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Based on observation and interview, the facility failed to ensure an exit sign was visible for 1 of 2 remote exit access paths (to the main egress corridor) on the ground floor, in accordance with NFPA 101, 19.2.10.1 and 7.10.1.8.

This failure could delay evacuation in the event of a fire or emergency and affect the safety of the building's occupants.

Findings included:

During observations and interviews on 05/08/25 at 11:35 a.m., on the ground floor in the exit access corridor outside the emergency room staff exit, the path to the main egress corridor (north-south orientation and running the length of the hospital) had its exit sign visually obstructed by a bulkhead and additional informational signage. The director of plant operations confirmed the observations when the surveyor discussed the finding.

Based on observation, interview, and record review, the facility failed to conduct monthly quick check inspections for 2 of 2 fire suppression hood systems (in the dietary kitchen), in accordance with NFPA 17A, 7.2, as referenced by NFPA 96, 10.2.6(4) and NFPA 101, 19.3.2.5.1 and 9.2.3.

This failure could affect the reliability of the fire suppression hood system and potentially adversely affect the safety of the building's occupants in the event of a cooking related fire in the kitchen.

Findings included:

During observation, interview, and record review on 05/08/25 from 3:30 p.m. to 3:40 p.m., the inspection tag at the manual pull actuator for both range hood fire suppression systems in the kitchen did not contain any dates or initials of a person performing quick check inspections.

The facility's Life Safety and maintenance records did not include any other documentation that quick check inspections (owner performed) for the kitchen's fire suppression hood system. The director of plant operations confirmed the observations when the surveyor discussed the finding.

Based on observation and interview, the facility failed to ensure of 3 of 9 smoke barrier walls on the ground floor (separating smoke compartments 1C and 1D, 1C and 1E, 1H and 1I) and 1 of 2 smoke barrier walls on the 2nd floor (separating the Labor Delivery Recovery Post-Partum suite), were constructed to least a ½-hour fire resistance rating and all penetrations sealed, in accordance with NFPA 101, 19.3.7.3, 8.5, 8.5.6.

This failure could allow fire/smoke to spread from one smoke compartment to another, and adversely affect the safety of the building's occupants in the event of a fire or emergency.

Findings included:

During observations and interviews on 05/09/25 from 09:30 a.m. to 11:00 a.m., the following were noted during inspection of smoke barrier walls:

At the ground floor smoke barrier wall separating smoke compartments 1C and 1D, above the ceiling over the pair of corridor smoke barrier doors there was a one-inch hole in the wall.

At the ground floor smoke barrier wall separating smoke compartments 1C and 1E, above the ceiling in the wall between the corridor and maintenance department there was a five-inch by five-inch opening in the wall and an opening around a flexible electrical conduit penetration.

At the ground floor smoke barrier wall separating smoke compartments 1H and 1I, above the ceiling over the pair of corridor smoke barrier doors there were openings around multiple rigid electrical conduit penetrations and openings around a bundle of low voltage wiring inside a sleeve penetration.

At the 2nd floor smoke barrier wall separating the Labor Delivery Recovery Post-Partum suite, on the corridor side past the elevators, above the ceiling there was a 3-inch open ended conduit with wire penetrations.

The maintenance supervisor confirmed the observations when the surveyor discussed the finding. He said a preventative maintenance program in place to inspect the hospital's smoke barrier walls and it has been about a year since they were last checked and are due for inspection again.

Based on observation and interview, the facility failed to ensure a junction box in 1 of 2 electrical rooms (Elec E107) in smoke compartment 1H was covered and protected, in accordance with NFPA 70, 314.17.

This failure could allow damage to electrical wiring, result in an electrical fire, and adversely affect the safety of the building's occupants.

Findings included:

During observations and interviews on 05/09/25 from 10:18 a.m., above the ceiling of the electrical room (Elec E107) there was an electrical junction box without a cover plate installed. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.

Based on observation and interview, the facility failed to ensure items powered from the essential electrical system were correctly located on the Life Safety branch and Critical branch, in accordance with NFPA 99, 6.4.2.2.3 and 6.4.2.2.4.

This failure could affect the reliability of certain items on the essential electrical system in the event of power loss and adversely affect the health and safety of the building occupants.

Findings included:

During observations and interviews on 05/08/25 from 10:00 a.m. to 10:10 a.m., in electrical room E109, there was an emergency panel designated as LSLA and labeled as life safety indicated it was a life safety branch panel. Panel LSLA contained critical branch items for electrical receptacles on operating rooms 1, 2, and 3, and other receptacles in the surgical suite. These items are not permitted on the life safety branch. Circuit #24 was for additional panels fire alarm panels in room E111 and circuit #3 was for the generator light and receptacle (these two items permitted only on the life safety branch). It could not be determined if this panel was mislabeled and intended as a critical branch panel, or if it was the life safety branch that was currently powering items only allowed on the critical branch. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.