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Based on observation, not all portions of the building's Essential Electrical System (EES) are installed as required. This deficient practice could affect patients, staff, and visitors in the building because life support equipment could fail to operate under emergency conditions if the essential electrical system is not installed properly.

The finding is:

On 02/11/2020 at 1:20pm, while accompanied by the DPO, PD and SO documentation review determined that battery-powered emergency lights are not being tested annually for 90 minutes. This condition does not comply with NFPA 99 2012 6.3.2.2.11.4 and NFPA 70 2011 517-63A.

Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

The finding is:

On 02/10/2020 at 9:20am while accompanied by the DPO only one path of exit access was observed to be identified by exit signage which does not comply with 39.2.5.2 and 7.5. Location observed: corridor adjacent to the Chapel direction observed toward the nursing home.

Based upon observation, vertical openings are not constructed and maintained to provide separation of floor levels in accordance with requirements. Failure to protect vertical openings can permit the effects of a fire/smoke event to expose and compromise the safety of any occupant.

The finding is:

On 02/10/2020 at 1:25pm while accompanied by the DPO, SO and PD a shaft wall was observed to not be completely enclosed with a minimum 2-hour fire rated construction to comply with 8.3.5.1, 8.3.5.7, and 9.2.1. Location observed: Lab Wing, Storage room, Medical Air compressor room and IT area. The shaft is open to multiple rooms/areas and is incomplete due to the following:

1. The use of two through wall openings into the compressor room.

2. The lack of a shaft wall between the IT area and the shaft.

3. A floor ceiling opening/gap located at the entry to the IT area.

Based upon observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material to block exiting.

Findings include:

A. On 02/10/2020 at 10:44am while accompanied by the DPO, a nonsprinklered room designated as hazardous is not separated from the means of egress by through wall penetrations which are not sealed against fire and smoke to comply with 19.3.2.1 and 19.3.2.1.5. Location observed: Boiler room pipe penetrations on wall above entry door and on opposite wall.

B. On 02/10/2020 at 11:10am while accompanied by the DPO, a nonsprinklered room designated as hazardous is not separated from the (non sprinklered) means of egress corridor by a minimum 1-hour fire rated enclosure to include a 3/4 hour self closing door and fire/smoke tight walls The condition does not comply with 19.3.2.1 and 19.3.2.1.5. Location observed: 300 Wing mechanical room with gas fired equipment.

C. On 02/10/2020 at 1:30pm while accompanied by the DPO, SO and PD a room has changed function from a patient care area to storage. The room contains numerous O2 tanks, wheelchairs with O2 tanks on them (NFPA 99, 2012 11.3.2.3), boxes, etc. However, the room lacks proper enclosure for a nonsprinklered hazardous area due to the lack of a self closing fire rated door installation for each door entering the room. Location observed: Diagnostic Wing Xray room used for storage.

D. On 02/10/2020 at 9:30am while accompanied by the DPO, a sprinklered room designated as hazardous (former Chapel, now storage) is not separated from the (non sprinklered) means of egress corridor by a minimum 1-hour fire rated enclosure to include a 3/4 hour self closing door and fire/smoke tight walls The condition does not comply with 19.3.2.1 and 19.3.2.1.5. Location observed: connector corridor between A Wing and Hospital. This corridor is part of the means of egress for patients using the Chapel.

The facility failed to provide a complete kitchen hood system. Due to the lack of maintenance, this deficient practice creates a high risk of fire and allows the spread of flames should a fire occur.

The finding is:

On 02/11/2020 at 2:15pm while accompanied by the DPO, PD and SO, during document review, the January 2020 inspection of the kitchen hood installation contained a corrective action remark. Replacement of the cartridge for the hydrostatic cylinder has become necessary. To date this defect has not been corrected, which does not comply with NFPA 17A 2009, 7.3.3.4.

Based on observation, not all portions of the building's fire alarm system are installed and maintained as required. This deficient practice could affect patients, staff, or visitors in the building because the fire alarm system could fail to activate under emergency conditions if the components are not properly installed and maintained.

The finding is:

On 02/10/2020 at 10:15am while accompanied by the DPO, a fire alarm manual pull station was not provided within 5' of a designated exit. This condition does not comply with NFPA 72-2010, 17.14.6. Location observed: Wing A corridor adjacent to the new Chapel with a designated exit at a 2-hour barrier wall leading toward the hospital.

Based on observation, not all use areas are separated from exit access corridors as required. These deficiencies could affect patients, staff, or visitors in the building because smoke or fire could pass from the use areas into the remainder of the building.

Findings include:

A. On 02/10/2020 at 11:50am while accompanied by the DPO, observation determined that 300 Wing lacks complete smoke detection to comply with 19.3.6.1. Location observed short corridor leading to a small mechanical room.

B. On 02/10/2020 at 10:50am while accompanied by the DPO, observation determined that A Wing lacks complete smoke detection to comply with 19.3.6.1. Location observed corridor adjacent to the new Chapel.

C. On 02/11/2020 at 12:20pm while accompanied by the DPO, document review determined that the smoke detector's sensitivity testing has not been performed every alternate year to comply with NFPA 72, 2010, 14.4.5.3.2.

