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Based on observation and interview with staff, the facility failed to provide rated construction meeting the requirements of 19.1.6 for a four story facility. Findings,

Food Storage in Kitchen: sprayed-on fire proofing has been removed from the bottom flange of steel beam.

Based on observation and interview with staff, the facility failed to provide smoke barriers that are at least a one half hour fire resistance rating. Findings,

The smoke compartment wall (smoke barrier) does not meet the separation requirement at the following locations:

First Floor
1) Between Gift Shop/Snack and Dining Room: the wall is incomplete.
2) Between Kitchen and adjacent east-west Corridor: there are unrated penetrations of sprinkler piping, wiring, and ductwork; an open gap exists at top of wall.
3) Above the double corridor doors leading from Emergency Department: unrated penetrations.
4) Doctor Sleep Room: an open gap exists at top of wall. Unrated penetrations exist in the other side of this wall.

Second Floor
1) Above smoke barrier double corridor doors: an unrated sleeve through the wall.

Third Floor
1) Above smoke barrier double corridor doors: an unrated sleeve through the wall.
2) Toilet Room: hole in wall above junction box.
3) East half of smoke barrier: open joints and unrated penetrations exists in the wall.

Fourth Floor
1) Waiting Room: fire rated sealant is not properly filling the open gap at top of wall, both sides, hole in wall.
2) Storage Room adjacent to Mechanical Room: The south wall of Storage Room is not sealed properly to the bottom of the double tee roof slab.

Based on observation and interview with staff, the facility failed to provide hazardous areas protected in accordance with 18.3.2.1/19.3.2.1. Note: areas renovated or constructed after 9/11/03 are subject to 18.3.2.1. Findings,

General
1) Gray unidentified caulk at top of several rated walls, need documentation of UL Listing.

First Floor
1) Soiled Utility in Emergency Department: open gap at top of wall all sides and wire penetrations.
2) Food Storage in Kitchen: unrated conduit penetration seal and hole in gypsum board patch.

Second Floor
1) Soiled Utility in OR Suite: unrated sprinkler piping penetration seal, hole in wall where duct support strapping penetrates the gypsum board.
2) Sterile Instruments in OR Suite: unrated penetration seal in the corridor wall.

Third Floor
1) Locker/Storage adjacent to NE Stair: openings and unrated penetration seal in corridor wall.
2) Soiled rooms in north corridor: open penetrations in the corridor wall.
3) Storage and Soiled Utility adjacent to SE Stair: open gap at top of wall.

Fourth Floor
1) Mechanical Room adjacent to C-Section OR: large hole in the wall between rooms.
2) Storage adjacent to SE Stair: gaps in wall around Storage.

Based on observation and interview with staff, the facility failed to provide exit and directional signs that are displayed in accordance with 19.2.10.1. Findings,

First Floor
1) Emergency Room Waiting: there is no exit light at the "back" exit from the waiting room.
2) Business Work Area: there are no exits visible from this area.

Based on observation and interview with staff, the facility failed to tested the fire alarm system in accordance with NFPA 70 National Electrical Code and NFPA 72, the facility also failed to have an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

The facility failed to test the Smoke Evacuation System and Magnetic Locks that are connected to the fire alarm system. These items were not listed on the annual fire alarm test report provided by the Fire Control Specialist.

The facility failed to provide the Fire Control Specialist with a complete list of equipment connected to the fire alarm system for annual testing.

Based on observation and interview with staff, the facility failed to provide HVAC complying with 19.5.2.1 and 9.2 Findings,

1) Janitor Closet in Kitchen, and Housekeeping Closet next to Room 414: exhaust fans are not operating.

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system complying with NFPA 99. Findings,

1) An Emergency Oxygen Supply Connection for connecting a temporary auxiliary source of supply for emergency or maintenance situations was not found. Refer to NFPA 99 - 1999 Edition, Section 4-3.1.1.8(h).

2) The Anesthesia Workroom in the OR Suite has oxygen and medical air outlets within the room. Verify the location of the shutoff valves serving this room. These valves shall be so arranged that shutting off the supply of gas to the Anesthesia Workroom will not affect any anesthetizing locations, i.e., Operating Rooms, PACU, etc.

