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Based on observation and interview, the facility failed to ensure penetrations through 3 of 5 smoke barriers in the 2007 surgery addition were protected to maintain the smoke resistance of the smoke barrier. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so that the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect any patient as well as staff and visitors.

Findings include:

Based on observations with the building service director on 05/19/15 from 1:20 p.m. to 2:00 p.m., the following smoke barrier walls above the drop ceiling had penetrations not fire stopped or missing drywall;
a. The Surgery entrance Hall west smoke barrier wall had an eight inch by eight inch square area of drywall missing and a three inch circular area of drywall missing.
b. The Surgery Hall north smoke barrier wall had three, two inch circular areas of drywall missing, and two, one half inch gaps around metal duct penetrations not fire stopped.
c. The Surgery Hall east smoke barrier wall had sixteen electrical conduit penetrations with one half inch gaps not fire stopped, a three inch circular area of drywall missing, and a four inch open conduit with no fire stopping material.
The smoke barrier penetrations not fire stopped and missing drywall was verified by the building service director at the time of observations and acknowledged by the chief executive office at the exit conference on 05/19/15 at 2:15 p.m.

Based on observation and interview, the facility failed to ensure penetrations through 5 of 12 smoke barriers in the original building were protected to maintain the smoke resistance of the smoke barrier. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so that the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect any patient as well as staff and visitors.

Findings include:

Based on observations with the building service director on 05/19/15 from 1:20 p.m. to 2:00 p.m., the following smoke barrier walls above the drop ceiling had penetrations not fire stopped or missing drywall;
a. The Laboratory Hall smoke barrier wall had a cable bundle penetration with a one inch gap around the cable bundle not fire stopped.
b. The X-ray Hall south smoke barrier wall had a four inch electrical conduit penetration which was open and not fire stopped.
c. The X-ray Hall west smoke barrier wall had a four inch by six inch opening with no drywall on the south side of the wall and four electrical conduit penetrations with one half inch gaps not fire stopped.
d. The Med 3 Hall north smoke barrier wall had a one inch gap around an electrical conduit penetration and a one half inch gap around a cable bundle not fire stopped.
e. The Unit 3 Hall south smoke barrier wall had a one inch circular area of drywall missing next to an electrical conduit penetration.
The smoke barrier penetrations not fire stopped and missing drywall was verified by the building service director at the time of observations and acknowledged by the chief executive office at the exit conference on 05/19/15 at 2:15 p.m.

Based on record review and interview, the facility failed to conduct quarterly fire drills on each shift for 3 of 4 quarters over the past year. This deficient practice affects all occupants in the facility including staff, visitors and patients in the 2007 surgery addition.

Findings include:

Based on review of Fire Drill & Alarm Reports with the building service director on 05/19/15 at 9:15 a.m., there were no records of a fire drill for the fourth quarter of the year 2014 on third shift, the third quarter of the year 2014 on second shift and the second quarter of the year 2014 on third shift. Additionally, based on an interview with the building service director on 05/19/15 at 9:30 a.m., there was no other documentation available for review to verify the missed fire drills were conducted. This was acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

Based on record review and interview, the facility failed to conduct quarterly fire drills on each shift for 3 of 4 quarters over the past year. This deficient practice affects all occupants in the facility including staff, visitors and patients.

Findings include:

Based on review of Fire Drill & Alarm Reports with the building service director on 05/19/15 at 9:15 a.m., there were no records of a fire drill for the fourth quarter of the year 2014 on third shift, the third quarter of the year 2014 on second shift and the second quarter of the year 2014 on third shift. Additionally, based on an interview with the building service director on 05/19/15 at 9:30 a.m., there was no other documentation available for review to verify the missed fire drills were conducted. This was acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

Based on observation and interview, the facility failed to ensure 1 of 24 smoke detectors in the 2007 surgery addition was not located where airflow would prevent the operation of the detector. LSC 9.6.1.4 refers to NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires spaces served by air handling systems, detectors shall not be located where airflow prevents operation of the detectors. This deficient practice could affect any patient, staff and visitor on the 2007 surgery addition near the mechanical room.

Findings include:

Based on observation on 05/19/15 at 11:05 a.m. with the building service director, the 2007 surgery addition mechanical had a smoke detector located one foot from a supply air duct.
This was verified by the building service director at the time of observation and acknowledged by the chief executive office at the exit conference on 05/19/15 at 2:15 p.m.

