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Based on observation and interview, the facility failed to ensure its two hour fire barrier contained two hour protective construction. This had the potential to affect all patients receiving services from the facility. The facility census was 27.

Findings include:

On 07/30/18 at 3:43 PM observation above the drop down ceiling of the two hour fire barrier between outpatient mental health care and smoke compartment 1E revealed, as seen from the mental health side, an unprotected steal I-beam within the barrier.

On 07/30/18 at 3:43 PM in an interview, Staff Q confirmed the finding.

Based on document review and interview, the facility failed to test its emergency lighting in accordance with NFPA 101, 2012 edition, 7.9. This had the potential to affect all patients receiving services from the facility. The facility census was 27.

Findings include:

On 07/31/18 at 3:45 PM, a tour was conducted of the building with Staff Q and S.

On 07/31/18 at 3:45 PM, observation of the area revealed the presence of emergency lighting, that when tested revealed one side not working.

On 08/02/18 a review of the building's life safety code documentation was completed. The review did not reveal when the emergency lighting had been tested.

On 08/02/18 in an interview, Staff Q confirmed he/she did not have testing information for the emergency lighting there.

Based on document review and interview, the facility failed to test its emergency lighting in accordance with NFPA 101, 2012 edition, 7.9. This had the potential to affect all patients receiving services from the facility. The facility census was 27.

Findings include:

On 08/02/18 a review of the facility's life safety code documentation was completed. The review did not reveal where the emergency, battery-operated lighting at the generator set was tested.

On 08/02/18 at 3:15 PM in an interview, Staff Q confirmed he/she did not have evidence of testing of the emergency, battery-operated lighting at the generator set.

Based on observation, interview, and document review, the facility failed to ensure each path of egress was marked with exit signs in accordance with NFPA 101, 2012 edition, 7.10, and where in use, inspected monthly in accordance with 7.10.9. This had the potential to affect all patients receiving services from the facility. The facility census was 27.

Findings include:

On 07/30/18 at 1:05 PM, a tour was conducted of the first floor with Staff Q and R.

1. On 07/30/18 at 4:32 PM, observation of the evacuation plan to the ambulatory surgery area revealed occupants were to travel in a north by northeast direction through the waiting area and from there into the exit access corridor. Observation of the exit signage in the patient care areas did not direct occupants in that direction.

On 07/30/18 at 4:32 PM in an interview, Staff Q confirmed the finding.

On 07/31/18 at 8:50 AM, a tour of the first floor was conducted with Staff Q and S.

2. On 07/31/18 at 9:26 AM, observation of the waiting area in radiology revealed the path of egress, as described on the evacuation plan, that directed occupants from the waiting area to the right, past the Radiology Director's office, to the lobby and out to the corridor did not have an exit sign.

On 07/31/18 at 9:26 AM in an interview, Staff Q confirmed the finding.

3. On 08/02/18 a review of the facility's life safety code documentation was completed. The review did not reveal where the exit signs were inspected for illumination for the month of June, 2018.

On 08/02/18 at 2:40 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure a life safety code feature, smoke detectors, were either maintained or removed, in compliance with NFPA 101, 2012 edition, 4.6.12.3. This had the potential to affect all patients receiving services from the facility. The facility census was 27.

Findings include:

On 07/31/18 at 2:41 PM, a tour was taken of the building with Staff Q and S.

On 07/31/18 at 2:55 PM, observation of the physical therapy area and its storage space revealed two smoke detectors in the therapy area and one in the storage room. Observation of the devices did not reveal evidence that they were active and linked to an alarm system.

On 07/31/18 at 2:55 PM in an interview, Staff S confirmed they were not linked to an alarm system.

Based on observation and interview, the facility failed to ensure doors to hazardous areas self closed and latched in accordance with 7.2.1.8, NFPA 101, 2012 edition. This had the potential to affect all patients receiving services from the facility. The facility census was 27.

Findings include:

On 07/30/18 at 1:05 PM, a tour was conducted of the first floor with Staff Q and R.

1. On 07/30/18 at 2:08 PM, observation of the door to the soiled utility room opposite room 56/k-9 revealed it had self closing and latching hardware that did not self close and latch.

