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Through observation testing during the survey, conducted December 13 and 14, 2016, it was determined that the facility failed to maintain the exits as readily accessible at all times.

During the walk through of the facility, with the Maintenance Director;
A) The OB back delayed egress door did not unlock with fire alarm activation.
B) The Ortho 2nd fl. Elevator door did not latch with fire alarm activation

This deficiency could effect two of seventeen smoke compartments.

Through observation and testing during the survey, December 13 and 14, 2016, it was determined that the facility failed to maintain the emergency lighting systems.
 

During the walk through of the facility, with the Facilities Manager, the main hall exit emergency battery back-up lighting was non-functional.


This deficiency could affect one smoke compartment.

Through observation during the survey, December 13, and 14 2016, it was determined that the facility failed to maintain the hazardous areas.
 
During the walk through of the facility, with the Maintenance Director: The OB IT closet had an unsealed sheet rock joint. Corrected during the survey.

This deficiency could effect one of seventeen smoke compartments.

Through observation during the survey, conducted December 13 and 14, 2016, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly.
 
During the walkthrough of the facility, with the Facilities Director, the alcohol based hand rub dispensers (ABHR) were installed above or adjacent to an electrical source and over carpet with out a drip pan"The dispensers shall not be installed over or directly adjacent to an ignition source."

Patient Rep room ABHR mounted over carpet without a drip pan. Corrected during survey
Lab back door ABHR mounted above electrical switch. Corrected during the survey.


This deficiency could effect two of seventeen smoke compartments.

Through observation and testing, during the survey conducted December 13, and 14, 2016, it was determined that the facility failed to install and maintain the fire alarm system with approved components, devices or equipment in accordance with NFPA 72.
 
During the walk through of the facility with the Facilities Director; Boiler room ice melt was stacked in front of the pull station and emergency stop button. Corrected during the survey.


This deficiency could effect one one of seventeen smoke compartments.

Through observation during the survey, conducted December 13, and 14, 2016 it was determined that the facility failed to maintain the fire alarm system in accordance with NFPA 72.
 
During the walk through of the facility, with the Maintenance Director, the ICU Ward fire alarm strobe lights were not synchronized per NFPA 72. Corrected during the survey.


This deficiency could effect one of seventeen smoke compartments.

Through observation during the survey, December 13, and 14, 2016 , it was determined that the facility failed to install an automatic sprinkler system per NFPA 13.
 
During the walk through of the facility, with the Maintenance Director;
a) The Hydrotherapy bathroom sprinkler escutcheon was missing. Corrected during the survey
b) The OB Case Management office sprinkler trim above ceiling. Corrected during the survey.


This deficiency could effect two of seventeen smoke compartments

Through observation during the survey, December 13, and 14, 2016 , it was determined the facility failed to maintain the doors to the corridor.
 
During the walk through of the facility with the Maintenance Director;
a) OR housekeeping door propped open. Corrected during the survey.
b) Shell space 1342 door with tape over latch. Corrected during the survey.


This deficiency could effect two of seventeen smoke compartments.

Through observation during the survey, December 13, and 14, 2016 , it was determined that the facility failed to maintain the smoke barrier walls.
 
During the walk through of the facility, with the Maintenance Supervisor, :
Smoke barrier wall penetrations not sealed in the following locations
a) Out Patient clinic wall above smoke door two penetrations
b) PT Waiting wall above smoke door, one large penetration
c)Mail Room wall above smoke door, multiple penetrations
d) Admin conference center wall above smoke door, two penetrations
e) CS wall above smoke doors, two penetrations
All penetrations corrected during survey.
Ceiling tile open in corridor near MRI equipment. Corrected during survey
Ceiling tile open in Rad room. Corrected during survey.

This deficiency could effect seven of seventeen smoke compartments.

Through observation during the survey, December 13, and 14, 2016, it was determined the facility had portable space heating devices and the elements were not listed as not to exceed 212F.
 
During a walk through of the facility with the Maintenance Director;
1) Portable space heater used in 2nd fl. Out patient clinic. Corrected during the survey.
2) Wellness Coordinator using portable space heater. Corrected during the survey.


This deficiency could effect two of seventeen smoke compartments.

Through observation during the survey, December 13, and 14, 2016 it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70.
 
During the walk through of the facility with the Maintenance Director:
a) Cardiac Rehab extension cords used for decorations. Corrected during the survey.
b) Compressor room extension cord ran around room. Corrected during the survey.


This deficiency could effect two of seventeen smoke compartments.

Through observation during the survey December 13, and 14, 2016 it was determined the facility failed to secure all cylinder tanks.

The Syrup room CO2 tank was setting on floor not supported. Corrected during survey.

This deficiency could effect one of seventeen smoke compartments.