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Based on observation and staff interview during the survey on October 3, 2018, it was determined that the facility failed to maintain sprinkler protected hazardous areas in accordance with Life Safety Section 19.3.2.1. The following evidenced this:

1) IT room has wall penetration through wire conduit. CORRECTED DURING SURVEY
2) Storage door in OR corridor does not positively latch.

The Hazard Area Enclosure deficiency has the potential to affect all room occupants, who might include staff, residents and visitors within all associated smoke compartments; items were discussed during the survey and again during the exit conference.

The maintenance director and ED acknowledged the hazardous area enclosures and door condition during a tour of the facility.

During the review of the facility records, with the staff on October 3, 2018, the facility failed to maintain the cooking equipment according to NFPA 96. The following evidenced this:

1) No commercial hood system installed above residential stove in inpatient break room.
2) Kitchen stoves and fryer are not equipped with floor cleats for proper placement.

The Cooking Facilities deficiency has the potential to affect all room occupants, who might include staff, residents and visitors all associated smoke compartments; items were discussed during the survey and again during the exit conference.

The maintenance director and ED acknowledge the lack of cleaning and inspection of the system during record review.

Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Based on observation and staff interview during the survey on October 3, 2018, it was determined that the facility failed to provide a safe location to install Alcohol Base Hand Rub Dispenser in accordance with Life Safety Code Chapter 19, Section 19.3.2.6. The following evidenced this:

1) ABHR dispenser mounted directly above electrical outlet next to patient room 117.

The ABHR deficiency has the potential to affect all room occupants, who might include staff, residents and visitors within all associated smoke compartments; items were discussed during the survey and again during the exit conference.


The maintenance director and ED acknowledged the (ABHR) location during a tour of the facility.

Life Safety Code 101, Section 19.3.2.6 Alcohol-Based Hand-Rub Dispensers shall be protected in accordance with 8.7.3, unless all of the following conditions are met:
(1) Where dispensers are installed in a corridor, the corridor shall have a minimum width of 6 ft. (1830mm).
(2) The maximum individual dispenser fluid capacity shall be as follows:
(a) 0.32 gallon (1.2.L) for dispensers in rooms, corridors, and areas open to corridors
(b) 0.53 gallon (2.0.L) for dispensers in suites of rooms
(3) Where aerosol containers are used, the maximum capacity of the aerosol dispenser shall be 18 oz. (051 kg) and shall be limited to Level I aerosol as defined in NFPA 30B, Code for the Manufacture and Storage of Aerosol Products.
(4) Dispensers shall be separated from each other by horizontal spacing of not less than 48 in. (1220mm).
(5) Not more than an aggregate 10 gal (37.8 L) of alcohol-based hand-rub solution or 1135 oz. (32.2 kg) of Level I aerosol not to exceed, in total, the equivalent of 10 gallons (37.8.L) or 1135 oz. (32.2 kg), shall be in use outside of a storage cabinet in a single smoke compartment, except as otherwise provided in 19.3.2.6 (6).
(6) One dispenser complying with 19.3.2.6 (2) or (3) per room and location in that room shall not be included in the aggregated quantity addressed in 19.3.2.6(5).
(7) Storage of quantities greater than 5 gallons (18.9 L) in a signal smoke compartment shall meet the requirements of (NFPA) 3, Flammable and Compostable Liquids Code.
(8) Dispensers shall not be installed in the following locations:
(a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source.
(b) To the side of an ignition source within a 1 in. (25 mm) horizontal distance from the ignition source.
(c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source
(9) Dispensers installed directly over carpeted floors shall be permitted only in sprinklered smoke compartments.
(10) The alcohol-based hand-rub solutions shall not exceed 95 percent alcohol content by
volume.
(11) Operation of the dispenser shall comply with the following criteria:
(a) The dispenser shall not release its contents except when the dispenser is activated
either manually or automatically by touch free activation.
(b) Any activation of the dispenser shall occur only when an object is placed within 4 in.
(100 mm) of the sensing device.
(c) An object placed within the activation zone and left in place shall not cause more than one activation.
(d) The dispenser shall not dispense more solution than the amount required for hand hygiene consistent with the label instructions.
(e) The dispenser shall be designed, constructed, and operated in a manner that ensures that accidental or malicious activation of the dispensing device is minimized.
(f) The dispenser shall be tested in accordance with the manufacture's care and use instructions each time a new refill is installed

Based on record review and staff interview during the survey, conducted on October 3, 2018, it was determined the facility failed to maintain the fire alarm system in accordance with NFPA 101, section 19.3.4. The following evidenced this:

1) OR 1 and OR 2 do not have proper visible notification for fire alarm system.