Based on observation and interview, the facility failed to ensure 1 of 68 smoke detectors in the original building was not located where airflow would prevent the operation of the detector. LSC 9.6.1.4 refers to NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires spaces served by air handling systems, detectors shall not be located where airflow prevents operation of the detectors. This deficient practice could affect any patient, staff and visitor on the Med 2 Hall.

Findings include:

Based on observation on 05/19/15 at 12:10 p.m. with the building service director, the Med 2 Hall had a smoke detector located one foot from a heating and air conditioning ceiling mounted unit. This was verified by the building service director at the time of observation and acknowledged by the chief executive office at the exit conference on 05/19/15 at 2:15 p.m.

Based on observation and interview, the facility failed to ensure 1 of 1 Post Indicator Valve (PIV) was provided with an electrical alarm which alarmed when the valve was closed. LSC Section 9.7.2.1 requires supervisory attachments to be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code and a distinctive supervisory signal to be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. This deficient practice affects all patients in the facility if the water to the sprinkler system was shut off and not detected due to lack of supervision.

Findings include:

Based on observation on 05/19/15 at 10:40 a.m. with the building service director, the post indicator valve, located in the staff parking lot, was not provided with an electrical connection on the valve. Furthermore, the fire alarm system main panel did not list the post indicator valve on the panel ' s label. The lack of an electrical alarm on the post indicator valve was verified by the director of building services at the time of observation and acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

Based on observation and interview, the facility failed to ensure 1 of 1 Post Indicator Valve (PIV) was provided with an electrical alarm which alarmed when the valve was closed. LSC Section 9.7.2.1 requires supervisory attachments to be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code and a distinctive supervisory signal to be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. This deficient practice affects all patients in the facility if the water to the sprinkler system was shut off and not detected due to lack of supervision.

Findings include:

Based on observation on 05/19/15 at 10:40 a.m. with the building service director, the post indicator valve, located in the staff parking lot, was not provided with an electrical connection on the valve. Futhermore, the fire alarm system main panel did not list the post indicator valve on the panels label. The lack of an electrical alarm on the post indicator valve was verified by the director of building services at the time of observation and acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

1. Based on record review and interview, the facility failed to ensure 1 of 1 automatic dry sprinkler piping systems was inspected every five years as required by NFPA 25, the Standards for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 10-2.2. This deficient practice affects all patients, staff and visitors in the 2007 surgery addition.

Findings include:

Based on record review with the director of building services on 05/19/15 at 9:45 a.m., there was no documentation to indicate an internal inspection of the dry sprinkler system had been conducted in the past five years. Based on a review of the dry sprinkler riser on 05/19/15 at 11:45 a.m. with the director of building services, the dry sprinkler riser, located in the main mechanical room, had a date of the last internal pipe inspection dated July 2006. The lack of a five year internal pipe inspection was verified by the director of building services at the time of record review and acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

2. Based on observation and interview, the facility failed to ensure 1 of 1 private fire hydrant was continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 1998 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems at Section 4-2.2.4 requires dry barrel hydrants to be inspected annually and after each operation. Hydrants shall be inspected, and the necessary corrective action shall be taken. This deficient practice affects all occupants in the facility including staff, visitors and patients in the 2007 surgery addition.

Findings include:

Based on observation on 05/19/15 at 1:15 p.m. with the director of building services, the facility had one private fire hydrant near the helicopter pad. Based on an interview with the director of building services on 05/19/15 at 1:25 p.m., there is no documentation of an annual inspection for the fire hydrant. The lack of an annual inspection for the one fire hydrant near the helicopter pad was acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

1. Based on record review and interview, the facility failed to ensure 1 of 1 automatic dry sprinkler piping systems was inspected every five years as required by NFPA 25, the Standards for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 10-2.2. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on record review with the director of building services on 05/19/15 at 9:45 a.m., there was no documentation to indicate an internal inspection of the dry sprinkler system had been conducted in the past five years. Based on a review of the dry sprinkler riser on 05/19/15 at 11:45 a.m. with the director of building services, the dry sprinkler riser, located in the main mechanical room, had a date of the last internal pipe inspection dated July 2006. The lack of a five year internal pipe inspection was verified by the director of building services at the time of record review and acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

2. Based on observation and interview, the facility failed to provide a complete supply of spare sprinklers for the automatic sprinkler system in accordance with NFPA 25, 1998 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 2-4.1.4 which requires supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. This deficient practice could affect all patients, staff and visitors if the sprinkler system had to be shut down because a proper sprinkler wasn't available as a replacement for the Med 2 West Hall.

