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Based on observation, the facility failed to direct occupants in the emergency function of a powered door in accordance with NFPA 101, 2012 Edition, Sections 7.1.10.1 and 19.2.3.4(5).

Findings include:

1. During an observation on 8/7/23 at 3:25 p.m., the sliding door at the entrance to the OR suite was inspected. The door was a horizontal sliding door with break-away hinges. The facility did not have a sign on the door with letters not less than one inch high on a contrasting background on the egress side of the door, which should read: IN EMERGENCY, PUSH TO OPEN.

Based on observation, the facility failed to ensure all exit passageways were marked in accordance with NFPA 101 2012 Edition, Section 7.1.10.2.1, and Section 7.10.1.2.2.

Findings include:

1. During an observation on 8/8/23 at 12:02 p.m., the ER was inspected. The west end of the ER needs exit signage guiding occupants out of the ER suite. The east end of the ER has exit signs guiding occupants through the sliding doors of the ambulance bay. These sliding doors are not able to break away and would not be able to be opened during a power outage.

Based on observation, the facility failed to assure hazardous rooms/areas had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 8/7/23 3:20 p.m., the soiled utility room within the OR suite was inspected. The door was exercised twice and failed to close and latch under the power of the self-closer.

2. During an observation on 8/8/23 at 10:44 a.m., the linen room doors were exercised. One of the doors failed to close and latch under the power of the self-closer.

3. During an observation on 8/8/23 at 1:21 p.m., room 346 was inspected. It was a tub room storage room, it was greater than 50 square feet. The corridor door was not fitted with the required self-closer.

4. During an observation on 8/8/23 at 1:33 p.m., the old delivery suite was inspected. The rooms in the suite were being used as storage and they were all open to the corridor in the suite. The main corridor door leading to the suite did not have a self-closer to close off the corridor to all the storage within the suite.

5. During an observation on 8/8/23 at 1:58 p.m., room 429 was inspected. The room was being used as a storage room and was greater than 50 square feet. The corridor door to the room was lacking the required self-closer.

Based on record review, the facility failed to maintain the kitchen hood extinguishing system in accordance with NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition, Section 11.2.1.

This deficiency affects all residents in the facility.

Findings include:

1. Record review of the kitchen hood system cleaning records reflected a lack of documentation to show the contractor had performed services on a semi-annual basis. The last recorded inspection of the hood extinguishing system was October of 2022. The hood system was due to be inspected again in April of 2023. The last hood cleaning was in December of 2022, the hood should have had a semi-annual cleaning in June of 2023.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8).

Findings include:

1. During an observation on 8/7/23 at 3:30 p.m., the same day surgery area was inspected. There was an ABHR station mounted over an outlet in cubical number 5.

Based on record review and observation, the facility failed to maintain the sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Table 5.1.1.2., and failed to ensure the inspector's test orifice was installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.17.4.2.1.

Findings include:

1. During a review of facility records and observation of the standpipe vendor tags on 8/7/23-8/8/23, the facility failed to ensure the quarterly sprinkler inspections had been completed. There was no inspection completed for the first quarter of 2023.

2. During an observation on 8/8/23 at 11:45 a.m., the inspector's test valve in the ICU was inspected. The orifice for the test, below the valve is a 3/4" pipe. The valve above was also a 3/4' valve. The test orifice cannot be greater than 1/2' or the size of one sprinkler head to be a legitimate test.

Based on observation, the facility failed to install portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.8.1.

Findings include:

1. During an observation on 8/8/23 at 12:11 p.m., the CT room was inspected. There was a portable fire extinguisher mounted about 65" inches high on the wall. The maximum height to the top of the handle can be no more than 60 inches.

Based on observation, the facility failed to maintain corridor door openings in accordance with NFPA 101, 2012 Edition, Section 19.3.6.3.10.

Findings include:

1. During an observation on 8/8/23 at 2:18 p.m., room 553 was inspected. The room contained a second bed which was found to be blocking the corridor door from being pulled closed.

Based on observations, the facility failed to assure that a fire-rated door, protecting the linen chute, closed and latched with the efforts of the self-closing device per NFPA 101 2012 Edition, Sections 19.5.4.4.
The findings include:

1. During an observation on 8/8/23 at 10:50 a.m., the chute room was inspected. The corridor door to the chute room was exercised twice. The corridor door failed to close and latch under the power of the self-closer.

Based on observations, the facility failed to maintain areas with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d).

Findings include:

1. During an observation on 8/8/23 at 12:15 p.m., the MRI control room was inspected. An electrical panel was observed with a shelving unit stored in front of it.

Based on observation the facility failed to maintain oxygen cylinders per NFPA 99-2012, Section 11.6.2.3.

Findings Include:

1. During an observation on 8/7/23 at 3:28 p.m., the janitors room within the OR suite was inspected. There was a bottle of compressed carbon dioxide free standing in the room.