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Based upon an Emergency Preparedness Program (EPP) survey performed on 08/29/2024 at 1:00 PM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials' effort to maintain an integrated response during s disaster or emergency situation.

Findings include:

During the review of the facilities Emergency Preparedness Program with the Compliance Official (employee #27) on 08/29/2024 at 1:00 PM through 4:00 PM it was noted that the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials as required under
§482.15(a)(4) of the Emergency Preparedness.

Based upon an Emergency Preparedness Program (EPP) survey performed on 08/29/2024 at 1:00 PM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop procedures to track the location of on-duty staff and sheltered patients in the hospitals facility's care during an emergency.

Findings include:

During the review of the facilities Emergency Preparedness Program with the Compliance Official (employee #27) on 08/29/2024 at 1:00 PM through 4:00 PM it was noted that the EP failed to have written procedures to document the specific name and location of the receiving facility or other location.

Based upon an Emergency Preparedness Program (EPP) survey performed on 08/29/2024 at 1:00 PM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to provide means to shelter in place for patients, staff and volunteers who remain in the facility.

Findings include:

During the review of the facilities Emergency Preparedness Program with the Compliance Official (employee #27) on 08/29/2024 at 1:00 PM through 4:00 PM it was noted that the EP failed to have written process for activation and designation of a shelter in place area in the Hospital during and after an emergency.

Based upon an Emergency Preparedness Program (EPP) survey performed on 08/29/2024 at 1:00 PM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to stablish the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act.

Findings include:

During the review of the facilities Emergency Preparedness Program with the Compliance Official (employee #27) on 08/29/2024 at 1:00 PM through 4:00 PM it was noted that the EP failed to include policies and procedures which outline the facility's role in the provision of care and treatment under section 1135 waivers during a declared public health emergency in alternate care sites as required under §482.15(b)(8).

Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility's Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to observe that hazardous area enclosure are self-closing and kept in the closed position as required in 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8.

Findings include:

1. On 08/27/2024 approximately at 9:35 AM the Patholgy Room door located on the Surgery Department was found unlocked in the open position.

2. On 08/27/2024 approximately at 9:35 AM the Mantainance Equipment Room Door on the Surgery Department did not have self closing mechanism and was found unlocked.

3. On 08/28/2024 approximately at 9:45 AM the Mantainance Equipment Room Door on the Diet Department did not have self closing mechanism and was found unlocked.

4. On 08/28/2024 approximately at 1:45 PM Bio Hazard Room on ninth floor did not have self closing mechanism and was found unlocked.

5. On 08/28/2024 approximately at 2:15 PM Bio Hazard Room on seventh floor did not have self closing mechanism and was found unlocked.

Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility's Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to provide emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9..

Findings include:

During made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM the following was observed:

1. No emergency light on exit of Sugicenter.

2. No emergency light on exit and pathway to the outside of the building from the back emergency exit to parking lot on the Surgicenter.

3. No emergency light on hallways of the second floor from Hospital all the way to the Endoscopy Department.

4. No emergency light on Nuclear Medicine waiting room area and hallway.

Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility's Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to have exit and directional signs that are displayed in accordance with 7.10 with continuous illumination as required on 19.2.10.1.

Findings include:


1. On ER observation area there is no exit sign stating obvious exit pathway, at least three (3) exit signs are needed to state exit route.

2. Exit sign on Endoscopy Department entrance door was found unoperable.

3. On endoscopy room #1 exit sign was found unoperable.

4. Pharmacy Department:
a. No exit sign on main door
b. No visible exit sign stating obvious exit pathway from computer desk to outside.

5. Nuclear Medicine:
a. No exit sign on main door
b. No exit sign on hallway stating obvious exit pathway

Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility's Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to identify and ensure free acces to emergengy shutt-off valves for medical gases.

Findings include:

1. On 08/27/24 approximately at 1:30 PM it was observed that the four (4) zone valves on the Surgicenter were not identified as emergency shut-off valves.

2. On 08/27/24 approximately at 9:30 AM it was observed that the emergency shut-off valves on Surgery Department were blocked by medical equipmnet.

3. On 08/28/24 approximately at 10:30 AM it was observed that the emergency shut-off valves on Endoscopy Department were blocked by chair and trash can.

Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility's Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the faclity falied to comply with Alcohol Based Hand Rub Dispenser (ABHR)regulations in accordance with 8.7.3.1.

Findings include:

During visual inspection of the Emergeny Department area it was observed:

1. On 08/28/24 approximately at 10:00 AM a ABHR was observed mounted on top of a receptacle (PANEL Y A CKT 17) on Triage 1 room.

Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility's Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the faclity did not provide automatical occupant notification in accordance with 9.6.3 by audible and visual signals.

Findings include:

1. On 08/28/2024 approximately at 2:15 PM a manual activation devise (Pull Station) was activated, audible notification was heard throughout facility but no visible notification was observed on the devises.

Based on observation and interview, the facility did not provide and maintain complete and accurate documentation, testing of the fire alarm system by qualified individuals in accordance with the requirements of NFPA 72, 2012 Edition, Section 10.4.3, 10.4.3.1, 10.4.3.2, 14.3.1, 14.4.2.2, 14.4.5 and 23.8.2. The deficient practice of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the fire alarm system, proper operation and prompt repair affects all occupants.

Findings include:

During visual inspection of the alarm panel with facility's Compliance Officer (Employee #27) on 08/28/2024 proximately at 9:15 AM the following was found:

1. No dated Inspection, Testing and Maintenance (ITM) label on fire alarm panel and fire alarm system batteries.

Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility's Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to secure that Portable Fire Extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10

Findings include:

1. On 08/27/2024 approximately at 8:45 AM a fire extinguisher was observed blocked by a printer on Surgery Recovery area.

2. On 08/27/2024 approximately at 10:30 AM two fire extinguishers were observed blocked by wheelchairs and by desk on the Surgicenter area.

3. Fire extinguishers on Surgicenter and on main building were observed exceeding the 5 feet mounting highth

Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility's Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to comply with smoke barriers integrity on all areas.

Findings include:

During observations made during the survey for life safety it was identified that material used for fire proofing penetrations do not assure the integrity minimum requirement of 1/2 hour fire resistance for the compartment.

Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility's Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to certify that window curtains and divisional curtains are up to standard with NFPA 701 in accordance with 10.3.1.

Findings include:

No tag with flame retardant or fire resistant in accordance with standard to NFPA 701 on:

1. Five (5) curtains on Surgery Recovery Area
2. Four (4) curtains on Surgery Recovery Area Fase II
3. Five (5) curtains on Surgicenter
4. Four (4) curtains on Cardiology Department
5. Two (2) curtains on Endoscopy Room
6. Eight (8) curtains on Cathetherism
7. Eight (8) curtains on Cathetherism Holding
8. Four (4) curtains on Nuclear Medicine
9. Ninth floor room dividing curtains
10. Fifth floor window curtains

Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility's Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to prohibit Combustible decorations. 19.7.5.6

Findings include:

1. On 08/28/2024 approximately at 2:35 PM it was observed on the seventh floor nurses pantry cardboard birthday decorations and filled ballons.

Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility's Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to prohibit the use of portable heating devices. 18.7.8, 19.7.8

Findings include:

On 08/27/24 during observational tour of the facity it was observed:

1. One (1) portable heating device was osberved under desk on the triage of Surgicenter.
2. One (1) portable heating device was osberved under desk on the Doctors office in the ER.

Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility's Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to secure medical gas piping as requiered on Chapter 5 (NFPA 99).

Findings include:

On 08/28/24 during observational tour of the Emergency Department it was observed:

1. Cublicle #10 and #11 has exposed oxygen piping and un protected gauge that could be affected by stretcher or patient in area.

Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility's Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to guard electrical live parts as required on Chapter 6 (NFPA 99).

Findings include:

During observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM the fallowing was found:

1. Unlocked panel found on Ultra Sound Room

2. Unlocked panel found on Orthopedia Warehouse

3. Unlocked panel found on esterilizatiion room on Surgery Unit

4. Unlocked panel found on Opeartion Room #7

5. Unlocked panel found on X Ray Department

6. Unlocked panel found on ninth floor (LP9B)

Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility's Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to have Hospital grade power cords or multy plugs in hospital areas as required in 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Findings include:

Non Hospital Grade multy-plugs were found in:

1. One (1) on oparation room #7 un the surgery department
2. One (1) on ER waiting area behind vending machines
3. One (1) on X Ray Department
4. One (1) on Nuclear Medicine administrative offices
5. One (1) on Cardiology Department
6. Two (2) on Farmacy

Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility's Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to observe precautionary measures to ensure safety on the cylinder storage room as requested on 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Findings include:

On 08/28/24 during observation of the cylinder storage room it was observed:

1. Two (2) NITROUS OXIDE (UN 1070) full tanks were observed un fastened to a cart inside cylinder storage room.

2. One (1) COMPRESSED NITROGEN (UN 1066) empty tank was observed un fastened inside cylinder storage room.

3. One (1) CARBON DIOXIDE (UN 1013) full tank was observed un fastened to a cart in Surgery Department