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Based on observations during the survey walk of the facility on the morning of 11/21/2017, with the Plant operation manager, the facility failed to maintain the integrity of the egress corridors. Door was not kept closed at X-Ray file room.
NFPA 101; 2012; 19.3.6.1? Corridor Separation. Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (see also 19.2.5.4),

Based on observations during the survey walk of the facility on the morning of 11/21/2017, with the Plant operation manager, the facility failed to provide acceptable location for alcohol based hand rub dispensers at room 223A.
NFPA 101; 2012: 19.3.2.6 .... (8)?Dispensers shall not be installed in the following locations:(a)?Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source(b)?To the side of an ignition source within a 1 in. (25 mm) horizontal distance from the ignition source(c)?Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source

Based on observations during the survey walk of the facility on the morning of 11/21/2017, with the Plant operation manager, the facility failed to provide acceptable clearance between the sprinkler deflector and the top of storage at dietary locker storage room.
NFPA 13; 2010: 8.5.6.1* Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4, or 8.5.6.5 are met, the clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

Based on observations during the survey walk of the facility on the morning of 11/21/2017, with the Plant operation manager; the facility failed to assure the doors in suites had the required smoke control amenities. At emergency department suite, 2 pairs of suite doors did not have astragals, which would provide a smoke tight seal at the meeting edges of the doors when closed. Also add astragal to doors near maintenance dock area.




Based on observations during the survey walk of the facility on the morning of 11/21/2017, with the Plant operation manager, the facility failed to maintain the integrity of the egress corridors. The dietary ware wash was opened to the corridor. There was a rolling grill but it was manual and not tied to the fire alarm. Smoke from the kitchen can move into the egress corridor.
NFPA 101; 2012; 19.3.6.1? Corridor Separation. Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (see also 19.2.5.4),




Based on observations during the survey walk of the facility on the morning of 11/21/2017, with the Plant operation manager, the facility failed to maintain the integrity of the egress corridors. When a machine was removed from the abandoned dark room, a large cased opening was left opened between room, used as storage, and corridor
NFPA 101; 2012; 19.3.6.2.3* Corridor walls shall form a barrier to limit the transfer of smoke.

Based on observations during the survey walk of the facility on the morning of 11/21/2017, with the Plant operation manager, the facility failed to provide labeling on critical care receptacles at emergency department.
HLR 2007: §133.162 (d)(5)(H)(vi) .... All critical care area receptacles shall be identified. The face plate for the receptacle(s) shall have a nonremovable label or be engraved indicating the panel and circuit number.