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Based on observation, the facility failed to ensure a bathroom door had more than one latching device in accordance with NFPA 101, 2012 Edition, Section 7.2.1.10.6. The deficiency affects 1 of 5 main level smoke compartments.

Findings include:

1. During an observation on 4/3/17 at 3:21 p.m., the sleep room lab, changing room door had been installed with an inside deadbolt, this condition could allow a patient to be trapped in the room, staff would have no means available to access the patient and the door had a latching mechanism as well.

Based on observation and interview, the facility failed to maintain corridors and exits free of all obstructions to full use in case of emergency in accordance with NFPA 101, 2012 Edition, Section 19.2.2.2.4, 7.2.1.4.2 and 19.2.3.4(5)(a). These deficiencies affect 2 of 5 main level and basement smoke compartments.

Findings include:

1. During observations of 4/5/17 at 7:55 a.m., the exit out of the south end of the basement transitioned to the clinic.

In an interview on 4/5/17 at 7:55 a.m., staff member A said this exit out of the front doors of the clinic would be locked after 5:00 p.m.

This would not be in accordance with 19.2.2.2.4 which indicates doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

2. During observation on 4/4/17 at 12:00, a plant stand over a foot wide with a plant was in the corridor by the exit out of wing three and two plants sat on the floor at the double door exit out of wing three.



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3. During an observation on 4/5/17 at 8:00 a.m., the door assembly in an exit enclosure did not swing in the direction of egress travel, per 7.2.1.4.2

Based on observations, the facility failed to provide for a hard surface path of egress from several exit discharge locations to the public way in accordance with NFPA 101, 2012 Edition, Section 7.7.1, and Annex A.7.7.1. These deficiencies affect 2 of 5 main level smoke compartments.

Findings include:

1. The following deficiencies were noted on egress paths:

a.) During observations on 4/4/17 at 9:47 a.m., on the public way from the two exits from the Special Care Unit, on hall #2, lacked a hard path surface for egress.

b.) During observations on 4/4/17 at 9:47 a.m., the public way from two exits on hall #3 lacked hard path surfaces for egress.

Based on observation, the facility failed to ensure that all veridical openings were sealed in accordance with NFPA 101, 2012 Edition, Section 19.3.1.1. This deficiency affects 2 of 5 main level smoke compartments and the basement smoke compartment.

Findings include:


1. During an observation on 4/3/17 at 1:23 p.m., in the new CT room there were two open electrical conduits in the floor with cables passing through them that were not sealed.

2. During an observation on 4/4/17 at 2:30 p.m., water pipes above the washing machines in the laundry created annular openings that needed to be sealed.

3. During an observation on 4/3/17 at 3:15 p.m., penetrations existed in the floor in room with sterilizer that needed to be sealed. They were annular openings around the pipes.

Based on observations, the facility failed to ensure alcohol based hand rub dispensers (ABHR) were not installed within one inch horizontal distance of an ignition source and above an ignition source in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8)(a)(b). This deficiency affects 2 of 5 main level smoke compartments.

Findings include:

1. During an observation on 4/3/17 at 11:35 a.m., an ABHR was secured directly over an electric outlet in the laboratory.

2. During an observation on 4/4/17 between 3:15 p.m. to 3:40 p.m., a light switch was one half inch from ABHR.

Based on observation, the facility failed to provide for occupant notification to alert occupants of a fire in accordance with NFPA 101, 2012 Edition, Section 19.3.4.3.1. This deficiency affects 1 of 5 main level smoke compartments.

Findings include:


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1. During an observation on 4/3/17 at 3:00 p.m., in the first level the Operating Arena and Post Operative Recovery had no fire alarm notification devices throughout the area.

Based on record review, the facility failed to include in the Fire Watch policy an individual who has no other responsibility when the fire alarm system is out of service for more than 4 hours in a 24 hour period other than to the fire watch in accordance with NFPA 101, 2012 Edition, Sections A.9.6.1.6. and 3.3.104. This deficiency affects all smoke compartments.

Findings include:

1. Review of the facility's fire watch policy did not include some special action beyond normal staffing, such as assigning an additional security guard to walk the area affected.

Based on observation, the facility failed to ensure positioning of sprinklers to avoid obstructions by light fixtures in accordance with NFPA 13, 2010 Edition, Table 8.6.5.1.2 and that duct work over four feet wide was protected in accordance with NFPA 13, 2010 Edition, Section 8.5.5.3.1 and storage was not less than 18 inches from the sprinkler. This deficiency affects the basement smoke compartment.

