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Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to 1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection of exiting from interior rooms to the egress corridor was non-compliant the specific items include:

The corridor door to the Pharmacy is equipped with a dead bolt that required more than one motion of the hand to exit the room when the device is locked. Releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified. Doors shall be arraigned to be opened readily from the egress side whenever the building is occupied.

Ref: 2012 NFPA 101 Sections 19.2.1; 7.2.1.5.1; 7.2.1.5.10.3, 7.2.1.10.4, 7.2.1.5.10.6.

This deficiency affected one smoke zone in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

Based on observations, staff interview, and/or documentation on January 24, 2019 at 9:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

The facility inspection and maintenance of the exit discharge was non-compliant the specific items include:

The facility did not provide a solid walking surface other than grass or soil from the required exit from the rear area of the facility leading to the public way. Required exit shall allow a level walking surface terminating directly at a public way.

Ref: 2012 NFPA 101 Sections 39.2.1.1; 7.7.1*

This deficiency affected one of two required exits from the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview, and/or documentation on January 24, 2019 at 9:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

The facility inspection and maintenance of the exit discharge was non-compliant the specific items include:

The means of egress from the back exit discharge to the public way was not maintained in good condition. There was tree limbs and branches that were cut and laying across the sidewalk. The sidewalk was not maintained clear of all obstructions

Ref: 2012 NFPA 101 Sections 39.2.1.1; 7.1.10.1

This deficiency affected one of two required exits from the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to 1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection and maintenance of suite separation was non-compliant the specific items include:

1. The corridor doors to the intensive care suite (3155 sq. ft. in size) has a set of double doors that open onto the corridor and are not equipped with positive latching hardware as required.

2. The corridor doors to the emergency department suite (6799 sq. ft. in size) located next to room 2-3 has a set of double doors that open onto the corridor and are not equipped with positive latching hardware as required.

3. One of two corridor doors to the emergency department suite (6799 sq. ft. in size) located next to break room has one of two doors that open onto the corridor where the positive latching hardware does not operate as required.

Ref: NFPA 101 Sections 19.2.5.7.1.2 (1); 19.3.6.3.5


1. The smoke partition located in the OR in the wall above the ceiling tile in the break room and woman's locker room was not sealed as required.

2. The smoke partition in the Medical Surgical unit above the ceiling at the bathroom wall has three hole that were not sealed as required.

Ref: NFPA 101 Section 19.2.5.7.1.2

3. The smoke partition above the door to the labor and delivery suite was not sealed as required to limit the passage of smoke at that location.

Ref: 2012 NFPA 101 19.2.5.7.1.2

These deficiencies affected four smoke zones in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to 1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection of hazardous areas was non-compliant the specific items include:

The facility has unsealed penetrations in the rated ceiling in the main laundry department above the gas fired dryers where the exhaust duct penetrates the rated ceiling. The laundry department has gas fired dryers installed and is greater than 100 square feet in size.

Ref: 2012 NFPA 101 Sections 19.3.2.1; 8.7.1; 8.3.1.1

This deficiency affected one smoke zone in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview, and/or documentation on January 24, 2019 at 9:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

The facility maintenance and inspection storage area doors was non-compliant the specific items include:

The facility storage room across from the doctor's office was not equipped with a self-closing device. This room has combustible materials storied inside and is greater than 50 square feet. Doors in barriers required to have a fire resistance rating shall have a minimum 3/4 hour protection rating and shall be self-closing or automatic-closing.

Ref: 2012 NFPA 101 Sections 39.3.2.1; 8.7.1.3; 7.2.1.8

This deficiency affected one of two storage rooms in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview, and/or documentation on January 24, 2019 at 9:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

The facility maintenance and inspection storage area doors was non-compliant the specific items include:

The facility storage room with liquid nitrogen storage and supplies was not equipped with a self-closing device. This room has combustible materials storied inside and is greater than 50 square feet. Doors in barriers required to have a fire resistance rating shall have a minimum 3/4 hour protection rating and shall be self-closing or automatic-closing.

Ref: 2012 NFPA 101 Sections 39.3.2.1; 8.7.1.3; 7.2.1.8

This deficiency affected one of two storage rooms in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to 1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection of locations of Alcohol Based Hand Rub Dispenser (ABHR) was non-compliant the specific items include:

The facility has soap dispensers installed above electrical receptacles on the patient care wings of the hospital. The soap in these dispensers have a concentration of alcohol within them that the soap is considered flammable.