Based on observation and interview with staff, the facility failed to provide a Type I Essential Electrical System in accordance with NFPA 99 - 1999 Edition. Findings,

Section 3-4.1.1.15 states that "a remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station." The facility does not have a remote annunciator.

1). Based on observation and interview with staff, the facility failed to provide maintenance and testing of electrical equipment used within healthcare facilities as required by NFPA 99, Chapter 7. Findings,

Model 840 Puritan Bennett Ventilator was located in the Emergency Department, the machine's last Preventive Maintenance Test was October of 2009. A staff member was asked when the machine was last used and the staff member replied, about two weeks ago. Testing intervals for critical care equipment areas requires testing every 6 months, 7-6.2.1.2 (b). Facility failed to test and replace battery every two years per the manufacturer's recommendations. Facility failed to follow scheduled preventive maintenance program and remove equipment that is out of date for its latest scheduled test per 7-6.2.2.4.

Facility failed to keep Life Support Equipment (Ventilators) plugged in to keep the internal battery charged to capacity. Manuals for appliances were not available for staff [see 9-2.1.8.1 (m)] to set limits for electrical variations. A scheduled preventive maintenance program shall be followed. 7-6.2.2.2

2). Based on observation and interview with staff, the facility failed to provide access to not less than two approved exits in accordance with Section 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies per 19.2.5.9. Findings,

The Administration Corridor in the northeast corner of the building (First Floor) has a pair of single egress control doors at the south end of the corridor. These doors create a dead-end corridor in the Administration Wing.

Based on observation and interview with staff, the facility failed to provide a Type I Essential Electrical System in accordance with NFPA 99 - 1999 Edition. Findings,

There was no way to determine whether the required emergency Power Distribution system was separated into Life Safety, Critical Care, and Equipment Branches as required by NFPA 99, 1999 Edition, Chapter 3, Type I System.

Based on observation and interview with staff, the facility failed to provide electrical wiring in accordance with NFPA 70, National Electrical Code. Findings,

Various items were found stored in front of electrical panels in the electric room. Section 110.26 requires sufficient access and working space provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Table 110.26(A)(1) shows required clear distance in front of the electrical panels.

Based on observation and interview with staff, the facility failed to provide rated construction meeting the requirements of 19.1.6 for a four story facility. Findings,

Food Storage in Kitchen: sprayed-on fire proofing has been removed from the bottom flange of steel beam.

Based on observation and interview with staff, the facility failed to provide smoke barriers that are at least a one half hour fire resistance rating. Findings,

The smoke compartment wall (smoke barrier) does not meet the separation requirement at the following locations:

First Floor
1) Between Gift Shop/Snack and Dining Room: the wall is incomplete.
2) Between Kitchen and adjacent east-west Corridor: there are unrated penetrations of sprinkler piping, wiring, and ductwork; an open gap exists at top of wall.
3) Above the double corridor doors leading from Emergency Department: unrated penetrations.
4) Doctor Sleep Room: an open gap exists at top of wall. Unrated penetrations exist in the other side of this wall.

Second Floor
1) Above smoke barrier double corridor doors: an unrated sleeve through the wall.

Third Floor
1) Above smoke barrier double corridor doors: an unrated sleeve through the wall.
2) Toilet Room: hole in wall above junction box.
3) East half of smoke barrier: open joints and unrated penetrations exists in the wall.

Fourth Floor
1) Waiting Room: fire rated sealant is not properly filling the open gap at top of wall, both sides, hole in wall.
2) Storage Room adjacent to Mechanical Room: The south wall of Storage Room is not sealed properly to the bottom of the double tee roof slab.

Based on observation and interview with staff, the facility failed to provide hazardous areas protected in accordance with 18.3.2.1/19.3.2.1. Note: areas renovated or constructed after 9/11/03 are subject to 18.3.2.1. Findings,

General
1) Gray unidentified caulk at top of several rated walls, need documentation of UL Listing.

First Floor
1) Soiled Utility in Emergency Department: open gap at top of wall all sides and wire penetrations.
2) Food Storage in Kitchen: unrated conduit penetration seal and hole in gypsum board patch.

Second Floor
1) Soiled Utility in OR Suite: unrated sprinkler piping penetration seal, hole in wall where duct support strapping penetrates the gypsum board.
2) Sterile Instruments in OR Suite: unrated penetration seal in the corridor wall.

