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Based on observations and interviews made during the Fire & Life Safety tour, the facility failed to maintain proper maintenance of the egress doors. This could impede or deny the exiting of occupants in an emergency and result in harm to the building occupants.

The findings include:

During the Fire & Life Safety tour of the facility with the Vice President (VP) of Operations on 10/10/2023 from 9:00 am to 1:00 pm, it was observed that the following egress doors were not opening properly:

1. The glass doors in the main lobby were not breaking away when pushed.
2. The lab exit door to the outside was not opening properly.
3. The glass exit doors to the helicopter pad were not breaking away when pushed.

The VP of Operations was present during the observation, and confirmed the findings at the time of observation.

This is a violation of NFPA 101 (2012 edition) Chapter 19.2.

Based on observation and interview with the VP of Operations, the facility failed to maintain their fire alarm system in accordance with NFPA 72 requirements. Failure to maintain initiating devices could result in a smoke detector failing to activate the alarm system resulting in the potential endangerment of the occupants of the building in the event of a fire.

The findings include:

During the Fire & Life Safety tour of the facility with the VP of Operations on 10/10/2023 from 9:00 am to 1:00 pm, it was observed the fire alarm panel was indicating "trouble" status. Staff were unable to provide documentation to the extent of the trouble with the system.

The VP of Operations and Administrator confirmed the findings at the time of the observation.

This is a violation of NFPA 72 (2010 edition).

Based on observation and interviews made during the Fire & Life Safety tour, the facility failed to maintain proper maintenance of the fire/smoke doors. This condition could result in smoke compartments becoming involved in a fire and/or smoke situation. This could allow fire, smoke and fire gases to enter the compartment, which would impede or deny the exiting of occupants in an emergency and result in harm to the building occupants.

The findings include:

During the Fire & Life Safety tour of the facility with the VP of Operations on 10/10/2023 from 9:00 am to 1:00 pm, it was observed that the following fire and smoke doors were not closing properly:

1. The kitchen door leading to the dining room was stuck open.
2. The dry storage door in the kitchen was not latching.
3. The dish room door to the hall needs a closer.
4. The main hall door to the dining room needs a closer.
5. Room 3C105-House Keeping is missing a fire door.

The VP of Operations was present during the observation and concurrently confirmed the findings.

This is a violation of NFPA 101 (2012 edition,) Chapter 19, 19.3.6.3.5, which states, "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction."

Based on observation and interview made during the Fire & Life Safety tour, the facility failed to maintain electrical equipment and wiring in accordance with NFPA 70, The National Electric Code (NEC), and NFPA 99 Health Care Facilities Code to provide a facility free from electrical hazards. Failure to maintain electrical devices, equipment, and wiring in accordance with the applicable standards can result in the hazards of electric shock, electrocution, energized equipment and fire resulting from electric sources.

The findings include:

During the Fire & Life Safety tour of the facility with the VP of Operations on 10/10/2023 from 9:00 am - 1:00 pm, it was observed that re-locatable power taps (RPT's) were in use in the following locations:

1. ICU supply room.
2. Room 2A131 Converted IT room from Office.
3. Room 5C1127 RPT's 3 in daisy chain.
4. Room 5D201 Communication room daisy chained RPT's

The VP of Operations was present during the observation and confirmed the findings.

Extension cords are not to be used as a substitute for fixed wiring of a structure. Extension cords used temporarily must be removed immediately upon completion of the purpose for which it was installed and meet the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), and 590.3(D).