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Based on observation and staff interview, the facility failed to provide a smoke barrier that would resist the passage of smoke. This condition had the potential to allow smoke to migrate between smoke compartments.

Findings are:
Observation above ceiling during the facility tour on 4/6/15, at 11:57 am revealed a hole around a data cable and a copper pipe above the smoke doors by Administration failed to be sealed.
In an interview conducted at the time of observation, (4/6/15, at 11:57 am), Maintenance A confirmed the findings.

Based on record review and staff interview, the facility failed to conduct fire drills in accordance with the National Fire Protection Association 101. This condition would not provide simulated training for staff to respond to a fire emergency.

Findings are:
Record review of fire drills during the survey on 4/6/15 at 10:03 am revealed:
1. Fire drill times failed to be varied, and were conducted within the same hour of each drill during the 3rd shift of 2015 and 2014.
2. A fire drill failed to be documented for the 2nd Shift in the 2nd Quarter of 2014.
3. Fire drills for the lab failed to be conducted quarterly, as only one fire drill was documented over the last year.
In an interview conducted at the time of record review (4/6/15 at 10:03 am), Maintenance A acknowledged the findings.

NFPA 101, 2000, 19.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

NFPA 99, 10-2.1.4.3*
(Lab) Fire exit drills shall be conducted at least quarterly. Drills shall be so arranged that each person shall be included at least annually.

Based on observation and staff interview, the facility failed to maintain and provide sprinkler protection in all areas of the facility. This condition would prevent a fire from being suppressed by the sprinkler system.

Findings are:
Observations during the facility tour on 4/6/15, from 10:31 am to 11:22 am revealed:
1. Ceiling tiles failed to be replaced in the IT Server Room to prevent the delay of sprinkler activation.
2. A sprinkler head failed to be installed in the Gift Shop Storage Room, in the otherwise full sprinkler protected facility.
In an interview conducted at the time of observation, (4/6/15, from 10:31 am to 11:22 am), Maintenance B confirmed the findings after speaking with the architect in reference to the absence of a sprinkler head in the Gift Shop Storage Room.

NFPA 13, 1999, 5-1.1*
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

Based on observation and staff interview, the facility failed to secure oxygen bottles and other compressed gas cylinders to prevent the bottles from tipping over. This condition had the potential to cause an injury to an occupant.

Findings are:
Observation during the facility tour on 4/6/15, from 10:24 am to 11:14 am revealed:
1. Three Oxygen bottles in the Oxygen Storage/Supply Room were free-standing, and failed to be secured.
2. A carbon dioxide bottle in the Kitchen was free-standing, and failed to be secured.
In an interview conducted at the time of observation, (4/6/15, from 10:24 am to 11:14 am), Maintenance A acknowledged the compressed air bottles failed to be secured.

Actual NFPA Standard:
NFPA 99, 1999 ed, 4-3.1.1* Source - Level 1.
4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Based on record review and staff interview, the facility failed to maintain humidity levels in operating rooms in accordance with the National Fire Protection Association 99 throughout the last year. This condition created the potential for a burn or fire to occur during a procedure.

Findings are:
Record review during the facility tour on 4/6/15, at 11:50 am of OR humidity levels revealed all Operating Rooms failed to have humidity levels maintained at a minimum of 35% consistently throughout the last 12 months.
In an interview conducted at the time of record review, (4/6/15, at 11:50 am), Maintenance A acknowledged the humidity levels recorded failed to consistently be at 35% or greater for the past year.

Based on record review and staff interview, the facility failed to maintain the emergency generator in accordance with the National Fire Protection Association (NFPA), 110. This condition increased the potential that the generator would fail to run during loss of power.

Findings are:
Record review on 4/6/15, at 9:36 am of the provided emergency generator maintenance revealed the documentation failed to exhibit information for weekly and monthly testing in accordance with NFPA 110:
1. Documentation that the generator picked up the emergency system load within 10 seconds after loss of normal power failed to be recorded.
2. An inspection for the 4th week in December 2014 failed to be documented.
In an interview conducted at the time of record review, (4/6/15, at 9:36 am), Maintenance A confirmed that the generator testing documentation failed to be completed.

Actual NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
NFPA 99, 1999, 3-4.1.1.8 + Load Pickup.
The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 3-4.1]

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with the National Fire Protection Association 70. This condition had the potential to cause an electrical fire.

Findings are:
Observation during the facility tour on 4/6/15, from 10:53 am to 11:21 am revealed:
1. A coffee maker in the Report Room was plugged into a power strip, and the heat-producing appliance failed to be plugged directly into a hard wired outlet.
2. A refrigerator in the CT Control Room was plugged into a power strip, and the appliance failed to be plugged directly into a hard wired outlet.
3. An extension cord in Room 206 failed to not be used in lieu of permanent wiring. Appliances were also plugged into a power strip, and failed to be plugged directly into a hard wired outlet.
4. A microwave in Room 208 was plugged into a power strip, and the heat-producing appliance failed to be plugged directly into a hard wired outlet.
5. Clearance around electrical panels failed to be maintained in the electrical room by Vending due to tables and chairs stored in the room.
6. Power strips were daisy chained in the IT Office, and failed to be plugged directly into a hard wired outlet.
In an interview conducted at the time of observation (4/6/15, from 10:53 am to 11:21 am), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to provide a smoke barrier that would resist the passage of smoke. This condition had the potential to allow smoke to migrate between smoke compartments.

