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Based on observations made in the presence of the plant manager on 03-19-2019, it was determined that the facility did not maintain doors with self-closing devices in accordance with NFPA 19.2.2.2.8

This deficiency affected 1 of several smoke compartments.

Findings include:
1-During the facility tour it was observed that the women's services elevator machine room did have a self-closing device on the door but did not close to the full latching position and was not in accordance with 19.2.2.2.7, 19.2.2.2.8

Based upon observations made in the presence of the plant manager on 03-19-2019, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1, 19.3.2.1.1 through 19.3.2.1.5(18.3.2.1)

This deficiency affected several smoke compartments

Findings include:
1- During the facility tour it was observed that the women's services storage room near patient room 233 was observed to have a 3'x2' penetration that was not sealed, Hazardous areas shall be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1
2- During the facility tour it was observed that the PACU storage room was observed to have a 2'x2' penetration that was not sealed, Hazardous areas shall be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1
3- During the facility tour it was observed that the 3RD floor storage room was observed to have penetration's around a hvac duct, a sprinkler pipe and wire conduit that was not sealed at the time of this inspection, Hazardous areas shall be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1
4- During the facility tour it was observed that the 4th floor soiled utility room was observed to have a several penetration's that was not sealed, Hazardous areas shall be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1

Based upon observations/record review made in the presence of the plant manager on 03-19-2019, it was determined that the facility did not maintain the fire sprinkler system in accordance with NFPA 101, 9.7.5.

This deficiency affected several sprinkler heads.

Findings include:
1-During the facility tour it was observed that the sprinkler head in room 450 had corrosion on the head of the sprinkler, Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation in accordance with NFPA 25
2--During the facility tour it was observed that the sprinkler head in room 447 had corrosion on the head of the sprinkler, Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation in accordance with NFPA 25
3-During the facility tour it was observed that the sprinkler head in room 441 had corrosion on the head of the sprinkler, Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation in accordance with NFPA 25
4-During the facility tour it was observed that the sprinkler heads in the therapy pool area had corrosion on the head of the sprinkler, Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation in accordance with NFPA 25
5-During the facility tour it was observed that the sprinkler heads in the therapy pool change rooms had corrosion on the head of the sprinkler, Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation in accordance with NFPA 25

Based upon observations made in the presence of the plant manager on 03-19-2019, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

This deficiency affected 13 of several GFIC outlets.

Findings include
1-During the facility tour it was observed that the outlet in the kitchen by the hand wash sink were not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
2- During the facility tour it was observed that the 2 outlet's in the east community class room was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
3-During the facility tour it was observed that the outlet in the radiology control room was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
4- During the facility tour it was observed that the outlet in the radiologist special control room was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
5- During the facility tour it was observed that the outlet in the same day surgery by the nutrition sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
6- During the facility tour it was observed that the outlet in the same day surgery by the break room sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
7- During the facility tour it was observed that the outlet in the same day surgery nurses station sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
8- During the facility tour it was observed that the outlet in the operating room 4&5 sub sterile sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
9- During the facility tour it was observed that the outlet in the women's services conference room sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
10- During the facility tour it was observed that the outlet in the women's services kitchen sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
11- During the facility tour it was observed that the outlet in the medical surgical soiled utility room sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
12- During the facility tour it was observed that the outlet in the 4th floor laundry room hopper sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
13- During the facility tour it was observed that the outlet in the hyperbaric lab room sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

Based upon made in the presence of the plant manager on 03-19-2019, it was determined that the facility did not install or maintain the buildings heating, ventilating and air conditioning systems in accordance with NFPA 101 19.5.2.1 and 9.2.

This deficiency affected all smoke dampers.

Findings include:
1-During the record review the facility failed to provide the testing documentation that the (Emergency control functions) smoke damper operations had been tested annually with the initiating device that activates the damper and not in accordance with NFPA 19.5.2.1, 9.2 and NFPA 72 Table 14.4.2.2