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Based on observation, the facility failed to ensure that corridor walls and doors are constructed to resist the passage of smoke. The findings were:

Observation of the means of egress at the North corridor on 5/19/15 at 10:15 AM revealed that the door to the mechanical/electrical room contained a transfer air louver. Interview with the accompanying facility maintenance staff confirmed the observation.
Ref:2000 NFPA 101, Section 19.3.6.4

Based on observation and staff interview, the facility failed to install corridor doors constructed to resist the passage of smoke in one of three smoke compartments on the second floor. The findings were:

Observation on 5/19/15 at 9:27 AM revealed that a 2' x 3' ventilation air louver was installed on the bottom half of the corridor door for Storage room 249A on the second floor. Interview with the Director of Plant Operations during the observation revealed the ventilation louver was installed for cooling the computer equipment in the room.
Ref:2000 NFPA 101, Section 19.3.6.4

Based on observation, the facility failed to provide protection of hazardous areas from adjacent corridors and non-hazardous rooms in 1 of 1 smoke compartments. The findings were:

1. Observation of the Laundry Room on 5/19/15 at 8:56 AM revealed that the door was held open with a door chock. Interview with the accompanying facility maintenance staff verified that the door was typically chocked open.

2. Observation of Room #1 on 05/19/15 at 9:11 AM revealed that the room contained an employee office, a patient exam area, and was also being utilized as a storage area for clean linens. The linen storage area consisted of approximately 40 percent of the room. Observation revealed that no closer was provided on the door. Interview with the accompanying facility maintenance staff verified that the room was utilized as storage for linens and that a closer was not provided on the door.

Ref:
2000 NFPA 101, Sections 19.3.1.1 and 19.2.2.2.6

Based on observation, the facility failed to provide protection of hazardous areas from adjacent corridors and non-hazardous rooms in 1 of 1 smoke compartments. The findings were:

Observation of the Office and Reception Room on 5/19/15 at 10:06 AM revealed that the area utilized a 3 ft by 3 ft pass-through opening into the corridor, and that the corridor door had been removed from its frame. The south wall of this room was full height open shelving utilized for general record storage. Interview with the accompanying facility maintenance staff confirmed the observation.

Ref:
2000 NFPA 101, Section 19.3.2.1

Based on observation and staff interview, the facility failed to mark access to exits with approved, readily visible signs. The findings were:

Observation on 05/19/15 at 11:07 AM revealed the exit sign in the Lions Den Circle was not internally or externally illuminated. At the time of the observation, the Facility Maintenance Staff acknowledged the exit sign was not illuminated.

Ref:
2000 NFPA 101, Sections 39.2.10 and 7.10.5.1

Based on observation and facility staff interview, the facility failed to separate hazardous areas from other spaces by smoke resistance doors. The findings were:

1. Observation of the Pre Op storage room on 05/19/15 at 1:25 PM revealed the door was provided with a self-closing device, but when activated would not completely close into the door frame. At the time of the observation, the Facility Maintenance Manager acknowledged the door was not smoke resistive.

2. Observation of the OR storage room on 05/19/15 at 1:30 PM revealed the door was provided with a self-closing device, but when activated would not completely close into the door frame. At the time of the observation, the Facility Maintenance Manager acknowledged the door was not smoke resistive.

3. Observation of OR storage room #1504 on 05/19/15 at 1:45 PM revealed the door was provided with a self-closing device, but when activated would not completely close into the door frame. At the time of the observation, the Facility Maintenance Manager acknowledged the door was not smoke resistive.

4. Observation on 05/19/15 at 1:57 PM revealed that dressing rooms #1 and #2 in the Women's Imaginary Area were being utilized as storage areas. The dressing rooms were only provided with curtains for separation from the corridor. At the time of the observation, the Facility Maintenance Staff acknowledged the two dressing rooms being utilized as storage areas.

5. Observation on 5/19/15 at 10:05 AM revealed that a self-closing device was not installed on the door between the pulmonary storage and its adjacent space on the first floor. Interview with the Director of Plant Operations during the observation revealed an acknowledgement of the doors inability to resist the passage of smoke.


