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STANDARD not met, as evidenced by the observation and staff interview. It was determined that the facility failed to arrange and maintain the means of egress per Life Safety Code Section 19.2 and Chapter 7. This deficient practice could affect all residents, staff, and visitors throughout the facility if an exit discharge to the public way is not provided.

A wall has been constructed across the corridor that served as the second exit from the temporary IT office, blocking the alternative accessible exit to the public way. This area also contains licensed bed space.

2012 Life Safety Code 101-7.5.4.3 Each required accessible means of egress shall be continuous from each accessible occupied area to a public way or area of refuge in accordance with 7.2.12.2.2.

The deficient item was discussed with numerous facility staff during the exit conference.

STANDARD was not met, as evidenced by observation and staff interviews during the survey. It was determined that the facility failed to maintain the marking of means of egress per the 20212 Life Safety Code 101- Section 7.10. This deficient practice could affect all residents, staff, and visitors in the area if code-compliant exit signage is not provided for building egress.

Missing exit signage, including directional arrows pointing in the wrong direction, was found throughout the facility on all floors.

Life Safety Code 19.2.10.1. Means of egress shall have signs per section 7.10. The directional indicator shall be outside the Exit legend, not less than 3/8 in. (1cm) from any letter. The directional indicator shall be of a chevron type. The directional indicator shall be identifiable as a directional indicator at a distance of 40 ft. (12.2m). A directional indicator larger than the minimum established in this paragraph shall be proportionately increased in height, width, and stroke. The directional indicator shall be located at the end of the sign for the direction indicated.

The deficient item was discussed with numerous facility staff during the exit conference.

STANDARD not met: Through observation and discussion during the facility tour, it was determined that the facility failed to install and maintain fire resistance rating per NFPA 2012 Life Safety Code 101 Chapter 9. 19.3.1. Failure to maintain fire resistance rating has the potential to harm all occupants, staff, and visitors in the building if a fire was to occur.

Stairwell 3 is missing fire stopping and evidence of drywall damage.

19.3.1 Protection of Vertical Openings. Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8.

19.3.1.1 Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
The deficient item was discussed with numerous facility staff during the exit conference.

STANDARD is not met, as evidenced by: During observation of the kitchen gas-fired cooking equipment, it did not meet the requirements of the 2012 Edition of NFPA 54 Fuel and Gas Code 9.6.1.2. This deficient practice could affect all residents and staff should a fire occur due to failure to operate safely due to non-code compliance.

1. One gas-fired cooking appliance in the main kitchen was not equipped with a restraining device or wheel chocks.
2. The kitchen fire-extinguishing system's manual activation device lacks a proper placard.

NFPA 54 -2012 Fuel and Gas Code 9.6.1.2 Restraints. Movement of the appliance with casters shall be limited by a restraining device installed per the connector and appliance manufacturer installation instructions.

13.5.5. The manual activation device for the fire-extinguishing system shall be clearly identified.

The deficient item was discussed with numerous facility staff during the exit conference.

STANDARD not met, as evidenced by: Based on observation and staff interviews, it was determined that the facility needed to provide a safe location to install an Alcohol-Based Hand Rub dispenser per Life Safety Code Chapter 19, Section 19.3.2.6(8). This deficient practice could affect all patients, visitors, and staff should an electrical fault ignite the dispenser.

Alcohol-based hand rub dispensers (ABHR) were positioned directly above an electrical outlet in the Radiology Office.

Life Safety Code 101, Section 19.3.2.6 Alcohol-Based Hand-Rub Dispensers shall be protected per 8.7.3 unless all of the following conditions are met:
(8) Dispensers shall not be installed in the following locations:
(a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source.
(b) To the side of an ignition source within a 1 in. (25 mm) horizontal distance from the ignition source.
(c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source

The deficient item was discussed with numerous facility staff during the exit conference.

STANDARD is not met as evidenced by: Through observation and staff interview of the fire alarm system during the tour of the facility, the facility failed to install and maintain the fire alarm system with approved components, devices, or equipment per NFPA 101 Life Safety Code (2012 Edition), section 19.3.4.3.1 and NFPA 72, section 17.7.4.1. Failure to maintain the fire alarm system has the potential to harm all occupants, staff, and visitors if the fire alarm system fails to operate as designed if a fire was to occur.

