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Based on observations, means of egress components were not being maintained free and clear of obstructions per NFPA 101, 2012 Edition, Section 7.1.10.1. These deficiencies affect 2 exits.

Findings include:

1. During an observation on 7/24/17 at 11:30 a.m., in smoke compartment 1I, a loading dock exit was blocked by carts.

2. During an observation on 7/25/17 at 11:25 a.m., in smoke compartment 2C, the southwest exit from Behavioral Health there was a car parked at the end of the public way.

Based on observation, fire doors in horizontal exits must closed when exercised per NFPA 80 Standard for Fire Doors and other Opening Protectives, 2010 Edition, Section 6.1.4.2. This deficiency affects 1 of 2, 2nd floor smoke compartments.

Findings include:

1. During an observation of building 2J, on 7/25/17 at 11:00 a.m., the eastern door of the double, 2-hour rated fire doors would not close and latch when exercised.

Based on observations, cross corridor doors in rated horizontal exits were not being maintained per NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, Sections 5.1.3.2 and 5.2.4. These deficiencies affects 1 of 11, 1st floor and 2 of 12, 2nd floor smoke compartments.

Findings include:

1. During an observation on 7/24/17 at 4:00 p.m., in smoke compartment 1F, Radiation Oncology and Physical Therapy corridor south most door failed to latch.

2. During an observation on 7/25/17 at 11:45 a.m., between smoke compartments 2C & 2B, the 2-hour doors contained holes in the doors themselves.

Based on observations, firewall ratings were not being maintained because of penetrations or improper wall ratings and not being maintained per NFPA 101, 2012 Edition, Section 19.3.6.2.2. The deficiencies affect 3 of 12, 2nd floor smoke compartments.

Findings include:

1. During an observation on 7/25/17 at 12:20 p.m., the cross corridor smoke barrier doors in smoke compartment 2E, near room 2606, failed to latch.

2. During an observation on 7/25/17 at 3:00 p.m., the 2-hour rated wall in smoke compartment 2D was observed. The west fire wall contained a one inch conduit sleeve which was not sealed on both ends to maintain the fire rating of the wall.

3. During an observation on 7/25/17 at 3:30 p.m., room 2633 of smoke compartment 2E, above the lay in ceiling a 4 inch by 8 inch penetration of the rated fire wall was observed. A damper rod goes through this penetration.

4. During an observation on 7/25/17 at 3:40 p.m., the ICU waiting room wall in smoke compartment 2F indicated as 2-hour on the floor plans was reviewed. The plan did not match the actual 1-hour rating of the wall.

Based on observations, exit signs lacked proper directional indicators or were not existent per NFPA 101, 2012 Edition, Section 19.2.10. These deficiencies affect 1 of 2 smoke compartment exits and 1 of 4 smoke compartment exits from another smoke compartment.

Findings include:

1. During an observation of the Professional Wing suite of rooms, compartment 2M at 9:40 a.m. on 7/25/17, the exit sign near elevator #1 had directional indicators in the exit sign that were pointed in the wrong direction.

2. During an observation from the same day surgery area in smoke compartment 2I, on 7/25/17 at 11:55 a.m., the area lacked an exit sign directing evacuees to the correct means of egress.

Based on observations, a vertical opening between floors was not protected per NFPA 101, 2012 Edition, Section 8.3.5.1 and an elevator lobby enclosure door failed to latch per NFPA 101, 2012 Edition, Section 9.4. These deficiencies affect two patient tower floors (2nd & 3rd) and one smoke compartment on each floor.

Findings include:

1. During observation of smoke compartment 2J, on 7/25/17 at 10:00 a.m., the east side elevator enclosure south east door rated for 1 hour failed to latch.

2. During observation of smoke compartment 2J, on 7/25/17 at 10:40 a.m., a conduit between the 2nd and 3rd floor was not sealed with fire rated material at the 2nd floor level.

Based on observations, the corridor doors to the boiler room doors failed to latch and hardware for rated doors was missing per NFPA 101, 2012 Edition, Section 19.3.2.1.2 and NFPA 80 Fire Doors and other Opening Protectives, 2010 Edition, Section 5.2 Inspections. These deficiencies affect 2 of 11, 1st floor smoke compartments.

Findings include:

1. During an observation on 7/24/17 at 12:30 p.m., in smoke compartment 1C, doors into the boiler rooms west door failed to latch.

2. During an observation on 7/24/17 at 12:30 p.m., in smoke compartment 1B, the laundry room double doors, rated at 1.5 hours, on the north end had two out of six screws missing from the top hinge.

Based on observation, the automatic sprinkler system coverage for mechanical room F was not adequate below a four foot wide duct per NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.5.3.1. This deficiency affects 1 of 12, 1st floor smoke compartments.

Findings include:
1. During an observation on 7/24/17 at 2:20 p.m., in smoke compartment 1D, Mechanical room F, two Heating Ventilation and Air Conditioning (HVAC) truck lines were greater than 4 feet in width and there was not sprinkler coverage underneath them.

Based on observations, the automatic fire sprinkler system was not being maintained to ensure required performance when needed per NFPA 25 Standard for Inspection, Testing, and Maintenance of Water-Based Fire Spray Systems, 2011 Edition. These deficiencies affect 2 of 11, 1st floor and 2 of 12, 2nd floor smoke compartments.

Findings include:

1. During an observation on 7/24/17 at 11:45 a.m., in smoke compartment 1B, a soiled laundry area lint was on three sprinkler heads and one cover for the light canopy.

2. During an observation on 7/24/17 at 12:00 p.m., in smoke compartment 1B, a dryer room had lint on sprinkler heads and lights.

3. During an observation on 7/24/17 at 2:50 p.m., in smoke compartment 1F Radiology Oncology, one escutcheon ring was missing on a sprinkler head.

4. During an observation on 7/25/17 at 9:50 a.m., in smoke compartment 2I Pharmacy, the storage bathroom sprinkler head was not the same type of head as all others in this smoke zone.

5. During an observation on 7/25/17 at 11:12 a.m., in smoke compartment 2C Behavioral Health Nutrition Room,one sprinkler escutcheon ring was missing on a sprinkler head.

Based on observation, power strip usage was reviewed per NFPA 99 Health Facilities Code, 2012 Edition, Section 10.2.3.6. These deficiencies affect 2, 2nd floor smoke compartments.

Findings include:

1. During an observation of building 2M, Room 2731 on 7/25/17 at 8:30 a.m., a microwave oven was plugged into a power strip. A microwave oven is considered a high amperage device and shall be plugged directly into the facility wiring.

2. During an observation of building 2F, in the ER Suite at 12:10 p.m. on 7/25/17, two power strips were suspended from their electrical cord without support.

Based on observations, the use of extension cords in permanent installations and correct power strip usage was reviewed per NFPA 99 Health Facilities Code, 2012 Edition, Sections 10.2.2.4 and 10.2.3.6. These deficiencies affect data rooms and a patient room on three of the four floors of the patient tower.

Findings include:

1. During an observation of smoke compartment 2J, 2nd floor data room #1 on 7/25/17 at 10:20 a.m., an extension cord was in use and plugged into a UPS station.

2. During an observation of smoke compartment 3B, in Room 3177 at 2:40 p.m. on 7/25/17, a power strip was found hanging from the power cord to the device.

3. During an observation of smoke compartment 3B, in the 3rd floor data room #1 at 2:50 p.m. on 7/25/17, an extension cord was in use and plugged into a UPS station.

4. During an observation of smoke compartment 4B, in the 4th floor data room #1 at 3:00 p.m. on 7/25/17, an extension cord was in use.