Ref:
2000 NFPA 101, Section 19.3.2.1

Based on observation and staff interview, the facility failed to arrange protected stairwells in a way to avoid the potential to interfere with the continuous path of escape. The findings were:

Observation of the East Protected Stairwell on 05/19/15 at 9:38 AM revealed a sitting bench, two EVS trash carts, and a hand sanitizer stand all being stored on the first floor landing. At the time of the observation, the Facility Maintenance Staff acknowledged the items being stored within the stairwell.

Ref:
2000 NFPA 101, Sections 38.2.2.3.1 and 7.2.2.5.3

Based on observation and staff interview, the facility failed to provide one of the three exits on the second floor with door locking arrangement per NFPA 101. The findings were:

1. Observation on 5/19/15 at 9:20 AM revealed a magnetic lock with a key pad and a baby abduction security system on the exit (enclosed stairway) door of the Obstetric Unit and a sign attached stating: "STOP!! This is NOT an exit. Alarm will sound if door is opened." in bold red letters. An exit sign was observed installed on the wall directly over this door. Interview with the Director of Plant Operations during the observation revealed the door would sound an alarm when the latch release device was pushed and held. The manager's demonstration had the alarm activate and the lock releasing in about 15 seconds functioning as a permitted delayed-release lock. The door was absent the sign required by the LSC for delayed-release locks.

Based on observation and staff interview, the facility failed to arrange the doors in the means of egress without locks that requires use of a tool or key from the egress side. The findings were:

2. Observation on 5/19/15 at 10:10 AM revealed that a magnetic lock with a staff activated card reader was installed on the cross-corridor doors (old vacant ICU area) in the mean of egress for the second floor where patients were not housed for clinical needs requiring special security measures (e.g., psychiatric units, Alzheimer units, dementia units). Interview with the Director of Plant Operations during the observation revealed an acknowledgement of the lock in the means of egress and that it was not installed according to the permitted delayed-egress requirements of NFPA 101: 19.2.2.2.4, 7.2.1.6.1.
Ref:2000 NFPA 101, Sections 19.2.2.2.4 and 7.2.1.6.1

Based on observation, the facility failed to continuously maintain a means of egress free of obstructions or impediments to full instant use in case of fire or emergency. The findings were:

Observation of the means of egress at the North Stairwell on 5/19/15 at 9:20 AM revealed that the stairwell was being utilized for the storage of cardboard boxes and wooden tables. Interview with the accompanying facility maintenance staff confirmed that the stair area was being utilized for storage of combustible materials.

Ref:
2000 NFPA 101, Section 7.1.3.2.3

Based on observation, the facility failed to provide emergency lighting in 1 of 1 smoke compartments. The findings were:

Observation of the means of egress at the first level for all patient sleeping rooms on 5/19/15 at 9:04 AM revealed that the illumination of the means of egress was not continuous during the time of occupancy-24 hours. The wall switch opened the lighting circuit where no continuous 24-hour illumination was available to illuminate the walking surface to a level of 1 ft-candle. Interview with the accompanying facility maintenance staff confirmed that no source of continuous 24-hour lighting was provided within the means of egress.

Ref:
2000 NFPA 101, Sections 7.8.1.2 and 7.8.1.3

Based on observation and staff interview, the facility failed to protect the building throughout by an approved, supervised automatic sprinkler system. The findings were:

1. Observation on 5/19/15 at 11:15 AM revealed that sprinkler heads were not installed at the top of the sloped roof of the sunroom located off the dining room on the first floor. Interview with the Director of Plant Operations during the observation revealed an acknowledgement of the sprinkler coverage requirements. NFPA 13: 1-6.1

2. Observation on 5/19/15 at 10:00 AM revealed the top of the shelving unit in the pulmonary storage room was measured 8 inches below a pendent sprinkler head in lieu of the required 18 inches. Interview with the Director of Plant Operations during the observation revealed an acknowledgement of the sprinkler coverage requirements. NFPA 13: Table 5-6.5.2.3
Ref:1999 NFPA 13, Section 1-6.1 and Table 5-6.5.2.3

Based on observation, the facility failed to provide clearance to storage for sprinkler systems in 1 of 1 smoke compartments. The findings were:

Observation of the Laundry Room on 5/19/15 at 8:56 AM revealed that shelving storage was provided with the upper level of storage approximately ten inches below the sprinkler deflector. Interview with the accompanying facility maintenance staff confirmed the observation.
Ref:2000 NFPA 101, Sections 19.1.6.2, Table 19.1.6.2, and 9.7.11999 NFPA 13, Section 5-5.6

Based on observation and facility staff interview, the facility failed to maintain sprinkler systems in a reliable operating condition. The findings were:

Observation of the basement fire riser in the monument area on 05/19/15 at 10:53 AM revealed that no hydraulic design information sign was provided at the riser. At the time of the observation, the Facility Maintenance Staff acknowledged the missing hydraulic information.

Ref:
2000 NFPA 101, Sections 39.3.2.1, 8.4.1.1 (2), and 9.7.1.1
1999 NFPA 13 Section 10-5

Based on observation and staff interview, the facility failed to maintain means of egress free of all obstructions or impediments to full instant use. The findings were:

1. Observation of the Basement #13 Fire Stairwell entrance on 05/19/15 at 10:30 AM revealed a laundry cart being stored in front of the fire exit door, obstructing the means of egress. At the time of the observations, the Facility Maintenance Staff acknowledge the cart being stored in front of the exit.

2. Observation of the Central Supply Corridor on 05/19/15 at 11:00 AM revealed pallets, boxes, and hand carts being stored on the floor inside the corridor. At the time of the observation, Facility Maintenance Staff and the Central Supply Manager acknowledged the items being stored in the corridor.

Ref:
2000 NFPA 101, Sections 39.2.1.1 and 7.1.10.1

Based on observations and staff interview, the facility failed to store an operational supply of oxygen cylinders in small quantities (less than 300 cubic feet) per the NFPA 99 requirements. The findings were:

Observation on 5/19/15 at 9:50 AM revealed that two wire racks were available in the pulmonary storage room on the first floor with a total capacity of 18 "E" cylinders of compressed oxygen. A quantity over 300 cubic feet (12 "E" cylinders) requires a designated storage room. In addition, one cylinder rack (12 cylinders) was located within a foot of paper file storage in lieu of the required 5-foot clearance of NFPA 99. Interview with the Director of Plant Operations during the observation revealed an acknowledgement of the oxygen storage requirements. NFPA 99: 8-3.1.11.
Ref:1999 NFPA 99, Section 8-3.1.11

Based on observation and staff interview, the facility failed to provide a sufficient number of electrical receptacles located to avoid the need for multiple outlet adapters. The findings were:

1. Observation on 5/19/15 at 9:40 AM revealed that a 3-way outlet wall plug adapter was in use for two appliances on one electrical receptacle in Massage room #2. Interview with the Director of Plant Operations during the observation revealed the facility's policy for the use of outlet wall plug adapters was not being followed by staff. The adapter was removed during the observation. NFPA 99: 3-3.3.2.1.2 (d) (2)

Based on observation and staff interview, the facility failed to equip electrical appliances with power cords in the anesthetizing locations (operating rooms) that were continuous from the appliance to the wall receptacle. The findings were:

2. Observation on 5/19/15 at 6:15 PM revealed that an extension cord was used between the surgical table attachment plug and the wall mounted electrical receptacle in OR #2. Interview with the Director of Plant Operations during the observation revealed an acknowledgement of the power cord requirements. NFPA 99: 7-5.1.2.5

Based on observation and staff interview, the facility failed to establish the electrical circuits were installed in the operating rooms per NFPA 99. The operating rooms were required to be served from the critical branch circuits, and at least one circuit served by the normal power distribution or by a system originating from a second critical branch transfer switch. The findings were:

3. Observation on 5/19/15 at 6:20 PM revealed the circuits to the receptacles (all red cover plates) in the operating rooms were powered by the critical branch panels (isolated power system panels). There were GFCI protected electrical receptacles having red cover plates indicating installation from another critical branch panel. Documentation was requested to establish the GFCI electrical receptacles were served by a system from a second critical branch transfer switch and were not made available during the survey. The lighting circuits were on one wall switch that operated all the general lighting with identifications that they were served by the critical branch circuits. However, there were no additional wall switches controlling the general lighting of any other circuits as required. Interview with the Director of Plant Operations during the observation revealed the electrical circuiting was upgraded after 2003 and an acknowledgement of the circuit requirements. NFPA 99: 3-3.2.1.2 (a) 1.
Ref:1999 NFPA 99, Sections 3-3.3.2.1.2 (d) (2), 7-5.1.2.5, and 3-3.2.1.2 (a) 1