On 07/30/18 at 2:08 PM in an interview, Staff Q confirmed the finding.

On 07/31/18 at 11:05 AM, a tour was taken of the basement with Staff Q and S.

2. On 07/31/18 at 12:12 PM observation of the kitchen revealed a wall with two doors separating it from the dining and serving area. Observation of that wall revealed it contained two doors with self closers. Observation of the self closers revealed they were defeated by door stops that needed to be manually pulled to allow the doors to self close.

On 07/31/18 at 12:12 PM in an interview, Staff S confirmed the finding.

Based on observation, interview, and document review, the facility failed to ensure each smoke detector was functional, the devices in its alarm system matched the devices as reported on inspection reports in accordance with NFPA 72, 2010 edition, 14.6.2.4, and fire alarm transmission signals were sent monthly in accordance with NFPA 72, 2010 edition, 14.4.5. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 07/31/18 at 11:05 AM, a tour was taken of the basement with Staff Q and S.

1. On 07/31/18 at 11:47 AM, observation of the room on the east side of the pump room revealed a smoke detector in place with tape placed over the sensors.

On 07/31/18 at 11:47 AM in an interview, Staff S confirmed the finding.

On 08/01/18 at 11:07 AM, a tour was taken of the first floor with Staff S.

2. On 08/01/18 at 11:07 AM, two alarm speakers were observed in the chemotherapy room and one in the oncology intake room.

On 08/01/18 at 11:29 AM, two strobes were observed in the intensive care unit area.

On 08/01/18 at 11:41 AM, near treatment room one a strobe was observed.

On 08/01/18 at 11:56 AM, in the exercise room a strobe was observed.

On 08/01/18 a review of the facility's fire alarm report was completed. The review revealed the fire alarm system was tested and inspected on 03/15/18. The review revealed an itemized list of notification devices. Review of that list did not reveal the speakers in the oncology area, the strobes in the intensive care unit, listed the device (#59) in the treatment room as a horn and strobe, and listed the device (#61) in the exercise room as a horn and strobe.

On 08/01/18 at 11:41 AM in an interview, Staff S confirmed the observation.

3. On 08/01/18 at 2:45 PM, observation of the sprinkler system revealed three tamper switches labeled M100.

On 08/01/18 at 2:45 PM, review of the inspection of the tamper switches revealed they were inspected on 05/15/18, but there were only four listed.

On 08/01/18 at 2:45 PM in an interview, Staff S confirmed the finding.

4. On 08/02/18 a review of the facility's life safety code documentation was completed. The review did not reveal where the facility tested the fire alarm transmission signal to the monitoring station on a monthly basis.

On 08/02/18 at 1:50 PM in an interview, Staff Q and S confirmed they did not have evidence the fire alarm transmission signal had been tested monthly.

Based on interview and policy review, the facility failed to have a fire watch policy for when the fire alarm system was out of service. This had the potential to affect all patients receiving services from the facility. The facility census was 27.

Findings include:

On 08/02/18 a review of the facility's life safety code documentation was completed. The review did not reveal a policy for a fire watch when the facility's fire alarm was out of service.

On 08/02/18 at 2:40 PM in an interview, Staff Q confirmed the finding.

Based on observation, interview, and document review, the facility failed to ensure the hydraulic name plates to its sprinkler system were in place in accordance with NFPA 101, 2012 edition, 9.7.1.1(1) and therefore NFPA 13, 2010 edition, 24.6. This had the potential to affect all patients receiving services from the facility. The facility census was 27.

Findings include:

On 07/31/18 at 1:35 PM the sprinkler riser was observed to have six hydraulic name plates with nothing written on them.

On 07/31/18 at 1:35 PM in an interview, Staff Q confirmed the observation.

On 08/02/18 a review of the facility's life safety code documentation was completed. The review revealed the sprinkler system was inspected on 05/15/18. The review of that inspection report revealed the hydraulic name plates passed inspection.

Based on observation, interview, and document review, the facility failed to ensure tiles in the drop down ceiling were in place for full functionality of the sprinkler system and its sprinkler valves were inspected weekly in accordance with NFPA 25, 2011 edition, 13.3.2.1. This had the potential to affect all patients receiving services from the facility. The facility census was 27.

