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Based on observation and staff interview, the facility failed to provide corridor doors that resist the passage of smoke. The findings were:

Observation on 06/15/2016 at 9:28 AM located in the O.R. Smoke Compartment, revealed the smoke compartment door was not smoke resistant and was missing an astragal, a rabbet, or a bevel. Interview with the Facility Maintenance Manager at the time of the observation acknowledge the door was not compliant with the requirements of NFPA 101.

Ref:
2000 NFPA 101, Section 19.3.6.3.6

Based on observation and staff interview, the facility failed to provide protection from hazards in accordance with NFPA 101. The findings were:

1. Observation on 06/15/2016 at 10:35 AM located in the lab storage revealed a door closer had been disconnected from the wall preventing the door from self-closing. Interview with the Facility Maintenance Manager at the time of the observation acknowledge the door closer was out of compliance with the requirements of NFPA 101.

2. Observation on 06/15/2016 at 9:28 AM located in the generator room revealed a lack of the required 2-hour fire-barrier separation as a fire door was missing from the frame into the garage. Interview with the Facility Maintenance Manager at the time of the observation revealed he was unaware of the requirement.

Ref:
2000 NFPA 101, Section 19.3.2.1

Based on observation and staff interview, the facility failed to provide a self closing door to resist passage of smoke in accordance with NFPA 101. The finding was:

Observation on 06/15/2016 at 10:44 AM in the lab revealed a rolling fire door open to the corridor incapable of closing upon activation of the fire alarm. Interview with Facility Lab Staff confirmed that the rolling door would not close upon activation of the fire alarm.

Ref:
2000 NFPA 101, Section 19.2.2.2.6 and 7.2.1.8.2
1999 NFPA 72

Based on observation and staff interview, the facility failed to arrange exit access so that exits are readily accessible at all times. The findings were:

Observation on 06/15/2016 at 11:48 AM of the Ambulance/ER exit doors revealed that under a power failure the power doors could not be opened by switch. No panic hardware or door knobs are installed on the doors, however the doors are designed to break away but were not provided with the required readily visible sign located adjacent to the door. At the time of the observation the Facility Maintenance Manager acknowledged the doors were not provided with the required sign.

Ref:
2000 NFPA 101, Sections 19.2.1 and 7.2.1.9.1

Based on observation and staff interview, the facility failed to provide evidence that emergency lighting is provided per the requirements of NFPA 101. The findings were:

Observation on 06/15/2016 from 8:40 AM to 8:56 AM could not confirm that the O.R. #1, O.R. #2, and PACU rooms were equipped with emergency lighting. Interview with the Facility Maintenance Manager at the time of the observation could not establish that the rooms were equipped with emergency lighting.

Ref:
2000 NFPA 101, Sections 19.2.8

Based on observation and staff interview, the facility failed to install a manual fire alarm box in accordance with NFPA 72. The finding was:

Observation on 06/15/2016 at 10:15 AM revealed a manual fire alarm box located in the corridor heading to the care center from the kitchen was installed approximately 58 inches above the floor. Interview with the Facility Maintenance Manager at the time of observation acknowledged the installed height of the manual fire alarm box.

Ref:
2000 NFPA 101, Sections 19.3.4 and 9.6
1999 NFPA 72, Section 2-8.1

Based on observation and staff interview, the facility failed to ensure that automatic sprinkler systems are installed and continuously maintained per the requirements of NFPA 13 and NFPA 25. The findings were:

1. Observation on 06/15/2016 at 9:22 AM revealed a missing escutcheon ring with a resulting gap around the sprinkler head in the cardiac rehab and wellness center adjacent to the cardiac rehab area. Interview with the Facility Maintenance Manager at the time of the observation acknowledged the missing escutcheon ring.

Ref:
2000 NFPA 101, Sections 18.3.5.1, 19.3.5.1, and 9.7.1.1
1999 NFPA 13, Section 3-2.7.2

2. Observation on 06/15/2016 at 11:30 AM of the x-ray room revealed that (4) sprinkler heads were obstructed by the x-ray machine. Interview with the Facility Maintenance Manager at the time of the observation acknowledged that the machine obstructed the sprinkler heads.