Based on observation and staff interview, the facility failed to install two of the electrical receptacles in wet locations per the National Electrical Code. The findings were:

Observation on 5/19/15 at 9:36 AM revealed that a UV sterilizer within the power cord's length of the handwash sink and the whirlpool were plugged into an electrical receptacle (without GFCI designated protection). Additionally, a wall-mounted electrical receptacle was observed within the power cord's length of the adjacent handwash sink. Interview with the Director of Plant Operations during the observation could not establish that the identified electrical receptacles were GFCI protected. During the survey, the manager revealed the facility's electrician had verified and replaced the receptacles with GFCI protected receptacles.
Ref:1999 NFPA 70, Sections 517.20(A); 680.62; 680.71

Based on observation and staff interview, the facility failed to notify the AHJ (HLS) of the downed sprinkler system and then to either evacuate the building or implement an approved fire watch system where a portion of the required automatic sprinkler system was shut off for demolition of the system for construction projects. One of three floors had the automatic sprinkler system out of service. The findings were:

Observation on 5/19/15 at 9:05 AM and 11:15 AM revealed planned construction projects for the complete demolition of the areas for the third floor office suites and outpatient chemical dependency and the first floor partial area for medical records. Interview with the Director of Plant Operations during the observation revealed that the facility's fire watch policy was to implement a fire watch for those areas during the time where the automatic sprinkler system was out of service. Documentation of the actual fire watches were requested and were not made available during the survey. NFPA 101: 9.7.6.1
Ref:2000 NFPA 101, Section 9.7.6.1

Based on observation and staff interview, the facility failed to ensure alcohol based hand rub (ABHR) dispensers were not installed over or adjacent to an ignition source. The findings were:

Observation on 05/19/15 at 11:02 AM revealed the ABHR dispenser outside Medical Records was installed directly over and electrical outlet. At the time of the observation, the Facility Maintenance Staff acknowledge the location of the ABHR dispenser.

Ref:
CFR 485.623 (7)(iv)

Based on observation, the facility failed to ensure that corridor walls and doors are constructed to resist the passage of smoke. The findings were:

Observation of the means of egress at the North corridor on 5/19/15 at 10:15 AM revealed that the door to the mechanical/electrical room contained a transfer air louver. Interview with the accompanying facility maintenance staff confirmed the observation.
Ref:2000 NFPA 101, Section 19.3.6.4

Based on observation and staff interview, the facility failed to install corridor doors constructed to resist the passage of smoke in one of three smoke compartments on the second floor. The findings were:

Observation on 5/19/15 at 9:27 AM revealed that a 2' x 3' ventilation air louver was installed on the bottom half of the corridor door for Storage room 249A on the second floor. Interview with the Director of Plant Operations during the observation revealed the ventilation louver was installed for cooling the computer equipment in the room.
Ref:2000 NFPA 101, Section 19.3.6.4

Based on observation, the facility failed to provide protection of hazardous areas from adjacent corridors and non-hazardous rooms in 1 of 1 smoke compartments. The findings were:

1. Observation of the Laundry Room on 5/19/15 at 8:56 AM revealed that the door was held open with a door chock. Interview with the accompanying facility maintenance staff verified that the door was typically chocked open.

2. Observation of Room #1 on 05/19/15 at 9:11 AM revealed that the room contained an employee office, a patient exam area, and was also being utilized as a storage area for clean linens. The linen storage area consisted of approximately 40 percent of the room. Observation revealed that no closer was provided on the door. Interview with the accompanying facility maintenance staff verified that the room was utilized as storage for linens and that a closer was not provided on the door.

