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Based on observation and staff interview, the facility failed to maintain the 2-hour fire barrier, and a fire door in the 2-hour fire barrier between the Business Occupancy and the Health Care Occupancy. This condition had the potential to allow fire and smoke to spread between the two separate occupancies.

Findings are:
Observation on 8/6/18, from 11:40 am to 2:05 pm revealed:
1. The 90-minute fire door between the Business Office and Registration did not positively latch when self-closed.
2. Two one foot square holes were not sealed in the 2-hour fire barrier above the Surgery Waiting Door on the Surgery side.
3. A hole around a yellow conduit was not sealed in the 2-hour fire barrier above the Lobby to X-Ray Door.

In an interview on 8/6/18, from 11:40 am to 2:05 pm, Maintenance A confirmed the doors did not positively latch, and the unsealed penetrations.

Based on observation, record review and staff interview, the facility failed to ensure doors within the means of egress would not be locked to prevent egress. This condition would prevent the evacuation of occupants during an emergency.

Findings are:
Observation on 8/6/18, from 10:20 am to 1:28 pm revealed:
1. A thumb latch was installed in both sets of powered horizontal sliding doors at the "River" Main Entrance/Exit. The doors would not break away when locked.
2. A thumb latch was installed in both sets of powered horizontal sliding doors at the West ER Exit. The doors would not break away when locked.
3. A thumb latch was installed in both sets of powered horizontal sliding doors at the Ambulance Garage Exit. The doors would not break away when locked.

Record review on 8/6/18, at 1:28 pm of the LS-10 Floor Plan revealed all of the exit discharge noted in the observations served the Hospital.

In an interview on 8/6/18, from 10:20 am to 1:28 pm, Maintenance A confirmed the locking arrangement.

NFPA 101, 2012, 7.2.1.5.1 Door leaves shall be arranged to be opened readily
from the egress side whenever the building is occupied.

Based on observation and staff interview, the facility allowed a corridor door to be held open by an unapproved method. This practice would allow smoke to migrate into the exit corridors.

Findings are:
Observation on 8/6/18, at 12:54 pm revealed the Anesthesia Office door was held open by a door wedge, which prevented the door from self-closing and positively latching. The room was not deemed a hazardous area.

In an interview on 8/6/18, at 12:54 pm, Maintenance A acknowledged the door was wedged open.

Based on record review and staff interview, the facility failed to test battery backup emergency lights monthly and annually. This condition created the potential for the failure of emergency lighting.

Findings are:
Record review on 8/6/18, at 11:16 am revealed:
1. An annual 90 minute test of all battery backup lights in OR 1 and OR 2 was not documented for the last year.
2. Monthly function testing of all battery backup lights in OR 1 and OR 2 was not documented for the last year.

In an interview on 8/6/18, at 11:16 am, Maintenance A confirmed the testing was not completed.

Based on observation and staff interview, the facility failed to separate hazardous areas with smoke resistive doors and partitions. This condition would allow smoke to migrate into the exit corridors.

Findings are:
Observation on 8/6/18, from 11:52 am to 1:33 pm revealed:
1. The ends of pass-through conduits in the north wall of the Main Electrical Room were unsealed.
2. The Anesthesia Work Room was used for combustible storage, and exceeded 50 square feet. The room door did not self-close.
3. The Environmental Services 1140 Door did not fully close or positively latch when self-closed.
4. The shell space across from Observation was used for combustible storage, and exceeded 50 square feet. Multiple unsealed penetrations were observed in all four room walls.

In an interview on 8/6/18, from 11:52 am to 1:33 pm, Maintenance A acknowledged the unsealed penetrations.

Based on observation and staff interview, the facility failed to install complete fire sprinkler coverage in all areas, and failed to label post indicator valves (PIV) as to the areas they served. This condition would prevent the suppression of a fire, or allow shutting off the wrong sprinkler system during a fire.