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.5
1998 NFPA 25, Section 2-2.1.1

3. Observation on 06/15/2016 at 12:00 PM revealed that the riser room was missing a sprinkler wrench critical for replacing sprinkler heads. Interview with the Facility Maintenance Manager at the time of observation acknowledge the missing wrench.

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.5
1998 NFPA 25, Section 2-2.1.3

4. Observation on 06/15/2016 at 12:00 PM revealed that gauges in the riser room on the riser had not been replaced or calibrated within the past 5 years. Interview with the Facility Maintenance Manager at the time of observation acknowledge the past due replacement or calibration on the gauges.

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.5
1998 NFPA 25, Section 2-3.2

Based on observation and staff interview, the facility failed to install an essential electrical system per NFPA 99 and NFPA 110 in life support areas. The findings were:

1. Observation on 06/15/2016 at 8:40 AM located in O.R. #1 and O.R. #2 revealed no indication of electrical power to the room as provided by the Essential Electric System (EES). Normal power was observed, but no other power was indicated visually. Interview with the Facility Maintenance Manager at the time of observation acknowledge no indication of EES power and could not demonstrate there was emergency power in the room.

2. Observation on 06/15/2016 at 8:55 AM located in the PACU room revealed only EES power receptacles and no primary power. Interview with the Facility Maintenance Manager at the time of the observation could not determine if the power was provided via two transfer switches from the generator.

Ref:
1999 NFPA 99, Section 3-4.2.2

3. Observation on 06/15/2016 at 12:00 PM located at the generator annunciator panel revealed the annunciator panel missing the required alarm for when the battery charger is malfunctioning. The Facility Maintenance Manager at the time of the observation was unaware of the requirement.

Ref:
1999 NFPA 99, Sections 3-4.1.1.15

Based on observation and interview, the facility failed to ensure that the electrical wiring and equipment was in accordance with NFPA 70. The findings were:

Observation on 06/15/2016 at 9:06 AM of the Cardiac Rehab room revealed an outlet next to the hand washing sink that was not provided with a ground-fault circuit-interrupter. Interview with the Facility Maintenance Manager at the time of the observation acknowledged that the outlet was not wired according to NFPA 70.

Ref:
1999 NFPA 70, Section 210.8

Based on observation and staff interview, the facility failed to provide corridor doors that resist the passage of smoke. The findings were:

Observation on 06/15/2016 at 9:28 AM located in the O.R. Smoke Compartment, revealed the smoke compartment door was not smoke resistant and was missing an astragal, a rabbet, or a bevel. Interview with the Facility Maintenance Manager at the time of the observation acknowledge the door was not compliant with the requirements of NFPA 101.

Ref:
2000 NFPA 101, Section 19.3.6.3.6

Based on observation and staff interview, the facility failed to provide protection from hazards in accordance with NFPA 101. The findings were:

1. Observation on 06/15/2016 at 10:35 AM located in the lab storage revealed a door closer had been disconnected from the wall preventing the door from self-closing. Interview with the Facility Maintenance Manager at the time of the observation acknowledge the door closer was out of compliance with the requirements of NFPA 101.

2. Observation on 06/15/2016 at 9:28 AM located in the generator room revealed a lack of the required 2-hour fire-barrier separation as a fire door was missing from the frame into the garage. Interview with the Facility Maintenance Manager at the time of the observation revealed he was unaware of the requirement.

Ref:
2000 NFPA 101, Section 19.3.2.1

Based on observation and staff interview, the facility failed to provide a self closing door to resist passage of smoke in accordance with NFPA 101. The finding was:

Observation on 06/15/2016 at 10:44 AM in the lab revealed a rolling fire door open to the corridor incapable of closing upon activation of the fire alarm. Interview with Facility Lab Staff confirmed that the rolling door would not close upon activation of the fire alarm.

Ref:
2000 NFPA 101, Section 19.2.2.2.6 and 7.2.1.8.2
1999 NFPA 72

Based on observation and staff interview, the facility failed to arrange exit access so that exits are readily accessible at all times. The findings were:

Observation on 06/15/2016 at 11:48 AM of the Ambulance/ER exit doors revealed that under a power failure the power doors could not be opened by switch. No panic hardware or door knobs are installed on the doors, however the doors are designed to break away but were not provided with the required readily visible sign located adjacent to the door. At the time of the observation the Facility Maintenance Manager acknowledged the doors were not provided with the required sign.

