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Based upon observation, the building construction type is not being maintained in compliance with Code requirements. Failure to maintain the minimum required protection of building structural elements can result in injury to occupants if premature failure of the building structure were to cause collapse when exposure of unprotected structural elements to fire conditions occurs.

Findings include:

On March 4, 2019 at 1:15pm while in the company of MP1 & MP2 it was observed that the south wing Soiled Utility room (containing IT storage) had a 12"x12" portion of the gypsum ceiling, which forms the bottom membrane of the required 1-hour rated roof/ceiling assembly to comply with 19.1.6.1, was removed exposing the unprotected steel structure.

Based on observation and staff interview, means of egress doors are locked with systems that are not in full compliance with the Code requirements. Failure to provide security locking devices in full compliance can prevent occupant egress during a fire emergency.

Findings include:

A. On March 4, 2019 at 1:55pm while in the company of MP1 & MP2, it was observed that the exit doors from the ER suite have magnetic locking devices which do not comply with 19.2.2.2.4 and 7.2.1.6.2 Access Controlled Egress systems.

Locations observed:

1. The exterior exit door at the ambulance delivery location is a door equipped with a panic bar exit device, a power door operator with wall switch at the interior and a keypad at the exterior controlling the magnetic lock and operator.

a. The magnetic lock is disengaged upon activation of the power door operator but is not provided with sensor required by 7.2.1.6.2(1)

b. It was not confirmed that the magnetic lock released upon loss of power to comply with 7.2.1.6.2(2).

c. It was not confirmed that the magnetic lock released upon activation of the fire alarm system by sprinkler system activation or the fire detection system to comply with 7.2.1.6.2(6).

2. The interior corridor door allowing egress from the ER suite is a pair of doors with panic devices on the corridor side and magnetic locking devices.

a. The use of panic hardware on the corridor side which does not release the magnetic locking device does not comply with 7.2.1.7.3. A keypad on the corridor side permits authorized entry.

b. The magnetic lock is disengaged upon activation of the manual release button on the suite side but is not provided with the sensor required by 7.2.1.6.2(1).

c. The magnetic locks are disengaged upon activation of the wall button as required by 7.2.1.6.2(3) but there is no delay between pushing & releasing the button and relocking the door. The button and the opening of the door must occur simultaneously which requires both hands simultaneously. This arrangement does not comply with 7.2.1.5.6(3).

d. It was not confirmed that the magnetic lock released upon loss of power to comply with 7.2.1.6.2(2).

e. It was not confirmed that the magnetic lock released upon activation of the fire alarm system by sprinkler system activation or the fire detection system to comply with 7.2.1.6.2(6)

Based upon observation, EXIT signs are not placed appropriately to identify available exit paths. Failure to correctly identify exit paths can confuse occupants if they identify paths which are not compliant means of egress during a fire emergency.

Findings include:

On March 4, 2019 at 1:55pm while in the company of MP1 & MP2 it was observed that the exit sign above the full glazed door to the ER registration area, as viewed from the east side, identified the ER suite as an available exit path. This arrangement does not comply with 7.5.1.2 which prohibits corridors from exiting through a suite.

Based upon observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material to block exiting.

Findings include:

A. On March 4, 2019 while in the company of MP1 & MP2 it was observed that non-sprinkler protected storage rooms failed to be provided with 1-hour rated separation including 3/4-hour rated self-closing door assemblies to comply with 19.3.2.1 and sprinkler protected storage rooms lacked self-closing doors to comply with 19.3.2.1.3.

Locations observed include:

1. At 1:35pm the EMS Storage room adjacent the ER waiting room lacked complete 1-hour separation above the ceiling and the corridor door was not minimum 3/4-hour rated and self-closing.

2. At 1:45pm the Disaster Equipment/Supply Storage room adjacent the rural clinic nurse station had separation and sprinkler protection, but the door could be held-open to prevent self-closing because it was rubbing on the floor when fully opened.

3. At 1:50pm the IT Equipment/storage room adjacent the EMS office was observed to have unsealed penetrations at the ceiling and corridor wall conduit sleeves.

4. At 2:00pm the ER Clean Supply Storage room (two) doors were not minimum 3/4-hour rated and self-closing.

5. At 2:15pm the East Wing Patient rooms 50, 51.52.& 53 were indicated and observed to be utilized as storage rooms and lacked minimum 3/4-hour rated, self-closing doors.

Based upon record review & staff interview, sprinkler system testing & maintenance does not comply with Code requirements. Failure to maintain the sprinkler system can result in injury to occupants if the system failed to perform as intended during a fire condition.

On March 4, 2019 at 10:30am while in the company of MP1 & MP2 it was observed that documentation of an annual visual inspection (from the floor) of the sprinkler system to comply with NFPA 25-2011, 5.2.1.1 was not completed during the 2018 year. The last available record of visual inspection of sprinkler heads was dated 12/28/17. 2018 inspections listed this activity as "N/A".

Based upon observation, areas open to the exit access corridors are not protected in accordance with Code requirements. Failure to provide the added degree of protection for these areas can compromise the safety of occupants by preventing the corridors' use as a means of egress during a fire/smoke emergency.

Findings include:

A. On March 4, 2019 while in the company of MP1 & MP2, Non-sprinkler protected Waiting/seating areas of less than 600 sf which are open to the corridor are not provided with smoke detection within the seating area to comply with 19.3.6.1(8). (The main reception desk waiting complies.)

1. At 2:35pm the North Wing Patient room corridor alcove containing the table & chairs lacks a detector located within the alcove space.

2. At 2:50pm the South Wing Main Entry hall seating alcove across from the new accounts receivable window lacks smoke detection.

