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The facility failed to maintain a two-hour fire resistance-rated occupancy separation between the hospital of Type II (222) construction and the attached clinic of Type V (000) construction.

Observation determined numerous unsealed penetrations and open holes in the two-hour fire resistance wall separating the hospital from the attached clinic.

Failure to maintain the integrity of the two-hour-fire rated occupancy separation increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) two-hour fire resistance barriers in the facility.

The facility failed to maintain the means of egress in accordance with Chapter 7.

1) During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open. 7.2.1.4.3.1

Observation determined the following corridor doors opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.

a) The corridor door to Storage Room GD32.
b) The corridor door to West Boiler Room GDM18.

The deficiency affected two (2) of numerous corridor doors in the means of egress throughout the facility.

2) Means of egress must be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. The width of means of egress shall be measured in the clear at the narrowest point of the exit component under consideration. Exception: Projections not more than 4 1/2 in. (114 mm) on each side shall be permitted at 38 in. (965 mm) and below. 7.1.10.1, 7.3.2.2

Observation determined a wall mounted heater located in the corridor near the Emergency Room extended approximately eight (8) inches from the corridor wall and protruded into the exit corridor.

This deficiency affected egress from one (1) of numerous exit corridors throughout the facility.

Failure to maintain the means of egress to be available at all times increases the risk of death or injury due to fire.

The facility failed to install the automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

Observation determined:

1) There was an open access hatch in the ceiling in the Kitchen Storage Room.

2) There was one (1) normal temperature sprinkler in the corridor near Exit number 8, within 7' of a ceiling mounted horizontal discharge unit heater.

3) There were ten (10) sprinklers in the Business Office that were located within 6' of the adjacent sprinkler.

4) The dressing room in the Mammography Room lacked sprinkler coverage.

5) There were missing ceiling tile throughout the facility.

Failure to install the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury or death due to fire.

This deficiency affects numerous areas of the 1971 and 1991 buildings protected by the automatic sprinkler system.

Portable fire extinguishers shall be provided in all health care occupancies. Extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 19.3.5.12, 9.7.4.1

Fire extinguishers having a gross weight not exceeding 40 lb. (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb. (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm). NFPA 10 6.1.3.8.1, 6.1.3.8.2, 6.1.3.8.3

The facility failed to install fire extinguishers in accordance with NFPA 10.

Observation determined portable fire extinguishers throughout the facility were installed with the top of the extinguisher more than 5 ft. above the floor.

Failure to install fire extinguishers in accordance with NFPA 10 increases the risk of injury or death due to fire.

The deficiency affected numerous fire extinguishers in the facility.

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke. 19.3.6.3.1.

The facility failed to ensure corridor doors resisted the passage of smoke.

Observation determined the corridor doors on the first floor to Rooms 104 and 105 had a small hole through the door near the door handle.

Failure to ensure corridor doors resist the passage of smoke increases the risk of injury or death due to fire.

This deficiency affected two (2) of numerous corridor doors in the facility.

Ground-fault circuit-interruption for personnel shall be provided as required. The ground-fault circuit-interrupter shall be installed in a readily accessible location. All 125-volt, single-phase, 15- and 20-ampere receptacles located in areas other than kitchens where receptacles are installed within 6 ft. of the outside edge of the sink shall have ground-fault circuit-interrupter protection for personnel. NFPA 70, 210.8, 210.8(A)(7)

The facility failed to provide electrical wiring and equipment in accordance with NFPA 70, National Electrical Code.

Observation determined electrical receptacles in the Operating Room and the Respiratory Therapy Room were installed within 6 ft. of a sink and were not ground-fault circuit-interrupter protected.

Failure to provide electrical wiring and equipment in accordance with NFPA 70 increases the risk of injury or death due to fire.

The deficiency affected two (2) of numerous receptacles throughout the facility.