Ref:
2000 NFPA 101, Sections 19.2.1 and 7.2.1.9.1

Based on observation and staff interview, the facility failed to provide evidence that emergency lighting is provided per the requirements of NFPA 101. The findings were:

Observation on 06/15/2016 from 8:40 AM to 8:56 AM could not confirm that the O.R. #1, O.R. #2, and PACU rooms were equipped with emergency lighting. Interview with the Facility Maintenance Manager at the time of the observation could not establish that the rooms were equipped with emergency lighting.

Ref:
2000 NFPA 101, Sections 19.2.8

Based on observation and staff interview, the facility failed to install a manual fire alarm box in accordance with NFPA 72. The finding was:

Observation on 06/15/2016 at 10:15 AM revealed a manual fire alarm box located in the corridor heading to the care center from the kitchen was installed approximately 58 inches above the floor. Interview with the Facility Maintenance Manager at the time of observation acknowledged the installed height of the manual fire alarm box.

Ref:
2000 NFPA 101, Sections 19.3.4 and 9.6
1999 NFPA 72, Section 2-8.1

Based on observation and staff interview, the facility failed to ensure that automatic sprinkler systems are installed and continuously maintained per the requirements of NFPA 13 and NFPA 25. The findings were:

1. Observation on 06/15/2016 at 9:22 AM revealed a missing escutcheon ring with a resulting gap around the sprinkler head in the cardiac rehab and wellness center adjacent to the cardiac rehab area. Interview with the Facility Maintenance Manager at the time of the observation acknowledged the missing escutcheon ring.

Ref:
2000 NFPA 101, Sections 18.3.5.1, 19.3.5.1, and 9.7.1.1
1999 NFPA 13, Section 3-2.7.2

2. Observation on 06/15/2016 at 11:30 AM of the x-ray room revealed that (4) sprinkler heads were obstructed by the x-ray machine. Interview with the Facility Maintenance Manager at the time of the observation acknowledged that the machine obstructed the sprinkler heads.

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.5
1998 NFPA 25, Section 2-2.1.1

3. Observation on 06/15/2016 at 12:00 PM revealed that the riser room was missing a sprinkler wrench critical for replacing sprinkler heads. Interview with the Facility Maintenance Manager at the time of observation acknowledge the missing wrench.

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.5
1998 NFPA 25, Section 2-2.1.3

4. Observation on 06/15/2016 at 12:00 PM revealed that gauges in the riser room on the riser had not been replaced or calibrated within the past 5 years. Interview with the Facility Maintenance Manager at the time of observation acknowledge the past due replacement or calibration on the gauges.

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.5
1998 NFPA 25, Section 2-3.2

Based on observation and staff interview, the facility failed to install an essential electrical system per NFPA 99 and NFPA 110 in life support areas. The findings were:

1. Observation on 06/15/2016 at 8:40 AM located in O.R. #1 and O.R. #2 revealed no indication of electrical power to the room as provided by the Essential Electric System (EES). Normal power was observed, but no other power was indicated visually. Interview with the Facility Maintenance Manager at the time of observation acknowledge no indication of EES power and could not demonstrate there was emergency power in the room.

2. Observation on 06/15/2016 at 8:55 AM located in the PACU room revealed only EES power receptacles and no primary power. Interview with the Facility Maintenance Manager at the time of the observation could not determine if the power was provided via two transfer switches from the generator.

Ref:
1999 NFPA 99, Section 3-4.2.2

3. Observation on 06/15/2016 at 12:00 PM located at the generator annunciator panel revealed the annunciator panel missing the required alarm for when the battery charger is malfunctioning. The Facility Maintenance Manager at the time of the observation was unaware of the requirement.

Ref:
1999 NFPA 99, Sections 3-4.1.1.15

Based on observation and interview, the facility failed to ensure that the electrical wiring and equipment was in accordance with NFPA 70. The findings were:

Observation on 06/15/2016 at 9:06 AM of the Cardiac Rehab room revealed an outlet next to the hand washing sink that was not provided with a ground-fault circuit-interrupter. Interview with the Facility Maintenance Manager at the time of the observation acknowledged that the outlet was not wired according to NFPA 70.

Ref:
1999 NFPA 70, Section 210.8