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Based on observations, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Sections 7.1.10.1 and 19.2.3.4(5). This deficiency affects 1 of 4 smoke compartments on the first floor.

Findings include:

1. During an observation on 6/4/19 at 2:38 p.m., the lab waiting area was inspected. There was a row of chairs and a table in the corridor. It reduced the corridor width to 6 feet. The furniture was not bolted to the wall or the floor.

Based on observation, the facility failed to post mandatory signage regarding the function of the delayed egress on the exit doors, in accordance with NFPA 101, 2012 Edition, Section 7.2.1.6.1.1 and Section 19.2.2.2.4. These deficiencies affect 1 of 4 smoke compartments.

Findings include:

1. During an observation on 6/4/19 at 2:50 p.m., the visitor entrance to the gallery hallway door was inspected. There was a visible exit sign in place on the side of the main visitor entrance. The cross corridor doors were fitted with magnetic locks which locked on a schedule in the evening. There was no delayed egress on the door going toward the gallery hall, which could override the magnetic lock. The deficiency was fixed while surveyor was on site.

Based on observations, the facility failed to ensure rooms being used as storage had doors which were able to close, and latch under the power of a self-closing device in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3. This deficiency affects 1 of 4 smoke compartments on the second floor, and 1 of 4 smoke compartments on the first floor.

Findings include:

1. During an observation on 6/4/19 at 12:33 p.m., the last room near the DHIM clinic was inspected. The room was being used as storage, and was greater than 50 square feet and was not fitted with the necessary self-closing device.

2. During an observation on 6/4/19 at 2:30 p.m., the pre-op storage area was inspected. The room was greater than 50 square feet, and was not fitted with a self-closing device. There were also items in front of the door which inhibited the door from closing.

Based on record review and interview, the facility failed to ensure that load voltage tests were conducted on the batteries of the fire alarm control panel (FACP) semi-annually, as required per NFPA 72-2010, Table 7-3.2. The deficiency affects 8 of 8 smoke compartments between first and second floor.

Findings include:

1. During a review of facility records on 6/4/19, the facility maintenance and testing documents for the fire alarm systems reflected a load voltage test in September of 2018 during the annual alarm service. There was no load voltage tests documented since the annual alarm service. These are required every six months.

Based on observation, interview and record review, the facility failed to:

a) provide documentation of completion of all the required automatic sprinkler system tests and inspections.
b) ensure proper sprinkler maintenance in accordance with NFPA 101-2012 and NFPA 25-2011, Sections 5.1.1.1 and Table 5.1.1.2.

This deficiency affects the entire smoke compartment.

Findings include:

1. During an observation on 6/5/19 at 11:29 a.m., the outside oxygen storage and manifold system was inspected. There was one sprinkler head in the small closet comprising the oxygen storage area. There was no actual standpipe in the building, and there was no demonstrable way to tell where the water supply to the head came from. There were no quarterly inspections on the head itself.

In an interview on 6/5/19 at 11:29 a.m., staff member A stated they did not know about this sprinkler head being here in this space.

Based on observation, the facility failed to maintain corridor doors and to ensure a means suitable for keeping the doors closed in accordance with NFPA 101, 2012 Edition, Section 19.3.6.3.1 and 19.3.6.3.5. This deficiency effects 1 of 4 smoke compartments on the second floor.

Findings include:

1. During an observation on 6/4/19 at 11:57 p.m., the corridor door to resident room 3231 was exercised. The door would not close and positively latch with a nominal amount of force placed on it. This was fixed while the surveyor was on site.

Based on observation, the facility failed to ensure smoke barriers were maintained to prevent the potential for smoke to spread in accordance with NFPA 101-2012, Section 19.3.7.3. This deficiency affects 2 of 4 smoke compartment on the first floor.

Findings include:

1. During an observation on 6/5/19 at 10:00 a.m., the smoke barrier above the above the communications room on first floor was inspected. There was an unsealed opening with a large bundle of IT wires running through the wall. This was fixed while the surveyor was on site.

Based on observation, the facility failed to keep soiled linen receptacles greater than 32 gallons in an area protected as hazardous in accordance with NFPA 101, 2012 Edition, Section 19.7.5.7.1. This deficiency affects 1 of 4 smoke compartments on the first floor.

Findings include:

1. During an observation on 6/4/19 at 3:45 p.m.,the hallway outside the surgery zone was inspected. There was a 44 gallon, rolling container left outside a protected room. The largest size allowed to be unattended in the corridor is 32 gallons. This was fixed while the surveyor was on site.

Based on interview, the facility failed to ensure a labeled remote manual stop station for the generator was installed in accordance with NFPA 110-2010, Section 5.6.5.6 and 5.6.5.6.1. The deficiency affects the entire building.

Findings include:

1. During an interview on 6/4/19 at 11:00 a.m., staff member A stated the generator lacked a labeled manual stop station at a remote location outside of the room housing the prime mover, of a type in order to prevent inadvertent or unintentional operation of the generator in an emergency.

Based on observation, the facility failed failed ensure oxygen storage rooms were lockable to unauthorized entry in accordance with NFPA 99 Health Care Facilities Code, 2012 Edition, Sections 11.3.2.1. The deficiency affects 1 of 4 smoke compartments on that floor.

Findings include:

1. During an observation on 6/4/19 at 12:04 p.m., the oxygen storage room on the second floor inpatient area was inspected. The room was not lockable and there was not any means from keeping the room free from unauthorized entry. This was fixed while the surveyor was on site.