Findings include:

Based on observations on 05/19/15 during the tour of the Med 2 West Hall with the director of building services from 12:20 p.m. to 1:00 p.m., the fourteen rooms on the Med 2 West Hall each had sidewall sprinklers. Based on observation of the spare sprinkler cabinets in the maintenance office sprinkler riser room and the main mechanical sprinkler riser room, the two spare sprinkler cabinets lacked sidewall sprinklers. The lack of spare sidewall sprinklers was verified by the director of building services at the time of observation and acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

3. Based on observation and interview, the facility failed to ensure 1 of 1 private fire hydrant was continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 1998 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems at Section 4-2.2.4 requires dry barrel hydrants to be inspected annually and after each operation. Hydrants shall be inspected, and the necessary corrective action shall be taken. This deficient practice affects all occupants in the facility including staff, visitors and patients.

Findings include:

Based on observation on 05/19/15 at 1:15 p.m. with the director of building services, the facility had one private fire hydrant near the helicopter pad. Based on an interview with the director of building services on 05/19/15 at 1:25 p.m., there is no documentation of an annual inspection for the fire hydrant. The lack of an annual inspection for the one fire hydrant near the helicopter pad was acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

Based on record review and interview, the facility failed to ensure 15 of 44 fire dampers were repaired after the necessary four year maintenance was conducted in accordance with NFPA 90A. LSC 9.2.1 requires air conditioning, heating, ventilating ductwork (HVAC) and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 1999 Edition, 3.4.7, Maintenance, requires at least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify they fully close; the latch, if provided, shall be checked, and moving parts shall be lubricated as necessary. This deficient practice affects all patients in the original building.

Findings include:

Based on record review on 05/19/15 at 9:45 a.m. with the director of building services, the most recent fire damper inspection record provided for review was from Life Safety Services dated 12/07/2010. Furthermore, the report listed fifteen dampers that failed the inspection because the actuators failed to open and close. Based on an interview with the director of building services on 05/19/15 at 10:00 a.m., the fifteen fire dampers that failed the 12/07/2010 inspection had not been repaired. The lack of repair work to fifteen failed fire dampers after the inspection was conducted was verified by the director of building services at the time of interview and acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

Based on observation and interview, the facility failed to ensure 1 of 3 emergency generators with over 100 horsepower in the original building were equipped with a remote manual stop. NFPA 110, 1999 edition, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for shutting down the engine at the engine and from a remote location. This deficient practice could affect all patients, staff and visitors in the 2007 surgery addition.

Findings include:

Based on an interview with the director of building services on 05/19/15 at 9:00 a.m., the 2007 surgery addition has one two hundred fifty horse power emergency generator set powering the 2007 surgery addition during periods of power outages. Based on observation of the emergency generator set outside enclosures on 05/19/15 at 1:10 p.m. with the director of building services, the 2007 surgery addition emergency generator set was not provided with a manual stop switch at a remote location. This was verified by the director of building services at the time of observation and acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

Based on observation and interview, the facility failed to ensure 2 of 3 emergency generators with over 100 horsepower in the original building were equipped with a remote manual stop. NFPA 110, 1999 edition, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for shutting down the engine at the engine and from a remote location. This deficient practice could affect all patients, staff and visitors in the original building.

Findings include:

Based on an interview with the director of building services on 05/19/15 at 9:00 a.m., the facility had three emergency generator sets powering the facility during periods of power outages. The original building has two, two hundred fifty horse power diesel generator sets and the 2007 surgery addition has one, two hundred fifty horse power diesel generator set.
Based on observation of the emergency generator set outside enclosures on 05/19/15 at 1:10 p.m. with the director of building services, the two emergency generator sets for the original building were not provided with a manual stop switch at a remote location. This was verified by the director of building services at the time of observation and acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

Based on observation and interview, the facility failed to ensure penetrations through 3 of 5 smoke barriers in the 2007 surgery addition were protected to maintain the smoke resistance of the smoke barrier. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so that the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect any patient as well as staff and visitors.