Findings include:

1. During the observation on 4/3/17 at 2:08 p.m., three walk in coolers were inspected. In each of the walk ins sprinkler spray pattern would be blocked from reaching all parts of the walk in cooler. The following observations were made:
a.) In the first cooler the light fixture was six inches below the sprinkler and the sprinkler five inches from the light fixture.
b.) The same situation as (a) above was observed in the middle cooler as well.
c.) In the third cooler the light fixture was 12 inches from the sprinkler and the sprinkler was six inches above the light.

2. During an observation on 4/4/17 at 3:15 p.m., sprinklers were less then 18 inches from top storage in the medical records room.

3. During an observation on 4/4/17 at 3:40 p.m., a light fixture, in the basement biohazard room, blocked the spray pattern of a sprinkler in that the light fixture was 15 inches from the sprinkler and the sprinkler was 5 inches above the light fixture.




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4. During observation on 4/4/17 at 4:35 p.m. and 4/5/17 at 7:20 a.m., the two HVAC handling rooms did not have sprinkler coverage installed under fixed obstructions over 4 ft. wide, such as duct work, per 8.5.5.3.1.

Based on observation, record review and interview, the facility failed to test or replace gauges on the sprinkler system every five years, and maintain sprinklers free of foreign material in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 13.2.7.2 and 5.2.1.1.1. These deficiencies affect the entire facility.

Findings include:

1. Review of the facility's sprinkler reports did not show evidence of the gauges being replaced or recalibrated.

In an interview on 4/4/17 at 10:45 a.m., staff member A said that there was no five year gauge replacement nor recalibration.

2. During an observation on 4/3/17 at 2:00 p.m., sprinklers were observed in the dish room of the kitchen to be covered with lint.

Based on record review, the facility failed to include in the Fire Watch policy an individual who has no other responsibility when the sprinkler system is out of service for more than 10 hours in a 24 hour period other than to the fire watch in accordance with NFPA 101, 2012 Edition, Sections 3.3.104, and NFPA 25, Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems, 2011 Edition Sections 15.5.2.(4)(b),(5) and A.15.5.4.2. This deficiency affects all smoke compartments.

Findings include:

1. Review of the facility's fire watch policy did not include a person for the express purpose of notifying the fire department, the building occupants, or both of an emergency; preventing a fire from occuring; extinguishing small fires; or protecting the public from fire or life safety dangers.

Based on observation, the facility failed to maintain portable fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers 2010 edition, per 6.1.3.4 portable extinguishers other than wheeled extinguishers shall be installed using any of the following means, (1) securely on a hanger intended for the extinguisher, Installation Height per 6.1.3.8.1 fire extinguishers having a gross weight not exceeding 40 lb shall be installed that the top of the fire extinguisher is not more than 5 ft above the floor. Per 7.2.1.2 fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals. Per 7.2.4.4 where manual inspections are conducted, records for manual inspections shall be kept on a tag or label attached to the fire extinguisher, or on an inspection checklist on file, or by an electronic method. A visual obstruction was observed per 6.1.3.3.1 fire extinguishers shall not be obstructed or obscured from view. The deficiency affects 3 first floor smoke compartments and the basement smoke compartment.

Findings include:

1. During an observation on 4/4/17 at 8:43 a.m., a fire extinguisher in the Extended Care unit was blocked by a piece of equipment.
2. During an observation 4/3/17 at 1:20 p.m., two deficiencies were noted in the Acute Care CT Scan Room.
a.) a carbon dioxide fire extinguisher was not mounted but was on the floor, and
b.) review of the tag on the extinguisher showed it was not inspected for the months of November 2016 to March 2017.

3. During observation on 4/4/17 at 2:40 p.m., it was observed in the basement area in the Laundry Room had a fire extinguisher that was mounted 73 inches from the floor.

4. During the observation on 4/4/17 at 5:00 p.m., another fire extinguisher in the hallway near the old CT room was mounted 63 inches from the floor,

5. During an observation on 4/4/17 at 5:15 p.m., in the Purchasing Department there were two fire extinguishers mounted in excess of 60 inches.

Based on observations and interview, the facility failed to ensure corridor doors were provided with a means suitable for keeping the door closed in accordance with NFPA 101, 2012 Edition Section 19.3.6.3.5. and did not contain a transfer grille in accordance with NFPA 101, 2012 Edition, Section 19.3.6.4.1. This deficiency affects 3 of 5 main level and basement smoke compartments.

Findings include:

1. During an observation, on 4/3/17 at 10:55 a.m., the door into acute storage did not latch when exercised. This door was on a self closer where the room measured 17 foot by 16 foot ( 272 square feet) and contained storage of hand sanitizer, adult incontinence briefs, syringes and cleaning wipes.

2. During an observation on 4/3/17 at 11:02 a.m., the pantry door near the nurses station on acute would not latch when exercised. It was on a hold open device.

