findings include:

1. Observation on September 5, 2019, at 8:00 a.m., revealed the facility lacked a remote manual stop station located outside of the generator enclosure.

Interview with the Chief Operating Officer and Maintenance Director on September 5, 2019, at 9:30 a.m., confirmed the generator deficiency.

Based upon observation and interview, it was determined that the facility failed to maintain minimum required clearance in front of electrical panels in one instance, out of over twenty-five electrical panels inspected. Electrical equipment shall be maintained as per NFPA 101, 2012 Edition, Section 9.1.2..

Findings include:

1. Observation on September 5, 2019, at 8:10 a.m., revealed the electrical panel in the lunch box prep room was obstructed by multiple cases of drinks.

Interview with the Chief Operating Officer and Maintenance Director on September 5, 2019, at 9:30 a.m., confirmed the electrical panel deficiency.