Findings include:

Based on observations with the building service director on 05/19/15 from 1:20 p.m. to 2:00 p.m., the following smoke barrier walls above the drop ceiling had penetrations not fire stopped or missing drywall;
a. The Surgery entrance Hall west smoke barrier wall had an eight inch by eight inch square area of drywall missing and a three inch circular area of drywall missing.
b. The Surgery Hall north smoke barrier wall had three, two inch circular areas of drywall missing, and two, one half inch gaps around metal duct penetrations not fire stopped.
c. The Surgery Hall east smoke barrier wall had sixteen electrical conduit penetrations with one half inch gaps not fire stopped, a three inch circular area of drywall missing, and a four inch open conduit with no fire stopping material.
The smoke barrier penetrations not fire stopped and missing drywall was verified by the building service director at the time of observations and acknowledged by the chief executive office at the exit conference on 05/19/15 at 2:15 p.m.

Based on observation and interview, the facility failed to ensure penetrations through 5 of 12 smoke barriers in the original building were protected to maintain the smoke resistance of the smoke barrier. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so that the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect any patient as well as staff and visitors.

Findings include:

Based on observations with the building service director on 05/19/15 from 1:20 p.m. to 2:00 p.m., the following smoke barrier walls above the drop ceiling had penetrations not fire stopped or missing drywall;
a. The Laboratory Hall smoke barrier wall had a cable bundle penetration with a one inch gap around the cable bundle not fire stopped.
b. The X-ray Hall south smoke barrier wall had a four inch electrical conduit penetration which was open and not fire stopped.
c. The X-ray Hall west smoke barrier wall had a four inch by six inch opening with no drywall on the south side of the wall and four electrical conduit penetrations with one half inch gaps not fire stopped.
d. The Med 3 Hall north smoke barrier wall had a one inch gap around an electrical conduit penetration and a one half inch gap around a cable bundle not fire stopped.
e. The Unit 3 Hall south smoke barrier wall had a one inch circular area of drywall missing next to an electrical conduit penetration.
The smoke barrier penetrations not fire stopped and missing drywall was verified by the building service director at the time of observations and acknowledged by the chief executive office at the exit conference on 05/19/15 at 2:15 p.m.

Based on record review and interview, the facility failed to conduct quarterly fire drills on each shift for 3 of 4 quarters over the past year. This deficient practice affects all occupants in the facility including staff, visitors and patients in the 2007 surgery addition.

Findings include:

Based on review of Fire Drill & Alarm Reports with the building service director on 05/19/15 at 9:15 a.m., there were no records of a fire drill for the fourth quarter of the year 2014 on third shift, the third quarter of the year 2014 on second shift and the second quarter of the year 2014 on third shift. Additionally, based on an interview with the building service director on 05/19/15 at 9:30 a.m., there was no other documentation available for review to verify the missed fire drills were conducted. This was acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

Based on record review and interview, the facility failed to conduct quarterly fire drills on each shift for 3 of 4 quarters over the past year. This deficient practice affects all occupants in the facility including staff, visitors and patients.

Findings include:

Based on review of Fire Drill & Alarm Reports with the building service director on 05/19/15 at 9:15 a.m., there were no records of a fire drill for the fourth quarter of the year 2014 on third shift, the third quarter of the year 2014 on second shift and the second quarter of the year 2014 on third shift. Additionally, based on an interview with the building service director on 05/19/15 at 9:30 a.m., there was no other documentation available for review to verify the missed fire drills were conducted. This was acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

Based on observation and interview, the facility failed to ensure 1 of 24 smoke detectors in the 2007 surgery addition was not located where airflow would prevent the operation of the detector. LSC 9.6.1.4 refers to NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires spaces served by air handling systems, detectors shall not be located where airflow prevents operation of the detectors. This deficient practice could affect any patient, staff and visitor on the 2007 surgery addition near the mechanical room.

Findings include:

Based on observation on 05/19/15 at 11:05 a.m. with the building service director, the 2007 surgery addition mechanical had a smoke detector located one foot from a supply air duct.
This was verified by the building service director at the time of observation and acknowledged by the chief executive office at the exit conference on 05/19/15 at 2:15 p.m.

