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Based on observation during the course of the survey conducted on September 11-12 2012, it was determined the facility failed to maintain/provide a valid two-hour fire rated occupancy separation between the Existing Health Care Occupancy and adjoining non-Health Care Occupancy in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, there were conduit penetrations in the wall separating the two occupancies and the wood-frame roof was connected between the two occupancies without any separation.

Based on observation during the course of the survey conducted on September 11-12 2012, it was determined the facility failed to provide complete fire sprinkler protection throughout in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, the construction type II (111) of the building was not maintained. There were access panels to the attic that no longer self-closed, it appears rated hard lid ceilings were replaced with drop tile ceilings and renovations where unprotected ductwork, lighting and conduits now passed unprotected through the rated ceiling.

Based on observation during the course of the survey conducted on September 11-12 2012, it was determined the facility failed to maintain the doors that protect the corridors in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, wedges were observed obstructing the closing of corridor doors at the front office, the mail room, the nurses lounge and the cast room. There were roller latches in corridor doors to the recovery room, the cast room, the trauma room and to ER2. Additionally, the corridor door to ER1 was a dutch type door and the door does not meet latching, astragal or smoke seal requirements.

Based on observation during the course of the survey conducted on September 11-12 2012, it was determined the facility failed to provide proper hold open devices on corridor doors protecting vertical openings and hazardous areas in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, the corridor doors to various areas that are required to be automatic-closing did not have proper corridor detection or spot detection for the doorways; the facility shall have detection properly installed where required.

Based on observation during the course of the survey conducted on September 11-12 2012, it was determined the facility failed to maintain the smoke barriers in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, the smoke barrier wall above the ceiling penetrations of various sizes through it.

Based on observation during the course of the survey conducted on September 11-12 2012, it was determined the facility failed to maintain the separation of hazardous areas in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, the door to lab storage and the nurses lounge meet hazardous area definition guidance of NFPA 101 Section 19.3.2.1 but were not one-hour rated or self-closing/automatic-closing corridor doors.

Based on observation during the course of the survey conducted on September 11-12 2012, it was determined the facility failed to provide/maintain exit components in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, the door at the top of the stairway was not labeled as ¾-hour fire rated.

Based on observation during the course of the survey conducted on September 11-12 2012, it was determined the facility failed to maintain exit access ready and accessible at all times in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, there were non-compliant double keyed cylinder locks on the lab storage room and the blood draw room.

Based on record review and staff interview during the course of the survey conducted on September 11-12 2012, it was determined the facility failed to conduct fire drills in accordance with NFPA 101. The following evidenced this:
During the review of the facility records with the maintenance staff, it was confirmed the shift schedules were first shift from 0700-1900 and second shift 1900-0700; documentation provided only showed one fire drill during the second shift hours in the past twelve months.

Based on observation during the course of the survey conducted on September 11-12 2012, it was determined the facility failed to provide fire alarm system components in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, manual pull stations were located too high in the corridor by the laboratory and in the stairway and the fire alarm dialer was without electronic supervision.

Based on observation during the course of the survey conducted on September 11-12 2012, it was determined the facility failed to provide an automatic fire sprinkler system in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, there were no fire sprinklers installed on the first floor or the bottom of the elevator pit and the basement only had partial fire sprinkler protection.

Based on observation and record review during the course of the survey conducted on September 11-12 2012, it was determined the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 101. The following evidenced this:
1.) During the walkthrough of the facility with the maintenance staff, the water flow pattern of the fire sprinkler head in the hydro therapy room was obstructed and there was an upright sprinkler head observed in the pendant position in the stairway.
2.) During the review of the facility records with the maintenance staff, documentation was not provided to show any testing of the water flow devices since December 21, 2009 and the tamper devices were only being tested annually instead of semiannually.

Based on observation and record review during the course of the survey conducted on September 11-12 2012, it was determined the facility failed to provide a Kitchen Hood Suppression System in accordance with NFPA 101. The following evidenced this:
1.) During the walkthrough of the facility with the maintenance staff, the roof termination of the exhaust duct was not compliant.
2.) During the review of the facility records with the maintenance staff, documentation provided showed the kitchen suppression hood was not interconnected with the building fire alarms system.

Based on observation during the course of the survey conducted on September 11-12 2012, it was determined the facility failed to maintain the clear and usable width of the means of in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, there was storage observed in the stairway and in the corridor by respiratory therapy room.

Based on observation and record review during the course of the survey conducted on September 11-12 2012, it was determined the facility failed to install loosely hanging fabrics in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, there were decorations observed in the corridor and a folding fabric partition in the corridor by respiratory therapy; documentation was not provided to show fire retarded properties of the decorations/fabrics.

Based on observation during the course of the survey conducted on September 11-12 2012, it was determined the facility failed to protect mobile trash carts in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, a mobile trash cart greater than 32-gallons was unattended in the corridor by the kitchen.

Based on observation and record review during the course of the survey conducted on September 11-12 2012, it was determined the facility failed to maintain the Medical Gas and Vacuum Systems in accordance with NFPA 101. The following evidenced this:
1.) During the review of the facility records with the maintenance staff, the documentation provided showed the medical gas system has not been tested since April 12, 2011, additionally, no documentation was provided to show the deficiencies listed had been corrected from the last report; these deficiencies listed three " critical " , three " major " and five " minor " concerns as documented from an independent contractor.
2.) During the walkthrough of the facility with the maintenance staff, the service outlets were not separated from the zone valves in the respiratory therapy room.

Based on record review and staff interview during the course of the survey conducted on September 11-12 2012, the laboratory did not have required policies in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance supervisor, documentation was not provided to show fire exit drills specific to the laboratory were conducted in the past twelve months.

Based on observation during the course of the survey conducted on September 11-12 2012, the emergency electrical system was not in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance supervisor, there was no battery powered emergency lighting in the transfer switch room.

Based on observation during the course of the survey conducted on September 11-12 2012, it was determined the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, there were extension cords and power strips used as an extension to permanent wiring of the facility.

Based on observation during the course of the survey conducted on September 11-12 2012, the alcohol based hand rub (ABHR) dispensers were not properly installed in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance supervisor, there was an ABHR installed over carpet in the corridor of the non-sprinklered lobby and an ABHR was installed above a light switch in the blood draw room.