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Based on observation and staff interview, the facility failed to maintain exit stairwell doors in accordance with the 2012 NFPA 101, Life Safety Code. The findings were:

Observation on 5/4/2017 at 1:10 PM of the exterior stairwell located adjacent to room 107 revealed that the exit stairwell door failed to latch when tested. The door was equipped with panic hardware and had exit signage. Failure to maintain exit stairwells as required could result in injury or death in a fire. Interview with the Facility Administrator and Facility Maintenance Manager at the time of observation indicated they were aware of the requirement and thought the door latched.

REF: 2012 NFPA 101 Sections 19.2.2.3; 7.2.2; 7.1.3.2.1(8); 7.2.1.8.2

Based on observation and staff interview, the facility failed to provide ramps in accordance with the 2012 NFPA 101, Life Safety Code. The findings were:

Observation on 5/4/2017 at 12:20 PM located at the emergency room walk-in entrance revealed a rise greater than 8 inches with no handrails on either side of the walkway. Per the definition of the Life Safety Code a ramp is classified as a walkway with a slope greater than 1:20. During observation a length measurement of approximately 73 inches and a height of approximately 8.75 inches was measured. The height exceeded the allowed 3.65 inches and therefore was classified a ramp. Further observation revealed the door leading to the ramp was labeled an exit with signage. Failure to install handrails could result in injury from a fall. Interview with the Facility Administrator and Facility Maintenance Manager at the time of observation indicated the area was under construction and the ramp would be removed, but temporary handrails could be installed.

REF: 2012 NFPA 101 Sections 19.2.2.6; 3.3.219; 7.2.5.2(2)(c)

Based on observation and staff interview, the facility failed to maintain portable fire extinguishers in accordance with the 2012 NFPA 101, Life Safety Code and 2010 NFPA 10, Standard for Portable Fire Extinguishers. The findings were:

Observation on 5/4/2017 at 12:40 PM located in the laboratory revealed a fire extinguisher not secured to the wall, but was sitting on the floor. Failure to maintain portable fire extinguishers as required could result in injury or death during a fire. Interview with the Facility Maintenance Manager at the time of observation indicated awareness of the requirement, but the contractor associated with the current construction project had not yet mounted the extinguisher.

REF: 2012 NFPA 101 Sections 19.3.5.12; 9.7.4.1
2010 NFPA 10 Section 6.1.3.8.3

Based on observation and staff interview, the facility failed to maintain trash containers in accordance with the 2012 NFPA 101, Life Safety Code. The findings were:

Observation on 5/4/2017 at 1:20 PM located in the business area revealed two 64 gallon trash collection receptacles in a non-rated room. Further observation revealed that the average density of the containers exceeded the .5 gallon per square foot requirement. Failure to maintain trash collection as required could result in death or injury during a fire. Interview with the Facility Maintenance Manager at the time of observation indicated he was unaware of the requirement.

REF: 2012 NFPA 101 Section 19.7.5.7.1

Based on observation and staff interview, the facility failed to maintain gas equipment storage in accordance with the 2012 NFPA 99, Health Care Facilities Code. The findings were:

1. Observation on 5/4/2017 at 12:54 PM located adjacent to the nurse's station revealed 15 "E" tanks of oxygen with a total of 375 cubic feet stored in a temporary room. It could not be established that the door was capable of being secured. Failure to maintain stored oxygen as required could result in injury or death during a fire. Interview with the Facility Administrator and Facility Maintenance Manager at the time of observation indicated they were unaware of the requirement.

REF: 2012 NFPA 99 Section 5.1.3.3.2(4)

2. Observation on 5/4/2017 at 2:10 PM located in the oxygen storage room revealed a gas storage quantity in excess of 3000 cubic feet with a light switch mounted and not protected at 50 inches from the floor. Failure to maintain gas equipment storage as required could result in injury or death during a fire. Interview with the Facility Administrator and Facility Maintenance Manager at the time of observation indicated they were unaware of the requirement.

REF: 2012 NFPA 99 Section 5.1.3.3.2(10)