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Based upon observations and staff interviews on August 2, 2021 between approximately 0800 and 1615 hours the facility has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the patients, staff and/or visitors within the facility.

The findings include:

Penetrations were observed in the following locations:

Fire wall above door 10032427
Communications closet/electrical room room C - in ceiling

NFPA 101 19.1.6.1 8.3.5, 8.4.4.1, 8.5.6.2 2012

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on August 2, 2021 between approximately 0800 and 1615 hours the facility has failed to maintain all means of egress continuously free of obstructions. This could inhibit the orderly exit of patients, staff, and visitors out of the building during an emergency and may prevent emergency responders from entering.

The findings include:

Dining room door was blocked by a cart.
Kitchen door was blocked a garbage cart.

NFPA 101 19.2.1, 19.1.1.1 7.1.10.1 (2012)

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on August 2, 2021 between approximately 0800 and 1615 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close upon activation of the fire alarm. This could result in the passage of smoke or fire from one compartment into another compartment thereby exposing patients, staff and/or visitors to the toxic products of combustion.

The findings include:

Doors did not have enough closing force to latch when closed in the following locations:
Laundry storage door
Door 10032439

Doors were blocked open inhibiting the ability to close and latch in the following locations:
Cafe'/Dining room door
Door between admitting and lab

NFPA 101 (2012) 19.2.2.2.7, 8.5.4.4

The above was discussed and acknowledged by facility staff.

Based upon documentation review, observations and staff interviews on August 2, 2021 between approximately 0800 and 1615 hours the facility has failed to maintain proper exit signage. This could potentially misdirect patients, staff, and/or visitors during an emergency.

The findings include:

1) The facility has not performed annual 90 minute power test of the emergency lighting and exits signs within the past twelve months.

2) Exit sign EEL023 did not illuminate when tested.

NFPA 101 19.2.8, 19.1.1.1.1, 7.9.3.1.1 (2012)

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on August 2, 2021 between approximately 0800 and 1615 hours the facility has failed to conduct testing/maintenance of the hood and duct fire suppression equipment protecting the commercial cooking equipment. This could result in the failure of the system to operate properly which would endanger the residents/patients, staff and/or visitors within the facility.

The findings include:

The facility was unable to provide documentation of two semi annual service reports of the kitchen hood suppression system within the past twelve months. Reports provided a picture of the kitchen hood but no documentation of the service performed.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.2.5.1, 9.2.3, 2.1, NFPA 96 (2011 ed) 1.1.1, 11.2.1

Contractor service reports must free of deficiencies.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interviews on August 2, 2021 between approximately 0800 and 1615 hours the facility has failed to have their fire alarm system installed in accordance with the references NFPAs and in a manner that is approved. This could result in a fire not being detected by the fire alarm system, possible leading to harm and delayed evacuation of patients, staff, and visitors.

The findings include:

Emergency Department on call sleeping room in the Rehabilitation department corridor is not protected with smoke detection.

NFPA 101 29.3.4.1, 9.6.2.10.1.2

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interviews on August 2, 2021 between approximately 0800 and 1615 hours the facility has failed to provide maintain their smoke detection system. This could result in the late notification to patients, staff, and visitors within the facility of smoke and fire.

The findings include:

Anesthesia on call sleep room - the smoke detector had tape on it. Corrected during inspection.

NFPA 101 (2012) 29.3.4.5, 9.6, 9.6.1.5, 2.1, NFPA 72 1.1.1 17.1.1, 17.1.3, 14.5.1 (2010)

The above was discussed and acknowledged by the facility staff.

Based on documentation review and staff interviews on August 2, 2021 between approximately 0800 and 1615 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

1) The facility failed to provide documentation of five year internal pipe inspection within the past 60 months. Previous reports are dated March 1, 2015 and June 12, 2015.

NFPA 101 19.3.5.1, 19.1.1.1.1, 9.7.5, 2.1 (2012), NFPA 25 1.1, 14.2.1 (2011)

2) Fire sprinkler heads were loaded in the following locations:
Kitchen- outside the reach-in cooler
Pharmacy
OR PACU office

NFPA 101 19.3.5.1, 19.1.1.1.1, 9.7.5, 2.1 (2012), NFPA 25 5.2.1.1.4 (2011)

3) Concealed sprinkler head in the OR procedure room was missing the sprinkler head cover.

NFPA 101 19.3.5.1, 19.1.1.1.1, 9.7.5, 2.1 (2012), NFPA 25 5.2.1.1.1 (2011)

4) Wires were hanging from fire sprinkler pipes in the basement storage and the rehabilitation janitor closet. Corrected during inspection.

5) Lighting ballast attached to wood was hanging from fire sprinkler pipes in the basement storage.

NFPA 101 19.3.5.1, 19.1.1.1.1, 9.7.5, 2.1 (2012), NFPA 25 5.2.2.2 (2011)

6) Visual Inspection of the kitchen cooler sprinkler heads showed they were dated 2006. Dry sprinkler heads shall be replaced or representative samples shall be tested and then retested at 10-year intervals. The facility was unable to provide documentation of UL testing or replacement.

NFPA 101 19.3.5.1, 19.1.1.1.1, 9.7.5, 2.1 (2012), NFPA 25 5.3.1.1.1.6 (2011)

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interviews on August 2, 2021 between approximately 0800 and 1615 hours the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This potentially delays a quick response to contain a fire from spreading which could expose and endanger patients, staff, and/or visitors within the facility.

The findings include:

1) Second floor Mechanical/Communication Room H - unsecured fire extinguisher was observed.

NFPA 101 (2012) 19.3.5.12, 19.1.1.1, 9.7.4.1, 2.1 NFPA 10 1.1, 6.1.3.4 (2010)

2) Helipad - wheeled fire extinguishers were last serviced in May 2020.

