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Based on observation and interview the facility failed to provide an exit discharge that was not constructed in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.2, 19.2.1, 19.2.7, 7.1, 7.1.1, 7.1.6, 7.1.6.1, 7.1.6.1.1, 7.1.6.2, 7.7 and 7.7.1. This deficient practice could affect all of the potential four inpatients, an indeterminable number of outpatients, staff, and visitors if occupants had to use the exit in the event of an emergency.

Findings include:

On 10/23/19 at 1:55pm, observation revealed that exterior exit at door H6 discharged to an area that had an approximate 10 foot section of dirt and gravel between two sections of concrete sidewalks. This exit arrangement did not provide a level walking surface. The were unlevel sections of gravel that had between one inch and two inch variances in height.

This finding was confirmed by the Facility Manager at the time of discovery.

Based on observation and interview, the facility failed to maintain the protection of vertical openings in accordance with the requirements of NFPA 101 - 2012 edition, Sections 39.3.1, 39.3.1.1, 39.3.7.3, 8.3, 8.3.1 8.3.1.2, 8.6, 8.6.2, 8.6.4 and 8.6.5. This deficient practice could affect all of the potential four inpatients, an indeterminable number of outpatients, staff, and visitors if the smoke barrier did not limit the transfer of smoke in the event of a fire.

Findings include:

On 10/23/19 at 9:07am, observation revealed that above the ceiling at the smoke barrier in the lab blood draw room there were penetrations of three pipes that were not properly firestopped and there was a 2 inch gap at the top of the wall at the metal deck flutes that were not properly firestopped.

This finding was confirmed by the Facility Manager, the Staff Engineer and the Maintenance Supervisor at the time of discovery.

Based on observation and interview, the facility failed to install the kitchen range hood system baffles in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.2.5 and 9.2.3; NFPA 96 - 2011 edition, Sections 3.3.33, 6.1, 6.1.1 and 6.2.1.5. This deficient practice could affect all of the potential four inpatients, an indeterminable number of outpatients, staff, and visitors if a build up of grease in the baffles that did not drain properly caught fire.

Findings include:

On 10/23/19 at 1:11pm, observation revealed that the kitchen range hood had steel baffles that were installed in a horizontal position and not a vertical position.

This finding was confirmed by the Facility Manager at the times of discovery.

Based on interview the facility failed to have a reliable fuel source for the hospital emergency generator in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.5, 19.5.1, 9.1, NFPA 99 - 2012 edition, Sections 6.4.1.1.4 and 6.4.1.1.5, as well as NFPA 110 - 2010 edition Section 7.3 and 7.3.1. This deficient practice could affect all of the potential four inpatients, an indeterminable number of outpatients, staff, and visitors if the emergency generator did not to function in the event of a power outage.

Findings include:

On 10/22/19 at 1:50pm, an interview with the Facility Manager revealed that the facility had two emergency generators. A hospital emergency generator and a clinic emergency generator. The Facility Manager stated that the hospital emergency generator was fueled by natural gas and had a propane backup that was disconnected. The facility did not have a letter of reliability from the natural gas provider.

The letter from the natural gas supplier must state that the fuel source is reliable with a statement as to why that is true, there must be a statement that there is a low likelihood of an interruption with a description as to why that is true and the letter must be authored by an individual who had the technical knowledge to make the statements.

This finding was confirmed by the Facility Manager, the Staff Engineer and the Safety Officer at the time of discovery.

Based on interview the facility failed to have a reliable fuel source for the hospital emergency generator in accordance with the requirements of NFPA 101 - 2012 edition, Sections 21.5, 21.5.1, 9.1, NFPA 99 - 2012 edition, Sections 6.4.1.1.4 and 6.4.1.1.5, as well as NFPA 110 - 2010 edition Section 7.3 and 7.3.1. This deficient practice could affect all of the potential four inpatients, an indeterminable number of outpatients, staff, and visitors if the emergency generator did not to function in the event of a power outage.

Findings include:

On 10/22/19 at 1:50pm, an interview with the Facility Manager revealed that the facility had two emergency generators. A hospital emergency generator and a clinic emergency generator. The Facility Manager stated that the hospital emergency generator was fueled by natural gas and had a propane backup that was disconnected. The facility did not have a letter of reliability from the natural gas provider.

The letter from the natural gas supplier must state that the fuel source is reliable with a statement as to why that is true, there must be a statement that there is a low likelihood of an interruption with a description as to why that is true and the letter must be authored by an individual who had the technical knowledge to make the statements.

This finding was confirmed by the Facility Manager, the Staff Engineer and the Safety Officer at the time of discovery.