Third Floor
1) Locker/Storage adjacent to NE Stair: openings and unrated penetration seal in corridor wall.
2) Soiled rooms in north corridor: open penetrations in the corridor wall.
3) Storage and Soiled Utility adjacent to SE Stair: open gap at top of wall.

Fourth Floor
1) Mechanical Room adjacent to C-Section OR: large hole in the wall between rooms.
2) Storage adjacent to SE Stair: gaps in wall around Storage.

Based on observation and interview with staff, the facility failed to provide exit and directional signs that are displayed in accordance with 19.2.10.1. Findings,

First Floor
1) Emergency Room Waiting: there is no exit light at the "back" exit from the waiting room.
2) Business Work Area: there are no exits visible from this area.

Based on observation and interview with staff, the facility failed to tested the fire alarm system in accordance with NFPA 70 National Electrical Code and NFPA 72, the facility also failed to have an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

The facility failed to test the Smoke Evacuation System and Magnetic Locks that are connected to the fire alarm system. These items were not listed on the annual fire alarm test report provided by the Fire Control Specialist.

The facility failed to provide the Fire Control Specialist with a complete list of equipment connected to the fire alarm system for annual testing.

Based on observation and interview with staff, the facility failed to provide HVAC complying with 19.5.2.1 and 9.2 Findings,

1) Janitor Closet in Kitchen, and Housekeeping Closet next to Room 414: exhaust fans are not operating.

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system complying with NFPA 99. Findings,

1) An Emergency Oxygen Supply Connection for connecting a temporary auxiliary source of supply for emergency or maintenance situations was not found. Refer to NFPA 99 - 1999 Edition, Section 4-3.1.1.8(h).

2) The Anesthesia Workroom in the OR Suite has oxygen and medical air outlets within the room. Verify the location of the shutoff valves serving this room. These valves shall be so arranged that shutting off the supply of gas to the Anesthesia Workroom will not affect any anesthetizing locations, i.e., Operating Rooms, PACU, etc.

Based on observation and interview with staff, the facility failed to provide a Type I Essential Electrical System in accordance with NFPA 99 - 1999 Edition. Findings,

Section 3-4.1.1.15 states that "a remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station." The facility does not have a remote annunciator.

1). Based on observation and interview with staff, the facility failed to provide maintenance and testing of electrical equipment used within healthcare facilities as required by NFPA 99, Chapter 7. Findings,

Model 840 Puritan Bennett Ventilator was located in the Emergency Department, the machine's last Preventive Maintenance Test was October of 2009. A staff member was asked when the machine was last used and the staff member replied, about two weeks ago. Testing intervals for critical care equipment areas requires testing every 6 months, 7-6.2.1.2 (b). Facility failed to test and replace battery every two years per the manufacturer's recommendations. Facility failed to follow scheduled preventive maintenance program and remove equipment that is out of date for its latest scheduled test per 7-6.2.2.4.

Facility failed to keep Life Support Equipment (Ventilators) plugged in to keep the internal battery charged to capacity. Manuals for appliances were not available for staff [see 9-2.1.8.1 (m)] to set limits for electrical variations. A scheduled preventive maintenance program shall be followed. 7-6.2.2.2

2). Based on observation and interview with staff, the facility failed to provide access to not less than two approved exits in accordance with Section 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies per 19.2.5.9. Findings,

The Administration Corridor in the northeast corner of the building (First Floor) has a pair of single egress control doors at the south end of the corridor. These doors create a dead-end corridor in the Administration Wing.

Based on observation and interview with staff, the facility failed to provide a Type I Essential Electrical System in accordance with NFPA 99 - 1999 Edition. Findings,

There was no way to determine whether the required emergency Power Distribution system was separated into Life Safety, Critical Care, and Equipment Branches as required by NFPA 99, 1999 Edition, Chapter 3, Type I System.

Based on observation and interview with staff, the facility failed to provide electrical wiring in accordance with NFPA 70, National Electrical Code. Findings,

Various items were found stored in front of electrical panels in the electric room. Section 110.26 requires sufficient access and working space provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Table 110.26(A)(1) shows required clear distance in front of the electrical panels.