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Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building to comply with 18.3.2.1. This condition may prevent the use of a means of egress for staff along with patients and visitors within the dining area during a fire emergency.

The finding is:

A. At 10:45 am while accompanied by the Director of Facilities and Head of Maintenance, the "pantry" was observed located in the Kitchen containing numerous combustible items stored along with equipment in an amount deemed hazardous. This room is approximately 88 square feet with four, six foot tall units each unit with 5 shelves containing Styrofoam cups, Styrofoam containers, cardboard boxed items, and plastic wrapped items. This room lacks separation from a path of egress in the kitchen and does not comply with 18.3.6.3.4 and 8.4.

Based on random observation during the survey walk-through, exit access was not readily accessible at all times to comply with 7.1 and 18.2. This condition could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily utilizing an available exit during a fire or smoke event.

The finding is:

A. At 11:30 am while accompanied by the Director of Facilities and Head of Maintenance, Corridor # 219 (based on the facility Life Safety floor plan) was observed to lack a means to identify both egress paths in order to comply with 18.2.5.9. a single exit sign was observed leading to Corridor # 127.

During record document review of the facility's Procedure in Case of Fire, failure to comply with NFPA 101 18.7.2 could result in a delayed response or inadequate response in a fire emergency.

The finding is:

A. At 1:30 pm, while accompanied by the Head of Maintenance and the Director of Facilities, the surveyor finds that the provider's written fire plan is based on the R A C E acronym however the C component identified as Contain appears to be # 11 on the list of items associated with the R A C E procedures. The compartmentation component makes no reference to the immediate area in danger.

Based on random observation through the Hospital, the surveyor finds the sprinkler system is not installed and maintained in accordance with NFPA 13. Failure to maintain the sprinkler system will result in poor performance of this system in a fire emergency.

Findings include:

A. At 8:45 am while accompanied by the Director of Facilities and Head of Maintenance, Fluoroscopy room # 332 was observed which contains ceiling mounted equipment located to compromise sprinkler protection in this space. The surveyor observed two sprinkler heads within the overhead track system by which the placement of equipment may block one of the two sprinkler heads covering the room.

B. At 12:30 pm while accompanied by the Director of Facilities and Head of Maintenance, PFT room was observed which contains sprinkler pipe supported more than 8 feet from the wall. This condition may compromise sprinkler coverage of the room through hydrostatic water pressure within the pipe thereby moving the sprinkler head away from the plain of the finished ceiling.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building to comply with 18.3.2.1. This condition may prevent the use of a means of egress for staff along with patients and visitors within the dining area during a fire emergency.

The finding is:

A. At 10:45 am while accompanied by the Director of Facilities and Head of Maintenance, the "pantry" was observed located in the Kitchen containing numerous combustible items stored along with equipment in an amount deemed hazardous. This room is approximately 88 square feet with four, six foot tall units each unit with 5 shelves containing Styrofoam cups, Styrofoam containers, cardboard boxed items, and plastic wrapped items. This room lacks separation from a path of egress in the kitchen and does not comply with 18.3.6.3.4 and 8.4.

Based on random observation during the survey walk-through, exit access was not readily accessible at all times to comply with 7.1 and 18.2. This condition could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily utilizing an available exit during a fire or smoke event.

The finding is:

A. At 11:30 am while accompanied by the Director of Facilities and Head of Maintenance, Corridor # 219 (based on the facility Life Safety floor plan) was observed to lack a means to identify both egress paths in order to comply with 18.2.5.9. a single exit sign was observed leading to Corridor # 127.

During record document review of the facility's Procedure in Case of Fire, failure to comply with NFPA 101 18.7.2 could result in a delayed response or inadequate response in a fire emergency.

The finding is:

A. At 1:30 pm, while accompanied by the Head of Maintenance and the Director of Facilities, the surveyor finds that the provider's written fire plan is based on the R A C E acronym however the C component identified as Contain appears to be # 11 on the list of items associated with the R A C E procedures. The compartmentation component makes no reference to the immediate area in danger.

Based on random observation through the Hospital, the surveyor finds the sprinkler system is not installed and maintained in accordance with NFPA 13. Failure to maintain the sprinkler system will result in poor performance of this system in a fire emergency.

Findings include:

A. At 8:45 am while accompanied by the Director of Facilities and Head of Maintenance, Fluoroscopy room # 332 was observed which contains ceiling mounted equipment located to compromise sprinkler protection in this space. The surveyor observed two sprinkler heads within the overhead track system by which the placement of equipment may block one of the two sprinkler heads covering the room.

B. At 12:30 pm while accompanied by the Director of Facilities and Head of Maintenance, PFT room was observed which contains sprinkler pipe supported more than 8 feet from the wall. This condition may compromise sprinkler coverage of the room through hydrostatic water pressure within the pipe thereby moving the sprinkler head away from the plain of the finished ceiling.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.