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K-293 Based upon observations made in the presence of the plant manager on 03/07/2017, it was determined that the facility did not maintain exit and directional signs with continuous illumination that is served by the emergency lighting system in accordance with NFPA 101 19.2.10.1 and 7.10.

This deficiency affected 1 of numerous exit signs.

Findings include:

During the facility tour it was observed that the exit signage was missing from the south end of East 8 at the temporary wall. Exit and directional signs shall be displayed in accordance with NFPA 101 7.10.

K-321 Based upon observations made in the presence of the plant manager on 03/07/2017, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1, 19.3.2.1.1 through 19.3.2.1.5.

This deficiency affected 3 of 32 smoke compartments.

Findings include:

During the facility tour it was observed that the central processing door failed to close completely. The door is required to be self-closing or automatic closing to the latch position in accordance with NFPA 101 19.3.2.1.

During the facility tour it was observed that patient room E 635 was being used as a storage room. Patient room E 635 did not have an automatic closing device. The door is required to be self-closing or automatic closing to the latch position in accordance with NFPA 101 19.3.2.1.

During the facility tour the CT storage room was observed not to have an automatic closing device. The door is required to be self-closing or automatic closing to the latch position in accordance with NFPA 101 19.3.2.1.

K-341 Based upon observations made in the presence of the plant manager on 03/07/2017 it was determined that the facility failed to have a fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building.

This deficiency affected 1 of 32 smoke compartments.

Findings include:

During the facility tour it was observed that the smoke detector in the electrical closet was missing. A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70.

K-351 Based upon observations made in the presence of the plant manager on 03/07/2017, it was determined that the facility did not provide a fire sprinkler system in accordance with NFPA 101 19.3.5, 9.7.

This deficiency affected 3 of 32 smoke compartments.

Findings include:

During the facility tour it was observed that the robotic dispenser enclosure was not sprinklered. Buildings containing hospitals
or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance
with Section 9.7.

During the facility tour it was observed that the basement IT closet had ceiling tiles removed to provide ventilation. This will allow smoke and heat to rise above the level of the sprinkler head potentially delaying the activation of the sprinkler head.

K-353 Based upon observations/record review made in the presence of the plant manager on 03/07/2017, it was determined that the facility did not maintain the fire sprinkler system in accordance with NFPA 101 19.3.5.1, 9.7.5.

This deficiency affected 2 of 32 smoke compartments.

Findings include:

During the facility tour multiple sprinkler heads in patient rooms W701, W702 and W754 were observed to be blocked by light fixtures. The minimum clearance required by the installation standard shall be maintained in accordance with NFPA 101 19.3.5.1, 9.7.5. and NFPA 25 5.2.1.2.

During the facility tour several sprinkler heads in the basement chiller room were observed to be painted. Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage;
and shall be installed in the correct orientation in accordance with NFPA 25 5.2.1.1.

During the facility tour several sprinkler heads in the generator room were corroded and had dirt and dust coating them. Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage;
and shall be installed in the correct orientation in accordance with NFPA 25 5.2.1.1.

K-363 Based upon observations made in the presence of the plant manager on 03/07/2017, it was determined that the facility did not maintain corridor doors to be positively latching and to resist the passage of smoke in accordance with NFPA 101 19.3.6.3.5.

This deficiency affected 1 of 32 smoke compartments.

Findings include:

During the facility tour the doors to O.R. rooms 3 and 14 did not close and positively latch when tested . Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, in accordance with NFPA 101 19.3.6.3.5.

During the facility tour the environmental services closet on the north end of east 8 was observed to have a one inch gap at the top of the door allowing the passage of smoke. Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke in accordance with NFPA 101 19.3.6.3.1.

K-374 Based upon observations made in the presence of the plant manager on 03/07/2017, it was determined that the facility did not maintain the door openings in smoke barriers to have at least a 20 minute fire protective rating. The doors shall be self-closing or automatic closing in accordance with NFPA 101 19.3.7.8.

This deficiency affected 4 of 32 smoke compartments.

Findings include:

During testing of the smoke barrier doors in 4th floor maternity hall and the 2nd floor hallway to materials the doors failed to close completely allowing the passage of smoke in accordance with NFPA 101 19.3.7.8.

K-511 Based upon observations made in the presence of the plant manager on 03/07/2017, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

This deficiency affected 3 of 32 smoke compartments.

Findings include:

During the facility tour two electrical panels 2E and 2B1 were observed to be unlocked allowing unauthorized access to unqualified persons not in accordance with NFPA 70,110-31.

During the facility tour electrical panels in room 3 laser panel and the line isolation panel for room 17 were observed to be blocked. Service panels are to have a clear working space of 36" maintained in front of them at all times. NFPA 101 19.5.1, 9.1.2., NFPA 70, 110-26 (a)

K-920 Based upon observations made in the presence of the plant manager on 03/07/2017, it was determined that the facility did not use power and extension cords in accordance with NFPA 101, 99 and 70.

This deficiency affected 2 of 32 smoke compartments.

Findings include:

During the facility tour power strips were observed to be "daisy chained" in care management and same day surgery office. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling in accordance with NFPA 70 110-3b