Based on observation and interview, the facility failed to ensure 1 of 68 smoke detectors in the original building was not located where airflow would prevent the operation of the detector. LSC 9.6.1.4 refers to NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires spaces served by air handling systems, detectors shall not be located where airflow prevents operation of the detectors. This deficient practice could affect any patient, staff and visitor on the Med 2 Hall.

Findings include:

Based on observation on 05/19/15 at 12:10 p.m. with the building service director, the Med 2 Hall had a smoke detector located one foot from a heating and air conditioning ceiling mounted unit. This was verified by the building service director at the time of observation and acknowledged by the chief executive office at the exit conference on 05/19/15 at 2:15 p.m.

Based on observation and interview, the facility failed to ensure 1 of 1 Post Indicator Valve (PIV) was provided with an electrical alarm which alarmed when the valve was closed. LSC Section 9.7.2.1 requires supervisory attachments to be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code and a distinctive supervisory signal to be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. This deficient practice affects all patients in the facility if the water to the sprinkler system was shut off and not detected due to lack of supervision.

Findings include:

Based on observation on 05/19/15 at 10:40 a.m. with the building service director, the post indicator valve, located in the staff parking lot, was not provided with an electrical connection on the valve. Furthermore, the fire alarm system main panel did not list the post indicator valve on the panel ' s label. The lack of an electrical alarm on the post indicator valve was verified by the director of building services at the time of observation and acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

Based on observation and interview, the facility failed to ensure 1 of 1 Post Indicator Valve (PIV) was provided with an electrical alarm which alarmed when the valve was closed. LSC Section 9.7.2.1 requires supervisory attachments to be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code and a distinctive supervisory signal to be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. This deficient practice affects all patients in the facility if the water to the sprinkler system was shut off and not detected due to lack of supervision.

Findings include:

Based on observation on 05/19/15 at 10:40 a.m. with the building service director, the post indicator valve, located in the staff parking lot, was not provided with an electrical connection on the valve. Futhermore, the fire alarm system main panel did not list the post indicator valve on the panels label. The lack of an electrical alarm on the post indicator valve was verified by the director of building services at the time of observation and acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

1. Based on record review and interview, the facility failed to ensure 1 of 1 automatic dry sprinkler piping systems was inspected every five years as required by NFPA 25, the Standards for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 10-2.2. This deficient practice affects all patients, staff and visitors in the 2007 surgery addition.

Findings include:

Based on record review with the director of building services on 05/19/15 at 9:45 a.m., there was no documentation to indicate an internal inspection of the dry sprinkler system had been conducted in the past five years. Based on a review of the dry sprinkler riser on 05/19/15 at 11:45 a.m. with the director of building services, the dry sprinkler riser, located in the main mechanical room, had a date of the last internal pipe inspection dated July 2006. The lack of a five year internal pipe inspection was verified by the director of building services at the time of record review and acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

2. Based on observation and interview, the facility failed to ensure 1 of 1 private fire hydrant was continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 1998 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems at Section 4-2.2.4 requires dry barrel hydrants to be inspected annually and after each operation. Hydrants shall be inspected, and the necessary corrective action shall be taken. This deficient practice affects all occupants in the facility including staff, visitors and patients in the 2007 surgery addition.

Findings include:

Based on observation on 05/19/15 at 1:15 p.m. with the director of building services, the facility had one private fire hydrant near the helicopter pad. Based on an interview with the director of building services on 05/19/15 at 1:25 p.m., there is no documentation of an annual inspection for the fire hydrant. The lack of an annual inspection for the one fire hydrant near the helicopter pad was acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

1. Based on record review and interview, the facility failed to ensure 1 of 1 automatic dry sprinkler piping systems was inspected every five years as required by NFPA 25, the Standards for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 10-2.2. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on record review with the director of building services on 05/19/15 at 9:45 a.m., there was no documentation to indicate an internal inspection of the dry sprinkler system had been conducted in the past five years. Based on a review of the dry sprinkler riser on 05/19/15 at 11:45 a.m. with the director of building services, the dry sprinkler riser, located in the main mechanical room, had a date of the last internal pipe inspection dated July 2006. The lack of a five year internal pipe inspection was verified by the director of building services at the time of record review and acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

2. Based on observation and interview, the facility failed to provide a complete supply of spare sprinklers for the automatic sprinkler system in accordance with NFPA 25, 1998 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 2-4.1.4 which requires supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. This deficient practice could affect all patients, staff and visitors if the sprinkler system had to be shut down because a proper sprinkler wasn't available as a replacement for the Med 2 West Hall.

