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Based upon record review and interview, the facility failed to ensure that automatic emergency lighting of 1-1/2 hour duration is provided in accordance with 7.9 as required by 19.2.9.1. This deficient practice could potentially affect all 13 patients of the facility, all of the staff and any visitors present at the time of a potential incident to be injured if the battery-operated emergency lights failed to operate properly during a fire emergency. Findings include:

1. On 04/25/18 at 10:30 AM, during review of the facility's preventative maintenance (PM) Logs it was observed that the Monthly 30 Second Tests of the battery-operated emergency lights was missed during the months of September and December of 2017 and January and February of 2018.

In an interview on 04/25/17 at 10:31 AM, DPO#1 verified that the monthly tests of the battery-operated emergency lights were missed for the above listed months.

Based upon observation and interview, the facility failed to ensure that hazardous areas are protected by a fire barrier having a 1-hour fire-resistance rating or protected by an automatic extinguishing system in accordance with 8.7.1 as required by 19.3.2.1. This deficient practice could potentially affect 4 patients and 3 staff on the 2nd Floor and 2 patients and 8 staff on the 1st Floor to be injured if smoke and hot gases were allowed to pass from one area to another.

1. On 04/25/18 at 10:21 AM a penetration was observed in the In-Patient Rehab telecommunication closet on the 2nd Floor.
In an interview on 04/25/18 at 10:22 AM, MT#1 verified that there was a penetration in the In-Patient Rehab telecommunication closet on the 2nd Floor.

2. On 04/25/18 at 10:36 AM a penetration was observed in Room ERT113 on the 1st Floor.
In an interview on 04/25/18 at 10:37 AM, MT#1 verified that there was a penetration in Room ERT113 on the 1st Floor.

3. On 04/25/18 at 10:39 AM a penetration was observed in the Decon Room in the emergency room (ER) on the 1st Floor.
In an interview on 04/25/18 at 10:40 AM, MT#1 verified that there was a penetration in the Decon Room in the ER on the 1st Floor.

4. On 04/25/18 at 10:47 AM the door leading from the corridor to the computed tomography (CT) Control Room on the 1st Floor failed to self-close and positively latch when tested.
In an interview on 04/25/18 at 10:48 AM, MT#1 verified that the door leading from the corridor to the CT Control Room on the 1st Floor failed to self-close and positively latch when tested.

5. On 04/25/18 at 10:56 AM the door leading from the corridor to the Cardiovascular Lab (CVL) Locker Room on the 1st Floor failed to self-close and positively latch when tested.
In an interview on 04/25/18 at 10:57 AM, MT#1 verified that the door leading from the corridor to the Cardio Vascular Lab (CVL) Locker Room on the 1st Floor failed to self-close and positively latch when tested.


32432


1. On 04/25/18 at 2:00 PM, an open penetration in the ceiling of the Sterile Processing Room, caused by a 3 inch copper pipe was observed.
In an interview on 04/25/18 at 2:01 PM, DPO#1 verified that a 3 inch copper pipe was penetrating the Sterile Processing Room ceiling.

2. On 04/25/18 at 2:15 PM, an open door to a chase way was observed next to the ice machine in the pantry of the Ambulatory Surgery Area.
In an interview on 04/25/18 at 2:16 PM, DPO#1 verified that the door to the chase way was open in the pantry of the Ambulatory Surgery Area.

Based upon observation, record review, and interview, the facility failed to ensure that 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 potentially affect all 13 patients of the facility, all of the staff and any visitors present at the time of a potential incident to be injured if the hood suppression system failed to operate properly during a fire emergency. Findings include:

1. On 04/25/18 at 10:49 AM a toaster oven was observed in the X-Ray back hallway.
In an interview on 04/25/18 at 10:50 AM, MT#1 verified that there was a toaster oven in the X-Ray back hallway.


32432


1. On 04/25/18 at 9:45 AM during review of the hood suppression records it was observed that the semi-annual inspection of hood suppression system was late. Reviewed records were dated 04/24/17 and 10/16/17.
In an interview on 04/25/18 at 9:46 AM, DPO#1 verified the dates of the hood suppression records.