Findings are:
Observation above ceiling during the facility tour on 4/6/15, at 11:57 am revealed a hole around a data cable and a copper pipe above the smoke doors by Administration failed to be sealed.
In an interview conducted at the time of observation, (4/6/15, at 11:57 am), Maintenance A confirmed the findings.

Based on record review and staff interview, the facility failed to conduct fire drills in accordance with the National Fire Protection Association 101. This condition would not provide simulated training for staff to respond to a fire emergency.

Findings are:
Record review of fire drills during the survey on 4/6/15 at 10:03 am revealed:
1. Fire drill times failed to be varied, and were conducted within the same hour of each drill during the 3rd shift of 2015 and 2014.
2. A fire drill failed to be documented for the 2nd Shift in the 2nd Quarter of 2014.
3. Fire drills for the lab failed to be conducted quarterly, as only one fire drill was documented over the last year.
In an interview conducted at the time of record review (4/6/15 at 10:03 am), Maintenance A acknowledged the findings.

NFPA 101, 2000, 19.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

NFPA 99, 10-2.1.4.3*
(Lab) Fire exit drills shall be conducted at least quarterly. Drills shall be so arranged that each person shall be included at least annually.

Based on observation and staff interview, the facility failed to maintain and provide sprinkler protection in all areas of the facility. This condition would prevent a fire from being suppressed by the sprinkler system.

Findings are:
Observations during the facility tour on 4/6/15, from 10:31 am to 11:22 am revealed:
1. Ceiling tiles failed to be replaced in the IT Server Room to prevent the delay of sprinkler activation.
2. A sprinkler head failed to be installed in the Gift Shop Storage Room, in the otherwise full sprinkler protected facility.
In an interview conducted at the time of observation, (4/6/15, from 10:31 am to 11:22 am), Maintenance B confirmed the findings after speaking with the architect in reference to the absence of a sprinkler head in the Gift Shop Storage Room.

NFPA 13, 1999, 5-1.1*
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

Based on observation and staff interview, the facility failed to secure oxygen bottles and other compressed gas cylinders to prevent the bottles from tipping over. This condition had the potential to cause an injury to an occupant.

Findings are:
Observation during the facility tour on 4/6/15, from 10:24 am to 11:14 am revealed:
1. Three Oxygen bottles in the Oxygen Storage/Supply Room were free-standing, and failed to be secured.
2. A carbon dioxide bottle in the Kitchen was free-standing, and failed to be secured.
In an interview conducted at the time of observation, (4/6/15, from 10:24 am to 11:14 am), Maintenance A acknowledged the compressed air bottles failed to be secured.

Actual NFPA Standard:
NFPA 99, 1999 ed, 4-3.1.1* Source - Level 1.
4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Based on record review and staff interview, the facility failed to maintain humidity levels in operating rooms in accordance with the National Fire Protection Association 99 throughout the last year. This condition created the potential for a burn or fire to occur during a procedure.

Findings are:
Record review during the facility tour on 4/6/15, at 11:50 am of OR humidity levels revealed all Operating Rooms failed to have humidity levels maintained at a minimum of 35% consistently throughout the last 12 months.
In an interview conducted at the time of record review, (4/6/15, at 11:50 am), Maintenance A acknowledged the humidity levels recorded failed to consistently be at 35% or greater for the past year.

Based on record review and staff interview, the facility failed to maintain the emergency generator in accordance with the National Fire Protection Association (NFPA), 110. This condition increased the potential that the generator would fail to run during loss of power.

Findings are:
Record review on 4/6/15, at 9:36 am of the provided emergency generator maintenance revealed the documentation failed to exhibit information for weekly and monthly testing in accordance with NFPA 110:
1. Documentation that the generator picked up the emergency system load within 10 seconds after loss of normal power failed to be recorded.
2. An inspection for the 4th week in December 2014 failed to be documented.
In an interview conducted at the time of record review, (4/6/15, at 9:36 am), Maintenance A confirmed that the generator testing documentation failed to be completed.

Actual NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
NFPA 99, 1999, 3-4.1.1.8 + Load Pickup.
The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 3-4.1]

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with the National Fire Protection Association 70. This condition had the potential to cause an electrical fire.

Findings are:
Observation during the facility tour on 4/6/15, from 10:53 am to 11:21 am revealed:
1. A coffee maker in the Report Room was plugged into a power strip, and the heat-producing appliance failed to be plugged directly into a hard wired outlet.
2. A refrigerator in the CT Control Room was plugged into a power strip, and the appliance failed to be plugged directly into a hard wired outlet.
3. An extension cord in Room 206 failed to not be used in lieu of permanent wiring. Appliances were also plugged into a power strip, and failed to be plugged directly into a hard wired outlet.
4. A microwave in Room 208 was plugged into a power strip, and the heat-producing appliance failed to be plugged directly into a hard wired outlet.
5. Clearance around electrical panels failed to be maintained in the electrical room by Vending due to tables and chairs stored in the room.
6. Power strips were daisy chained in the IT Office, and failed to be plugged directly into a hard wired outlet.
In an interview conducted at the time of observation (4/6/15, from 10:53 am to 11:21 am), Maintenance A acknowledged the findings.