In an interview on 4/3/17 at 11:03 a.m., staff member A said the hold open device (a magnet) was connected to the fire alarm.

3. During an observation on 4/3/17 at 11:44 a.m., the fire doors in the egress corridor out of acute did not latch when exercised.

4. During an observation on 4/4/17 at 11:30 a.m., the 90 minute fire doors in the two hour barrier on hall three of the extended care did not latch when exercised.

5. During an observation on 4/4/17 at 3:45 p.m., the door into the biohazard room in the basement did not latch when exercised.

In an interview on 4/4/17 at 3:45 p.m., staff member A said there was no latch it was just a dead bolt.

6. During an observation on 4/5/17 at 8:00 a.m., a corridor in the path of egress out of the basement to the clinic at the south end had a louver in the bottom one third of the door.

Based on observation, the facility failed to ensure that all smoke barriers were continuous in accordance with NFPA 101, 2012 Edition, Sections 8.5.2 and A.8.5.2. This deficiency affects 2 of 5 main level smoke compartments and the basement smoke compartment.

Findings include:

1. During an observation on 4/4/17 at 2:13 p.m., the basement Information Technology room was observed and there were five, unsealed ceiling penetrations.

2. During an observation on 4/4/17 at 4:50 p.m., in the old computerized tomography (CT) room in the basement there were three penetrations in the lay in ceiling tile.

3. During an observation on 4/5/17 at 8:47 a.m., a two hour wall was observed above the lay in tile across from the nurses station and the emergency room. An unsealed penetration in the two hour wall could be seen.

4. During an observation on 4/5/17 at 7:26 a.m., in an air handler room there was a penetration in the wall with flexible braided heated lines running along the water pipe that passed through the wall. There were patient rooms above this wall.

Based on observation, the facility failed to ensure electrical wiring complied with NFPA 70, 2011 Edition, Section 210.8(B)(5). These deficiencies affect 1 of 5 main level smoke compartments and the basement smoke compartment.

Findings include:

1. During an observation on 4/3/17 at 11:33 a.m. and 2:03 p.m., two locations had electrical outlets within six feet of the sinks. The following deficiencies were noted:
a.) The wall mounted power receptacles in the laboratory did not have ground fault circuit interruption (GFCI) protection. The receptacles were approximately four feet from the sink.
b.) The kitchen window mounted air conditioner was plugged into a non rated GFCI outlet located within five feet of the sink, and not the required six feet from sinks.

Based on observation and interview, the facility failed to ensure adequate make up air for the three Type 2 dryers in the laundry in accordance with NFPA 54, National Fuel Gas Code, 2012 Edition, Section 10.4.3.2. This deficiency affects 1 of 1 smoke compartments in the basement.

Findings include:

1. During an observation on 4/4/17 at 2:40 p.m., the laundry area was observed. Three dryers were in the area. There was seven circular vents in the ceiling. One dryer was 215,000 BTU's and the other two were 175,000 each. The seven openings in the ceiling were measured. These vents were measured and the aggregate area measured just over 197 square inches.

In an interview on 4/4/17 at 2:40 p.m., staff member A said that these vents blew air from the air handler just for the laundry and thought that the volume of air forced out of these vents may be enough make up air.

It was not evident there was a 565 square inch opening for make up air in accordance with section 10.4.3.2 that indicated there should be a minimum of one square inch per 1000 BTU's.

Based on observation, the facility failed to ensure decorations such as photographs did not exceed 50% of the wall, ceiling and non-fire rated door in accordance with NFPA 101, 2012 Edition, Section 19.7.5.6 (d). This deficiency affects 1 of 5 main level smoke compartments.

Findings include:

1. During an observation on 4/4/17 at 8:25 a.m., extended care resident room 10 was reviewed. Over two thirds of the closet door/wall was covered with papers and photographs.

Based on observation and interview, the facility failed to maintain fire protection features in rooms where alteration of data cable was being installed in accordance with NFPA 101, 2012 Edition, Section 4.6.10.1. This deficiency affects 2 of 5 main level smoke compartments.

Findings include:

1. During observations on 4/3/17 at 2:00 p.m. and 4/4/17 at 11:15 a.m., tiles were out of the ceilings for cable work in the X-ray room next to the computerized tomography (CT), the server room behind the fire panel in extended care and the server room in the administrative area. The integrity of the sprinkler to be set off in these rooms could not be ensured as in case of a fire heat would by-pass the sprinklers with the tile removed.

In an interview on 4/4/17 at 11:15 a.m., staff member A said two months ago work started on cable work. They worked a couple of weeks in acute with the tile out of place. When they are done with all the work they will replace the tile in the ceiling.

This area would need to have a fire watch conducted until all work is complete, or ceiling tiles would need to be replaced daily.