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Based on observation, the facility failed to maintain smoke barrier doors in conformance with NFPA guidelines.

The evidence includes:

Observation on December 8 & 9 , 2015 revealed the following deficiencies:

1. The double smoke barrier doors labeled 2AB-3B, had a large gap due to warping and misalignment.

2. The double smoke barrier doors labeled 2AB-2A, adjacent to room number 2002, were warped and had an excessive 1" cutout at the bottom as well as an open gap at the astragal greater than the 1/8" maximum allowance.

3. The double smoke barrier doors labeled 2AB-10A, adjacent to gastroenterolgy, required manual assistance to fully close.

4. The double smoke barrier doors labeled 2C-4A, are unable to fully close.

5. The double smoke barrier doors labeled 3AB-2B, required manual assistance to fully close.

6. The double smoke barrier doors in the vicinity of the main elevator bank on the first floor had a vertical gap greater than the 1/8" maximum allowance.

7. The double smoke barrier doors in the vicinity of room number 1001 had a vertical gap greater than the 1/8" maximum allowance.

8. The double smoke barrier doors in the vicinity of room number 1101 had a vertical gap greater than the 1/8" maximum allowance.

9. The double smoke barrier doors in the vicinity of room number 3002 had a vertical gap greater than the 1/8" maximum allowance.

10. The double smoke barrier doors in the vicinity of room number 1099 had a vertical gap greater than the 1/8" maximum allowance.

The facility maintenance representative confirmed the observations during the facility survey walk through.

Based on observations, the facility failed to maintain the required fire and smoke separation from hazardous areas in conformance with NFPA 101 Section 19.3.2.1.

The evidence includes:

Observation on the afternoon of December 9, 2015 revealed the following deficiency:

1. The corridor door servicing the uninterrupted power supply room number 217, was unable to fully close and latch without manual assistance.

The facility maintenance representative confirmed the observation during the facility survey walk through..

Based on observations, the facility failed to maintain the required fire and smoke separation from hazardous areas in conformance with NFPA 101 Section 19.3.2.1.

The evidence includes:

Observations during the facility survey walk through from December 8 through 10, 2015 revealed the following deficiencies:

1. The carpenter's shop corridor double door required manual assistance to fully close and latch.

2. The laundry corridor double door required manual assistance to fully close and latch.

3. The housekeeping, room 1015, corridor double door required manual assistance to fully close and latch.

4. The double corridor doors to the electrical/shop room required manual assistance to fully close and latch and had an open vertical gap between the door leafs which would facilitate the passage of smoke.

5. The double corridor doors to the general storage room had an open vertical gap between the door leafs which would facilitate the passage of smoke.

6. The corridor door servicing the radiology film handling storage room is not provided with the required self-closing and latching hardware.

7. The multiple rooms in acute care which are used for storage of combustibles are not provided with the required self-closing and latching hardware.

8. The corridor door servicing OR storage room number 2086 required manual assistance to fully close and latch.

The facility maintenance representative confirmed the observations during the survey walk through.

Based on observations, the facility failed to provide complete sprinkler coverage for all portions of the building as required by NFPA 101 Section 19.1.6.

The evidence includes:

A review of available documentation, staff interview and facility survey walk through revealed the following deficiencies:

1. Observations during the facility survey walk through on December 9, 2015 revealed that the installation of fire sprinklers for the loading dock was only partially completed. Full fire sprinkler coverage is required for the loading dock area.

2. Observation during the facility survey walk through on December 9, 2015 revealed that the fire sprinklers in the elevator machine room have been removed and the piping capped.

The elevator machine room fire construction is rated for one hour and requires fire sprinkler coverage,

The facility maintenance representative confirmed the observations during the facility survey walk through.

The facility failed to maintain the emergency generators in accordance with NFPA 99 Section 3.4.4.1 requirements.

The evidence includes:

The VICC building is serviced by a pair of emergency generators, one of which is utilized for redundancy.

Based on document review and staff interview, the facility failed to exercise the redundant generator weekly and run it under load for at least 30 minutes monthly.

In addition, documentation failed to record amperage readings for each of the three power legs during load testing, to verify that the generator is operating under a load equal to or greater than the nameplate rating of the equipment.

An annual load bank test is required for each generator if the 30% minimum load is not achieved every month of the calendar year.

The facility maintenance representative confirmed the findings during the document review and staff interview process.

The facility failed to maintain the emergency generators in accordance with NFPA 99 Section 3.4.4.1 requirements.

The evidence includes:

The main building is serviced by a pair of emergency generators, one of which is utilized for redundancy.

1. Based on document review and staff interview, the facility failed to exercise the redundant generator weekly and run it under load for at least 30 minutes monthly.

In addition, documentation failed to record amperage readings for each of the three power legs during load testing, to verify that the generator is operating under a load equal to or greater than the nameplate rating of the equipment.

An annual load bank test is required for each generator if the 30% minimum load is not achieved every month of the calendar year.

2. Based on document review and staff interview, the facility failed to provide full preventive maintenance services for each of the emergency generators.

As a direct result, the facility was without emergency power for an extended period of time during a power outage.

One emergency generator has been offline for most of the calendar year awaiting parts replacement.

The redundant emergency generator failed to operate during the power outage to the building.

The facility maintenance representative confirmed the findings during the document review and staff interview process.

