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Based upon observation and interview, the facility failed to ensure aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7 and continuously maintained free of all obstructions to full use in care of an emergency as required by 19.2.1 and 7.1.10.1. This deficient practice could affect 22 occupants in the event of emergency.

Findings Include: (Building 1)
On 06/14/18 at approximately 11:00 am during an inspection of the corridors with the maintenance supervisor, the following observations were made:

1. Level 3 North had a nurse charting station near room 302, not self closing during inspection.

This finding was confirmed by interview at the time of observation with the maintenance supervisor.

Based upon observation and interview, the facility failed to ensure doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area were self-closing and kept in the closed position unless held open in accordance with 7.2.1.8.2 as required by 19.2.2.2.7 and 19.2.2.2.8. This deficient practice could affect 14 occupants in the event of Emergency.

Findings Include: (Building 1)
On 06/14/18 at approximately 2:10 pm during an inspection of fire barrier walls with the maintenance supervisor, the observation was made:

1. Inside of behavioral health a door from the nurse station along corridor wall was found to be part of the one hour fire barrier wall and was found to not have a self closing device.

This finding was confirmed by interview at the time of observation with the maintenance supervisor.

Based upon observation and interview, the facility failed to ensure the means of egress is illuminated in accordance with 7.8 as required by 19.2.8. This deficient practice could affect 7 or more occupants in the event of an emergency.

Findings Include: (Building 2)
On 06/13/18 at approximately 10:45 am -12:00 pm during an inspection of exits with the maintenance supervisor the following observations were made:

1. Temporary hallway by emergency room (ER) was observed at the exit to not have dual bulb egress lighting.

2. Angled wall exit near ER was observed not having dual bulb Egress lighting.

These findings were confirmed by interview at the time of observation with the maintenance supervisor.

Based upon observation and interview, the facility failed to ensure manual initiation of the fire alarm system is arranged as required by 19.3.4.2.1, 19.3.4.2.2, and 9.6.2.5. This deficient practice could affect 4 occupants in the event of an emergency.

Findings Include: (Building 2)
On 06/13/18 at approximately 10:45 am during an inspection of the facility's exits the following observation was made:

1. Main floor door #5 was observed to be a designated exit for an office without a pull-station installed.

This finding was confirmed by interview at the time of observation with the maintenance supervisor.

Based upon observation and interview, the facility failed to ensure an automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 and records are readily available as required by 9.7.5, 9.7.7, 9.7.8, and NFPA 25. This deficient practice could affect 17 occupants in the event of Emergency.


Findings Include: (Building 1)
On 06/14/18 at approximately 11:20 am during an inspection of the automatic sprinkler system with the maintenance supervisor, the following observation was made:

1. Third level east intensive care unit (ICU) corridor near the "T" intersection of ICU and Pediatrics was observed to have a bracket device attached to the threaded rod support of the fire sprinkler piping.

This finding was confirmed by interview at the time of observation with the maintenance supervisor.

Based upon observation and interview, the facility failed to ensure an automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 and records are readily available as required by 9.7.5, 9.7.7, 9.7.8, and NFPA 25. This deficient practice could affect 17 occupants in the event of Emergency.

Findings Include: (Building 2)
On 06/13/18 at approximately 11:10 am during an inspection of the automatic sprinkler system with the maintenance supervisor, the following observation was made:

1. ER staff locker was observed having shoes and storage within 18" of a sprinkler head.

This finding was confirmed by interview at the time of observation with the maintenance supervisor.

Based upon observation and interview, the facility failed to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, resist the passage of smoke, equipped with a means suitable for keeping the door closed, and there is no impediment to the closing of doors as required by 19.3.6.3 and 42 CFR 403, 418, 460, 482, 483, and 485. This deficient practice could affect 20 or more occupants in the event of an Emergency.


Findings Include: (Building 1)
On 06/14/18 at approximately 1:00 pm during inspection of the smoke barrier doors with the maintenance supervisor, the following observations were made:

1. On the fourth floor South building cross corridor smoke barrier doors entering from Central floor was observed not closing and when manually pushed closed a gap larger than 1/8".

This finding was confirmed by interview at the time of observation with the maintenance supervisor.

Based upon observation and interview, the facility failed to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, resist the passage of smoke, equipped with a means suitable for keeping the door closed, and there is no impediment to the closing of doors as required by 19.3.6.3 and 42 CFR 403, 418, 460, 482, 483, and 485. This deficient practice could affect 20 or more occupants in the event of an Emergency.

Findings Include: (Building 2)
On 06/13/18 at approximately 11:15 am -2:00 pm during inspection of the smoke barrier doors with the maintenance supervisor, the following observations were made:

1. Basement smoke barrier doors by specials 2 was observed having a gap greater than 1/8"
2. Second floor storage room 223, formerly a patient room, did not have a selfclosing device on the door.

These finding were confirmed by interview at the time of observation with the maintenance supervisor.

Based upon observation and interview, the facility failed to ensure equipment using gas or gas-related piping complies with NFPA 54 and electrical wiring and equipment complies with NFPA 70 as required by 19.5.1.1, 9.1.1, and 9.1.2. This deficient practice could affect 2 occupants in the event of an emergency.

Findings Include: (Building 2)
On 06/13/18 at approximately 11:55 am during an inspection of a hazard room with the maintenance supervisor, the following observations were made:

1. ER's electrical/equipment room was observed having equipment stored within 3 feet of electrical panels.

This finding was confirmed by interview at the time of observation with the maintenance supervisor.