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Based on observation, the facility failed to maintain a horizontal exit per the requirements of:

2012 NFPA 101, 18.2.2.5, 7.2.4.3.1, and 8.3.5.1

This deficiency affects 1 of 2 two-hour fire barriers (tenant separation walls).

Findings include:

During a tour of the facility, the surveyor observed an unsealed penetration of a red cable in the 2-hour fire barrier (tenant separation wall), over the door between the Hospital Emergency Department Lobby near the vending machines and the Medical Office Building.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the fire alarm system per the requirements of:

2012 NFPA 101, 18.3.4.1, and 9.6.1.3
2010 NFPA 72, Table 14.3.1(9)(h)

This deficiency affects all smoke detectors.

Findings include:

During a tour of the facility, the facility failed to provide documentation of conducting semi-annual visual inspections on the smoke detectors within the past 12 months.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain areas open to the corridor per the requirements of:

2012 NFPA 101, 18.3.6.1 (1) (c)

This deficiency affects 1 of 7 smoke compartments.

Findings include:

During a tour of the facility, the surveyor observed the First Floor Main Lobby Wheelchair Storage space was open to the corridor, and did not have an electrically supervised automatic smoke detection system. This space did not allow direct supervision by the facility staff from a Nurses' Station or similar space.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 18.3.7.3, 8.5.1, 8.5.6.2, and 8.5.6.3

This deficiency affects 2 of 7 smoke compartments.

Findings include:

During a tour of the facility, the surveyor observed an unsealed 1 1/4" conduit used as a chase for 1 gray cable in the smoke barrier, above the ceiling in the C.T. Room. This is the east wall between the C.T. Room and the Emergency Department.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the electrical wiring and equipment per the requirements of:

2012 NFPA 101, 18.5.1.1, and 9.1.2
2011 NFPA 70, 314.27 (2) and 410.5

This deficiency affects 1 of 1 electrical rooms on the 2nd floor.

Findings include:

During a tour of the facility, the surveyor observed exposed wiring from a flexible conduit coming out of the bottom of Panel C2LA in the 2nd floor Electrical Room.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the oxygen cylinders per the requirements of:

2012 NFPA 99, 11.6.2.3 (11), 11.3.2.3 and 11.6.5.4

This deficiency affects all oxygen cylinders in the outside liquid oxygen fenced-in area.

Findings include:

During a tour of the facility, the surveyor observed the facility failed to protect the oxygen cylinders located outside in the liquid oxygen fenced-in area against continuous exposure to direct rays of the sun where extreme temperatures prevail.

A member of the maintenance staff was present when this deficiency was identified.