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Based on observation, the facility failed to install and maintain emergency illumination components as required. This deficient practice could affect patients, visitors, and staff because failure of emergency lighting would render occupants unable to navigate and emergency event.

The findings are:

A. On July 15, 2025 at 3:30pm, while in the company of CNO and QRMD evidence of monthly functional testing for a minimum of 30-seconds for the emergency battery-operated lights was unavilable for review. This does not comply with 7.9.3.1.1.(1).

B. On July 15, 2025 at 3:30pm, while in the company of CNO and QRMD evidence of annual 90-minute functional test of for the battery-operated emergency lights was unavilable for review. This does not comply with 7.9.3.1.1.(3).

Based on observation, the facility failed to install and maintain exit signage components as required. This deficient practice could affect patients, visitors, and staff because failure of exit signage would render occupants unable to navigate to an exit during an emergency event.

The findings is:

On July 15, 2025 at 3:30pm, while in the company of CNO and QRMD evidence of monthly visual inspection for battery-operated Exit Signs was unavilable for review. This does not comply with 7.10.9.1

Based upon documentation, fire alarm system components are not maintained in accordance with Code requirements. Failure to install components in accordance with requirements can result in failure of the system to operate as intended and delay proper repairs when necessary.

Findings include:

A. On July 15, 2025 at 3:30pm, while in the company of CNO and QRMD evidence of two visual inspections of all the devices of the fire alarm system within the last 12 months in accordance with NFPA 72-2010 Edition, 14.3.1. and Table 14.3.2. was unavailable for review.

B. On July 15, 2025 at 3:30pm, while in the company of CNO and QRMD evidenceof the annual functional testing of alarm initiating and notifying fire alarm devices within the last 12 months in accordance with NFPA 72-2010, 7.3.1. and Table 7.3.2.

Based on observation the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

On July 15, 2025 at 2:30pm while in the company of the QRMD and SO, it was observed in the storage room off the purchasing hallway that the room is not provided with fire sprinkler protection. This is not in compliance with NFPA 13-2010, 8.1.

Based upon documentation, fire supression system components are not maintained in accordance with Code requirements. Failure to install components in accordance with requirements can result in failure of the system to operate as intended and delay proper repairs when necessary.

Findings include:

A. On July 15, 2025 at 1:30pm, while in the company of CNO and QRMD it was observed that a sprinkler head over the Emergency Department entrance was missing an escutcheon ring. This does not comply with NFPA 13-2010, 6.2.7.1.

B. On July 15, 2025 at 2:30pm, while in the company of CNO and QRMD it was observed in the storage room off the purchasing hallway that combustible materials are stored to within 18" of the sprinkler, in violation of NFPA 13-2010, 8.5.6.

Based upon documentation, fire/smoke doors are not maintained in accordance with Code requirements. Failure to maintain fire/smoke doors can result in failure of the doors to offer protection as design during an emergency event.

Findings include:

On July 15, 2025 at 3:30pm, while in the company of CNO and QRMD evidence of annual inspection of fire rated door assemblies and the fire rated building separation doors in accordance with Section 7.2.1.15.2 in accordance with the requirements of NFPA 80, 2010, Section 5.2, including the testing and 11-point inspection.

Based on observation, the facility failed to install and maintain the electrical and medical gas piping systems as required. This deficient practice could affect patients, staff and visitors because a failure of the electrical system could result in a fire or electric shock if an unbonded metallic pipe becomes energized.

The finding is:

On July 15, 2025 at 1:50pm while in the company of the QRMD, it could not be determined by direct observation that medical gas piping systems were bonded together and to the building's grounding electrode system in accordance with NFPA 70-2011, 250.104(B).

Based on observation, the facility failed to install and maintain the electrical system as required. This deficient practice could affect patients and staff in the Operating Room because a failure of the electrical system could result in electric shock.

The findings are:

A. On July 15, 2025 at 12:45pm, while in the company of the SO, CNO, and QRMD it was directly observed that the facility Conference Room contained an extension cord in use, which passed through the plane of the suspended acoustic ceiling above. This is not in accordance with NFPA 99-2012, Sections 10.2.3.6, Section 10.2.4, NFPA 70-2011, 400.8(2).

B. On 7/15/25 at 1:50 p.m. while in the company of the QRMD it was observed branch circuit panels from the normal electrical system and the critical branch of the essential system were serving the Operating Room patient care vicinity with no evidence of grounding interconnects between them in accordance with NFPA 99 -2012, 6.3.2.2.3.

Based on observation, the facility failed to install and maintain the electrical system as required. This deficient practice could affect patients and staff in the building because a failure of the electrical system could result in electric shock or electrocution.

The finding is:

A. On July 15, 2025 at 1:40 p.m. while in the company of the QRMD, it was observed the Operating Room was not equipped with GFCI protected receptacles or an Isolated Power System in accordance with NFPA 99-2012, 6.3.2.2.8.1 and 6.3.2.2.8.4.

B. On July 15, 2025 at 1:40 p.m. while in the company of the CNO and QRMD, it was observed that emergency department bay #2 contained an electrical receptacle (outlet) within six feet of a sink that was not protected by a ground fault interrupter (GFI) in accordance with NFPA 70-2010 Edition, 210.8(7).

Based upon documentation, the Emergency Electrical System (EES) components are not maintained in accordance with Code requirements. Failure to install components in accordance with requirements can result in failure of the system to operate as intended during an emergency event.

Findings include:

A. On July 15, 2025 at 3:30pm, while in the company of CNO and QRMD evidence of records of weekly visual inspection of emergency generator in accordance with NFPA 110-2010 Edition, Section 8.4.1.

B. On July 15, 2025 at 3:30pm, while in the company of CNO and QRMD evidence of records of monthly emergency generator exercise under load for 30 minutes with a connected minimum load of 30% of the generator's capacity in accordance with NFPA 110-2010, Section 8-4.2. Emergency diesel generators that are not able to be exercised monthly with at least a minimum 30% load capacity can use alternate testing that include records showing the available amperage load for each phase monthly and complete a 1-1/2- hour annual load test by a generator testing service provider.