Based on observation, the facility failed to provide access to fire protection appliances within the ventilation duct system. Failure to install and maintain this installation could result in the passage of fire and products of combustion from one fire compartment to another. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

A. While accompanied by the DPO, SO and PD installed access panels located at a duct for inspection and maintenance of fire dampers lack labeling to identify if the damper is abandoned or active. This condition exists throughout the facility does not comply with NFPA 80-2010, 19.2.3
Example locations observed:

1. On 02/10/2020 at 11:11am 300 Wing small mechanical room.

2. On 02/11/2020 at 10:45am second floor corridor adjacent to surgery

B. While accompanied by the DPO, SO and PD duct work entering shafts, hazardous rooms and 2-hour fire rated barriers lack access panels located at a duct for inspection and maintenance of fire dampers. This condition exists in numerous locations and does not comply with NFPA 80-2010, 19.2.3
Example locations observed:

1. On 02/10/2020 at 10:45am second floor corridor adjacent to surgery shaft adjacent to exit stair

2. On 02/11/2020 at 10:55am second floor corridor adjacent to surgery, approximately mid way down the corridor (wall on surgery side of corridor) at approximate location of numerous ducts exiting a shaft (shaft shared with the large sized return air duct for surgery).

3. On 02/11/2020 at 11:45am electrical room at main lobby adjacent to restrooms, janitor closet.

4. On 02/11/2020 at 11:55am shaft adjacent to IT room, Storage room and Med/Air compressor

C. On 02/10/2020 at 9:50am, while accompanied by the DPO, SO and PD duct work entering mechanical rooms(with gas fired equipment) lack fire/smoke dampers to maintain a fire rated separation between the hazardous area and a means of egress. This condition exists in numerous locations and does not comply with NFPA 80-2010, 19.2.3. Location observed: 300 Wing small mechanical room.

D. On 02/11/2020 at 12:30pm while accompanied by the DPO, during document review it was determined that fire damper maintenance and inspection lacked a 6 year interval. The existing fire dampers have not been inspected every 6 years to comply with NFPA 80, 2010, 19.4.1.1.

Based on document review and staff interview, the facility failed to document / conduct fire drills as required. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills.

The finding is:

On 02/11/2020 at 12:25pm during document review with the DPO, SO and PD, Facility fire drill documentation for the past 12 months did not indicate that staff are familiar with basic fire response procedures, and the requirements set forth in the Facility's Fire Safety Plan to comply with 19.7.1. and 4.7.2. There is no indication that staff are updated on training and drill requirements due to the following examples:

1. Not all Departments shown on the fire drills as participating, fill out the forms or indicate the protocol. For example Drill conducted on 01/31/2019 there is no indication of knowing where the "fire" was located.

2. Fire Drills do not indicate the device which was activated.

3. The Fire Plan "Code Red" indicates that persons are to follow RACE, however, the procedures indicated activation of a device, then report to a nurse station for directions and identify the location. These actions do not follow nor reference Rescue, Alarm, Contain and Evacuate and do not comply with 19.7.2.1.2.

Based upon review of record documentation, doors are not being maintained in fully functional condition to afford the protection they are intended to provide. This deficient practice could affect, patients, staff and visitors if a failure to maintain doors can compromise adjacent spaces during a fire condition.

The finding is:

On 02/11/2020 at 12:30 am, while in the company of the DPO, SO and PD, documentation for fire rated doors was reviewed. Documentation provided does not comply with 7.2.1.15.7 and NFPA 80, 2010, 5.2.1. The following information was not available:

1. There is no indication of a complete fire door inspection being conducted for 2019 to comply with 7.2.1.15.3. The list was titled as inspecting doors having exit hardware only.

2. Documents did not indicate any door requiring repair, therefore, there is no list of the actual repair or maintenance provided for any door's condition.

3. There is no list of the specific hardware per each door and the function of the door (hazardous room, barrier door, exit door door associated with a vertical opening, etc.)

Based upon observation, the monitoring of medical air systems is not in accordance with Code requirements. This deficient practice could affect patients, staff and visitors if failure to provide proper analyses the use of medical gases were to contribute to the accelarated spread or intensity of a fire at the location.

The finding is:

On 02/11/2020 at 11:30am while accompanied by the DPO, SO and PD the medical compressed air system contains no means of detecting targeted gasses or monitoring of dewpoint to comply with NFPA 99, 2012, 5.1.3.6.3.9. There is no means to comply with 5.1.3.6.3.13 for operating alarms and local signals, and 5.1.3.6.3.14 for the monitoring of the medical air quality.
Location observed: Lab Wing, Compressor room (connected to a Storage room).

On 02/10/2020 at 2:30pm while accompanied by the DPO, SO and PD the medical compressed air system lacks compliant means for the room's ventilation to comply with NFPA 99, 2012, 5.1.3.6.3.1 and 5.1.3.3.3.2.
Location observed: Lab Wing, Compressor room (connected to a Storage room).

Based upon direct observation during the survey walk-thru, electrical systems are not maintained in conformance with Code requirements. Failure to maintain the electrical system can lead to confusion when selected components require shut-down for maintenance and power circuits cannot be accurately identified.

The finding is:

On 02/10/2020 at 2:45pm while in the company of the DPO, SO and PD, it was unknown which branch of the essential electrical system serves the panel #003177 in the ICU to comply with NFPA 70-2011, 408.4.

Based upon observation, medical gas storage is not in accordance with Code requirements. This deficient practice could affect patients, staff and visitors if failure to properly store medical gases were to permit stored gases to contribute to the accelarated spread or intensity of a fire at the location.

The finding is:

On 02/10/2020 at 10:50am while in the company of the DPO empty, partial and full cylinders are not stored in a separated manner within the same enclosure to comply with NFPA 99, 2012 11.6.5.2. There is no signage for cylinders which makes it clear which group is empty or full since there is no separation. This condition does not comply with NFPA 99, 2012, 11.6.5.3. Location observed: Med gas storage room.