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Based upon observation and staff interviews on 5/1/2018 during the physical tour of the facility between 0930 and 1445 hours, the facility has also failed to ensure locked doors in the means of egress do not require two operations to unlatch and are in accordance with the requirements of NFPA 101. This could cause an inability or delay in the evacuation of residents in the event of an emergency and could result in the failure of the fire rated door to operate properly which would endanger the patients, staff and/or visitors within the facility.

The findings include, but are not limited to:


-The Surgery PACU suite's exit double-doors into the main exit corridor are equipped with two separate surface mounted manual flush-bolts.

Per NFPA 101: 7.2.1.5.11 Where pairs of door leaves are required in a means of egress, one of the following criteria shall be met:
(1) Each leaf of the pair shall be provided with a releasing device that does not depend on the release of one leaf before the other.
(2) Approved automatic flush bolts shall be used and arranged such that both of the following criteria are met:
(a) The door leaf equipped with the automatic flush bolts shall have no doorknob or surface-mounted hardware.
(b) Unlatching of any leaf shall not require more than one operation.
Only locking devices that meet NFPA 101: 7.2.1.6 are permitted on egress doors.

The above was discussed and acknowledged by the Facility Staff Member #1 who said they were unaware manual flush-bolts are not permitted on exit doors.

Based upon observation and staff interviews on 5/1/2018 during the physical tour of the facility between 0930 and 1445 hours, the facility has also failed to ensure exit enclosures are not used for any purpose that could interfere with egress. This could cause an inability or delay in the evacuation of residents in the event of an emergency and could result in the failure of the fire rated door to operate properly which would endanger the patients, staff and/or visitors within the facility.

The findings include, but are not limited to:


- The enclosed interior exit stairwell from the basement had miscellaneous storage in the open space under the stairs.

Per NFPA 101:

7.1.3.2.3: An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if
so designated, as an area of refuge.

7.2.2.5.3.1 Open space within the exit enclosure shall not be used for any purpose that has the potential to interfere with egress.

7.2.2.5.3.2 Enclosed, usable space shall be permitted under stairs, provided that both of the following criteria are met:
(1) The space shall be separated from the stair enclosure by the same fire resistance as the exit enclosure.
(2) Entrance to the enclosed, usable space shall not be from within the stair enclosure.

The above was discussed and acknowledged by the Facility Maintenance Director who said they were unaware they could not have storage in the stairwell.

Based upon observations and staff interviews on 5/1/18 during the physical tour of the facility between approximately 0930 and 1445 hours, the facility has failed to maintain doors to hazardous areas as self or automatic closing and able to resist the passage of smoke and fire. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:


-The door to the corridor from the OB Storage room over 50 square feet was not equipped with a self-closing device.

-The Surgery storage room is not separated by complete smoke resistant construction from the adjacent waiting room / corridor.

-The door to the corridor from the OR Clean Utility room over 50 square feet did not have enough self-closer force to fully close and latch.



The above was discussed and acknowledged by Maintenance Staff member #1 who said the OB storage room's closer had recently broken and they were in the process of replacing it and that the Surgery Storage room was just designed to be temporary use, which is why the wall separating it from the adjacent waiting room was not complete. In addition the staff member said they were unaware the OR clean utility room's self closer was not operating correctly.

Based upon observations and staff interviews along with record review on 5/1/2018 during the inspection of the facility between 0930 and 1445 hours the facility has failed to maintain the laboratory fire protection plan in accordance with NFPA 45. This could result in a failure to for staff to respond appropriately in the event of a lab fire, resulting in potential harm to staff, patients and visitors.


The findings include, but are not limited to:

-The Laboratory does not have procedures for extinguishing a clothing fire in their lab-specific emergency plan as required by NFPA 45-6.6.3.2.

The above was discussed and acknowledged by the Lab Director who said that they were unaware the requirements.

Based upon observation and staff interviews on 5/1/18 during the physical inspection of the facility between approximately 0930 and 1445 hours, the facility has failed to maintain and install the fire sprinkler system as required by NFPA 13 and NFPA 25. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire which would endanger the residents, staff and/or visitors within the facility.


The findings include, but are not limited to:

-The storage alcove in the Pre-Surgical corridor is not provided with any sprinkler coverage.




The above was discussed and acknowledged by Maintenance Staff member #1 who said the missing sprinkler coverage has not been previously identified.

Based upon observation and staff interviews on 5/1/18 during the physical inspection of the campus, the facility has failed to maintain the fire sprinkler system as required by NFPA 13 and NFPA 25. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire which would endanger the residents, staff and/or visitors within the facility.