Findings include:

Based on observations on 05/19/15 during the tour of the Med 2 West Hall with the director of building services from 12:20 p.m. to 1:00 p.m., the fourteen rooms on the Med 2 West Hall each had sidewall sprinklers. Based on observation of the spare sprinkler cabinets in the maintenance office sprinkler riser room and the main mechanical sprinkler riser room, the two spare sprinkler cabinets lacked sidewall sprinklers. The lack of spare sidewall sprinklers was verified by the director of building services at the time of observation and acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

3. Based on observation and interview, the facility failed to ensure 1 of 1 private fire hydrant was continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 1998 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems at Section 4-2.2.4 requires dry barrel hydrants to be inspected annually and after each operation. Hydrants shall be inspected, and the necessary corrective action shall be taken. This deficient practice affects all occupants in the facility including staff, visitors and patients.

Findings include:

Based on observation on 05/19/15 at 1:15 p.m. with the director of building services, the facility had one private fire hydrant near the helicopter pad. Based on an interview with the director of building services on 05/19/15 at 1:25 p.m., there is no documentation of an annual inspection for the fire hydrant. The lack of an annual inspection for the one fire hydrant near the helicopter pad was acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

Based on record review and interview, the facility failed to ensure 15 of 44 fire dampers were repaired after the necessary four year maintenance was conducted in accordance with NFPA 90A. LSC 9.2.1 requires air conditioning, heating, ventilating ductwork (HVAC) and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 1999 Edition, 3.4.7, Maintenance, requires at least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify they fully close; the latch, if provided, shall be checked, and moving parts shall be lubricated as necessary. This deficient practice affects all patients in the original building.

Findings include:

Based on record review on 05/19/15 at 9:45 a.m. with the director of building services, the most recent fire damper inspection record provided for review was from Life Safety Services dated 12/07/2010. Furthermore, the report listed fifteen dampers that failed the inspection because the actuators failed to open and close. Based on an interview with the director of building services on 05/19/15 at 10:00 a.m., the fifteen fire dampers that failed the 12/07/2010 inspection had not been repaired. The lack of repair work to fifteen failed fire dampers after the inspection was conducted was verified by the director of building services at the time of interview and acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

Based on observation and interview, the facility failed to ensure 1 of 3 emergency generators with over 100 horsepower in the original building were equipped with a remote manual stop. NFPA 110, 1999 edition, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for shutting down the engine at the engine and from a remote location. This deficient practice could affect all patients, staff and visitors in the 2007 surgery addition.

Findings include:

Based on an interview with the director of building services on 05/19/15 at 9:00 a.m., the 2007 surgery addition has one two hundred fifty horse power emergency generator set powering the 2007 surgery addition during periods of power outages. Based on observation of the emergency generator set outside enclosures on 05/19/15 at 1:10 p.m. with the director of building services, the 2007 surgery addition emergency generator set was not provided with a manual stop switch at a remote location. This was verified by the director of building services at the time of observation and acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.

Based on observation and interview, the facility failed to ensure 2 of 3 emergency generators with over 100 horsepower in the original building were equipped with a remote manual stop. NFPA 110, 1999 edition, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for shutting down the engine at the engine and from a remote location. This deficient practice could affect all patients, staff and visitors in the original building.

Findings include:

Based on an interview with the director of building services on 05/19/15 at 9:00 a.m., the facility had three emergency generator sets powering the facility during periods of power outages. The original building has two, two hundred fifty horse power diesel generator sets and the 2007 surgery addition has one, two hundred fifty horse power diesel generator set.
Based on observation of the emergency generator set outside enclosures on 05/19/15 at 1:10 p.m. with the director of building services, the two emergency generator sets for the original building were not provided with a manual stop switch at a remote location. This was verified by the director of building services at the time of observation and acknowledged by the chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.