Based upon observation and interview, the facility failed to ensure that occupant notification is provided automatically in accordance with 9.6.3 by audible and visual signals as required by 19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, and 9.6.4. This deficient practice could potentially affect 1 patient and 2 staff on the 3rd Floor present at the time of a potential incident to be injured if notification of a fire emergency was not received. Findings include:

1. On 04/25/18 at 9:43 AM it was observed that there was no notification device in Sleep Room #1.
In an interview on 04/25/18 at 9:44 AM, MT#1 verified that there was no notification device in Sleep Room #1.

Based upon observation, record review, and interview, the facility failed to ensure that the fire alarm system was tested and maintained in accordance with an approved program complying with NFPA 70 and NFPA 72 and records were readily available as required by 19.3.4.1, 9.6.1.5, NFPA 70, and NFPA 72. This deficient practice could potentially affect 2 patients and 2 staff on the 2nd Floor present at the time of a potential incident to be injured if the fire alarm system did not function as designed during a fire emergency. Findings include:

1. On 04/25/18 at 10:28 AM it was observed that a smoke detector at Room 205 was missing its installation bracket.
In an interview on 04/25/18 at 10:29 AM, MT#1 verified that a smoke detector at Room 205 was missing its installation bracket.


32432


1. On 04/25/18 at 10:35 AM during review of the facility's records it was observed that there were several missing weeks of testing and maintenance of the two (2) battery-operated smoke detectors located in the Sleep Testing Rooms. These missing weeks occurred during the months of February, March and April of 2018.
In an interview on 04/25/18 at 10:36 AM, DPO#1 verified that several weeks of testing and maintenance for the battery-operated smoke detectors were missing.

Based upon observation and interview, the facility failed to ensure that 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 potentially affect 2 staff on the 3rd Floor and 3 staff members in the Sterile Processing Room present at the time of a potential incident to be injured if the sprinkler system did not operate as designed during a fire emergency. Findings include:

1. On 04/25/18 at 9:48 AM it was observed that the storage in the DOC Storage Room was stacked within 18 inches of the sprinkler head.
In an interview on 04/25/18 at 9:49 AM, MT#1 verified that the storage in the DOC Storage Room was stacked within 18 inches of the sprinkler head.


32432


1. On 04/25/18 at 2:02 PM a hole in a ceiling tile was observed in the Sterile Processing Room.
In an interview on 04/25/18 at 2:03 PM, DPO#1 verified that there was a hole in a ceiling tile in the Sterile Processing Room.

Based upon records review and interview, the facility failed to ensure that portable fire extinguishers are selected, installed, inspected and maintained in accordance with NFPA 10 as required by 19.3.5.12. This deficient practice could potentially affect all 13 patients, all of the staff and any visitors present at the time of a potential incident to be injured if the fire extinguishers failed to operate properly during a fire emergency. Findings include:

1. On 04/25/18 at 10:20 AM, during the review of the facility's records it was observed that the monthly fire extinguisher inspections were not conducted for the month of January, 2018.
In an interview on 04/25/18 at 10:21 AM, DPO#1 verified that the monthly fire extinguisher inspections were missed in January of 2018.

Based upon observation and interview, the facility failed to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, resist the passage of smoke, equipped with a means suitable for keeping the door closed, and there is no impediment to the closing of doors as required by 19.3.6.3 and 42 CFR 403, 418, 460, 482, 483, and 485. This deficient practice could potentially affect 12 staff on the 3rd Floor and 4 patients and 2 staff on the 2nd Floor present at the time of a potential incident to be injured if the corridor doors failed to operate as designed during a fire emergency. Findings include:

1. On 04/25/18 at 9:45 AM it was observed that the smoke barrier door frame on the 3rd Floor had no fire rating label attached to it.
In an interview on 04/25/18 at 9:46 AM, MT#1 verified that the smoke barrier door frame on the 3rd Floor had no fire rating label attached to it.

2. On 04/25/18 at 9:52 AM it was observed that the door from the corridor to Computer Room #354 had holes in it.
In an interview on 04/25/18 at 9:53 AM, MT#1 verified that the door from the corridor to Computer Room #354 had holes in it.