The findings include, but are not limited to:


-There was IT cabling attached to/ hanging from the sprinkler piping in the basement Central supply storage area. Per 2010 NFPA 13-9.1.1.7: Sprinkler piping or hangers shall not be used to support non-system components.

-The exterior exit stairwell from the Administration wing has two side-wall dry-barrel sprinkler heads with manufacture dates of 1996. Per NFPA 25-5.3.1.1.1.6 Dry sprinklers that have been in service for 10 years
shall be replaced or representative samples shall be tested and then retested at 10-year intervals.


The above was discussed and acknowledged by maintenance staff member #1 who said he had not previously observed the cabling on the sprinkler piping and that he was unaware that the dry sidewall sprinkler heads were past due for replacement/testing.


Based upon record review and staff interviews on 5/1/18 during the review of facility documentation between approximately 0830 and 0930 hours, the facility has failed to maintain the fire sprinkler system as required by NFPA 13 and NFPA 25. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire which would endanger the residents, staff and/or visitors within the facility.



The findings include, but are not limited to:


-The January, April, July and October 2017 quarterly sprinkler inspection reports did not provide documentation of the residual water pressure reading during the main drain tests.

-The facility could not provide documentation indicating the 5-year internal fire sprinkler pipe inspection has been conducted within the previous five years.

-The facility has a deluge/preaction dedicated system and riser installed in the MRI suite that was added in 2016. The facility was unable to provide any records indicating the system has been inspected within the last 12 months.


The above was discussed and acknowledged by maintenance staff member #1 who said he was unaware the residual pressure needed to be recorded and that he was unaware if the five year and preaction system tests had been conducted.

Based upon record review and staff interviews on 5/1/18 during the review of facility documentation between approximately 0830 and 0930 hours the facility has failed to maintain and test fire and smoke dampers in accordance with NFPA 80 and NFPA 105. This could result in failure of the dampers to operate and close in the event of a fire, allowing the spread of the products of combustion from one compartment to another, endangering the patients, staff and/or visitors.

The findings include, but are not limited to:


The facility could not provide any documentation indicating their fire and smoke dampers have been inspected and tested within the last four years.

Per NFPA 90A-5.4.8.1, fire dampers shall be maintained in accordance with NFPA 80. Per NFPA 80-19.4.1, each damper shall be tested and inspected 1 year after installation and 19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.


The above was discussed and acknowledged by maintenance staff #1 who said they are currently developing a plan to inspect the dampers.

Based upon record review and staff interviews on 5/1/18 during the review of facility documentation between approximately 0830 and 0930 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering residents, staff and/or visitors.

The findings include, but are not limited to:
There were no staff participants listed on the 6-30-17 day shift, 8-1-17 night shift, 10-3-17 night shift, 10-17-17 day shift, 12-6-17 night shift and the 1-4-18 day shift fire drill records.

The above was discussed and acknowledged by facility maintenance staff #1 who said he is unsure why staff participants were not logged in the fire drill records.

Based upon observations and staff interviews 5/1/2018 during the review of the facility documentation between approximately 0830 and 0930 hours, the facility has failed to properly maintain records of testing and maintenance of hospital grade receptacles at patient bed locations in accordance with NFPA 99. This could result in electrical malfunction which could potentially endanger residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

- The facility could not provide a policy and documentation indicating they have conducted polarity, grounding and tension periodic testing as required by NFPA 99-6.3.4 of all hospital grade electrical receptacles located within six feet of patient care locations within the last 12 months.


The above was discussed and acknowledged by the facility maintenance staff member #1 who said they are in the process of starting a receptacle testing program.

Based upon record review and staff interviews on 5/1/18 during the document review portion of the inspection between approximately 0830 and 0930 hours, the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and work lighting in the event of a power failure which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

-The facility could not provide documentation indicating an annual diesel fuel test has been conducted within the last 12 months as required by 2010 NFPA 110-8.3.8.

The above was discussed and acknowledged by the maintenance staff member #1 who said he was unaware an annual fuel test was required.

Based upon observations and staff interviews on 5/1/18 during the physical tour of the campus between approximately 0930 and 1445 hours, the facility has failed to ensure all electrical wiring is in accordance with NFPA 99, NFPA 70 and that extension cords are not used as a substitute for fixed wiring of a structure. This could result in an electrical hazard due to misuse or prolonged use of an extension cord, endangering the residents, staff and/or visitors within the facility.



The findings include, but are not limited to:

-There was a powerstrip plugged into a wall-mounted multiplug adapter in ED rooms 7, 8 and 6.




The above was discussed and acknowledged by the Maintenance Staff member #1 who said they were unaware the powerstrips were plugged into the adapters.