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Based on observation and staff interview, the facility failed to maintain means of egress in accordance with the 2012 NFPA 101, Life Safety Code. The findings were:

Observation on 07/19/17 at 3:13 PM of the OB corridor revealed a glass door opening to the adjacent courtyard. Further observation revealed that there was no means of egress from within the courtyard. The door from the OB courtyard was able to be mistaken for an exit and was not provided with a sign that reads NO EXIT. Failure to identify a door that can be easily mistaken as a means of egress can lead to injury or death in an emergency. Interview with the facility maintenance staff at the time of the observation confirmed that the door does not provide a means of egress, but that it can easily be mistaken as an exit to the exterior.

REF: 2012 NFPA 101, Section 7.10.8.3



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Based on observation and staff interview, the facility failed to maintain means of egress in accordance with the 2012 NFPA 101, Life Safety Code. The findings were:

1. Observation on 07/19/17 at 2:09 PM of the entrance vestibule at the Ambulance Bay revealed that the interior sliding doors were provided with a deadbolt lock which required a key to unlock from the egress side. Failure to maintain egress doors as required could result in injury or death during an emergency situation. Interview with the facility maintenance staff at the time of the observation revealed that they were unaware of the requirement.

REF: 2012 NFPA 101, Section 19.2.2.2.4

2. Observation on 07/19/17 at 2:36 PM of the double doors at the materials drop-off location for Central Sterile, Room 1536, revealed that the doors were provided with an automatic opening device that was activated from the corridor via a card key. Observation from within the space revealed that the doors were held in the closed position via a magnetic lock, with no other means to open the door other than a push button located approximately 2 feet to the right of the door. The push button was damaged and did not include a plunger pad, requiring the user to be familiar with the remaining post protruding from the wall for activation. No label was provided to indicate that the button must be pressed to egress from the space. Further observation revealed that the primary means of egress from the space had been blocked with stored materials, making the double doors the only means of egress from the room to the corridor, as well as for occupants from within the sterile processing area who may exit via this path. Interview with the facility maintenance staff at the time of the observation acknowledged the damaged push button, and indicated that they were in the process of replacing the damaged plunger pad. Additional interview revealed that the push button was to be relocated to an opposite side of the room as the button has been damaged multiple times due to the receiving process. They also acknowledged that the primary path of egress had been modified from the original design intent.

REF: 2012 NFPA 101, Section 19.2.2.2.4




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Based on observation and staff interview, the facility failed to maintain cooking equipment in accordance with the 2012 NFPA 101, Life Safety Code, and 2011 NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. The findings were:

Observation on 07/19/17 at 3:29 PM of the Kitchen revealed that the commercial hoods were provided with removable grease baffles. Further observation revealed that the baffles were damaged, and did not maintain a uniform separation, allowing gaps in the grease removal system and grease laden air to pass to the exhaust systems. Failure to maintain commercial kitchen hoods can result in injury or death due to an increased risk of fire. Interview with the facility maintenance staff at the time of the observation revealed that they were aware of the requirement.

REF: NFPA 96, Section 6.2



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Based on Observation and staff interview, the facility failed to maintain a fire alarm in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 72, National Fire Alarm and Signaling Code. The findings were:

Observation on 07/19/17 at 2:22 PM of Panel L3H, located in Electrical Room 1706, revealed that the fire alarm circuit disconnect was not identified with red markings. Failure to maintain a fire alarm as required can result in injury or death in an emergency. Interview with the facility maintenance staff at the time of the observation revealed that they were aware of the requirement.

REF: 2010 NFPA 72, Section 10.5.5.2.3



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Based on observation and staff interview, the facility failed to provide an automatic sprinkler system in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 13, Standard for the Installation of Sprinkler Systems. The findings were:

1. Observation on 07/19/17 at 1:26 PM in the Storage Room adjacent to the Specialty Clinic revealed a sprinkler head with no escutcheon, which resulted in a gap of approximately 0.5 inches in the ceiling around the circumference of the sprinkler head. Failure to install escutcheons in accordance with NFPA 13 can result in a delayed response time of the sprinkler system and result in injury or death in an emergency. Interview with the facility maintenance staff at the time of the observation revealed that they were aware of the requirement, but had not identified the missing escutcheon.