Ref: 2012 NFPA 101 Sections 19.3.2.6 (8)

This deficiency affected two smoke zones in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to 1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection and maintenance of the fire alarm system components was non-compliant the specific items include:

During the inspection and testing of the facility fire alarm system that consisted of multiple components the automatic dialer component was tested. During this test the phone line communicator for the Fire Alarm Control Panel (FACP) was disconnected. The audible alert was not in a regularly manned area of the hospital.

Ref: 2012 NFPA 101 Sections 19.3.4; 9.6; 9.7.5
2010 NFPA 72 Section 26.6.3.2

This deficiency affected the entire facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection of areas requiring sprinkler coverage was non-compliant the specific items include:

The facility has paper backed insulation in the interstitial space above the ceiling tiles in the follow areas:

1. Purchasing department's storage room.
2. The service corridor bathrooms.

Concealed spaces filled with noncombustible insulation shall not require sprinkler protection. The paper backed insulation at the above mentioned areas are combustible and require sprinkler protection.

Ref: 2012 NFPA 101 Sections 19.3.5.1; 9.7.2.1
2010 NFPA 13 Section 8.15.1.2.7

This deficiency affected one smoke zone in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection and testing of supervisory signals to the fire alarm control panel was non-compliant the specific items include:

The supervisory signal for the electronically supervised tamper alarm on the sprinkler control valve at the Fire Alarm Control Panel (FACP) could be silenced permanently when the valve was in the closed position in the sprinkler riser room. Supervisory signals shall not be silenced permanently except by reopening/restoration of the valve to the normal operating position.

Where supervised automatic sprinkler systems are required by another section of this code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed at a location within the protected building that is constantly attended by qualified personnel.

Ref: 2012 NFPA 101 Sections 19.3.5.1; 9.7.2.1
2012 NFPA 72 Section 14.1.1

This deficiency affected the entire facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection of area that are open to the egress corridor was non-compliant the specific items include:

The Gift Shop is open to the corridor and is not equipped with sprinkler protection. This smoke zone in the facility is not covered by an approved automatic sprinkler system. If the gift shop is less than 500 sq. ft. the Gift Shop may remain open to the corridor provided that the one of the following criteria is met:

(a) The building is protected throughout by an approved automatic sprinkler system in accordance with section NFPA 101: 9.7.

(b) the gift shop is protected throughout by an approved automatic sprinkler system in accordance with section NFPA 101: 9.7 and storage is separately protected.

Ref: 2012 NFPA 101 Section 19.3.6.1(4)

This deficiency affected one smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to 1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection of smoke barrier wall areas was non-compliant the specific items include:

The facility has unsealed penetrations in the rated smoke barrier walls at the following locations:

1. The kitchen above the ceiling tile at the door connecting the nursing home dining room to the kitchen.
2. The waiting room of the intensive care unit.

Ref: 2012 NFPA 101 Sections 19.1.6.1; 8.3.5.6.1; 8.5.1

This deficiency affected two smoke zone in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview, and/or documentation on January 24, 2019 at 9:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

The facility maintenance and inspection of emergency electrical system was non-compliant the specific items include:

The outside electrical / mechanical room has storage in front of the electrical panels. The facility must maintain sufficient access and working space for the electrical panels to permit ready and safe operation of the electrical equipment.

Ref: 2012 NFPA 101 Sections 39.5.1; 9.1.2
2011 NFPA 70 Section 110-26

This deficiency affected the main electrical room at the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview, and/or documentation on January 24, 2019 at 9:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

The facility maintenance and inspection of emergency electrical system was non-compliant the specific items include:

The electrical closet/storage room located across from the nitrogen storage room has storage in front of the electrical panels The facility must maintain sufficient access and working space for the electrical panels to permit ready and safe operation of the electrical equipment.

