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Through observation during the survey, September 21 and 22, 2015, it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Maintenance Director;
1) The Medical Records corridor door would not latch into the frame.
2) The OR area janitor's closet door (4188) would not latch into the frame.
3) Patient room 101 (door 3181) was blocked open with a trash can. This item corrected during the survey.


These deficiencies could effect three of three smoke compartments.

Through observation during the survey, September 21 and 22, 2015, it was determined that the facility failed to maintain the smoke barrier walls.
 

During the walk through of the facility, with the Maintenance Director;
1) The Material Management north wall had a conduit penetration that was not sealed.
2) The smoke barrier wall above door 2101 had a hole through the wall not sealed.
3) The smoke barrier wall above door 2194 had pipe penetrations that were not sealed and pipe penetrations sealed with spray foam not listed for commercial use.


These deficiencies could effect three of three smoke compartments.

Through observation, during the survey September 21 and 22, 2015, it was determined that the facility failed to maintain the smoke barrier doors.
 

During the walk through of the facility, with the Maintenance Director, the smoke barrier doors 1109 did not close and seal.


This deficiency could effect two of three smoke compartments.

Through observation during the survey, conducted September 21 and 22, 2015, it was determined that the facility failed to maintain the dead end corridors.


During the walk through of the facility, with the Maintenance Director;
1) The Old Med Surgery East Hall, the south exit was locked creating a dead end corridor of forty five feet.
2) The old ER door to exterior was locked with no panic hardware creating a dead end corridor.



These deficiencies could effect two of four smoke compartments.

Through observation, during the survey conducted September 21 and 22, 2015, it was determined that the facility failed to maintain the corridors free of obstructions.
 

During the walk through of the facility, with the Maintenance Director, there were storage boxes stacked in the back corridor by the loading dock, through out the entire survey.


This deficiency could effect one of three smoke compartments.

Through record review and observation during the survey, September 21 and 22, 2015, it was determined that the facility failed to maintain the emergency lighting systems.
 

During the review of the facility ' s records, with the Maintenance Director, staff could not provide documentation of the required monthly thirty-second (30) test, and the annual 1-1/2-hour (90 minute) test of the battery operated emergency lighting per 2000 Edition NFPA 101 section 7.9.3.


This deficiency could effect the entire facility.

Through record review and observation during the survey, September 21 and 22, 2015, it was determined that the facility failed to maintain the emergency lighting systems.
 

During the review of the facility ' s records, with the Maintenance Director, the was no documentation available for the annual 90 minute emergency lighting testing.


This deficiency could effect the entire facility.

Through observation and record review during the survey, September 21 and 22, 2015, it was determined the facility failed to inspect, test and maintain the automatic sprinkler system per NFPA 25.
 

During the walk through of the facility, with the Maintenance Director, documentation was not available to indicate the quarterly testing of the sprinkler supervisory switches and flow alarms. Per 1999 Edition of NFPA 25, Chapter 2, section 2-3.3.


This deficiency could effect the entire facility.

Through observation during the survey, September 21 and 22, 2015, it was determined the facility failed to maintain the automatic sprinkler system in reliable operating condition.
 

During the walk through of the facility with the Maintenance Director;
1) The sprinkler riser gauges were dated 2008 and 2009, sprinkler gauges shall be replaced or re-calibrated every five years.
2) The Equipment Storage room 1104, had storage within 18" of the sprinkler head.



These deficiencies could effect the entire facility.

Through observation during the survey, Semptember 21 and 22, 2015, it was determined that the facility failed to maintain the Lab liquid flammables.

During a walk through of the facility with the Maintenance Director, the Lab Stoage room flammable cabinet was left open.


This deficiency could effect one of three smoke compartments.

Through observation during the survey, September 21 and 22, 2015, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70.
 

During the walk through of the facility, with the Maintenance Director, the plug strips in the raised office area were daisy chained together.



This deficiency could effect one of one smoke compartment.

Through observation during the survey, September 21 and 22, 2015, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70.
 

During the walk through of the facility, with the Maintenance Director;
1) Room OB2, plug strips were daisy chained together.
2) Basement Boiler Room, extension cord connected to light fixture.


These deficiencies could effect two of four smoke compartments.

