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Based on observation and discussion with the Director of Maintenance, it was determined that the facility failed to ensure that the walls and ceilings of certain hazardous areas in The Clatanoff Pavilion were properly sealed where penetrated as required to prevent the spread of smoke and fire. This could affect 100 percent of the occupants.

The findings include:

On December 27, 2016, between the hours of 09:30 am and 4:15 pm the Fire Safety Inspector observed that the following listed areas had wall and ceiling penetrations that were not properly sealed as required.

1. Communications closet 3rd floor.
2. Soiled utility room at front nurses station.
3. Isolette room.
4. Labor and delivery storage room. Four by three inch hole.
5. First floor environmental services with a wire over the door.
6. The I beam was not sealed near room 327.
7. There is a disabled fire rated grill vent in the soiled storage room near the staff hall that must be removed and a 3/4 hour fire door installed on that door system.

These findings were noted and affirmed by the Director of Maintenance and Administrator during the exit conference.

Based on observation and discussion with the facility Director of Maintenance, it was determined that the facility failed to ensure that the fire alarm system functioned as required. This could affect 100 percent of the occupants.

The findings include:

On December 28, 2016, between the hours of 09:30 am and 2:51 pm the Fire Safety Inspector observed that the fire alarm inspection report noted that two air handling duct detectors did not function when tested.

These findings were noted and affirmed by the Director of Maintenance and Administrator during the exit conference.

Based on observation and discussion with the hospital's Director of Maintenance, it was determined that the facility failed to ensure that the fire alarm system was properly maintained as required.

This could affect 100 percent of the occupants.

The findings include:

On December 27, 2016, between the hours of 09:30 am and 4:15 pm, the Fire Safety Inspector observed that the most recent fire alarm inspection revealed that two duct detectors failed when tested.

These findings were noted and affirmed by the Director of Maintenance and Administrator during the exit conference.

Based on observation and discussion with the hospital's Director of Maintenance, it was determined that the facility failed to ensure that the fire alarm system was properly maintained as required.

This could affect 100 percent of the occupants.

The findings include:

On December 27, 2016, between the hours of 09:30 am and 4:15 pm, the Fire Safety Inspector observed that the most recent fire alarm inspection found that there two supervisory alarms that could not be located.

These findings were noted and affirmed by the Director of Maintenance and Administrator during the exit conference.

Based on observation and discussion with the hosspital's Director of Maintenance, it was determined that the facility failed to ensure that the fire alarm tests located all devises tested. This could affect 100 percent of the occupants.

The finding include:

On December 27, 2016, between the hours of 09:30 am and 4:15 pm the Fire Safety Inspector observed that the most recent fire alarm inspection could not locate two supervisory alarms on two ball valves.

These findings were noted and affirmed by the Director of Maintenance and Administrator during the exit conference.

Based on observation and discussion with the hospital's Director of Maintenance, it was determined that the facility failed to ensure that the sprinkler heads were properly maintained as required. This could affect 100 percent of the occupants.

The findings include:

On December 27, 2016, between the hours of 09:30 am and 4:15 pm, the Fire Safety Inspector observed that there were sprinkler heads in the mechanical room of Clatanoff Wing with sprayed fire protection on the sprinkler heads, and there were two damaged sprinkler heads in the laundry that were bent on the deflectors. The sprinkler head at the top of the linen chute in the Pavilion Wing is corroded. The sprinkler head in the PRVCO room near room 336 is loaded with dust and dirt.

These findings were noted and affirmed by the Director of Maintenance and Administrator during the exit conference.

Based on observation and discussion with the Director of Maintenance, it was determined that the facility failed to ensure that the doors to the corridor did not contain any open transfer grill systems as required. This could affect 100 percent of the occupants.

The findings include:

On December 27, 2016, between the hours of 09:30 am and 4:15 pm, the Fire Safety Inspector observed that the door to the soiled linen room near the staff lobby was equipped with a disabled fire rate grill system which is not permitted in corridor door systems.

These findings were noted and affirmed by the Director of Maintenance and Administrator during the exit conference.

Based on observation and discussion with the hospital's Director of Maintenance, it was determined that the facility failed to ensure that the bulk storage system at the loading dock and the on site bulk storage system located at the rear parking area were properly maintained as required. This could affect 100 percent of the occupants.

The findings include:

On December 27, 2016, between the hours of 09:30 am and 4:15 pm, the Fire Safety Inspector observed that the oxygen storage system located at the loading dock area was exposed to the elements, had dirty cylinders, cylinders in storage for which there was not reason given for their use or function. Also there were three storage cages labeled flammable with only oxygen gases stored in them, and one cage labeled flammable with oxygen and flammable gas stored together in the same cage. There was only one door system to the cage area, not two as required in NFPA 99, 2013 edition, section 5-1-3-3-2. No. 3. NFPA 99 2012 edition, chapter 5, should be implemented to remove the cylinders from the elements and dust observed at the loading dock area, and create a compliant storage system for the gas cylinders.

These findings were noted and affirmed by the Director of Maintenance and Administrator during the exit conference.

Based on observation and discussion with the Director of Maintenance, it was determined that the facility failed to ensure that the outdoor bulk storage system was properly maintained as required. This could affect 100 percent of the occupants.

The findings include:

On December 27, 2016, between the hours of 09:30 am and 4:15 pm, the Fire Safety Inspector observed that the most recent inspection conducted on 3-28-16, of the outdoor bulk storage area revealed several deficiencies relating to the system. There was no chain and lock system on the gate to the storage area, and required decals were missing on the oxygen vessel. It appears these deficiencies were corrected on a return visit by RHE gas supplier representative. These records were not readily available for review at the time of the survey and took over a week to obtain from the facility. NFPA 1 2015 edition, section 10-2-5 requires all documents relating to a fire inspection or survey be maintained on site to aid in the completion of the survey.

These findings were noted and affirmed by the Director of Maintenance and Administrator during the exit conference.

Based on observation and discussion with the Director of Maintenance it was determined that the facility failed to ensure that the foam extinguishing system on the roof of the North Wing of the Hospital Pavilion functioned properly as required. This could affect 100 percent of the occupants.

The findings include:

On January 3, 2017, between the hours of 3:47 pm and 4:15 pm, the Fire Safety Inspector observed that the email received from the facility revealed that the foam test of the Helipad extinguishing test of the foam concentration mixture; test number one, failed the parameters of the test. This test was conducted on 10-6-2016 and the records of the results were available on 10-13-2016 but were not located until 1-3-2017. NFPA 11 2010 edition, requires all records pertaining to the facility safety systems be maintained on site for review during an inspection or survey by the authority having jurisdiction.

These findings were noted and affirmed by the Director of Maintenance and Administrator during the exit conference.