A smoke detector is installed 26 inches away from the HVAC diffuser in the North Tower elevator lobby.

NFPA 72, 29.11.3.48) Smoke alarms and smoke detectors shall not be installed within a 36 in. (910 mm) horizontal path from the supply registers of a forced air heating or cooling system and shall be installed outside of the direct airflow from those registers.

The deficient item was discussed with numerous facility staff during the exit conference.

STANDARD not met as evidenced by: Through record review and staff interview during the survey, the facility failed to inspect and test the fire alarm system per NFPA 72 and 2012 Life Safety Code 101. Failure to maintain and test the fire alarm system has the potential to harm all occupants, staff, and visitors within the facility if the fire alarm system fails to operate if a fire was to occur.

1. The fire alarm notification device 2A-01-07 is covered with plastic.
2. In the Equipment Room 4, combustible materials are obstructing the view of the strobe lights.
3. The alarm notification device in the soiled utility room is dangling by its wires.

2012 Life Safety Code 101 section 9.6.1.5*To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

The deficient item was discussed with numerous facility staff during the exit conference.

STANDARD not met as evidenced by: Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system per National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff, and visitors should the automatic sprinkler system fail to operate promptly and effectively due to non-code-compliant maintenance.
1. The storage in the kitchen walk-in cooler is stacked to the ceiling, obstructing the sprinkler's spray pattern.
2. GI Lab sprinkler head is missing an escutcheon plate.
3. Kitchen Dry Storage sprinkler head is missing an escutcheon plate.
4. The walk-in freezer in the kitchen sprinkler head broken escutcheon plate.
5. Throughout the kitchen pendent sprinkler shows signs of foreign materials around the working parts of the head.
6. Missing a list of the sprinklers installed in the property posted in the sprinkler cabinet.
7. Wires laying on sprinkler piping smoke compartment 5-4 south.
8. IT wires attached to fire sprinkler line in basement IT area.
9. Bed storage south shows signs of foreign materials around the working parts of the sprinkler head.

NFPA 101 2012 Edition Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating conditions and are installed, inspected, and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

The deficient item was discussed with numerous facility staff during the exit conference.

The standard has not been met, as indicated by observations and staff interviews. It was found that the facility did not properly maintain all portable fire extinguishers in accordance with NFPA 10, Chapter 4. This deficiency poses a risk to all residents, staff, and visitors, as the portable fire extinguishers may not function effectively if they are not maintained in compliance with the code.

1. Fifth-floor stairwell 4-5 fire extinguisher is not tagged.
2. Missing extinguisher near the Ultrasound Bone Density.
3. Extinguisher 1-20 missing tag.
4. Temporary IT office fire extinguisher not mounted.

Life Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire Extinguishers.

The deficient item was discussed with numerous facility staff during the exit conference.

STANDARD is not met, as evidenced by the observation and staff interview during the survey. It was determined that the facility failed to maintain corridor doors per the Life Safety Code Section 19.3.6.3. This deficient practice could affect all residents within the smoke compartments should the egress become untenable due to smoke and heat transfer via the non-latching corridor doors, as evidenced by the following:
Corridor doors were not maintained to close and positively latch, as required.
1. G4 smoke does do not seal into the frame.
2. Doors throughout the facility being propped open with wooden wedges.
3. North Tower 4-3, 4-2, 2-3 and 2-4 doors do not latch into the doorframes.
4. Stairwell 3 GF doors do not latch into the doorframes.
5. Physicians lounge door dose not latch into the doorframes.
6. Elevator 2 smoke/fire doors do not latch into the doorframes.
7. 4th floor stairwell 1-G7 excessive gap around doors.
8. 4th floor stairwell 3-G8 excessive gap around doors.

The Life Safety Code, Section 19.3.6.3.2, requires that corridor doors be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. Doors must be unobstructed from closing and positively latch into the door frame. Section 19.3.6.3.1, Exception #2, requires that corridor doors installed within sprinkler-protected smoke compartments be constructed to resist the passage of smoke.

