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Based on observation, the facility failed to ensure smoke-proof rated stairway enclosure was continuously maintained per NFPA 101-2012, Section 7.2.3.3.1.

Findings include:

1. During an observation on 5/2/22 at 2:57 p.m., the maintenance suite was inspected. There was a marked exit stairwell going up out of the suite. The bottom stairway door did not have a self-closing device to maintain the smoke proof enclosure of the stairs.

2. During an observation on 5/2/22 at 5:30 p.m., the third floor west stairwell door failed to latch under the power of the self-closers upon being exercised.

Based on observation, where the path of egress was not obvious, the facility failed to mark the path of egress by approved exit or directional exit signs in accordance with NFPA 101, 2012 Edition, Section 7.10.1.2.2, and 7.10.1.5.2, and 21.2.10.

Findings include:

1. During an observation on 5/2/22 at 4:36 p.m., the CCU corridor was inspected. One end of the corridor was the cross corridor doors leading to the CCU. 52 feet to the intersection at the other end of the corridor, there was no visible exit sign guiding occupants to the outside exit.

Based on observation, the facility failed to assure hazardous rooms had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 5/2/22 at 3:15 p.m., the first floor linen room was inspected. The room is considered a hazardous room. The corridor door to the room was found to have a large amount of items in front of it. The door would not close and latch under the power of the self-closer.

2. During an observation on 5/2/22 at 3:49 p.m., the PPE storage room was inspected. The room was over 50 square feet and there was no self-closing device on the corridor door.

3. During an observation on 5/2/22 at 5:55 p.m., room 558 was inspected. It was a storage room, it was over 50 square feet and it lacked a self-closing device on the corridor door.

Based on observation the facility failed to:

a) ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

b) sprinkle an electrical closet, in the same day surgery area in accordance with NFPA 101, Life Safety Code, 2012 Edition, Section 19.3.5.3.

c) maintain the sprinkler system by installing sprinkler heads too close to walls in accordance with NFPA 13 Standard for Automatic Sprinkler Systems, 2010 Edition, Section 8.5.5.2.2

d) maintain proper distances between sprinkler heads, in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.3.4.1.

Findings Include:

1. During an observation on 5/2/22 at 3:55 p.m., the ER linen storage was inspected. Just outside the room, there was a sprinkler head blocked by a ceiling mounted light.

2. During an observation 5/2/22 at 4:12 p.m., the same day surgery area was inspected. There was a bank of electrical panels in a closet which did not have any sprinkler heads in the space.

3. During an observation on 5/2/22 at 4:47 p.m., the laboratory was inspected. There was a sprinkler head less than 4 inches from the wall. It appeared a wall had been built to form up the vacuum tube system in the building. The wall is now too close to the pendant type sprinkler head.

4. During an observation on 5/2/22 at 5:41 p.m., the 4th floor conference room 4A was inspected. There were two heads in the room which were less than 6 feet apart. A wall had been removed at some point, leaving the two sprinkler heads too close together.

Based on observation and record review, the facility failed to:
a) ensure sprinkler pipes were free of external loads in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2.

b) ensure pendant type sprinkler heads were mounted at proper distances under unobstructed construction per NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.4.1.1.1.

b) Maintain spare sprinklers in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.5.

c) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1(3)

d) ensure sprinkler heads were free from obstruction from storage items in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1.

These deficiencies affect 1 of 6 smoke compartments.

Findings include:

1. During an observation on 5/2/22 at 2:42 p.m., the first floor mechanical room was inspected. There was an electrical conduit for the control valves of the house vacuum system suspended from the sprinkler pipe in the room.

2. During an observation on 5/2/22 at 2:57 p.m., the first floor maintenance suite was inspected. There was a sprinkler head mounted below the ceiling where the deflector was less than one inch below the ceiling, nearing being up inside the escutcheon ring.

3. During an observation on 5/2/22 at 3:04 p.m., the first floor standpipe was inspected. There were no directional heads in the spare sprinkler box.

4. During an observation on 5/2/22 at 2:57 p.m., the cardio-pulmonary rehab area was inspected. There was a sprinkler head mounted below the ceiling where the deflector was less than one inch below the ceiling, nearing being up inside the escutcheon ring.

5. During an observation on 5/2/22 at 3:40 p.m., the IT storage room was inspected. There was a sprinkler head in the room with storage up to within 5 inches of the head, and there was ceiling tiles found to be out of the ceiling in the room.

6. During an observation on 5/2/22 at 4:27 p.m., the OR overflow storage room was inspected. There were ceiling tiles found to be out of their place in the ceiling.

7. During an observation on 5/2/22 at 5:00 p.m., the old foot clinic area was inspected. There was storage within 18 inches of a sprinkler head in the room.

8. During an observation on 5/2/22 at 5:03 p.m., the electrical room in labor and delivery was inspected. There were ceiling tiles out of their place in the ceiling in the room.

9. During an observation on 5/2/22 at 5:06 p.m., room 363 was inspected. There was a recessed sprinkler head missing the cap in the room.

10. During an observation on 5/2/22 at 5:10 p.m., room 354 was inspected. There was a sprinkler head missing the escutcheon ring in the room.

11. During an observation on 5/2/22 at 5:46 p.m., the hospice storage room was inspected. There were ceiling tiles out in the room.

Based on observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1. This deficiency affects 1 of 8 smoke compartments.

Findings include:

1. During an observation on 5/2/22 at 4:00 p.m., the ER waiting room was inspected. There was a chair in front of the extinguisher in the waiting area.

2. During an observation on 5/2/22 at 4:20 p.m., the OR suite was inspected. There was a portable extinguisher which was blocked by some rolling carts parked in front of it.

Based on observation, the facility failed to ensure fire/smoke barrier doors located in the fire/smoke partitions were maintained per NFPA 101-2012, Section 19.3.7.8.

This deficiency affects 2 of 15 smoke compartments.

Findings include:

1. During an observation on 5/2/22 at 5:15 p.m., the smoke doors between OB and administration were exercised. They failed to close and latch under the power of the self-closers.

Based on observations, the facility failed to assure that a fire-rated door, protecting the linen chute, closed and latched with the efforts of the self-closing device per NFPA 101 2012 Edition, Sections 9.5, 8.3, and 7.2.1.8.1, and NFPA 80 Standard for Fire Doors and Other Opening Protectives 2010 Edition, Sections 6.1.4.2.1 and 6.1.4.3.1.

The findings include:

1. During an observation on 5/2/22 at 4:39 p.m., the CCU linen chute was inspected. The door to the chute appeared to be malfunctioning and was not latching.

Based on observations, the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d).

Findings include:

1. During an observation on 5/2/22 at 2:39 p.m., the electrical panels in the boiler room were blocked by items being stored on the floor in front of the panels.

Based on observation, the facility failed to ensure extension cords were not used in the facility per NFPA 99-2012, Health Care Facilities Code, Section 10.2.4.

Findings include:

1. During an observation on 5/2/22 at 4:27 p.m., the OR overflow storage room was inspected. There was an extension cord running from an office under construction next door, up and over the wall above the ceiling and down through an open ceiling tile in the room, being used as temporary power.