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Based on observation and interview, the facility failed to maintain the required building separation with functioning self-closers and positive latching on separation doors in accordance with NFPA 101 (2012 edition), 19.1.1.4 and 19.1.3.3. This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

On 3/5/18 at 2:46 PM, observation on the 3rd floor, at the occupancy separation doors between the hospital and west medical office building, revealed the door would not fully close to provide for positive latching and required separation.

This deficient practice was confirmed by Staff S at the time of discovery.

Based on observation and interview, the facility failed to maintain building construction type. Building construction type and stories as required by NFPA 101 (2012 edition), Sections meets Table 19.1.6.1, unless otherwise permitted by by NFPA 101 (2012 edition), Sections 19.1.6.2 through 19.1.6.7. This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 3/5/18 at 2:41 pm, observation revealed the construciton type was not being maintained in the Penthouse Mechanical Room. The bottom flange of the steel beam located at the roof access alternating tread device was missing spray fireproofing material for approximately 36". The condition was confirmed at the time of discovery by concurrent interview with Staff R.

Based on observation and interview, the facility failed to maintain egress doors. Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side. Where special locking arrangements for security needs are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants, as required by NFPA 101 (2012 edition), Sections 19.2.2.2.5.1, 19.2.2.2.6. This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 3/5/18 at 12:55 pm, observation revealed that the exit door serving the Emergency Department corridor was locked with a magnetic device that prevented unrestricted egress. The door hardware did not release the magnetic device. The condition was confirmed at the time of discovery by concurrent interview with Staff R.

Based on observation and interview, the facility failed to maintain exit discharge. Exit discharge is arranged as required by NFPA 101 (2012 edition), Sections in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface as required by NFPA 101 (2012 edition), Sections 19.2.7. This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 3/5/18 at 1:56 pm, observation revealed that exit door #6 lead to a construction area. The grade exit was an excavation area comprised of sand and dirt as well as egress was blocked with constrcution materials and no direct egress route to a discharge away from the building. The condition was confirmed at the time of discovery by concurrent interview with Staff R.

Based on observation and interview, the facility failed to maintain exit signage. Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system as required by NFPA 101 (2012 edition), Sections 19.2.10.1. This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 3/5/18 at 2:06 pm, observation revealed that Door #4 and Door #10 leading to exit stairways had signs attached that did not clearly provide direction. The signs attached to both doors stated "Danger Keep Out". The condition was confirmed at the time of discovery by concurrent interview with Staff R.

Based on record review and interview, the facility failed to inspect the sprinkler system as required by NFPA 101 (2012 edition), Sections 39.3.1.1 and 9.7, NFPA 13 (2010 edition) Section 8.15.10.3 and NFPA 25 (2011 edition) Table 5.1.1.2, 13.1.1.2 & Sections 5.2.4.1, 13.3.2.1.1, 13.6.1 & 13.6.1.1.1. These deficiencies had the potential to affect all patients as well as an undetermined number of staffs and visitors. These deficient practices were confirmed by Staff B (Director of Maintenance) at the time of discovery.

Findings include:

1. On 3/5/2018 at 12:30 PM, during review of the facility monthly fire sprinkler system inspection records it was revealed that the facility did not inspect the valves every month within the last year.

2. On 3/5/2018 at 12:35 PM, during review of the facility monthly fire sprinkler system inspection records it was revealed that the facility did not inspect the gauges every month within the last year.

3. On 3/5/2018 at 12:40 PM, during review of the facility monthly fire sprinkler system inspection records it was revealed that the facility did not inspect the back flow prevention valves and assemblies every month within the last year.

4. On 3/6/2018 at 11:30 AM, observation revealed at the Basement Elevator Equipment room that Elevator Equipment Room did not have sprinkler protection.

5. On 3/6/2018 at 11:15 AM, observation revealed at the Basement Electrical Equipment room that the Electical Equipment Room did not have sprinkler protection but was enclosed with a 2 hour rated wall. The door to the Electrical Equipment Room was not fire rated and was not equipped with a self or automatic closing device.

Based on observation and interview, the facility failed to provide self-closing doors with automatic positive latching and a sequencer/coordinator to provide separation between hazardous areas and other spaces in accordance with NFPA 101 (2012 edition), Sections 19.3.2.1.2, 19.3.2.1.5(7), 8.4.3.5 and 7.2.1.8. These deficient practices could affect all patients, and an undetermined number of staff and visitors.

Findings include:

1. On 3/5/18 at 12:39 PM, observation in the basement electrical storage room revealed a hazardous storage room greater than 50 square feet with combustible storage. A pair of double doors to the corridor had no sequencer/coordinator to ensure the doors closed in the proper sequence to provide for full closure and positive latching. The active door latched into the inactive door leaf which was outfitted with an upper and lower manual face bolt in-lieu-of an automatic flush bolt. This deficient practice was confirmed by Staff S at the time of discovery.