The Fire Alarm deficiency has the potential to affect all room occupants, who might include staff, residents and visitors within all associated smoke compartments; items were discussed during the survey and again during the exit conference.

Through a review of the records and discussion during the survey on October 3, 2018, it was determined the facility failed to inspect and test the fire alarm system per NFPA 101, Chapter 9 (Section 9.6 Paragraph 9.6.1.5) and NFPA 72, (Chapter 7, Paragraph 7-1.2.2). The following evidenced this:

1) Annual Fire Alarm inspection report shows FACP batteries need replaced. No documentation of replacement or repairs.
2) Strobe notifications do not flash in sequence during alarm in imaging corridor and ED corridor.

The Fire Alarm System deficiency has the potential to affect all room occupants, who might include staff, residents and visitors within all smoke compartments; items were discussed during the survey and again during the exit conference.

Maintenance Director and ED acknowledged the condition of testing the fire alarm system during the record review.

Based on observation and staff interview during the survey, October 3, 2018, it was determined the facility failed to install the automatic fire sprinkler system in accordance with NFPA 101, section 19.3.5, 19.3.5.1, 9.7, and NFPA 13. The following evidenced this:

1) Type V(000) shed approximately 18" from building is not equipped with an approved fire sprinkler system.

The Sprinkler System deficiency has the potential to affect all room occupants, who might include staff, residents and visitors within all associated smoke compartments; items were discussed during the survey and again during the exit conference.

Maintenance director and ED acknowledged the sprinkler system deficiency.

Based on record review, observation and staff interview during the course of the survey conducted on October 3, 2018, it was determined the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 101, section 19.3.5.1, 9.7, 9.7.5, NFPA 25 and NFPA 13. The following evidenced this:

1) No documentation for Fire Sprinkler internal pipe/obstruction inspection.
2) Escutcheon plate missing from FS head in patient bathroom #120, patient room 103, and Doctors lounge. CORRECTED DURING SURVEY.

The fire sprinkler deficiencies have the potential to affect all room occupants, who might include staff, residents and visitors within all associated smoke compartments; items were discussed during the survey and again during the exit conference.

NFPA 101 Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Based on observation, staff interview and record review on October 3, 2018, it was determined that the facility failed to maintain all portable fire extinguishers as required by Life Safety 101 and NFPA 10. The following evidenced this:

1) No portable fire extinguisher available for MRI room. Approved fire extinguisher required.
2) No portable fire extinguisher located in inpatient break room.

Maintenance director and ED acknowledged the lack of maintenance and inspection requirements of the portable fire extinguishers deficiency during record review of the facility.

The fire extinguisher deficiencies have the potential to affect all room occupants, who might include staff, residents and visitors within all associated smoke compartments; items were discussed during the survey and again during the exit conference.

Life Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire Extinguishers.

Based on observation and staff interview during the course of the survey conducted on October 3, 2018, it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 19.3.7.3 including 8.5. The following evidenced this:

1) Penetrations above ceiling in ED corridor, above ceiling at sterilization room, above ceiling in kitchen corridor, and above ceiling corridor side of soiled utility. CORRECTED DURING SURVEY

Maintenance Director and ED acknowledged the deficiency during a tour of the facility.

The smoke barrier deficiency has the potential to affect all occupants, who might include staff and visitors in all associated compartments; items were discussed during the survey and again during the exit conference.

Life Safety Code Section 19.3.7.3, in part, smoke barrier walls constructed in accordance with Section 8.5 with a minimum of 1/2-hour fire resistive rating. Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.

Through observation and record review during the survey on October 3, 2018, it was determined that the facility failed to maintain Electrical Systems in accordance with Life Safety Code, NFPA 70, and NFPA 99 Ch 6.
This was evidenced by the following:

1) Emergency generator is not equipped with an emergency power off (EPO) switch.
2) Open junction box above ceiling in conference room and above ceiling in dry goods. CORRECTED DURING SURVEY

The maintenance director and ED acknowledged the deficiency during the facility tour.

This deficiency has the potential to affect all occupants, who might include staff, residents and visitors within all smoke compartments; items were discussed during the survey and again during the exit conference.

Through observation and record review during the survey on October 3, 2018, it was determined that the facility failed to maintain Testing and Maintenance of Gas Equipment in accordance with NFPA 99 Ch 11.

This was evidenced by the following:

1) Exterior gas room has combustible storage inside. CORRECTED DURING SURVEY.

The Maintenance Director and ED acknowledged the deficiency during the facility tour.

This deficiency has the potential to affect all occupants, who might include staff, residents and visitors within all associated smoke compartments; items were discussed during the survey and again during the exit conference.