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Based upon observation, Exit signs are not provided to provide clear identification of exit access. Failure to identify available means of egress can result in occupant confusion or inability to reach an exit during a fire/smoke event.

The finding is:

On 11/09/2022 at 10:00an while in the company of the POM exit signage was observed to be indicating travel to areas not provided with a compliant means of egress the current condition does not comply with 7.5.1.1, 7.5.1.6.
Location observed - second floor exit signs within the North end smoke compartment indicate exiting to the Northern Stair which is located within a construction site considered hazardous.

Based on observation, not all vertical openings in the building are protected as required. Failure to protect vertical openings between floor levels can affect building occupants' safety if smoke and fire could pass between building stories when vertical openings are not protected.

The finding is:

On 11/09/2022 while in the company of the POM it was observed that a penetration between floor levels could not be confirmed to be protected to afford the1-hour rated floor-to-floor separation to comply with 8.3.5.
Location observed: Penthouse floor through floor exhaust covered with sheet metal approximately 10" x 16" rectangle.

Based on observations not all enclosures of hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building due to smoke and fire passing from the hazardous area through the remainder of the building.

Findings include:

A. On 11/09/2022 at 10:20 am while accompanied by the POM surveyor observed a corridor door to a hazardous area that did not comply with 19.3.2.1.3 for a self closing door. Location observed: second floor Pharmacy Storage.

B. On 11/09/2022 at 11:03 am while accompanied by the POM surveyor observed an unprotected opening between a construction area deemed hazardous and a patient care area which does not comply with 19.3.2.1.2, 8.4.3. Location observed, Physical Therapy and area of construction (former conference room).

Based on observation and interview, the building's fire alarm system is not installed in accordance with Code requirements. Failure to properly install components of a fire alarm system may compromise the operation of the system. The system may fail to provide an effective warning if there is a fire/smoke event.

The finding is:

On 11/09/2022 at 11:45pm while accompanied by the POM it was discussed that there is no fire alarm communication between the M.R.I. unit located in a trailor and the hospital. Currently this condition does not comply with NFPA 72-2010 24.4.1.

Based on observation, not all corridor doors are installed and maintained to remain in the closed position. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass into corridors if the corridor doors are not installed in a compliant manner.

Findings include:

A. On 11/09/2022 while accompanied by the POM corridor doors do not latch to a closed position which does not comply with 19.3.6.3.
Locations observed:

1. At 1:138am Second floor Group Room

2. At 12:10pm First floor sliding (barn style) door to Film Jacket Assembly room (per life safety floor plan)


B. On 11/09/2022 at 12:12pm while accompanied by the POM a corridor door does not maintain a closed position due to rebounding which does not comply with 19.3.6.3.5. Location observed: First floor sliding (barn style) door to Film Jacket Assembly room (per life safety floor plan)

Based on observation, the facility failed to provide identification of certain types of fire protection appliances within the ventilation duct system. This deficient practice could affect patients, staff and visitors during a fire event if failure to install and maintain this installation would result in the passage of fire and products of combustion from one fire compartment to another.

The finding is:

On 11/09/2022 at 9:45am while accompanied by the POM the surveyor observed access panels for damper locations are not labeled to comply with NFPA 80 2010 19.2.3.2, NFPA 90A 2012, 4.3.5.2.
Locations observed, Mechanical Penthouse.

Based on observation, the facility failed to install and maintain all elevators as required. This deficient practice could affect patients, staff, and visitors in the hospital because smoke and fire could be permitted to spread throughout the building via the elevator shafts, and the elevators could be unavailable to firefighters when needed, if the recall systems are not properly installed.

The finding is:

On 11/09/2022 at 9:35am, while accompanied by the POM, observation determined that a smoke detector is not provided within 2 feet of the sprinkler head located above the North Elevator Equipment to comply with NFPA 72 2010 21.4.2.

Based on document review and staff interview , the facility failed to document / conduct fire drills as required. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills.

Findings include:

A. On 11/09/2022 at 12:40om while accompanied by the POM documentation failed to indicate the transmission of a fire alarm signal to comply with 19.7.1.4. As part of the transmission requirements, there is no indication that the monitoring service achnowledges recieving a signal and at what time.

B. On 11/09/2022 at 12:45pm while accompanied by the POM documentation failed to demonstrate that staff are familiar with fire alarm devices in order to utilize the nearest manual device to comply with 19.7.1.8, 19.7.2.3.3

Based on observation and staff interview, the facility lacks complete electrical grounding/bonding of the medical gas piping system. Failure to install and maintain this installation could potentially result in the piping system becoming electrically energized. This deficient practice could affect patients, staff and visitors.

The finding is:

On 11/09/2022 at 10:50am while in the company of the POM it could not be confirmed through direct observation that electrical grounding of the facility's oygen farm has been completed. This is not in compliance with 2011 Edition of NFPA 70, Section 250.110. Further bonding of the medical gas piping system did not appear to be bonded to comply with NFPA 70, Section 250.104.