Based on observation, the facility failed to maintain smoke barrier doors in conformance with NFPA guidelines.

The evidence includes:

Observation on December 8 & 9 , 2015 revealed the following deficiencies:

1. The double smoke barrier doors labeled 2AB-3B, had a large gap due to warping and misalignment.

2. The double smoke barrier doors labeled 2AB-2A, adjacent to room number 2002, were warped and had an excessive 1" cutout at the bottom as well as an open gap at the astragal greater than the 1/8" maximum allowance.

3. The double smoke barrier doors labeled 2AB-10A, adjacent to gastroenterolgy, required manual assistance to fully close.

4. The double smoke barrier doors labeled 2C-4A, are unable to fully close.

5. The double smoke barrier doors labeled 3AB-2B, required manual assistance to fully close.

6. The double smoke barrier doors in the vicinity of the main elevator bank on the first floor had a vertical gap greater than the 1/8" maximum allowance.

7. The double smoke barrier doors in the vicinity of room number 1001 had a vertical gap greater than the 1/8" maximum allowance.

8. The double smoke barrier doors in the vicinity of room number 1101 had a vertical gap greater than the 1/8" maximum allowance.

9. The double smoke barrier doors in the vicinity of room number 3002 had a vertical gap greater than the 1/8" maximum allowance.

10. The double smoke barrier doors in the vicinity of room number 1099 had a vertical gap greater than the 1/8" maximum allowance.

The facility maintenance representative confirmed the observations during the facility survey walk through.

Based on observations, the facility failed to maintain the required fire and smoke separation from hazardous areas in conformance with NFPA 101 Section 19.3.2.1.

The evidence includes:

Observation on the afternoon of December 9, 2015 revealed the following deficiency:

1. The corridor door servicing the uninterrupted power supply room number 217, was unable to fully close and latch without manual assistance.

The facility maintenance representative confirmed the observation during the facility survey walk through..

Based on observations, the facility failed to maintain the required fire and smoke separation from hazardous areas in conformance with NFPA 101 Section 19.3.2.1.

The evidence includes:

Observations during the facility survey walk through from December 8 through 10, 2015 revealed the following deficiencies:

1. The carpenter's shop corridor double door required manual assistance to fully close and latch.

2. The laundry corridor double door required manual assistance to fully close and latch.

3. The housekeeping, room 1015, corridor double door required manual assistance to fully close and latch.

4. The double corridor doors to the electrical/shop room required manual assistance to fully close and latch and had an open vertical gap between the door leafs which would facilitate the passage of smoke.

5. The double corridor doors to the general storage room had an open vertical gap between the door leafs which would facilitate the passage of smoke.

6. The corridor door servicing the radiology film handling storage room is not provided with the required self-closing and latching hardware.

7. The multiple rooms in acute care which are used for storage of combustibles are not provided with the required self-closing and latching hardware.

8. The corridor door servicing OR storage room number 2086 required manual assistance to fully close and latch.

The facility maintenance representative confirmed the observations during the survey walk through.

Based on observations, the facility failed to provide complete sprinkler coverage for all portions of the building as required by NFPA 101 Section 19.1.6.

The evidence includes:

A review of available documentation, staff interview and facility survey walk through revealed the following deficiencies:

1. Observations during the facility survey walk through on December 9, 2015 revealed that the installation of fire sprinklers for the loading dock was only partially completed. Full fire sprinkler coverage is required for the loading dock area.

2. Observation during the facility survey walk through on December 9, 2015 revealed that the fire sprinklers in the elevator machine room have been removed and the piping capped.

The elevator machine room fire construction is rated for one hour and requires fire sprinkler coverage,

The facility maintenance representative confirmed the observations during the facility survey walk through.

The facility failed to maintain the emergency generators in accordance with NFPA 99 Section 3.4.4.1 requirements.

The evidence includes:

The VICC building is serviced by a pair of emergency generators, one of which is utilized for redundancy.

Based on document review and staff interview, the facility failed to exercise the redundant generator weekly and run it under load for at least 30 minutes monthly.

In addition, documentation failed to record amperage readings for each of the three power legs during load testing, to verify that the generator is operating under a load equal to or greater than the nameplate rating of the equipment.

An annual load bank test is required for each generator if the 30% minimum load is not achieved every month of the calendar year.

The facility maintenance representative confirmed the findings during the document review and staff interview process.

The facility failed to maintain the emergency generators in accordance with NFPA 99 Section 3.4.4.1 requirements.

The evidence includes:

The main building is serviced by a pair of emergency generators, one of which is utilized for redundancy.

1. Based on document review and staff interview, the facility failed to exercise the redundant generator weekly and run it under load for at least 30 minutes monthly.

In addition, documentation failed to record amperage readings for each of the three power legs during load testing, to verify that the generator is operating under a load equal to or greater than the nameplate rating of the equipment.

An annual load bank test is required for each generator if the 30% minimum load is not achieved every month of the calendar year.

2. Based on document review and staff interview, the facility failed to provide full preventive maintenance services for each of the emergency generators.

As a direct result, the facility was without emergency power for an extended period of time during a power outage.

One emergency generator has been offline for most of the calendar year awaiting parts replacement.

The redundant emergency generator failed to operate during the power outage to the building.

The facility maintenance representative confirmed the findings during the document review and staff interview process.