3. On 04/25/18 at 9:55 AM it was observed that the fire rating label for the smoke barrier door frame at the Administrative corridor was painted.
In an interview on 04/25/18 at 9:56 AM, MT#1 verified that the fire rating label for the smoke barrier door frame at the Administrative corridor was painted.

4. On 04/25/18 at 10:07 AM it was observed that the smoke barrier door frame at Room 217 had no fire rating label attached to it.
In an interview on 04/25/18 at 10:08 AM, MT#1 verified that the smoke barrier door frame at Room 217 had no fire rating label attached to it.

5. On 04/25/18 at 10:24 AM it was observed that the smoke barrier door frame at In-Patient Rehab had no fire rating label attached to it.
In an interview on 04/25/18 at 10:24 AM, MT#1 verified that the smoke barrier door frame at In-Patient Rehab had no fire rating label attached to it.

Based upon observation and interview, the facility failed to ensure that smoke barriers were constructed to a minimum 1/2-hour fire resistance rating in accordance with 8.5 as required by 19.3.7.3 and 8.6.7.1(1). This deficient practice could potentially affect 4 patients and 2 staff on the 2nd Floor present at the time of a potential incident to be injured if the smoke barriers did not perform as designed during a fire emergency. Findings include:

1. On 04/25/18 at 10:23 AM it was observed that there was a penetration in the smoke barrier wall at the In-Patient Rehab at Room #233.
In an interview on 04/25/18 at 10:23 AM, MT#1 verified that there was a penetration in the smoke barrier wall at the In-Patient Rehab at Room #233.

Based upon observation and interview, the facility failed to ensure that equipment using gas or gas-related piping complies with NFPA 54 and electrical wiring and equipment complies with NFPA 70 as required by 19.5.1.1, 9.1.1, and 9.1.2. This deficient practice could potentially affect 6 patients and 4 staff on the 2nd Floor present at the time of a potential incident to be injured if the electrical system caused a fire emergency. Findings include:

1. On 04/25/18 at 10:04 AM it was observed that there was an open electrical junction box in On-Call Room #T223.
In an interview on 04/25/18 at 10:05 AM, MT#1 verified that there was an open electrical junction box in On-Call Room #T223.

2. On 04/25/18 at 10:25 AM it was observed that Electrical Panel LS2W located in the corridor was not locked.
In an interview on 04/25/18 at 10:26 AM, MT#1 verified that Electrical Panel LS2W located in the corridor was not locked.

Based upon observation and interview, the facility failed to ensure that heating, ventilation, and air conditioning was in compliance with 9.2 and installed in accordance with the manufacturer's specifications as required by 19.5.2.1 and 9.2. This deficient practice could potentially affect all 13 patients, all of the staff and any visitors present at the time of a potential incident to be injured if the boilers caused a fire emergency. Findings include:

1. On 04/25/18 at 11:30 AM it was observed that the facility failed to display proper boiler inspection certificates.
In an interview on 04/25/18 at 11:31 AM, MT#1 verified that the facility failed to display proper boiler inspection certificates.

Based upon records review and interview, the facility failed to ensure that 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 potentially affect all 13 patients, all of the staff and any visitors present at the time of a potential incident to be injured if the emergency generator failed to operate properly in an emergency. Findings include:

1. On 04/25/18 at 10:56 AM during review of the facility's generator records for the past 12 months it was observed that several weeks of visual inspections were missing.

In an interview on 04/25/18 at 10:57 AM, DPO#1 verified that there were several weeks of visuals inspection records for the generator that were missing.

Based upon observation and interview, the facility failed to ensure that storage of nonflammable gasses meet all requirements of 11.3.1 through 11.3.4 and 11.6.5 of NFPA 99. This deficient practice could potentially affect 4 staff on the 1st Floor present at the time of a potential incident to be injured if unsecured gas cylinders created an emergency situation. Findings include:

1. On 04/25/18 at 11:12 AM it was observed that there were unsecured cylinders in two cylinder rooms on the 1st Floor.
In an interview on 04/25/18 at 11:13 AM, MT#1 verified that there were unsecured cylinders in two cylinder rooms on the 1st Floor.