Findings include:

On 07/30/18 at 1:05 PM, a tour was conducted of the first floor with Staff Q and R.

1. On 07/30/18 at 2:48 PM, observation of the drop down ceiling of the sprinklered room next to waiting room H-28 revealed an access panel had been removed and in its place a ceiling tile was loosely fitted, leaving gaps between it and the rest of the ceiling tile grid system.

On 07/30/18 at 2:48 PM in an interview, Staff Q confirmed the finding.

On 07/31/18 at 8:50 AM, a tour of the first floor was conducted with Staff Q and S.

2. On 07/31/18 at 10:31 AM, observation of the biohazard room in the birthing area revealed it had sprinklers and a drop down ceiling. Observation of the drop down ceiling revealed a tile was missing.

On 07/31/18 at 10:31 AM in an interview, Staff S confirmed the observation.

3. On 07/31/18 at 10:48 AM, observation of the IT room opposite the chapel revealed it was sprinklered and had a drop down ceiling. Observation of the drop down ceiling revealed it had holes where big bundles of cables and heating, ventilation, and cooling ducting ran through.

On 07/31/18 at 11:05 AM, a tour was taken of the basement with Staff Q and S.

4. On 07/31/18 at 11:15 AM, observation of the room on the south border of the south elevator and observation of the room connecting to it revealed each were sprinklered with drop down ceilings. Observation of the rooms revealed each had multiple tiles missing.

On 07/31/18 at 11:15 AM in an interview, Staff S confirmed the observation.

5. On 07/31/18 at 11:21 AM, observation of a storage room in the southwest corner of the basement revealed it contained many combustibles, was sprinklered, and had a drop down ceiling. Observation of the drop down ceiling revealed it was missing two ceiling tiles.

On 07/31/18 at 11:21 AM in an interview, Staff S confirmed the observation.

6. On 07/31/18 at 11:34 AM, observation of a smaller room connected to the south of the aforementioned storage room revealed it contained much paper, was sprinklered, and had a drop down ceiling. Observation of the drop down ceiling revealed it was missing a tile.

On 07/31/18 at 11:34 AM in an interview, Staff S confirmed the finding.

7. On 07/31/18 at 11:27 AM, observation of mechanical room two revealed it had a drop down ceiling and was sprinklered. Observation of the drop down ceiling revealed it had missing tiles.

On 07/31/18 at 11:27 AM in an interview, Staff S confirmed the finding.

8. On 07/31/18 at 11:47 AM, observation of the room immediately to the east of the pump room revealed it had sprinklers with a drop down ceiling. Observation of the drop down ceiling revealed it had missing ceiling tiles.

9. The review of the life safety code documentation did not reveal evidence for June 2018 the sprinkler system valves were inspected weekly to ensure they were secured with locks and/or supervisory devices.

On 08/02/18 at 2:40 PM in an interview, Staff Q confirmed he/she did not have the documentation for the inspection of the sprinkler valves for June 2018.

Based on interview and policy review, the facility failed to have a fire watch policy for when the sprinkler system was out of service. This had the potential to affect all patients receiving services from the facility. The facility cesus was 27.

Findings include:

On 08/02/18 a review of the facility's life safety code documentation was completed. The review did not reveal a policy for a fire watch when the facility's sprinkler system was out of service.

On 08/02/18 at 2:40 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure doors protecting corridor openings that had self closing and latching hardware, closed and latched. This had the potential to affect all patients receiving services from the facility. The facility census was 27.

Findings include:

On 07/31/18 at 8:50 AM, a tour of the first floor was conducted with Staff Q and S.

On 07/31/18 at 10:28 AM, observation of corridor door to room 181 in the obstetrics unit revealed it had self closing and latching hardware that did not self close and latch the door when tested.

On 07/31/18 at 10:28 AM in an interview, Staff S confirmed the observation.

Based on observation and interview, the facility failed to ensure its smoke barriers were free of penetrations. This had the potential to affect all patients receiving services from the facility. The facility census was 27.

Findings include:

On 07/30/18 at 1:05 PM, a tour was conducted of the first floor with Staff Q and R.

