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Based on observation and staff interview, the facility failed to provide a fire sprinkler system in accordance with the 2010 NFPA 13, Standard for the Installation of Sprinkler Systems. Failure to properly install fire sprinkler systems could result in injury or death in the event of a fire. The deficiency affected the building's main floor.

The findings were:

Observation on 11/29/18 at 10:56 AM in the X-Ray room revealed a ceiling mounted X-Ray machine, which was capable of moving under and obstructing coverage of three (3) sprinklers. When the machine is under the sprinkler head located closest to the corridor wall, the remaining heads do not provide full coverage of the room. Full sprinkler coverage must be provided when any sprinkler is obstructed by the X-Ray machine.

Interview with the maintenance director at the time of the observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2010 NFPA 13 8.5.5.1, 8.5.5.2.2, 8.6.5.1.2
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Based on observation and staff interview, the facility failed to maintain smoke barriers in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain smoke barriers could result in injury or death in the event of a fire. The deficiency affected one (1) of seven (7) smoke compartments on the main floor.

The findings were:

Observation on 11/29/18 at 10:15 AM revealed a smoke barrier separating the surgical area and administrative area, in the Monument lobby entrance. The smoke barrier had electrical and conduit penetrations that were unprotected. The penetrations were located above the ceiling at the cross corridor doors.

Interview with the maintenance director at the time of the observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 19.3.7.3
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Based on observation and staff interview, the facility failed to maintain electrical systems in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain clearance to electrical equipment could result in injury or death in the event of an emergency. The deficiency affected one (1) of seven (7) smoke compartments on the main floor.

The findings were:

Observation on 11/28/18 at 1:30 PM revealed an electrical disconnect located in the CT Exam Equipment room. Items were stored in front of the disconnect, which obstructed the required access. Electrical equipment shall be provided and maintained to provide access and working space.

Interview with the maintenance director at the time of the observation acknowledged that clearance to the electrical equipment was being obstructed, and indicated he was aware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 19.5.1, 9.1.2; 2011 NFPA 70 110.26(A)

Based on observation and staff interview, the facility failed to maintain electrical systems in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain clearance to electrical equipment could result in injury or death in the event of an emergency. The deficiency affected the building's main floor.

The findings were:

Observation on 11/29/18 at 10:50 AM revealed an electrical disconnect and electrical breaker panel located in the Storage room with items stored in front of both, which obstructed access. Electrical equipment shall be provided and maintained to provide access and working space.

Interview with the maintenance director at the time of the observation acknowledged that clearance to the electrical equipment was being obstructed, and indicated he was aware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 39.5.1, 9.1.2; 2011 NFPA 70 110.26(A)
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Based on observation and staff interview, the facility failed to properly store oxygen cylinders in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to properly store oxygen cylinders could result in injury or death in the event of an emergency. The deficiency affected the building's main floor.

The findings were:

Observation on 11/29/18 at 11:10 AM of the oxygen storage room revealed storage of oxygen in quantities greater than 3,000 cubic feet. The room provided a 1-hour fire separation, but had unprotected plumbing penetrations. Indoor oxygen storage rooms with greater than 3,000 cubic feet of oxygen shall be constructed and maintained to a minimum 1-hour fire resistance rating.

Interview with the maintenance director at the time of the observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 99 11.3.1, 5.1.3.3.3.2 (4)
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