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Based on observation and staff interview, the facility failed to provide a uniform walking path from an exit discharge to a public way. This condition would slow, or prevent occupants from reaching a safe distance from the building during evacuation.

Findings are:
Observation on 3/7/19, at 1:41 pm revealed heaved seams in the concrete sidewalk outside of the Patient Wing exceeded a ¼ inch change in elevation, up to approximately 1 and ½ inches.

In an interview on 3/7/19, at 1:41 pm, Maintenance A acknowledged the concrete was heaved, and stated that it was due to frost.

NFPA 101, 2012, 7.1.6.2 Changes in Elevation. Abrupt changes in elevation of
walking surfaces shall not exceed 1?4 in. (6.3 mm). Changes in
elevation exceeding 1?4 in. (6.3 mm), but not exceeding 1?2 in.
(13 mm), shall be beveled with a slope of 1 in 2. Changes in
elevation exceeding 1?2 in. (13 mm) shall be considered a change
in level and shall be subject to the requirements of 7.1.7.

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

Findings are:
Record review on 3/7/19, at 2:16 pm revealed an annual 90 minute test of all battery backup lights in the OR was not documented for the last year.

In an interview on 3/7/19, at 2:16 pm, Maintenance A confirmed the testing was not completed.

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

Findings are:
Observation on 3/7/19, from 2:26 pm to 2:30 pm revealed:
1. Holes around two sets of cables were not sealed above the double doors by the Vending Machines.
2. The end of a pass-through conduit was not sealed above the double doors by the Communication Room.

In an interview on 3/7/19, from 2:26 pm to 2:30 pm, Maintenance A acknowledged the unsealed holes.

Based on observation and staff interview, the facility failed to use space heaters so combustibles were kept at least 3 feet away from the heaters. This condition created the potential for the combustibles to ignite.

Findings are:
Observation on 3/7/19, from 12:29 pm to 12:45 pm revealed:
1. Oil-filled space heaters were observed in use, in offices throughout the Clinic/Specialty Clinic. Combustibles were not kept at least 3 feet from the heaters.
2. An oil-filled space heater was observed in use in the Foundation Office near the desk with papers directly over the heater.

In an interview on 3/7/19, from 12:29 pm to 12:45 pm, Maintenance B acknowledged that combustibles were located less than 3 feet from the heaters.

Based on observation and staff interview, the facility failed to use electrical wiring in a way that would not create a fire hazard. This condition created the potential to cause a fire.

Findings are:
Observation on 3/7/19, at 12:56 pm revealed the power cord for the Bio Med freezer in the Lab was pinched, due to the freezer having been pushed up against the plug. The cord appeared to be damaged.

In an interview on 3/7/19, at 12:56 pm, Maintenance B 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