1. On 07/30/18 at 3:18 PM, observation above the drop down ceiling of smoke compartment 1C's most eastern one hour barrier, above the double doors, as seen from the east side, revealed a penetration "pillow" had been pulled by a data line from the penetration it had been filling.

On 07/30/18 at 3:18 PM in an interview, Staff Q confirmed the finding.

On 07/31/18 at 8:50 AM, a tour of the first floor was conducted with Staff Q and S.

2. On 07/31/18 at 10:13 AM, observation above the drop down ceiling of the one hour barrier between an office and the kitchenette in the administrative area, as seen from within the office (south side of smoke compartment 1a), revealed a triangle shaped penetration to the right of the heating, ventilation, and cooling duct.

On 07/31/18 at 10:13 AM Staff S confirmed the observation.

Based on document review and staff interview, the facility failed to inspect the function of the smoke dampers within the heating, ventilating, and air-conditioning (HVAC) system in accordance with 9.2 of NFPA 101, 2012 edition, and therefore 5.4.8.2 of 90A, 2012 edition and therefore 19.4.1.1 in NFPA 80. This had the potential to affect all patients receiving services from the facility. The facility census was 27.

Findings include:

On 08/02/18 a review of the facility's life safety code documentation was completed.

The review revealed a list of dampers that had been inspected and provided a general location for where they were.

On 08/02/18 at 9:14 AM, a tour of the facility to find the dampers was taken with Staff Q and S.

Staff Q and S could not locate the dampers given the locations as described on the damper report to show those listed were in service.

On 08/02/18 at 9:14 AM in an interview, Staff Q explained they know when a damper had dropped because staff would complain of a lack of ventilation. He/she said to find the damper, personnel needed to search for it on a "hit or miss" basis.

Based on observation and interview, the facility failed to ensure portable space heating devices were not in place. This had the potential to affect all patients receiving services from the facility. The facility census was 27.

Findings include:

On 07/30/18 at 1:05 PM, a tour was conducted of the first floor with Staff Q and R.

1. On 07/30/18 at 1:40 PM, observation of the physician dictation room within smoke compartment 1E revealed a plugged in space heater.

On 07/30/18 at 1:40 PM in an interview, Staff Q and R confirmed the observation.

2. On 07/30/18 at 2:41 PM, observation of the physician office next to patient room 10 in the intensive care unit revealed a plugged in, turned on, and unattended space heater.

On 07/30/18 at 2:41 PM in an interview, Staff Q and R confirmed the observation.

3. On 07/30/18 at 3:10 PM, observation in the office on the east side of smoke compartment 1C's most eastern smoke barrier and near double doors revealed a space heater.

On 07/30/18 at 3:10 PM in an interview, Staff Q confirmed the finding.

Based on observation and document review, the facility failed to comply with NFPA 99, 2012, 5.1.4.8 in regard to having an intervening wall between gas shutoff valves and the outlets they served. This had the potential to affect all patients receiving services from the facility. The facility census was 27.


Findings include:

On 08/02/18 at 11:08 AM, a tour of the post anesthesia care unit area revealed the med gas shut off valves for beds one and two did not have any intervening wall.

On 08/01/18 at 11:08 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview the facility failed to have a remote annunciator panel installed in accordance with NFPA 99, 2012 edition, 6.4.1.1.17. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 07/31/18 at 1:50 PM, observation of the remote annunciator located at the triage area in the emergency department revealed it did not function.

On 07/31/18 at 1:50 PM in an interview, Staff S confirmed this and confirmed there should be two: one in engineering and another that could be attended at all times.

Based on interview and document review, the facility failed to test patient-care related electrical equipment in accordance with NFPA 99, 2012 edition, 10.5.2.1. This had the potential to affect all patients receiving services from the facility. The facility census was 27.

Findings include:

A review of a sample of the facility's testing of its patient-care related electrical equipment was completed on 08/02/18. The sample chosen was patient beds. The review revealed 40 of one brand of bed and 20 of another were tested as a group, but the facility could not provide an inventory list of the beds to show the beds tested were those in service.

On 08/02/18 at 2:00 PM in an interview, Staff T confirmed the finding.