Through observation during the survey, September 21 and 22, 2015, it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Maintenance Director;
1) The Medical Records corridor door would not latch into the frame.
2) The OR area janitor's closet door (4188) would not latch into the frame.
3) Patient room 101 (door 3181) was blocked open with a trash can. This item corrected during the survey.


These deficiencies could effect three of three smoke compartments.

Through observation during the survey, September 21 and 22, 2015, it was determined that the facility failed to maintain the smoke barrier walls.
 

During the walk through of the facility, with the Maintenance Director;
1) The Material Management north wall had a conduit penetration that was not sealed.
2) The smoke barrier wall above door 2101 had a hole through the wall not sealed.
3) The smoke barrier wall above door 2194 had pipe penetrations that were not sealed and pipe penetrations sealed with spray foam not listed for commercial use.


These deficiencies could effect three of three smoke compartments.

Through observation, during the survey September 21 and 22, 2015, it was determined that the facility failed to maintain the smoke barrier doors.
 

During the walk through of the facility, with the Maintenance Director, the smoke barrier doors 1109 did not close and seal.


This deficiency could effect two of three smoke compartments.

Through observation during the survey, conducted September 21 and 22, 2015, it was determined that the facility failed to maintain the dead end corridors.


During the walk through of the facility, with the Maintenance Director;
1) The Old Med Surgery East Hall, the south exit was locked creating a dead end corridor of forty five feet.
2) The old ER door to exterior was locked with no panic hardware creating a dead end corridor.



These deficiencies could effect two of four smoke compartments.

Through observation, during the survey conducted September 21 and 22, 2015, it was determined that the facility failed to maintain the corridors free of obstructions.
 

During the walk through of the facility, with the Maintenance Director, there were storage boxes stacked in the back corridor by the loading dock, through out the entire survey.


This deficiency could effect one of three smoke compartments.

Through record review and observation during the survey, September 21 and 22, 2015, it was determined that the facility failed to maintain the emergency lighting systems.
 

During the review of the facility ' s records, with the Maintenance Director, staff could not provide documentation of the required monthly thirty-second (30) test, and the annual 1-1/2-hour (90 minute) test of the battery operated emergency lighting per 2000 Edition NFPA 101 section 7.9.3.


This deficiency could effect the entire facility.

Through record review and observation during the survey, September 21 and 22, 2015, it was determined that the facility failed to maintain the emergency lighting systems.
 

During the review of the facility ' s records, with the Maintenance Director, the was no documentation available for the annual 90 minute emergency lighting testing.


This deficiency could effect the entire facility.

Through observation and record review during the survey, September 21 and 22, 2015, it was determined the facility failed to inspect, test and maintain the automatic sprinkler system per NFPA 25.
 

During the walk through of the facility, with the Maintenance Director, documentation was not available to indicate the quarterly testing of the sprinkler supervisory switches and flow alarms. Per 1999 Edition of NFPA 25, Chapter 2, section 2-3.3.


This deficiency could effect the entire facility.

Through observation during the survey, September 21 and 22, 2015, it was determined the facility failed to maintain the automatic sprinkler system in reliable operating condition.
 

During the walk through of the facility with the Maintenance Director;
1) The sprinkler riser gauges were dated 2008 and 2009, sprinkler gauges shall be replaced or re-calibrated every five years.
2) The Equipment Storage room 1104, had storage within 18" of the sprinkler head.



These deficiencies could effect the entire facility.

Through observation during the survey, Semptember 21 and 22, 2015, it was determined that the facility failed to maintain the Lab liquid flammables.

During a walk through of the facility with the Maintenance Director, the Lab Stoage room flammable cabinet was left open.


This deficiency could effect one of three smoke compartments.

Through observation during the survey, September 21 and 22, 2015, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70.
 

During the walk through of the facility, with the Maintenance Director, the plug strips in the raised office area were daisy chained together.



This deficiency could effect one of one smoke compartment.

Through observation during the survey, September 21 and 22, 2015, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70.
 

During the walk through of the facility, with the Maintenance Director;
1) Room OB2, plug strips were daisy chained together.
2) Basement Boiler Room, extension cord connected to light fixture.


These deficiencies could effect two of four smoke compartments.