2. On 3/5/18 at 1:07 PM, observation in the basement laundry soiled utility room revealed a hazardous storage room greater than 50 square feet with combustible materials storage. The double doors leading to the corridor had up to a 3/8 inch gap at the leading edge between the door leaves with no astragal to resist the passage of smoke. This deficient practice was confirmed by Staff S at the time of discovery.

3. On 3/5/18 at 1:57 PM, observation on the 1st floor in the #11 soiled utility room in the operating room smoke compartment revealed the entry door would not provide positive latching. This deficient practice was confirmed by Staff S at the time of discovery.

4. On 3/6/18 at 10:59 am, observation on the 2nd floor in the 2064 storage room containing respiratory care supplies revealed a hazardous storage room with an entry door lacking a self-closer. The room was greater than 50 square feet with combustible material storage including plastic and plastic wrapped respiratory care supplies. This deficient practice was confirmed by Staff S at the time of discovery.

5. On 3/5/18 at 1:25 pm, observation in Patient Room 2017 revealed that the room was being used for storage containing a variety of health care supplies. The room failed to provide self-closing doors with automatic positive latching. The room was greater than 50 square feet with combustible material storage including boxed and wrapped in plastic stored on wire racks. This deficient practice was confirmed by Staff R at the time of discovery.

Based on record review, interview and observation, the facility failed to maintain cooking facilities in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.2.6.1 and 9.2.3; NFPA 96 - 2011 edition, Table 11.4, Section 11.6.1. and 11.6.13. These deficient practices could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 3/5/2018 at 1:45 PM, review of the documents revealed that the facility did not inspect and clean the kitchen range hood system at least every six months as required by NFPA 96 - 2011 edition, Table 11.4. The kitchen range hood was inspected and cleaned on 7/19/2017 by Legacy Services Corporation within the last year.

2. On 3/5/2018 at 1:50 PM, observation revealed inside the kitchen, that the name of the person that performed the hood system cleaning work on 7/19/2017 was not maintained in the certification sticker inside the kitchen.

These deficient practices were confirmed by Staff Q (Plant Operations), Staff R (Plant Operations & Construction Supervisor), Staff T (Administrative Assistant), & Staff U (Director of Facilities & Support Services) at the time of discovery.

Based on observation and interview, the facility failed to provide a fire alarm system in accordance with the requirements of NFPA 101 (2012 edition), 19.3.4 and 9.6 and NFPA 72 (2010 edition), 10.5.5.2.2, 10.5.5.2.3, 17.7.4.1 and 17.7.6.3.2. These deficient practices could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 3/5/18 at 12:54 PM, observation in the basement electrical and fire alarm panel room revealed a fire alarm disconnection means without red marking and with improper labeling. The disconnecting means was labeled BE1A-4B in-lieu-of Fire Alarm Circuit as required by the code.
2. On 3/5/18 at 1:34 PM, observation on the first floor in the gift shop revealed a ceiling-mounted smoke detector located 10 inches edge to edge from a 2 foot by 2 foot air diffuser.

These deficient practices were confirmed by Staff S at the time of discovery.

Based on record review and interview, the facility failed to test smoke detectors for sensitivity as required by NFPA 101 (2012 edition), Sections 19.3.4 and 9.6, and NFPA 72 (2010 edition) Sections 14.4.5.3, 14.4.5.3.1 and 14.4.5.3.2. This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

On 3/5/2016 at 12:15 PM, during review of the facility fire alarm testing records performed by Simplex Grinnell, it was discovered that smoke detectors located in the facility were not tested for sensitivity within the last two years. When asked, Staff Q mentioned that they were told by the outside vendor Simplex Grinnell that the facility did not need to test the smoke detectors sensitivity as the facility had an addressable fire alarm control unit.

This deficient practice was confirmed by Staff Q (Plant Operations), Staff R (Plant Operations & Construction Supervisor), Staff T (Administrative Assistant), & Staff U (Director of Facilities & Support Services) at the time of discovery.

Based on observation and staff interview, the facility did not ensure sprinkler protection is installed in all areas as required per NFPA 101 Life Safety Code (2012 edition) 19.3.5 & 9.7.1, and NFPA 13 (2010 edition). These deficient practices could affect all inpatients and an undetermined number of staff and visitors.

Findings include:

1. On 3/5/18 at 1:12 pm, observation revealed that Treatment Room #2015 was not sprinkler protected. Half of the suspended ceiling tile was missing that would affect the fire protection sprinkler function. The condition was confirmed at the time of discovery by concurrent interview with Staff R.

