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Based on observation and interview, the facility failed to ensure doors in a required means of egress are not equipped with a latch or lock from the egress side in accordance with 2012 NFPA 101 19.2.2.2.3 This deficient practice could affect 25 occupants in the event of an emergency evacuation.

Findings Include:

1. On July 20, 2021, at approximately 11:45 a.m., observation revealed the hospital main entrance sliding doors are equipped with a 180 degrees thumb turn deadbolt lock. The lock will prohibit egress through the door when in the locked position in violation of 2012 NFPA 101, 19.2.2.2.3.

2. On July 20, 2021, at approximately 11:45 a.m., observation revealed the hospital main entrance sliding doors are equipped with a breakaway emergency egress function, however, the doors do not have a sign with a minimum of 1 inch high letters with a contrasting background indicating "IN EMERGENCY PUSH TO OPEN" in violation of 2012 NFPA 101, 7.2.1.9.1.3. This could potentially leave occupants trapped inside or delay activation during an emergency evacuation.

These findings were confirmed through interview with the maintenance director at the time of observation.

Based on observation and interview, the facility failed to ensure not less than 2 remote and accessible exits were provided from every part of every story and smoke compartment in accordance with 19.2.4.1 through 19.2.4.4. and 7.5.1.1.4. This deficient practice could affect all basement occupants in the event of an emergency evacuation.

Findings Include:

On July 20, 2021, at approximately 1:45 p.m., observation revealed the medical library basement has a single egress path that leads to a single emergency egress exit point. The basement does not have remote exiting as required by 2012 NFPA 101, 19.2.4.2 and 19.2.4.3. and 7.5.1.1.4. This could potentially trap occupants between an impassable emergency situation and the emergency exit.

These findings were confirmed through interview with the maintenance director at the time of observation.

Based on observation and interview, the facility failed to ensure cooking facilities are protected in accordance with NFPA 96, unless meeting the requirements of 19.3.2.5.2, 19.3.2.5.3 or 19.3.2.4.4, as required by 19.3.2.5.1 through 19.3.2.5.5, 9.2.3 and TIA 12-2. This deficient practice could affect 20 occupants in the event of kitchen appliance fire.

Findings Include:

On July 20, 2021, at approximately 12:45 p.m., observation revealed a shelf above the commercial kitchen range that obstructs the ansul wet chemical fire suppression system agent from reaching the cooking surface. This could potentially allow a cooking fire to be unimpaired by the limited amount of wet chemical agent and spread to the adjacent areas and into the roof.

These findings were confirmed through interview with the maintenance director at the time of observation.

Based on observation and interview, the facility failed to ensure a fire alarm system is installed in accordance with 2010 NFPA 72, 17.7.4.1 and as required by 19.3.4.1, 9.6 and 9.6.1.8. This deficient practice could affect 15 occupants in the event a smoke detector fails to activate during a fire or smoke event.

Findings Include:

1. On July 20, 2021, at approximately 12:00 PM, observation revealed the smoke detector in the Emergency Room located above bed 4 is directly within the airflow of an air supply diffuser in violation of 2010 NFPA 72, 17.7.4.1. This could potentially push smoke away from the detector and prevent or delay activation and notification to facility occupants.

2. On July 20, 2021, at approximately 2:00 PM, observation revealed the smoke detector in the Cat Scan Room located above the Cat Scan machine is directly within the airflow of an air supply diffuser in violation of 2010 NFPA 72, 17.7.4.1. This could potentially push smoke away from the detector and prevent or delay activation and notification to facility occupants.

These findings were confirmed through interview with the maintenance director at the time of observation.

Based on observation and interview, the facility failed to ensure nursing homes and hospitals where required by construction type are protected in accordance with NFPA 13, as required by 19.3.5.1 through 19.3.5.5, 19.4.2, 19.3.5.10, 9.7 and 9.7.1.1(1). This deficient practice could affect all occupants in the event of fire.

Findings Include:

1. On July 20, 2021, at approximately 1:00 PM, observation revealed the facility fire department connection (FDC) located in the rear of the building does not have a sign mounted on the side of the building. Such sign shall have the letters "FDC" at least 6 inches (152 mm) high and words in letters at least 2 inches (51 mm) high or an arrow to indicate the location.

2. On July 20, 2021, at approximately 11:40 PM, observation revealed the sprinkler head in the main lobby does not have a required escutcheon ring leaving an opening around the head. This will allow heat around the sprinkler head and delay activation.