Ref:
2000 NFPA 101, Sections 19.3.1.1 and 19.2.2.2.6

Based on observation, the facility failed to provide protection of hazardous areas from adjacent corridors and non-hazardous rooms in 1 of 1 smoke compartments. The findings were:

Observation of the Office and Reception Room on 5/19/15 at 10:06 AM revealed that the area utilized a 3 ft by 3 ft pass-through opening into the corridor, and that the corridor door had been removed from its frame. The south wall of this room was full height open shelving utilized for general record storage. Interview with the accompanying facility maintenance staff confirmed the observation.

Ref:
2000 NFPA 101, Section 19.3.2.1

Based on observation and staff interview, the facility failed to mark access to exits with approved, readily visible signs. The findings were:

Observation on 05/19/15 at 11:07 AM revealed the exit sign in the Lions Den Circle was not internally or externally illuminated. At the time of the observation, the Facility Maintenance Staff acknowledged the exit sign was not illuminated.

Ref:
2000 NFPA 101, Sections 39.2.10 and 7.10.5.1

Based on observation and facility staff interview, the facility failed to separate hazardous areas from other spaces by smoke resistance doors. The findings were:

1. Observation of the Pre Op storage room on 05/19/15 at 1:25 PM revealed the door was provided with a self-closing device, but when activated would not completely close into the door frame. At the time of the observation, the Facility Maintenance Manager acknowledged the door was not smoke resistive.

2. Observation of the OR storage room on 05/19/15 at 1:30 PM revealed the door was provided with a self-closing device, but when activated would not completely close into the door frame. At the time of the observation, the Facility Maintenance Manager acknowledged the door was not smoke resistive.

3. Observation of OR storage room #1504 on 05/19/15 at 1:45 PM revealed the door was provided with a self-closing device, but when activated would not completely close into the door frame. At the time of the observation, the Facility Maintenance Manager acknowledged the door was not smoke resistive.

4. Observation on 05/19/15 at 1:57 PM revealed that dressing rooms #1 and #2 in the Women's Imaginary Area were being utilized as storage areas. The dressing rooms were only provided with curtains for separation from the corridor. At the time of the observation, the Facility Maintenance Staff acknowledged the two dressing rooms being utilized as storage areas.

5. Observation on 5/19/15 at 10:05 AM revealed that a self-closing device was not installed on the door between the pulmonary storage and its adjacent space on the first floor. Interview with the Director of Plant Operations during the observation revealed an acknowledgement of the doors inability to resist the passage of smoke.


Ref:
2000 NFPA 101, Section 19.3.2.1

Based on observation and staff interview, the facility failed to arrange protected stairwells in a way to avoid the potential to interfere with the continuous path of escape. The findings were:

Observation of the East Protected Stairwell on 05/19/15 at 9:38 AM revealed a sitting bench, two EVS trash carts, and a hand sanitizer stand all being stored on the first floor landing. At the time of the observation, the Facility Maintenance Staff acknowledged the items being stored within the stairwell.

Ref:
2000 NFPA 101, Sections 38.2.2.3.1 and 7.2.2.5.3

Based on observation and staff interview, the facility failed to provide one of the three exits on the second floor with door locking arrangement per NFPA 101. The findings were:

1. Observation on 5/19/15 at 9:20 AM revealed a magnetic lock with a key pad and a baby abduction security system on the exit (enclosed stairway) door of the Obstetric Unit and a sign attached stating: "STOP!! This is NOT an exit. Alarm will sound if door is opened." in bold red letters. An exit sign was observed installed on the wall directly over this door. Interview with the Director of Plant Operations during the observation revealed the door would sound an alarm when the latch release device was pushed and held. The manager's demonstration had the alarm activate and the lock releasing in about 15 seconds functioning as a permitted delayed-release lock. The door was absent the sign required by the LSC for delayed-release locks.

Based on observation and staff interview, the facility failed to arrange the doors in the means of egress without locks that requires use of a tool or key from the egress side. The findings were:

2. Observation on 5/19/15 at 10:10 AM revealed that a magnetic lock with a staff activated card reader was installed on the cross-corridor doors (old vacant ICU area) in the mean of egress for the second floor where patients were not housed for clinical needs requiring special security measures (e.g., psychiatric units, Alzheimer units, dementia units). Interview with the Director of Plant Operations during the observation revealed an acknowledgement of the lock in the means of egress and that it was not installed according to the permitted delayed-egress requirements of NFPA 101: 19.2.2.2.4, 7.2.1.6.1.
Ref:2000 NFPA 101, Sections 19.2.2.2.4 and 7.2.1.6.1

Based on observation, the facility failed to continuously maintain a means of egress free of obstructions or impediments to full instant use in case of fire or emergency. The findings were:

Observation of the means of egress at the North Stairwell on 5/19/15 at 9:20 AM revealed that the stairwell was being utilized for the storage of cardboard boxes and wooden tables. Interview with the accompanying facility maintenance staff confirmed that the stair area was being utilized for storage of combustible materials.

