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Based on observation and interview, the facility failed to maintain 2 hour fire resistance rated barriers as required.

Findings include:

On 8/5/14 the fire doors located at the following locations did not close and latch as required when released from the open position.
· Next to CT scan room 1556, one of two leaves dragging on floor
· Between hospital and 2 story building in main corridor, one of two leaves dragging on floor
· Between hospital and 2 story building corridor to procurement, one of two leaves dragging on floor, one of two leaves not self-latching as required.

Fire doors located in fire barriers are required to swing easily and freely and shall be equipped with a closing device that cause the door to close and latch each time it is opened.

Ref: 2000 NFPA 101 Section 19.1.1.4.2, 8.2.3.2.1, 1999 NFPA 80 Section 2-1.4.1, 2-4.1.4
Ref: 2000 NFPA 101 Section 19.1.1.4.2, 8.2.3.2.1, 1999 NFPA 80 Section 2-4.4.5 (self-latching, auto flush bolts)

The Facility Engineer was present when the deficiency was identified.

Failure to maintain fire barriers as required increases the risk of death or injury due to fire.

The deficiency affected three of an estimated ten locations where fire doors are required.

Based on observation and interview, the facility failed to maintain corridor doors as required.

Findings include:

On 8/5/14 the following corridor doors were not provided with a suitable means for keeping the doors closed where the door would resist a force of 5 lbs. applied at the latch edge as required. The latches were malfunctioning.
· Room 245, patient room, inpatient ward
· Room 259, patient room, inpatient ward
· Room 263, patient room, inpatient ward
· Room 1202, storage room, inpatient ward

The Facility Engineer was present when the deficiency was identified.

Failure to maintain corridor doors as required increases the risk of death or injury due to fire.

The deficiency affected four of numerous corridor doors in the building.

Ref: 2000 NFPA 101 Section 19.3.6.3.2

Based on observation and interview, the facility failed to provide smoke barrier doors as required.

Findings include:

On 8/5/14 the following smoke barrier doors were not self-closing as required.
· Cross corridor doors near office 1200, one leaf drags on floor, doors do not fully close leaving ¾ inch gap that would not resist the passage of smoke

The Facility Engineer was present when the deficiency was identified.

Failure to provide smoke barrier doors as required increases the risk of death or injury due to fire.

The deficiency affected two of six smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.7.6

Based on observation and interview, the facility failed to protect hazardous areas as required.

Findings include:

On 8/5/14, the following storage rooms were found to have doors that were not self-closing.
· Room 1272, Kitchen (closer pulled out of frame)
· Physical Therapy fabrication/ storage, 10 ft x 25 ft= 250 square feet (sq)

Storage rooms that exceed 50 sf in size and contain combustible materials are considered hazardous areas. Doors to hazardous areas are required to be self-closing.

The Facility Engineer was present when the deficiency was identified.

Failure to protect hazardous areas as required increases the risk of death or injury due to fire.

The deficiency affected two of numerous hazardous areas in the building.

Ref: 2000 NFPA 101 Section 19.3.2.1

Based on observation and interview, the facility failed to maintain the means of egress a required.

Findings include:

On 8/5/14 deadbolt locks were mounted at a height of 57 inches above the finished floor at 2 operating rooms. Locks and latches on doors are required to be located between 32 inches and 48 inches above the floor.

Ref: 2000 NFPA 101 Section 19.2.1, 7.2.1.5.4

On 8/5/14 the following doors would not open when an excess of 50 lbs. force was applied. The opening for existing doors in existing buildings shall not exceed 50 lbs. applied to the latch style.
· Exit door near room 253, inpatient ward
· Room 247 anti-room

Ref: 2000 NFPA 101 Section 19.2.1, 7.2.1.4.5 exception #1

On 8/5/14 the following doors were equipped with two locking/latching devices where two releasing operations were required to operate the door. Doors in the means of egress are required to be operable with not more than one releasing operation.
· Administration conference room

Ref: 2000 NFPA 101 Section 19.2.1, 7.2.1.5.4

The Facility Engineer was present when the deficiency was identified.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

The deficiency affected four of numerous doors in the means of egress serving the building.

