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Based on observations made in the presence of the facility director on 11-29-2021 during the facility tour it was determined that the facility did not maintain Cooking Facilities in accordance with NFPA 101 Section 19.3.2.5.1, 9.2.3; 2011 NFPA 96 Section 6.2.3.3

This deficiency affected dietary exhaust grease filters and duct work.

Findings include:
The grease filters in the dietary exhaust hood were not arranged so that all exhaust air passes through the grease filter, at the time of this survey there was an approx. gap of 8 to 10 inches at the left end of the filter bank allowing grease to be vented out into the exhaust duct. Ref: 2012 NFPA 101 Section 19.3.2.5.1, 9.2.3; 2011 NFPA 96 Section 6.2.3.3

Based upon observations made in the presence of the facility director, it was determined that the facility did not maintain the subdivision of building spaces in accordance with NFPA 21.3.7.1., 42 CFR 416.44

This deficiency affected the 2 hour separation wall in-between the Hospital and the clinic.

Findings include:
1-During the facility tour it was observed that the building separation was not being maintained, the 2 hour fire wall separation in-between the Hospital and the clinic has several penetrations of various size and shapes cut thru it and sheet rock joints that were not sealed and not in accordance with NFPA 21.3.7.1. This finding was confirmed with the facility director.

Based on observations made during the record review in the presence of the facility director on 11-29-2021 it was determined that the facility did not maintain Area alarm panels to monitor all medical gas, medical-surgical vacuum, and piped WAGD systems.

This deficiency affected the O.R. medical gas alarm panel.

Findings include:
During the record review of the facility it was observed that the facility had been cited during their medical gas certification's/inspections for the years (2019, 2020 and 2021) for no alarm panel for the operating room area and not in accordance with NFPA 101 19.3.2.3, NFPA 99 8.7. There was no evidence at the time of this survey that the deficiencies had been addressed with staff/safety and a corrective action plan established.

Based upon observations made in the presence of the facility director on 11-29-2021, it was determined that the facility did not maintain the fire barrier wall rating in accordance with NFPA 101 19.3.7., 8.5.3

The deficiency affected 3 of several rated compartments.

Findings include:
1-During the tour of the facility it was observed that the Fire barrier wall in the ER vestibule had unsealed penetrations and not in accordance with NFPA 101 19.3.7.3, 8.5.
2- During the tour of the facility it was observed that the Fire barrier wall above the fire doors AC 023 in the corridor had unsealed penetrations and not in accordance with NFPA 101 19.3.7.3, 8.5.
3-- During the tour of the facility it was observed that the Fire barrier wall above the fire doors at the corridor into the LTC had unsealed penetrations I.E 3 inch communication conduit with no seal and not in accordance with NFPA 101 19.3.7.3, 8.5.

Based upon observations made in the presence of the plant manager on 11-29-2021, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

This deficiency affected 8 of several GFIC outlets.

Findings include
1-During the facility tour it was observed that the outlet in the Dr lounge at the hand wash sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
2- During the facility tour it was observed that the outlet in the radiology exam room at the hand wash sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

3- During the facility tour it was observed that the outlets in the pharmacy at the hand wash sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

4- During the facility tour it was observed that the outlets in the Nursery restroom at the hand wash sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

5- During the facility tour it was observed that the hand wash sink in the women's O.R. locker room was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

6- During the facility tour it was observed that the outlet at the medical surgical hand wash sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

7- During the facility tour it was observed that the outlet at the medical surgical soiled utility room at the hand wash sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

8- During the facility tour it was observed that the outlet in the Medication room at the hand wash sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)