3. On July 20, 2021, at approximately 12:00 PM, observation revealed a 2 foot x 2 foot ceiling tile missing above the emergency room operations desk. This could potentially allow heat and smoke above the barrier ceiling into the unprotected space delaying activation of the wet fire sprinkler system and the corresponding fire alarm activation.

These findings were confirmed through interview with the maintenance director at the time of observation.

Based on observation, record review, and interview, the facility failed to ensure the automatic sprinkler and standpipe systems are inspected, tested and maintained in accordance with NFPA 25, and records are readily available as required by 9.7.5, 9.7.7, 9.7.8 and NFPA 25. This deficient practice could affect 10 occupants in the event of fire.

Findings Include:

1. On July 20, 2021, at approximately 2:15 PM, observation revealed the sprinkler head located in the main Lab is dated 1967. This could potentially lead to failure of the sprinkler head when needed during a fire. Sprinkler heads 50 years or older are required to be changed out or tested per 2011 NFPA 25, 5.3.1.1.1.

2. On July 20, 2021 at approximately 2:40 PM, record review revealed the facility cannot produce documentation to verify the 5 year required internal, check valve and fire department connection hydro inspections have been conducted for the wet fire protection system per 2011 NFPA 25, 14.2.1.

These findings were confirmed through interview with the maintenance director at the time of observation and record review.

Based on observation and interview, the facility failed to ensure doors protecting corridor openings in other than required enclosures of vertical openings, exits or hazardous areas are 1 3/4 inch solid-bonded core wood or capable of resisting the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed as required by 19.3.6.3, and 42 CFR 403, 418, 460, 482, 483 and 485. There is no impediment to the closing of doors. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. This deficient practice could affect 40 occupants in the event of a fire or smoke event across fire/smoke compartments.

Findings Include:

1. On July 20, 2021, at approximately 12:30 p.m., observation revealed the door separating surgical services from the main corridor is being forced and held open by extending the closer beyond its functional range. This will allow smoke, heat and flames to spread across the smoke compartment into the adjacent smoke compartment.

2. On July 20, 2021, at approximately 2:15 p.m., observation revealed the micro lab door leading into the corridor does not latch when closed. This could potentially allow heat and smoke to spread into the emergency egress corridor.

These findings were confirmed through interview with the maintenance director at the time of observation.

Based on record review and interview, the facility failed to ensure heating, ventilation and air conditioning is in compliance with 9.2, and installed in accordance with the manufacturer's specifications as required by 2012 NFPA 101, 19.5.2.1 and 9.2., 2012 NFPA 90A, 5.4.8.1. and 2010 NFPA 80, 19.4.1.1. This deficient practice could affect all occupants in the event fire spreads through the rated barriers.

Findings Include:

On July 20, 2021, at approximately 3:00 PM, record review revealed the facility cannot produce documentation to verify fire dampers are inspected at 6 year intervals as required by 2010 NFPA 80, 19.4.1.1. This could potentially allow the fire dampers to fail to operate as designed and allow fire to spread beyond the rated barriers in the facility.

These findings were confirmed through interview with the maintenance director at the time of record review.

Based on record review and interview, the facility failed to ensure hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance date. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Records are maintained of required tests and associated repairs or modifications, contain date, room or area tested and results as required by 6.3.4 of NFPA 99. This deficient practice could affect 25 occupants in the event of an electrical outlet failure and failure of electrical medical equipment.

Findings Include:

On July 20, 2021, at approximately 3:15 PM, record review revealed the facility cannot produce documentation to verify the 12 month outlet testing in the patient bed vicinity has been completed. This could potentially allow the outlet and electrical treatment equipment plugged into the outlet to fail.

These findings were confirmed through interview with the maintenance director at the time of record review.

Based on observation and interview, the facility failed to ensure generators or other alternative power sources and associated equipment is capable of supplying service within 10 seconds, is maintained, inspected, tested and exercised in accordance with NFPA 110, and records are readily available as required by 6.4.4, 6.5.4 and 6.6.4 of NFPA 99, NFPA 110, NFPA 111 and 700.10 of NFPA 70. This deficient practice could affect 20 occupants in the event of fire.

Findings Include:

On June 24, 2021, at approximately 1:30 PM, observation revealed the facility diesel generator belly tank is not labeled according to NFPA 704, and 21.7.2.1 of NFPA 30-2012. The tank and fence around the tank do not display the proper placards or NO SMOKING COMBUSTIBLE LIQUIDS SIGN. This could potentially delay emergency response protocols and endanger occupants who introduce heat or flame to the area around the tank.

These findings were confirmed through interview with the maintenance director at the time of observation.