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Based upon observation and interview the facility failed to ensure the exit and directional signs are displayed in accordance with 7.10, continuously illuminated, and served by the emergency lighting system as required by 19.2.10.1. This deficient practice could affect 182 occupants in the event of a fire.

Findings Include:

On 11/27/18, between the hours of 9:30 a.m. and 4:00 p.m., the following was observed:

* Observed the exit sign above doors to Emergency Department is not directional.

These findings were observed and confirmed in an interview with the maintenance director at the time of discovery.

Based upon observation, records review and interview, the facility failed to ensure the stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings are enclosed with construction having a fire-resistance rating of at least 1 hour as required by 19.3.1.1 through 19.3.1.6. This deficient practice could affect 182 occupants in the event of a fire.

Findings Include:

On 11/27/18, between the hours of 9:30 a.m. and 4:00 p.m., the following was observed:

* Observed that the Central Sterile Processing (CSP) stairwell door did not close to a positive latch.

* Observed door from Operating Room (OR) to lower level stairs did not close to a positive latch.

These findings were observed and confirmed in an interview with the maintenance director at the time of discovery.

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 affect 182 occupants in the event of a fire.

Findings Include:

On 11/27/18, between the hours of 9:30 a.m. and 4:00 p.m., the following was observed:

* Observed door to soiled utility 5-R20 did not latch.

* Observed door to storage room 5T-21 did not latch.

* Observed door handle to room 4L-20 is broken.

* Observed door to equipment storage room 4M-16 is not rated.

* Observed door to storage room 4V-17 not latching.

* Observed door to room 5R-20 did not latch.

* Observed conference room 5U-17 has been converted into storage space, and is not compliant.

* Observed wall in storage room 3L-23 is not compliance.

* Observed 3T Observation Bays 16, 28 & 29 are being used for storage.

These findings were observed and confirmed in an interview with the maintenance director at the time of discovery.

Based upon observation and interview, the facility failed to ensure the 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 affect 182 occupants in the event of a fire.

Findings Include:
On 11/27/18, between the hours of 9:30 a.m. and 4:00 p.m., the following was observed:

* Observed the wheeled cooking equipment, under the exhaust hood, in the main kitchen, does not have the required wheel guides.

These findings were observed and confirmed in an interview with the maintenance director at the time of discovery.

Based upon observation and interview, the facility failed to ensure that a fire alarm system is installed in accordance with NFPA 70 and NFPA 72 as required by 19.3.4.1, 9.6, and 9.6.1.8. This deficient practice could affect 182 occupants in the event of a fire.

Findings Include:

On 11/27/18, between the hours of 9:30 a.m. and 4:00 p.m., the following areas were found not to have a required fire alarm notification devices:

* Room 5R-18
* 4N Break Room
* 4R-16 Family Room
* Room 3S-18
* Room 4Q-20

These findings were observed and confirmed in an interview with the maintenance director at the time of discovery.

Based upon observation and interview the facility failed to ensure the smoke detection systems are provided in spaces open to the corridor in accordance with 19.3.6.1 as required by 19.3.4.5.2. This deficient practice could affect 182 occupants in the event of a fire.

Findings Include:

On 11/27/18, between the hours of 9:30 a.m. and 4:00 p.m., the following was observed:

* Observed the fire alarm power supply in the 5N electrical closet, next to stairwell 16, does not have a smoke detector.

* Observed the fire alarm power supply in the 5U-13 electrical closet, does not have a smoke detector.

* Observed smoke detectors in various locations throughout the building are dust covered, including the trash room.

These findings were observed and confirmed in an interview with the maintenance director at the time of discovery.

Based upon observation and interview, the facility failed to ensure the 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 affect 182 occupants in the event of a fire.

Findings Include:

On 11/27/18, between the hours of 9:30 a.m. and 4:00 p.m., the following was observed:

* Observed two sprinkler heads in stairwell 21, 5th floor, are painted.

* Observed the sprinkler head in janitor's closet 5S-12 is painted.

* Observed painted sprinkler heads in cafeteria exit corridor, by tray return, are painted.

* Observed sprinkler head in 4S-14 teaching office is dust loaded.

* Observed the privacy curtain in Hydrotherapy room 4T-10, does not meet required mesh design.

* Observed inadequate sprinkler coverage in IL-23 mechanical room, under ductwork.

These findings were observed and confirmed in an interview with the maintenance director at the time of discovery.

Based upon observation and interview, the facility failed to ensure the corridors are separated from use areas by walls of at least 1/2-hour fire resistance rating or meet the requirements of smoke partitions in smoke compartments protected throughout by a supervised, automatic sprinkler system as required by 19.3.6.2 and 19.3.6.2.7. This deficient practice could affect 182 occupants in the event of a fire

Findings Include:

On 11/27/18, between the hours of 9:30 a.m. and 4:00 p.m., the following was observed:

* Observed unsealed wall penetration in room 5U-17.

* Observed unsealed conduit above door in 5N electrical closet.

* Observed multiple unsealed penetrations in the door to kitchen dry storage room 2W-10.1.

These findings were observed and confirmed in an interview with the maintenance director at the time of discovery.

Based upon observation and interview, the facility failed to ensure the 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 affect 182 occupants in the event of a fire.

Findings Include:

On 11/27/18, between the hours of 9:30 a.m. and 4:00 p.m., the following was observed:

* Observed the doors from 5S to 5T are damaged and are not reasonably smoke tight.

* Observed doors 5T to 5S, adjacent to stairwell 13 are warped and are not reasonably smoke tight,

* Door to IP-5 mail room has a gap between the edges exceeding 1/8".

* Observed the closing device on doors separating the 2nd floor corridor between DRH and Hyperbaric Area does not function.

* Observed door near room 2X-6 does not latch.

These findings were observed and confirmed in an interview with the maintenance director at the time of discovery.

Based upon interview, the facility failed to employees are kept informed of the facility's plan for the protection of all patients and for their evacuation in the event of an emergency, as required by 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2., and 19.7.2.3. This deficient practice could affect 248 occupants in the event of a fire.

Findings Include:

On 11/27/18, between the hours of 9:30 a.m. and 4:00 p.m., the following was observed:

Upon interviewing the kitchen staff, it was found that not all were clear on their role and responsibility in the event of a fire, including:

* How and when to activate the building's fire alarm system.
* How and when to activate the kitchen hood suppression system.
* How to handle fires not under the exhaust hood.
* Types of extinguisher's and use for each (K-Class as a back-up under hood, ABC for all other areas of kitchen).

These findings were confirmed in an interview with the maintenance director at the time of discovery.

Based upon observation, records review and interview, the facility failed to ensure the power strips are listed for the area in which they are used as required by 10.2.3.6 of NFPA 99 and 400-8 of NFPA 70, and TIA 12-5 and the extension cords are placed in use only temporarily as required by 10.2.4 of NFPA 99 and 590.3(D) of NFPA 70. This deficient practice could affect 182 occupants in the event of a fire.

Findings Include:

On 11/27/18, between the hours of 9:30 a.m. and 4:00 p.m., the following was observed:

* Observed mini refrigerator plugged into an unapproved power strip.

These findings were observed and confirmed in an interview with the maintenance director at the time of discovery.