NFPA 101 (2012) 19.3.5.12, 19.1.1.1, 9.7.4.1, 2.1 NFPA 10 1.1, 7.3.1.1.1, 7.3.1.4, 7.3.2 (2010)

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on August 2, 2021 the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment.

The findings include:

Cross corridor door 10032439 rubbed on the floor inhibiting the door's ability to close.

The accordion fire door at the hospital's main entrance had a check in desk in the door's closing path inhibiting the door's ability to close.

NFPA 101 19.3.6.3 (2012)

The above was discussed and acknowledged by the facility staff.

Based on documentation review, observation and staff interview on August 2, 2021 between approximately 0800 and 1615 hours the facility has failed to ensure dampers in the facility were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. NFPA 101 9.2.1 requires heating, ventilating and air conditioning (HVAC), ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems.

NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall be every 4 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all patients, staff, and visitors.

The findings include:

Repairs/corrections to dampers found deficient on the May 9-20, 2019 damper inspection report have not been completed.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.2.1, 7.2.1.15.2, NFPA 80 (2010 ed) 1.1, 19.5.3

The above was discussed and acknowledged by the facility staff.

Based on documentation review and staff interviews on August 2, 2021 between approximately 0800 and 1615 hours the facility has failed to perform monthly operation of the fire fighter emergency operations on the facility elevator(s). This could potentially result in the fire service personnel not responding in a coordinated manner in the event of a fire or other emergency and endangering patients, staff and/or visitors.

The findings include:

The facility was unable to provide documentation of monthly operation of the fire fighter emergency operations.

NFPA 101 19.5.3, 9.4.6 2012

The above was discussed and acknowledged by the facility staff.

Based upon documentation review, observations and staff interviews on August 2, 2021 between approximately 0800 and 1615 hours the facility has failed to test all fire rated doors in accordance with NFPA 80. This could lead to the doors not functioning as required in a fire, endangering patients, visitors, and staff inside the building.

The findings include:

1) The facility was unable to provide documentation of repairs/corrections to doors found deficient during the annual fire door inspection on May 5-20, 2019 report.

2) Door 10032439 had penetration in it.

NFPA 101 19.1.1.1.1, 19.2.1, 7.2.1.15.2 (2012), NFPA 80 1.1, 5.2.4.1, 5.1.5.1 (2010)

The above was discussed and acknowledged by the facility staff.

Based on documentation review and staff interviews on August 2, 2021 between approximately 0800 and 1615 hours the facility did not complete an evaluation including hazards associated with electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment. Operation rooms are by default considered wet locations and require either GFCI or isolated power. This could potentially endanger patients and staff in the operating room if liquids come in contact with the electrical receptacles.

The findings include:

The facility was unable to provide documentation an evaluation of hazards that could be encountered during surgical procedures.

NFPA 99 1.1.1, 6.3.2.2.8.4, 15.13.1 (2012)

The above was discussed and acknowledged by the facility staff.

Based on documentation and staff interviews on August 2, 2021 between approximately 0800 and 1615 hours the facility failed to keep records or conduct maintenance on their hospital grade receptacles, non-hospital grade receptacles, and Line Isolation Monitors. This could cause an increased risk of fire due to the non-maintenance of the electrical system, and place residents/patients, staff, and visitors of electrical shock or harm.

The findings include:

1) The facility was unable to provide documentation of testing hospital grade electrical receptacles

NFPA 99 1.1.1, 6.3.4.1.1 (2012)

2) The facility was unable to provide documentation of testing non-hospital grade electrical receptacles.

NFPA 99 1.1.1, 6.3.4.1.3 (2012)

The above was discussed and acknowledged by the facility staff.

Based on observations and staff interviews on August 2, 2021 between approximately 0800 and 1615 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger patients, staff, and visitors in the facility due to the increased fire risk.

The findings include:

1) Powerstrip was plugged into another powerstrip in the following locations:
Education and Training office - under the education desk
Rehabilitation office - under the desk

NFPA 99 1.1.4.2 (2012), NFPA 70 Scope, 400.7(B) (2011)

2) Extension cords were in use in place of permanent wiring in the following locations:
Rehabilitation rooms 2, 3, 4, 6, 7, 8, 10 & 11
Physical therapy office

NFPA 99 1.1.4.2 (2012), NFPA 70 Scope, 400.8 (2011)

NFPA 99 (2012) 10.2.4.2

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interviews on August 2, 2021 between approximately 0800 and 1615 hours the facility has failed to maintain the segregation and securement of compressed gas cylinders. This could allow for the tampering with or damage to of cylinders, which could endanger patients, staff, and/or visitors.

The findings include:

1) Second floor Soiled Utility Room - empty and full oxygen cylinders were stored in the same rack without separation.

NFPA 99 1.1.1, 1.1.9, 11.6.5.2 (2012)

2) Outside medical gas storage - 3 nitrous oxide cylinders were not secured.

NFPA 99 1.1.1, 1.1.9, 11.6.2.3(11) (2012)

The above was discussed and acknowledged by the facility staff.

Based on documentation review and staff interviews on August 2, 2021 between approximately 0800 and 1615 hours the facility has failed to provide documentation of personnel concerned with the application, maintenance, and handling of medical gases and cylinders that are trained on the risk and provide continuing education. Failure to provide training and continuing education on the safe handling and use of gases and cylinders could place patients, visitors, and staff at risk of oxygen malfunctions.

The findings include:

The facility was unable to provide documentation of staff training on the use of medical gas equipment.

NFPA 99 1.1.1, 11.5.2.1, 11.5.2.1.2 (2012)

The above was discussed and acknowledged by the facility staff.