Ref:
2000 NFPA 101, Section 7.1.3.2.3

Based on observation, the facility failed to provide emergency lighting in 1 of 1 smoke compartments. The findings were:

Observation of the means of egress at the first level for all patient sleeping rooms on 5/19/15 at 9:04 AM revealed that the illumination of the means of egress was not continuous during the time of occupancy-24 hours. The wall switch opened the lighting circuit where no continuous 24-hour illumination was available to illuminate the walking surface to a level of 1 ft-candle. Interview with the accompanying facility maintenance staff confirmed that no source of continuous 24-hour lighting was provided within the means of egress.

Ref:
2000 NFPA 101, Sections 7.8.1.2 and 7.8.1.3

Based on observation and staff interview, the facility failed to protect the building throughout by an approved, supervised automatic sprinkler system. The findings were:

1. Observation on 5/19/15 at 11:15 AM revealed that sprinkler heads were not installed at the top of the sloped roof of the sunroom located off the dining room on the first floor. Interview with the Director of Plant Operations during the observation revealed an acknowledgement of the sprinkler coverage requirements. NFPA 13: 1-6.1

2. Observation on 5/19/15 at 10:00 AM revealed the top of the shelving unit in the pulmonary storage room was measured 8 inches below a pendent sprinkler head in lieu of the required 18 inches. Interview with the Director of Plant Operations during the observation revealed an acknowledgement of the sprinkler coverage requirements. NFPA 13: Table 5-6.5.2.3
Ref:1999 NFPA 13, Section 1-6.1 and Table 5-6.5.2.3

Based on observation, the facility failed to provide clearance to storage for sprinkler systems in 1 of 1 smoke compartments. The findings were:

Observation of the Laundry Room on 5/19/15 at 8:56 AM revealed that shelving storage was provided with the upper level of storage approximately ten inches below the sprinkler deflector. Interview with the accompanying facility maintenance staff confirmed the observation.
Ref:2000 NFPA 101, Sections 19.1.6.2, Table 19.1.6.2, and 9.7.11999 NFPA 13, Section 5-5.6

Based on observation and facility staff interview, the facility failed to maintain sprinkler systems in a reliable operating condition. The findings were:

Observation of the basement fire riser in the monument area on 05/19/15 at 10:53 AM revealed that no hydraulic design information sign was provided at the riser. At the time of the observation, the Facility Maintenance Staff acknowledged the missing hydraulic information.

Ref:
2000 NFPA 101, Sections 39.3.2.1, 8.4.1.1 (2), and 9.7.1.1
1999 NFPA 13 Section 10-5

Based on observation and staff interview, the facility failed to maintain means of egress free of all obstructions or impediments to full instant use. The findings were:

1. Observation of the Basement #13 Fire Stairwell entrance on 05/19/15 at 10:30 AM revealed a laundry cart being stored in front of the fire exit door, obstructing the means of egress. At the time of the observations, the Facility Maintenance Staff acknowledge the cart being stored in front of the exit.

2. Observation of the Central Supply Corridor on 05/19/15 at 11:00 AM revealed pallets, boxes, and hand carts being stored on the floor inside the corridor. At the time of the observation, Facility Maintenance Staff and the Central Supply Manager acknowledged the items being stored in the corridor.

