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Based on observation and staff interview, the facility did not ensure that a proper two hour separation was maintained between the existing building and 2008 edition in accordance with NFPA 101 (2012 edition), 19.1.3.5 and 8.2.1.3. This deficient practice could affect an undetermined number of patients, staff and visitors.
Findings include:
On 12/13/16 at 5:22 pm, observation revealed that the double doors in the 2-hour rated separation wall between the existing building and the 2008 edition, near the Emergency Department / Hospital Corridor intersection, did not positively self-latch when closed. The latching mechanism was maintained in an open position by manner of a keyed switch on the wall. The condition was confirmed at the time of discovery by concurrent observation and interview with Staff Q.

Based on observation and staff interview, the facility did not ensure that the fire rated roof structure assembly, classified as Type II (1,1,1) Protected Noncombustible, is maintained in accordance with NFPA 101 (2012 edition), 19.1.6.1. This deficient practice could affect one patient and an undetermined number of staff.

Findings include:

1. On 12/13/16 at 5:29 pm, observation revealed within the Electrical Room, located in the Emergency Department, that fire resistance rated fire proofing had been removed from an approximately 4'-0" long portion of the edge of a structural steel beam. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff Q.

2. On 12/13/16 at 5:48 pm, observation revealed within the Ambulance Garage, located in the Emergency Department, that fire resistance rated fire proofing had been removed from portions of the edges of several structural steel beams. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff Q.

Based on observation and staff interview, the facility did not ensure that the kitchen range-hood fire suppression system and grease filters were installed and maintained as required per NFPA 101 Life Safety Code (2012 edition) section 19.3.2.5 and NFPA 96 (2011 edition) section 6.1.3. This deficient practice could affect one inpatient and an undetermined number of staff and visitors.

Findings include:

On 12/14/16 at 9:42 am, observation revealed that the grease filters, of the main kitchen exhaust hood, were of the mesh type and not constructed as a baffle type as required when the fire suppression system was previously upgraded to the UL300 standard.

The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff P.

Based on observation and staff interview, the facility did not ensure that the smoke detectors for the fire alarm system are installed per NFPA 101 (2012 edition), 9.6 and NFPA 72 (2010 edition), 17.7.4.1. This deficient practice could affect one inpatient and an undetermined number of staff and visitors.
Findings include:
1. On 12/13/16 between 3:35 pm and 4:16 pm, observations revealed within the Existing Acute Care Area Patients Rooms 1510, 1519, 1520, 1522, 1523, and 1532 that the smoke detectors were installed within 36 " of an air supply diffuser. These conditions were confirmed at the time of discovery by concurrent observation and interview with Staff Q.
2. On 12/13/16 at 5:05 pm, observation revealed within the Family Waiting Room near the Imaging Area that a smoke detector was installed within 36 " of an air supply diffuser. The condition was confirmed at the time of discovery by concurrent observation and interview with Staff Q.
3. On 12/13/16 between 5:38 pm and 5:56 pm, observations revealed within the Emergency Department Area Soiled Utility Room, Equipment Storage Room, Emergency Department Corridor, Nurses Station, and Clean Utility Room that the smoke detectors were installed within 36 " of an air supply diffuser. These conditions were confirmed at the time of discovery by concurrent observation and interview with Staff Q.
4. On 12/14/16 at 8:38 am, observation revealed within the Support Staff Room near the Hospital and Clinic intersection that a smoke detector was installed within 36 " of an air supply diffuser. The condition was confirmed at the time of discovery by concurrent observation and interview with Staff P.
5. On 12/14/16 between 8:57 am and 9:00 am, observations revealed within the Physical Therapy / Rehabilitation Area Staff Office, Treatment Rooms 1 through 6 and Equipment Storage Rooms that the smoke detectors were installed within 36 " of an air supply diffuser. These conditions were confirmed at the time of discovery by concurrent observation and interview with Staff P.
6. On 12/14/16 at 9:08 am, observation revealed within the Hospital Lab that a smoke detector was installed within 36 " of an air supply diffuser. The condition was confirmed at the time of discovery by concurrent observation and interview with Staff P.

Based on observation and staff interview, the facility did not ensure sprinkler protection is installed in all areas as required per NFPA 101 Life Safety Code (2012 edition) 19.3.5 & 9.7.1, and NFPA 13 (2010 edition). This deficient practice could affect one inpatient and an undetermined number of staff and visitors.
Findings include:

On 12/14/16 at 9:30 am, observation revealed that the Electrical Closet, located across the corridor from the Main Kitchen and adjacent to the Social Services Office, was not sprinkler protected. Further observation revealed that the room did not meet the requirements to be non-sprinkler protected as allowed per NFPA 13 (2010 edition) section 8.15.10.3.

The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff P.

Based on observation and staff interview, the facility did not ensure that the automatic sprinkler fire suppression system is properly maintained in a reliable operating condition as required per NFPA 101 Life Safety Code (2012 edition) 19.3.5 & 9.7.1, and NFPA 13 (2010 edition), 8.6.6.1. This deficient practice could affect one inpatient and an undetermined number of staff.