2. On 3/5/18 at 1:20 pm, observation revealed that Clean Linen Room #2017 was not sprinkler protected. Suspended ceiling tile; 2' x 2', 2' x 4' and 2' x 6' sections were missing that would affect the fire protection sprinkler function. The condition was confirmed at the time of discovery by concurrent interview with Staff R.

3. On 3/5/18 at 1:21 pm, observation revealed that Clean Utility Room #2018 was not sprinkler protected. Suspended ceiling tile; 2' x 6' section was missing that would affect the fire protection sprinkler function. The condition was confirmed at the time of discovery by concurrent interview with Staff R.

Based on observation, record review and interview, the facility failed to inspect the sprinkler system as required by NFPA 101 (2012 edition), Sections 19.3.5 and 9.7, NFPA 25 (2011 edition) Table 5.1.1.2, 13.1.1.2 & Sections 5.2.4.1, 13.3.2.1.1, 13.6.1 & 13.6.1.1.1 and NFPA 20 (2010 edition), Sections 4.12.1.1.4. These deficient practices could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 3/5/2018 at 12:30 PM, during review of the facility monthly fire sprinkler system inspection records it was revealed that the facility did not inspect the valves every month within the last year.

2. On 3/5/2018 at 12:35 PM, during review of the facility monthly fire sprinkler system inspection records it was revealed that the facility did not inspect the gauges every month within the last year.

3. On 3/5/2018 at 12:40 PM, during review of the facility monthly fire sprinkler system inspection records it was revealed that the facility did not inspect the back flow prevention valves and assemblies every month within the last year.

4. On 3/5/2018 at 2:30 PM, observation revealed in the Basement Fire Pump room, that the Fire Pump room was used for office and storage. A water quality control office was located inside the fire pump room with desk, computer, chair, books and office supplies. Three water softeners were installed inside the fire pump room that were not related to the operation of the fire pump. Also, twenty 50 lbs salt bags were stored on the three wooden crate inside the water pump room.

These deficient practices were confirmed by Staff Q (Plant Operations), Staff R (Plant Operations & Construction Supervisor), Staff T (Administrative Assistant), & Staff U (Director of Facilities & Support Services) at the time of discovery.

Based on observation and interview, the facility failed to provide corridor doors that meet the requirements of NFPA 101 (2012 edition), 19.3.6.3 and 19.3.6.3.1. This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

On 3/6/18 at 10:53 am, observation on the 2nd floor in the 2048 hyperbaric oxygen therapy room revealed a pair of corridor doors with no astragal and up to a 3/8 inch wide gap between the door leafs.

This deficient practice was confirmed by Staff S at the time of discovery.

Based on observation and interview, the facility failed to properly install and maintain the electrical system in accordance with NFPA 101 (2012 edition), 9.1.2 and 19.5.1 and NFPA 70 (2011 edition), Section 110.27. This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

On 3/5/18 at 2:13 PM, observation on the first floor in the cancer director's office above the drop ceiling revealed a 4 inch by 4 inch electrical box mounted on the ceiling with a missing cover.

This deficient practice was confirmed by Staff S at the time of discovery.

Based on interview and observation, the facility failed to provide an emergency electrical generator with a remote stop in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.5.1.1 & 9.1.3.1; NFPA 110 - 2010 edition, Sections 5.6.5.6 and 5.6.5.6.1. This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 3/5/2018 at 1:50 PM, observation revealed in the first floor generator room that two emergency generator's prime movers were located inside the generator room and remote manual stop stations were not provided outside the generator room.

This deficient practice was confirmed by Staff Q (Plant Operations) & Staff R (Plant Operations & Construction Supervisor) at the time of discovery.

Based on observation and staff interview, the facility did not ensure that extension cords are not used as a substitute for fixed wiring of a structure and that extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed, per NFPA 99 (2012 edition), 10.2.4 and NFPA 70 (2011 edition), 400.8. This deficient practice could affect all inpatients and an undermined number of staff and visitors.

Findings include:

1. On 3/5/18 at 1:17 pm, observation revealed within Office #202 that an extension cord was used to power a refrigerator and microwave oven. The condition was confirmed at the time of discovery by concurrent interview with Staff R.

Based on observation and interview, the facility failed to provide gas cylinder and container storage in accordance with NFPA 101 (2012 edition), 19.3.2, 19.3.2.4, and 8.7; as well as NFPA 99 (2012 edition), 5.1.3.3, 11.3.1 and 11.6.5. This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

On 3/5/18 at 1:18 PM, observation in the basement medical gas room revealed a 4 foot, 7 foot, and 4 foot (15 feet total) of rated gypsum drywall with the upper 5 foot portion with unprotected fasteners, and untaped and mudded drywall joints. The room contained a total of (8) cylinders each measuring 4 foot tall by 9" diameter in size, including four cylinders of nitrous oxide and four cylinders of nitrogen.

This deficient practice was confirmed by Staff S at the time of discovery.