3. At 2:50pm the new accounts receivable sliding window panels do not meet the minimum 1/2-hour rated corridor wall and minimum 20 minute rated window glazing required by 19.3.6.2.2 and 19.3.6.2.7 & 8.3.3. This area is not otherwise maintained as part of a suite because exit signage is directing means of egress through this area.

Based upon observation, corridor doors are being held open by non-approved hold-open devices. Failure to use acceptable means of holding corridor doors open can compromise the safety of occupants by restricting the prompt closure of the doors to provide fire/smoke containment during a fire/smoke emergency condition.

Findings include:

A. On March 4, 2019 while in the company of MP1 & MP2 it was observed that non-approved hold-open devices were provided on doors in non-compliance with 19.3.6.3.10.

Locations observed include:

1. At 1:30pm the Mammography room corridor door had a wood wedge.

2. At 1:40pm the Well Waiting room corridor door had a wood wedge.

3. At 2:45pm the CT room pair of corridor doors had kick-down door stops installed.

Based upon observation, smoke barrier doors are not maintained to allow full closure of the doors at all times. Failure to provide smoke barrier doors that will maintain the effectiveness of the smoke barrier can result in fire/smoke conditions migrating to adjacent smoke compartments and compromise the safety of occupants who seek refuge there.

Findings include:

A. On March 4, 2019 while in the company of MP1 & MP2 it was observed that hardware for cross corridor smoke barrier doors did not function to permit doors to close completely in their frames to comply with 19.3.7.8 and 8.5.4. Single swing cross corridor smoke barrier doors that were equipped with an astragal and coordinator did not function to permit the doors to always come to a closed condition particularly if the non-astragal equipped door was re-opened and the astragal equipped door held the non-astragal equipped door open.

Locations observed include:

1. At 1:20pm the smoke barrier doors near the main south entry reception.

2. At 1:55pm the smoke barrier doors near the ER entry.

3. At 2:30pm the smoke barrier doors at the East wing patient rooms.

Based upon record review and staff interview, fire drills are not conducted at varying times. Failure to conduct fire drills at varying times does not train staff to respond to a fire condition under varying circumstances.

Findings include:

A. On March 4, 2019 at 11:00am while in the company of MP1 & MP2 it was observed that fire drills for the night shift (7pm to 7am) have consistently been conducted within the same 2.5 hour period between 9:09pm & 11:36pm which is approximately during the later beginning and mid-shift period which does not comply with 19.7.1.6 for varied times & conditions. The 1st quarter shift was conducted at the beginning of the 2nd quarter and no drills were conducted at the beginning and later portions of the shift as evidenced by the following drills recorded:

12/28/18 at 9:55pm
9/20/18 at 11:36pm
6/9/18 at 9:09pm
4/9/18 at 10:11pm
12/8/17 at 10:30pm

B. On March 4, 2019 at 11:00am while in the company of MP1 & MP2 it was observed that fire drills for the day shift (7am to 7pm) have consistantly been conducted within the same 4 hour period between 10:00am & 2:00pm which is approximately during the later beginning and mid-shift period which does not comply with 19.7.1.6 for varied times & conditions. No drills were conducted at the beginning and later portions of the shift as evidenced by the following drills recorded:

11/29/18 at 11:51am
9/20/18 at 1:15pm
6/8/18 at 10:00am
3/29/18 at 1:50pm
12/5/17 at 2:00pm

Based upon observation, documentation of fire door inspections was not available for review. Failure to conduct and document annual fire door inspections and maintenance can compromise the safety of any building occupants if the door assemblies are not maintained as intended to restrict the spread of fire & smoke during a fire emergency.

Findings include:

On March 4, 2019 at 10:00am while in the company of MP1 & MP2, documentation of a fire door inspection program to comply with 19.7.6, 8.3.3.1 and 7.2.1.15 was not available.

Based upon review of record documents, the medical gas system is not maintained in accordance with Code requirements. Failure to maintain the medical gas system can result in failure of the system to perform as intended for patient use.

Findings include:

On March 4, 2019 at 11:30am while in the company of MP1 & MP2 during review of the Medical Gas System inspection reports it was observed that the 9/25/17 & 8/30/18 reports indicated the following deficiencies:

"Alarms are not operational/is not connected/does not indicate proper alarms."

"Alarms are not connected."

"Alarm system not connected to emergency power supply source."

No documentation was available to indicate resolution/repair of the noted deficiencies to comply with NFPA 99-2012, 5.1.14.2.2 and 6.4.2.2.3.3.

Based upon observation, ground fault circuit interruption (GFCI) is not provided in accordance with Code requirements. Failure to provide GFCI protection can result in electrical shock hazards to occupants.

Findings include:

A. On March 4, 2019 while in the company of MP1 &MP2, it was observed that receptacles within 6'-0" of sink fixtures were not provided with GFCI protection to comply with NFPA 70-2011, 210.8(B)(6).

Locations observed include:

1. At 1:25pm at the Lab, multiple sink locations.

2. At 1:45pm at the Rural Clinic Nurse station sink.

Based upon observation and staff interview during the survey walk-thru, the Essential Electrical System (EES) is not installed and maintained in accordance with Code requirements. Failure to maintain the emergency generator system in accordance with Code requirements may prevent the system from operating to maintain life support and emergency lighting systems which could affect all occupants during an emergency situation.

Findings include:

On March 4, 2019 at 1:05pm while in the company of MP1 & MP2 the generator set enclosure was observed not to be a conditioned building. The starting battery for the generator was not provided with a means of maintaining battery temperatures (battery warmer) for cold start as determined by generator manufacturer to comply with NFPA 110-2010, 5.3.1.