Findings include:

On 12/14/16 at 9:46 am, observation revealed that in the main kitchen Walk-in Cooler, food items were located on top of the storage shelf closer than the required minimum 18" (457 mm) clearance.

The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff P.

Based on observation and staff interview, the facility did not ensure that exit access corridors remain separated from use areas by walls constructed with at least ½ hour fire resistance rating or resist the passage of smoke as required per NFPA 101 Life Safety Code (2012 edition) 19.3.6.2. This deficient practice could affect one patient and an undetermined number of staff and visitors.

Findings include:

1. On 12/13/16 at 4:33 pm, observation within the Telephone Room in the Imaging Area revealed that a 4"x 3" cable tray rack, with multiple communication conductors, penetrated the corridor wall which was not properly caulked to resist the passage of smoke.

2. On 12/13/16 at 4:36 pm, observation within the Telephone Room in the Imaging Area revealed that a three 1 1/2" metal conduit sleeves, with multiple communication conductors, penetrated the corridor wall which were not properly caulked to resist the passage of smoke.

The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff Q.

Based on observation and staff interview, the facility did not ensure that the corridor doors were maintained in accordance with NFPA 101 (2012 edition), 19.3.6.3. This deficient practice could affect an undetermined number of patients, staff and visitors.
Findings include:
1. On 12/13/16 at 4:15 pm, observation revealed within the Existing Acute Care Area that the corridor door to the Obstetrics Instrument Cleaning Room did not positively self-latch. The condition was confirmed at the time of discovery by concurrent observation and interview with Staff Q.
2. On 12/14/16 at 8:36 am, observation revealed that the cross-corridor doors near the loading dock did not positively self-latch. The condition was confirmed at the time of discovery by concurrent observation and interview with Staff P.
3. On 12/14/16 at 8:54 am, observation revealed that the cross-corridor doors near the Rehab Staff Office did not positively self-latch. The condition was confirmed at the time of discovery by concurrent observation and interview with Staff P.
4. On 12/14/16 at 9:30 am, observation revealed that the passive door leaf to the electrical closet, located across the corridor from the Main Kitchen and adjacent to the Social Services Office, had a manual flush bolt mechanism, prohibiting the door from positively self-latching. The condition was confirmed at the time of discovery by concurrent observation and interview with Staff P.

Based on observation and staff interview, the facility did not ensure that all heating, ventilation, and air conditioning complies with NFPA 101 (2012 edition), 19.5.2.1 and 9.2. This deficient practice could affect an undermined number of patients, staff and visitors.
Findings include:
On 12/13/16 at 5:01 pm, observation revealed within the Imaging Area Radiology Office that the supply diffuser was plugged shut with a towel limiting supply air from entering the room. The condition was confirmed at the time of discovery by concurrent observation and interview with Staff Q.

Based on observation and staff interview, the facility did not ensure that all master area, and local alarm systems used for medical gas and vacuum systems comply with appropriate Category warning system requirements per NFPA 99 (2012 edition), 5.1.9. This deficient practice could affect one inpatient and an undermined number of staff and visitors.
Findings include:
On 12/13/16 at 4:06 pm, observation revealed within the Existing Acute Care Area Obstetrics Hallway that the visual indicators for condition monitoring of the local alarm system for medical gas and vacuum were not operational. The condition was confirmed at the time of discovery by concurrent observation and interview with Staff Q.

Based on observation and staff interview, the facility did not ensure that battery-powered lighting units were provided and maintained in accordance with NFPA 99 (2012 edition), 6.3.2.2.11. This deficient practice could affect a potential patient and an undermined number of operating room staff.
Findings include:
1. On 12/13/16 at 3:01 pm, observation revealed within the Existing Surgery Area Procedure Room that one or more battery-powered lighting units were not provided and maintained in a location where deep sedation and general anesthesia is administered. The condition was confirmed at the time of discovery by concurrent observation and interview with Staff Q.
2. On 12/13/16 at 3:15 pm, observation revealed within the Existing Surgery Area Operating Room that one or more battery-powered lighting units were not provided and maintained in a location where deep sedation and general anesthesia is administered. The condition was confirmed at the time of discovery by concurrent observation and interview with Staff Q.

Based on observation and staff interview, the facility did not ensure that extension cords are not used as a substitute for fixed wiring of a structure and that extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed, per NFPA 99 (2012 edition), 10.2.4 and NFPA 70 (2011 edition), 400.8. This deficient practice could affect one inpatient and an undermined number of staff and visitors.
Findings include:
1. On 12/13/16 at 3:03 pm, observation revealed within the Existing Surgery Area Patient Recovery Room that an extension cord was used to power a television. The condition was confirmed at the time of discovery by concurrent observation and interview with Staff Q.
2. On 12/13/16 at 4:51 pm, observation revealed within the Imaging Area Storage Files / Reading Room that an extension cord and power strip were used to power a toaster, microwave and coffee maker . The condition was confirmed at the time of discovery by concurrent observation and interview with Staff Q.