Findings are:
Observation on 8/6/18, from 11:25 am to 1:04 pm revealed:
1. Two PIVs were installed for the facility, and neither valve was labeled.
2. Ceiling tiles in the Environmental Services 1258 closet were missing.
3. A suspended ceiling for half of the Environmental Services 1205 Room was installed, with a fire sprinkler installed in the suspended ceiling. An upright fire sprinkler was not installed within 2 feet of the roof deck that was open to the room to provide coverage for the space where a suspended ceiling was not installed.

In an interview on 8/6/18, from 11:25 am to 1:04 pm, Maintenance A confirmed that neither PIV was labeled, and the lack of ceiling and ceiling tiles.

NFPA 24, 2010, 6.7 Identifying and Securing Valves.
6.7.1 Identification signs shall be provided at each valve to
indicate its function and what it controls.
NFPA 13, 2010, 8.6.4.1.2 Obstructed Construction. Under obstructed construction,
the sprinkler deflector shall be located in accordance
with one of the following arrangements:
(1) Installed with the deflectors within the horizontal planes
of 1 in. to 6 in. (25.4 mm to 152 mm) below the structural
members and a maximum distance of 22 in. (559 mm)
below the ceiling/roof deck

Based on observation, record review and staff interview, the facility failed to have the fire sprinkler system maintained, and tested semiannually. This condition created the potential for system failure.

Findings are:
Observation on 8/6/18, at 1:53 pm revealed the fire sprinkler outside of the Administrator's Office had been painted.

Record review on 8/6/18, at 1:45 pm revealed the fire sprinkler system was only tested annually, according to the provided inspection reports dated 5/14/18 - 5/5/17.

In an interview on 8/6/18, from 1:45 pm to 1:53 pm, Maintenance A confirmed the findings.

NFPA 25, 2011, 5.2.1.1.1* 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 (e.g., upright,
pendent, or sidewall).

NFPA 25, 2011, 5.3.3.2* Vane-type and pressure switch-type waterflow alarm
devices shall be tested semiannually.

Based on observation and staff interview, the facility failed to maintain a smoke barrier that would resist the passage of smoke. This condition would allow smoke to migrate between smoke compartments.

Findings are:
Observation on 8/6/18, at 2:00 pm revealed an open pass-through conduit, and a hole around a conduit above the X-Ray Double Doors were unsealed.

In an interview on 8/6/18, at 2:00 pm, Maintenance A acknowledged the unsealed penetrations.

Based on record review and staff interview, the facility failed to have a preventative maintenance plan adopted to inspect and test fire doors annually throughout the facility.
Findings are:

Record review on 8/6/18, at 10:51 am revealed a preventative maintenance plan to inspect and test fire doors annually was not provided for review.

In an interview on 8/6/18, at 10:51 am, Maintenance A confirmed fire door testing had not been implemented.

NFPA 80, 2010, 5.2* Inspections.
5.2.1* Fire door assemblies shall be inspected and tested not
less than annually, and a written record of the inspection shall
be signed and kept for inspection by the AHJ.

5.2.4 Swinging Doors with Builders Hardware or Fire Door
Hardware.
5.2.4.1 Fire door assemblies shall be visually inspected from
both sides to assess the overall condition of door assembly.
5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the
door or frame.
(2) Glazing, vision light frames, and glazing beads are intact
and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible
threshold are secured, aligned, and in working order
with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4
and 6.3.1.7.
(6) The self-closing device is operational; that is, the active
door completely closes when operated from the full
open position.
(7) If a coordinator is installed, the inactive leaf closes before
the active leaf.
(8) Latching hardware operates and secures the door when
it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation
are not installed on the door or frame.
(10) No field modifications to the door assembly have been
performed that void the label.
(11) Gasketing and edge seals, where required, are inspected
to verify their presence and integrity.

Based on observation and staff interview, the facility failed to provide a remote manual stop station for the emergency generator. This condition had the potential to prevent the shutdown of the generator during an emergency.

Findings are:
Observation on 8/6/18, at 11:26 am revealed a remote manual stop station for the emergency generator was not installed outside, and away from the generator enclosure.

In an interview on 8/6/18, at 11:26 am, Maintenance A confirmed a remote manual stop station was not installed, and that the generator was installed within the last two years.

