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Based on observation during the survey walk-thru, means of egress are not maintained in accordance with Code requirements. Failure to provide required means of egress can result in occupants inability to reach an exit or area of safety in the event of an emergency.

The finding is:

On 12/19/2017 at 9:50AM while in the company of the DDF and POM, it was observed that the pairs of doors from the Kitchen to the corridor are equipped with magnetic locks. These doors do not have the access controlled sensors connected to the power operators to prevent operation of the doors from opening when occupants are standing in the path of the door swing. The doors power operation have the potential to injure occupants when allowed to open when occupants are standing in the path of the door swings. The reliability of the door operation to prevent injury is not maintained to comply with 7.1.10.

Based on observation during the survey walk-through, 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 12/19/2017 at 11:10 AM while accompanied by the DDF and POM, 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: 2nd floor corridor adjacent to the Dining room and Kitchen.

Based on observation, sprinklered hazardous areas are not separated by a minimum of smoke resisting construction. Failure to separate hazardous areas can expose occupants to fire conditions before evacuation may occur.

The finding is:

On 12/19/ 2017 at 10:35AM while in the company of the DDF and POM, the surveyor observed on the 2nd floor, Room #610 former exam room is being used as equipment storage. This room is being used as storage of items of noncombustible and combustible materials in quantities greater than that for its original use. This room does not contain a self closing door and does not comply with 19.3.2.1, 8.7.1 & 8.4.

Based on observation, sprinklered hazardous areas are not separated by a minimum of smoke resisting construction. Failure to separate hazardous areas can expose occupants to fire conditions before evacuation may occur.

The finding is:

On 12/19/ 2017 while in the company of the DDF and POM, areas were observed being used for the storage of equipment, supply carts, gurneys and bassinets in quantities greater than that for the normal area's function.

Location observed:

At 10:05am 2nd Floor Kitchen storage room is being used for the storage of combustible cooking materials. This room is being used as storage for cooking oils, items within cardboard containers and plastic materials in quantities greater than that normal to a business occupancy. This room does not contain a self closing door and does not comply with 39.3.2.1, 8.4, and 7.2.1.8.

Based on document review and staff interview, documentation was not provided as to the maintenance of the Kitchen grease duct system. This deficient practice could result in the uncontrolled spread of fire, which may affect patients, staff and visitors.

The finding is:

On 11/15/16 at 9:00 AM accompanied by the DDF, POM & MS, the surveyor finds the lack of documentation as to the periodic inspection and cleaning of the kitchen grease duct system and components as required by NFPA 96, 2008, 11.6.

Based on observation during the survey walk through the facility failed to correctly install all require components of the wet pipe fire suppression system. Failure to install and maintain these systems could result in malfunction and delayed response. This deficient practice could affect patients, staff and visitors during a fire event.

The findings are:

A. On 12/19/17 at 9:30AM accompanied by the DDF & POM, it was observed in the 3rd Floor Elevator C Lobby that the wet pipe sprinkler heads deflector orientation are installed above the ceiling surface in noncompliance with NFPA 13, 2010, 8.5.4.2.

B. On 12/19/17 at 10:00AM accompanied by the DDF & POM, it was observed in the 2nd Floor Dietary Stairwell that the wet pipe sprinkler system flow switch test and drain is not piped to drain as required by NFPA 13, 2010, 8.17.4.2.

C. On 12/19/17 at 10:35AM accompanied by the DDF & POM, it was observed in the 1st Floor corridor by the Boiler Room & Elevator C that the wet pipe sprinkler system flow switch test and drain is not piped to drain as required by NFPA 13, 2010, 8.17.4.2.


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D. On 12/19/2017 at 11:10AM while in the company of the DDF and POM, the surveyor observed the 2nd floor level for the exit Stair (which is open to the exit Stair for the Main Hospital building) is not sprinkler protected. This does not comply with NFPA 13 2010 8.1. This combined stair serves separate fire divisions and, therefore, is to be sprinkler protected at every landing to comply with NFPA 13, 8.15.3.3.

E. On 12/19/2017 at 9:10 AM while in the company of the DDF and POM the surveyor observed that the 2nd floor corridor adjacent to Elevator C contained ceiling mounted sprinkler heads which were mounted such that the escutcheon plate interfered with the sprinkler head orientation and the discharge pattern which does not comply with NFPA 13, 8.6.4.

Based on observation during the survey walk through the facility failed to install all require components of the wet pipe fire suppression system. Failure to install and maintain these systems could result in malfunction and delayed response. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 12/19/2017 at 11:15AM while in the company of the DDf and POM, the surveyor observed the 1st floor level for the exit Stair (which is open to the exit Stair for the 1960's Building) contains an area below the 2nd floor landing. This area is not provided with sprinkler protection to comply with NFPA 13 2010 8.1.

Based on observation during the survey walk through the facility lacks correct signage for the use of fire extinguishers in the Kitchen. This deficient practice could affect patients, staff and visitors during a kitchen cooking grease fire event.

The finding is:

On 12/19/17 at 10:05AM accompanied by the DDF & POM, it was observed that the installed K fire extinguisher lack signage for the correct sequence and use of the extinguisher located by the grease hood per NFPA 96, 2008, 10.2.2.

Based on observation during the survey walk through the facility failed to identify components of the Category 1 medical gas systems. This deficient practice could affect patients during treatment while using these systems.

The findings are:

A. On 12/19/17 at 10:30AM accompanied by the DDF & POM, in the 1st Floor Boiler Room, it was observed that the source valves for the piped medical vacuum system is not labeled or identified as to its function as require by 19.3.2.4 / NFPA 99 2012, 5.1.11.

B. On 12/19/17 at 10:40AM accompanied by the DDF & POM, in the 1st Mechanical Room located in the Electrical Shop, it was observed that the source valves for the piped compressed medical air system is not labeled or identified as to its function as require by 19.3.2.4 / NFPA 99 2012, 5.1.11.

Based on observation during the survey walk through the facility failed to provide protection for electrical components in the medical gas manifold room. This deficient practice can result in an increased fire/explosion hazard affecting patients, staff and visitors.

The finding is:

On 12/19/17 at 11:00AM accompanied by the DDF & POM, in the 1st Floor Boiler Room, it was observed in the exterior accessed medical gas manifold room that the wall light switch does not have a physical means to protected it from damage. NFPA 99, 2012, 3.1.3.3.2 (10)

Based on 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 12/19/2017 at 9:45AM while in the company of the DFF & POM, it was observed in the electrical room adjacent to Dietary, that the panel directory for Panel KPL and EKP (both serve the hospital) were not accurate, relative to the placement of circuits in the panel, to comply with NFPA 70-2011, 408.4.

Based on observation during the survey walk-through, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.

The finding is:

On 12/19/2017 at 10:30AM while in the company of the DDF and POM, the surveyor observed that critical care patient areas lack electrical receptacles served by normal power to comply with NFPA 70 2011 517-19(A).

Location observed were the Operating Rooms.