The deficient item was discussed with numerous facility staff during the exit conference.

STANDARD is not met as evidenced by: Based on observation and staff interviews during the survey, it was determined that the fire resistance rating of smoke barrier walls was not maintained in accordance with Life Safety Code Section 19.3.2.1. This deficient practice could affect all residents in all smoke compartments by allowing the spread of fire and smoke to the adjoining compartments.

1. The fire/smoke barrier walls utilized for subdivisions must uphold a 1-hour fire rating; however, they were discovered to have
penetrations throughout the building on all floors.
2. Ceiling tiles throughout the building on all floors are broken, missing, or damaged.

Life Safety Code Section 19.3.2.1 requires that the smoke barrier wall be constructed in accordance with Section 8.3, and shall have a fire resistance rating of not less than 1 hour. Section 8.3.2 requires that the barrier be continuous through concealed spaces. Section 8-3.1.1 (3) requires, in part, that the space between piping penetrations.

The deficient item was discussed with numerous facility staff during the exit conference.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain sprinkler protected hazardous areas in accordance with Life Safety Section 19.3.2.1. and 9.5 This deficient practice could affect all residents and staff in all the main smoke compartment should there be smoke and heat transfer between the hazardous area and other portions of the building.

1. The door of the linen chute on the third floor south is not latching properly.
2. All the fusible links on the laundry chute doors have expired since 2006.

Life Safety Code 101-2012 edition. 9.5.2 Installation and Maintenance. Rubbish chutes, laundry chutes, and incinerators shall be installed and maintained in accordance with NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment, unless such installations are approved existing installations, which shall be permitted to be continued in service.

The deficient item was discussed with numerous facility staff during the exit conference.

STANDARD is not met as evidenced by: Based on observation and staff interview it was determined that the facility failed to maintain fire safe environment within the facility. This deficient practice could affect all patients, staff and visitors should a fire occur by the non-rated space heaters.

1. Surgical services non-rated space heater.
2. Housekeeping supervisor office non-rated space heater.
3. Administrative office first floor 4X non-rated space heater.

Life Safety Code, Section 19.7.8. Portable space-heating devices shall be prohibited in all heath care occupancies. Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee's areas where the heating elements of such devices do not exceed 212? F (100? C).

The Administrator and Maintenance Director acknowledge the deficiency of the prohibited space heaters during the facility tour.

STANDARD not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to install electrical equipment according to National Fire Protection Association 70, National Electrical Code. This deficient practice could affect all residents throughout the smoke compartments due to increased potential electrical fire hazards.
The facility utilizes power strips and extension cords rated for 15 amps to supply electricity to refrigerators and microwaves in the following locations.
1. PET CT portable cooler plugged into extension cord.
2. PET CT lobby refrigerator plugged into a power strip.
3. Consultant room near IR refrigerator plugged into a power strip.
4. Women newborn breakroom extension cord plugged into a power strip routing through the ceiling to power pipe heater on sprinkler
line.
5. Pathology refrigerator plugged into a power strip.
6. Physicians sleep room refrigerator plugged into a power strip.
7. HIM refrigerator plugged into a power strip.

NFPA 99 Section 10.2.3.1.1 The flexible cord, including the grounding conductor, shall be of a type suitable for the particular application; shall be listed for use at a voltage equal to or greater than the rated power line voltage of the appliance; and shall have an ampacity, as given in Table 400.5(A) of NFPA 70, National Electrical Code, equal to or greater than the current rating of the device.

The deficient item was discussed with numerous facility staff during the exit conference.

STANDARD not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to maintain all oxygen cylinders in storage as required by 2012 NFPA 99 Section 11.6.2.3. This deficient practice could affect all residents, staff and visitors should the facility fail to provide safe operation and management of cylinders.

Freestanding cylinders needed to be properly chained or supported in a cylinder stand or cart in the Supply chain oxygen storage room.

NFPA 99- 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures.
(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

The Maintenance Director acknowledged the lack of properly store cylinders during the tour of the facility.