NFPA 110, 2010, 5.6.5.6* All installations shall have a remote manual stop station
of a type to prevent inadvertent or unintentional operation located
outside the room housing the prime mover, where so installed,
or elsewhere on the premises where the prime mover is
located outside the building.
5.6.5.6.1 The remote manual stop station shall be labeled.

Based on record review and staff interview, the facility failed to test patient bed receptacles annually throughout the facility. This practice increased the risk of fire from a failed outlet.

Findings are:
Record review on 8/6/18, at 10:52 am revealed documentation of annual patient bed location receptacle testing was not provided for review.

In an interview on 8/6/18, at 10:52 am, Maintenance A confirmed the testing was not conducted, and was not aware of the requirement.

NFPA 99, 2012, 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.

Based on record review and staff interview, the facility failed to have the diesel fuel tested annually for quality. This practice increased the potential that emergency power would not be supplied to the facility.

Findings are:
Record review on 8/6/18, at 1:53 pm revealed documentation was not provided to verify the diesel fuel for the generator underground and aboveground tank was tested annually for quality.

In an interview on 8/6/18, at 1:53 pm, Maintenance A confirmed the testing was not conducted.

NFPA 99, 2012, 8.3.8 A fuel quality test shall be performed at least annually
using tests approved by ASTM standards.

Based on observation and staff interview, the facility allowed the use of extension cords in lieu of permanent wiring. This condition had the potential to cause a fire.

Findings are:
Observation on 8/6/18, from 11:34 am to 11:44 am revealed:
1. Two extension cords were in use for the desk in Materials Management.
2. Three extension cords were in use for the desk in the Imaging Supervisors Office.
3. A power strip hung by the cord for the desk in the Imaging Supervisors Office.

In an interview on 8/6/18, from 11:34 am to 11:44 am, Maintenance A acknowledged the findings.

NFPA 70, 2011, 400.8 Uses Not Permitted. Unless specifically permitted
in 400.7, flexible cords and cables shall not be used for the
following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings,
suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar
openings
(4) Where attached to building surfaces
Exception to (4): Flexible cord and cable shall be permitted
to be attached to building surfaces in accordance with the
provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located
above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted
in this Code
(7) Where subject to physical damage
NFPA 70, 2011, 400.10 Pull at Joints and Terminals. Flexible cords and
cables shall be connected to devices and to fittings so that
tension is not transmitted to joints or terminals.

Based on observation and staff interview, the facility failed to have the Bulk Oxygen location permanently placarded. This condition increased the potential of a fire.

Findings are:
Observation on 8/6/18, at 11:24 am revealed a "OXYGEN NO SMOKING - NO OPEN FLAMES" sign was not posted on the bulk oxygen fence. The placard on the tank was not visible when approaching the facility.

In an interview on 8/6/18, at 11:24 am Maintenance A stated the fence was recently replaced, and that the old fence would have had the required signage.

NFPA 55, 2010, 9.4.4 Signage. The bulk oxygen storage location shall be permanently
placarded to read as follows:
OXYGEN
NO SMOKING - NO OPEN FLAMES

Based on observation and staff interview, the facility failed to restrain medical gas cylinders to prevent them from tipping over, and to maintain the oxygen supply room enclosure. This condition would allow smoke to spread outside of the room, and endanger occupants where a cylinder could become a projectile if tipped over.

Findings are:
Observation on 8/6/18, at 1:35 pm revealed:
1. Two medical gas cylinders were unrestrained in the Oxygen Manifold Room.
2. Open pass-through conduits were unsealed in the ceiling of the Manifold Room.

In an interview on 8/6/18, at 1:35 pm, Maintenance A acknowledged the unrestrained cylinders and the unsealed conduits.

NFPA 99, 2012, 5.1.3.3.2* Design and Construction. Locations for central supply
systems and the storage of positive-pressure gases shall
meet the following requirements:
(4) If indoors, they shall be constructed and use interior finishes
of noncombustible or limited-combustible materials
such that all walls, floors, ceilings, and doors are of a
minimum 1-hour fire resistance rating.
(7) They shall be provided with racks, chains, or other fastenings
to secure all cylinders from falling, whether connected,
unconnected, full, or empty.