REF: 2012 NFPA 101, Sections 19.3.5.3; 9.7 and 2010 NFPA 13, Section 6.2.7

2. Observation on 07/19/17 at 1:30 PM at the exterior canopies and roof overhangs of the south addition revealed that the underside finish consisted of wooden tongue and groove sheathing. All overhangs and canopies were measured to exceed 4 feet in width. Interview with the facility maintenance staff could not establish that the wooden finish had been treated in any manner that would demonstrate compliance as a non-combustible, limited-combustible, or fire retardant-treated wood. Failure to provide sprinkler protection at canopies and overhangs in accordance with NFPA 13 may result in injury or death in the event of a fire. Interview with the facility maintenance staff at the time of the observation revealed that they were not aware of the requirement.

REF: 2012 NFPA 101, Sections 19.3.5.3; 9.7 and 2010 NFPA 13, Section 8.15.7

3. Observation on 07/19/17 starting at 2:50 PM in Fluoroscope Rooms #1, #2, and #3 revealed that sprinkler heads were installed within the perimeter of the ceiling-mounted track system utilized to support and relocate the imaging equipment. Further observation revealed that routine use of the imaging equipment will result in the obstruction of one or more sprinkler heads due to the equipment being located directly below the sprinkler head. Failure to provide unobstructed automatic sprinkler systems in accordance with NFPA 13 may result in injury or death in the event of a fire. Interview with the facility maintenance staff at the time of the observation revealed that they were unaware of the obstruction.

REF: 2012 NFPA 101, Sections 19.3.5.3; 9.7 and 2010 NFPA 13, Section 8.5.5

4. Observation on 07/19/17 at 3:57 PM of the facilities fire riser and inspector's test device for the sprinkler system revealed that the discharge did not have an orifice sized to simulate a sprinkler having the smallest orifice installed within the facility for testing of the waterflow alarm device. Failure to test sprinkler systems as required could result in injury or death during a fire. Interview with the facility maintenance staff at the time of the observation revealed that they were unaware of the requirement.

REF: 2012 NFPA 101, Sections 19.3.5.3; 9.7 and 2010 NFPA 13, Section 8.17.4.2.1



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Based on observation and staff interview, the facility failed to maintain areas that are open to corridors in accordance with the 2012 NFPA 101, Life Safety Code. The findings were:

Observation on 07/19/17 at 2:42 PM of the North Radiology Corridor revealed that patient record storage was located within an area that was open to the corridor. Additional observation revealed that the space was approximately 16 ft. by 16 ft. in size, and contained a large volume of paper records within sliding file cabinets. The space was identified as a hazardous area, and no separation was provided from the corridor. Failure to maintain areas which are open to the corridor as required could result in injury or death in an emergency. Interview with the facility maintenance staff at the time of the observation revealed that the space has been utilized in this manner for many years, and that they were unaware of the requirement.

REF: 2012 NFPA 101, Section 19.3.6.1



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Based on observation and staff interview, the facility failed to maintain doors in a means of egress in accordance with the 2010 NFPA 101, Life Safety Code. The findings were:

Observation on 07/19/17 at 2:55 PM of the dual-leaf doors exiting from the CT Room 1636 to the adjacent corridor revealed that the left leaf, as facing the doors from the corridor, was not provided with a self-latching device to ensure that the leaf was affixed in place to allow latching of the right leaf. Additional observation revealed that a manual push-pin style locking device was provided at the head and foot of the door to lock the leaf in the closed position. Failure to maintain corridor doors may result in injury or death in the event of an emergency. Interview with the facility maintenance staff at the time of the observation acknowledged that the door arrangement did not allow the doors to be held in the closed position without the activation of the manual locks on one door leaf.

REF: 2012 NFPA 101, Section 19.3.6.3.5



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