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Based on observation and interview, it was determined the facility failed to ensure corridor doors had a maximum undercut of 1-inch and closed to a positive latch.(NFPA 101, 19-3.6.3.1, 19-3.6.3.4)
The findings include:1. Observation and interview with the Maintenance Director, on March 2, 2015 at 12:03 p.m. confirmed the staff entrance door to radiology failed to close to a positive latch.
2. Observation and interview with the Maintenance Director, on March 2, 2015 at 2:11 p.m. confirmed the "C" wing soiled utility room door was undercut 1-3/4 inches.These findings were verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on March 3, 2015.

Based on observation and interview, it was determined the facility failed to ensure doors requiring to be self-closing were held open by approved devices. (NFPA 101, 7.2.1.8.1)
The findings include:
Observation and interview with the Maintenance Director, on March 2, 2015 at 11:56 a.m. confirmed the 1-1/2 hour rated CT room fire door had a door closer and was held open by a kickstand device.
This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on March 3, 2015.

Based on observation and interview, it was determined the facility failed to ensure hazardous area ' s fire rated construction was maintained.
The findings include:
1. Observation and interview with the Maintenance Director, on March 2, 2015 between 11:30 a.m. and 2:50 p.m. confirmed the following rooms were used to store combustible materials and greater than 50 square feet ftand not provided with self-closing doors (NFPA 101, 7.2.1.8.1):
- Patient rooms used for storage; 113, 115, 142
- Storage room marked "Private" between materials Management and Surgery.
- Dietary dry storage room.
2. Observation and interview with the Maintenance Director, on March 2, 2015 at 8:05 a.m. confirmed unsealed penetration in the mechanical room wall at both the B and C side stairwell walls above the fire door.
3. Observation and interview with the Maintenance Director, on March 2, 2015 at 2:15 p.m. confirmed the kitchen dry storage room doors was not provided with a door closers (NFPA 101, 19.3.2.1 (7).These findings were verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on March 3, 2015.

Based on observation, it was determined the facility failed to ensure smoke detectors were at least 3-feet from air flow.(NFPA 72, 2-3.5.1).
The findings include:
Observation and interview with the Maintenance Director, on March 3, 2015 at 8:45 a.m., confirmed the smoke detector at the "c" wing exit to the outside stairwell was 1-foot from the air diffuser.This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on March 3, 2015.

Based on observation, it was determined that the facility failed to sprinkler all areas.

The findings include:

Observation on March 3, 2015 at 10:10 a.m. revealed the central hall janitor's closet by the gift shop is not sprinkled.

This finding was verified by the director of the engineering department and acknowledged by administration during the exit conference on March 3, 2015.
NFPA 5-1.1*

Based on observation and record review, it was determined the facility failed to ensure the sprinkler system was maintained (NFPA 25, Table 9-1 & 9-2.7).
The findings include:
1. Observation and interview on March 2, 2015 between 10:00 a.m. and 2:30 p.m. revealed the following sprinkler heads are covered with lint or corroded;
- 1 of 3 sprinkler heads in the maintenance office is covered with lint.
- 1 of 2 sprinkler heads in the dietary dish room is covered with lint.
- 1 of 20 sprinkler heads above the 3 bay sink in dietary is corroded.

2. Observation with the Maintenance Director on March 2, 2015 at 2:50 p.m. confirmed standard response and quick response sprinkler heads mixed in the same compartment at the following locations:
- Corridor outside the diagnostic care center
- Operating room suite corridor
- Same day surgery corridor
These findings were verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on March 3, 2015.

Based on observation, interview and record review, it was determined fire extinguishers failed to comply with the maintenance requirements of NFPA 10.
The findings include:
1. Observation and interview with the Maintenance Director, on March 2, 2015 at 11:45 a.m. confirmed the CO2 portable extinguishers which were last tested in January 2010 have not had their 5-year Hydrostatic testing or annual conductivity test performed.

2. Record review with the Maintenance Director, on March 2, 2015 at 11:45 a.m. revealed the report dated 1/9/2015 had 40 portable fire extinguishers needing service that has not been corrected.

This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on March 3, 2015.

Based on record review and interview, it was determined that the facility failed to maintain fire and smoke dampers in the building. (NFPA 96)


The findings include:

Record review and interview with the maintenance director on March 2nd, 2015 at 12:00 p.m. revealed the following fire dampers and smoke dampers are not maintained;

1) Fire Dampers 1-FD-012, 1-FD-024 and P-FD-060 are not accessible.
2) Fire Damper P-FD-005 has a broken spring.
3) Smoke Dampers 1-SD-017 and 1-SD-018 are not accessible.
4) Smoke Damper 1-SD-014 has no air to the actuator.

This finding was verified by the maintenance director and acknowledged by the assistant administrator during the exit conference on March 3rd, 2015.

Based on record review, it was determined that the facility failed to maintain the kitchen hood suppression system.

The findings include:

Record review with the maintenance clerk on March 2nd, 2015 at 12:00 p.m. revealed a hydrostatic test has not been performed on the suppression system in dietary since 2002. Documentation indicates it was due in 2014.
(NFPA 96)

This finding was verified by the maintenance director and acknowledged by the assistant administrator during the exit conference on March 3rd, 2015.

(NFPA 99, 4-3.1.1.2 (a)(4) The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
Based on observation and interview, it was determined electrical components in medical gas storage locations were located greater than five (5) feet above the floor.
The findings include:
Observation and interview with the Maintenance Director, on March 2, 2015 at 10:52 a.m. confirmed the N2O2 manifold room light switch was located approximately 42" above the finished floor.
This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on March 3, 2015.

Based on observation and interview, it was determined that the facility failed to have an annunciator for the generator in a continuously monitored location.

The findings include:

Observation and interview with the director of the engineering department on March 3, 2015 at 9:00 a.m. revealed the annunciator for the generator that serves the West Wing is at a nursing station that is not being used anymore.

This finding was verified by the director of the engineering department and acknowledged by administration during the exit conference on March 3, 2015.
NFPA 99 3-4.1.1.15

Based on observation and interview, it was determined GFCI outlets were located in all wet areas.
The findings include:
Observation and interview with the Maintenance Director, on March 2, 2015 at 2:14 p.m. confirmed GFCI outlets were not provided in the B and C wing ice machine rooms at the counter. (NFPA 70, 517-20).This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on March 3, 2015.