Ref: 2012 NFPA 101 Sections 39.5.1; 9.1.2
2011 NFPA 70 Section 110-26

This deficiency affected the main electrical room at the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview, and/or documentation on January 24, 2019 at 9:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

The facility maintenance and inspection of emergency electrical system was non-compliant the specific items include:

The facility electrical closet/storage room located behind the main information desk has items stored in front of electrical panels. The facility must maintain sufficient access and working space for the electrical panels to permit ready and safe operation of the electrical equipment.

Ref: 2012 NFPA 101 Section 39.5.1; 9.1.2
2011 NFPA 70 Section 110-26

This deficiency affected the main electrical room at the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection of the duct detectors in the attic space above the procedure center was non-compliant the specific items include:

The facility has smoke duct detectors in the attic space that do not have an access door installed to visually inspect the sampling tubs to ensure that there are no changes in the system that effect the performance of the equipment.

Ref: 2012 NFPA 101 Sections 19.5.2.1; 9.2
2010 NFPA 72 Section 14.4.2.2*

This deficiency affected one of two smoke zones in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

The facility maintenance and inspection of Heating Ventilation and Air Conditioning System (HVAC) systems was non-compliant the specific items include:

1. The facility laundry department has two fire dampers installed in the one hour fire rated barrier on the main corridor. These dampers are not equipped with access doors in order to allow for inspection and testing as required.

Ref: 2012 NFPA 101 Section 19.5.2.1
2012 NFPA 90A Section 4.3.5.1

This deficiency affected two smoke compartments.

2. The smoke duct detector sampling tubes located in the Pharmacy department was not maintained clean and in good condition. The duct detector sampling tubes are not installed properly as required.

Ref: 2012 NFPA 101 Section 19.5.2.1; 9.2
2012 NFPA 90A Section 6.4.4.1
2010 NFPA 72 Section 14.4.2.2

This deficiency affected one smoke compartments.

3. The facility air handler shut down sequence did not stop the entire air flow at the return air registers at (a) Same Day Surgery, (b) Cardiopulmonary

Ref: 2012 NFPA 101 Section 19.5.2.1; 9.2
2012 NFPA 90A Section 4.2.4.1.1
2010 NFPA 72 Section 14.1.2

This deficiency affected two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility maintenance and inspection of areas soiled linen was stored was non-compliant the specific items include:
The facility has soiled linen and a trash containers of combustible materials located outside the ambulance entrance under the canopy overhang greater than 4 feet to the emergency department. The containers are left unattended under a canopy that is not protected with sprinkler coverage as required.

Ref: 2012 NFPA 101 Section 19.7.5.7.1 (3)

Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity and shall meet all of the following requirements:

(1) The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2).
(2) A capacity of 32 gal (121 L) shall not be exceeded within any 64 ft2 (6 m2) area.
(3)*Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
(4) Container size and density shall not be limited in hazardous areas.

This deficiency affected one smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection and records of the emergency power system was non-compliant the specific items include:

Record review of the facility's generator maintenance records for the 12 month period revealed the facility failed to have documentation showing monthly battery electrolyte / specific gravity checks values. Battery conductance testing shall be permitted in lieu of the testing of the specific gravity where applicable or warranted.

The facility did not have documentation from October and November of 2018.

Ref: 2012 NFPA 101 Sections 19.5.1; 9.1.2
2012 NFPA 99 Section 6.4.4.1
2010 NFPA 110, Sections 8.3.7*; 8.3.7.1

This deficiency affected the entire facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility maintenance and inspection of protection at the bulk oxygen area was non-compliant the specific items include:

The facility does not have noticeable bulk oxygen tank area protection from vehicular damage. The area does not have stop protection for the vehicle that fills the bulk oxygen tank.

Ref: 2012 NFPA 101 Section 19.3.2.4
2012 NFPA 99 Section 5.1.3.3.1 (4)
2010 NFPA 55 Section 4.11

This deficiency affected the main bulk oxygen storage area.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview, and/or documentation on January 24, 2019 at 9:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

The facility maintenance and inspection of information signs at the bulk oxygen area was non-compliant the specific items include:

The facility does not have noticeable signs at the bulk oxygen fencing noting that smoking is prohibited. This signage must be prominently and strategically placed to alert the public that this area does not allow smoking.

Ref: 2012 NFPA 101 Section 19.3.2.4
2012 NFPA 99 Section 11.5.3.2.3

This deficiency affected the main bulk oxygen storage fencing.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.