Ref:
2000 NFPA 101, Sections 39.2.1.1 and 7.1.10.1

Based on observations and staff interview, the facility failed to store an operational supply of oxygen cylinders in small quantities (less than 300 cubic feet) per the NFPA 99 requirements. The findings were:

Observation on 5/19/15 at 9:50 AM revealed that two wire racks were available in the pulmonary storage room on the first floor with a total capacity of 18 "E" cylinders of compressed oxygen. A quantity over 300 cubic feet (12 "E" cylinders) requires a designated storage room. In addition, one cylinder rack (12 cylinders) was located within a foot of paper file storage in lieu of the required 5-foot clearance of NFPA 99. Interview with the Director of Plant Operations during the observation revealed an acknowledgement of the oxygen storage requirements. NFPA 99: 8-3.1.11.
Ref:1999 NFPA 99, Section 8-3.1.11

Based on observation and staff interview, the facility failed to provide a sufficient number of electrical receptacles located to avoid the need for multiple outlet adapters. The findings were:

1. Observation on 5/19/15 at 9:40 AM revealed that a 3-way outlet wall plug adapter was in use for two appliances on one electrical receptacle in Massage room #2. Interview with the Director of Plant Operations during the observation revealed the facility's policy for the use of outlet wall plug adapters was not being followed by staff. The adapter was removed during the observation. NFPA 99: 3-3.3.2.1.2 (d) (2)

Based on observation and staff interview, the facility failed to equip electrical appliances with power cords in the anesthetizing locations (operating rooms) that were continuous from the appliance to the wall receptacle. The findings were:

2. Observation on 5/19/15 at 6:15 PM revealed that an extension cord was used between the surgical table attachment plug and the wall mounted electrical receptacle in OR #2. Interview with the Director of Plant Operations during the observation revealed an acknowledgement of the power cord requirements. NFPA 99: 7-5.1.2.5

Based on observation and staff interview, the facility failed to establish the electrical circuits were installed in the operating rooms per NFPA 99. The operating rooms were required to be served from the critical branch circuits, and at least one circuit served by the normal power distribution or by a system originating from a second critical branch transfer switch. The findings were:

3. Observation on 5/19/15 at 6:20 PM revealed the circuits to the receptacles (all red cover plates) in the operating rooms were powered by the critical branch panels (isolated power system panels). There were GFCI protected electrical receptacles having red cover plates indicating installation from another critical branch panel. Documentation was requested to establish the GFCI electrical receptacles were served by a system from a second critical branch transfer switch and were not made available during the survey. The lighting circuits were on one wall switch that operated all the general lighting with identifications that they were served by the critical branch circuits. However, there were no additional wall switches controlling the general lighting of any other circuits as required. Interview with the Director of Plant Operations during the observation revealed the electrical circuiting was upgraded after 2003 and an acknowledgement of the circuit requirements. NFPA 99: 3-3.2.1.2 (a) 1.
Ref:1999 NFPA 99, Sections 3-3.3.2.1.2 (d) (2), 7-5.1.2.5, and 3-3.2.1.2 (a) 1

Based on observation and staff interview, the facility failed to install two of the electrical receptacles in wet locations per the National Electrical Code. The findings were:

Observation on 5/19/15 at 9:36 AM revealed that a UV sterilizer within the power cord's length of the handwash sink and the whirlpool were plugged into an electrical receptacle (without GFCI designated protection). Additionally, a wall-mounted electrical receptacle was observed within the power cord's length of the adjacent handwash sink. Interview with the Director of Plant Operations during the observation could not establish that the identified electrical receptacles were GFCI protected. During the survey, the manager revealed the facility's electrician had verified and replaced the receptacles with GFCI protected receptacles.
Ref:1999 NFPA 70, Sections 517.20(A); 680.62; 680.71

Based on observation and staff interview, the facility failed to notify the AHJ (HLS) of the downed sprinkler system and then to either evacuate the building or implement an approved fire watch system where a portion of the required automatic sprinkler system was shut off for demolition of the system for construction projects. One of three floors had the automatic sprinkler system out of service. The findings were:

Observation on 5/19/15 at 9:05 AM and 11:15 AM revealed planned construction projects for the complete demolition of the areas for the third floor office suites and outpatient chemical dependency and the first floor partial area for medical records. Interview with the Director of Plant Operations during the observation revealed that the facility's fire watch policy was to implement a fire watch for those areas during the time where the automatic sprinkler system was out of service. Documentation of the actual fire watches were requested and were not made available during the survey. NFPA 101: 9.7.6.1
Ref:2000 NFPA 101, Section 9.7.6.1