Based on observation and interview, the facility failed to maintain the means of egress a required.

Findings include:

On 8/5/14, the door leading to the behavioral health offices was equipped with a lock that required a key in the direction of egress. Doors in the means of egress are not permitted to be equipped with a lock or latch that requires the use of a key in the direction of egress. This means of egress is required so that common path of travel does not exceed 75 feet for areas outside of the behavioral health offices. Areas more than 75 feet from the central stair are affected.

Ref 2000 NFPA 101 Section 39.2.2.2.1, 7.2.1.5.1, 39.2.5.3

The Facility Engineer was present when the deficiency was identified.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous doors in the means of egress serving the building.

Based on observation and interview, the facility failed to provide a fire plan as required.

Findings include:

On 8/6/14 the fire plan did provide for evacuation of smoke compartment as required.
The Facility Engineer was present when the deficiency was identified.

Failure to provide a fire plan as required increases the risk of death or injury due to fire.

The deficiency affected one of eight required components.

Ref: 2000 NFPA 101 Section 19.7.1.1, 19.7.2.2

Based on observation and interview, the facility failed to install automatic fire sprinklers as required.

Findings include:

On 8/5/14 the following locations were not protected with automatic fire sprinklers as required:
· Walk in refrigerator and freezer, kitchen

Ref: 2000 NFPA 101 Section 19.1.6.2, 19.3.5.1, 9.7.1.1; 1999 NFPA 13 Section 5-1.1

On 8/5/14 the following stairway did not have a sprinkler below the first landing at the bottom of the shaft as required.
· Stair 1 door 1504

Ref: 2000 NFPA 101 Section 19.3.5.3, 9.7.1.1; 1999 NFPA 13 Section 5-13.3.2

On 8/5/14 the following location did not maintain 18 inches or more clearance between the sprinkler deflector and storage as required.
· Room 1204, Inpatient Ward, soiled utility, 12 inches to shelf

Ref: 2000 NFPA 101 Section 31.3.5.1, 9.7.1.1; 1999 NFPA 13 Section 5-6.6

On 8/5/14 concealed sprinklers at the following location were not installed as required by their listing:
· Room 1186 - concealed sprinkler cover painted between sprinkler and ceiling.

Concealed sprinklers are required to maintain a 1/8 inch air gap between the lip of concealing plate and the ceiling to allow heat flow above the cover plate. Paint is not permitted to seal off any of the air gap.

Ref: 2000 NFPA 101 Section 19.1.6.2, 19.3.5.1, 9.7; 1999 NFPA 13 Section 5-3.1.1

The Facility Engineer was present when the deficiency was identified.

Failure to install automatic fire sprinklers as required increases the risk of death or injury due to fire.

The deficiency affected four of numerous locations requiring sprinkler protection.

Based on observation and interview, the facility failed to inspect and maintain the automatic fire sprinkler system as required.

Findings include:

On 8/5/14 sprinklers in the following location were not free of foreign material as required.
· The frangible element of 5 of 10 sprinklers in the basement medical records storage room were coated with what appeared to be dust from sanding of joint compound.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.5, 1998 NFPA 25 Section 2-2.1.1

The Facility Engineer was present when the deficiency was identified.

Failure to maintain automatic sprinklers as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous rooms with automatic sprinkler protection.

Based on observation and interview, the facility failed to protect cooking facilities as required.

Findings include:

On 8/6/14 the facility engineer verified that the hood ventilation system ductwork had never been inspected for cleaning or cleaned as required. Kitchen hood systems as used in this facility are required to be inspected semiannually to determine if they are contaminated with deposits from grease-laden vapors. If contaminated, the entire exhaust system is required to be cleaned to bare metal.

The Facility Engineer was present when the deficiency was identified.

Failure to protect cooking facilities as required increases the risk of death or injury due to fire.

The deficiency affected one of six smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.2.6, 9.2.3; 1998 NFPA 96 Section 8-3.1.1, 8-3.1.2

Based on observation and interview, the facility failed to store medical gasses as required.

Findings include:

On 8/5/14 the following room did not have dedicated mechanical ventilation or a natural vent opening measuring 72 square inches to the outside as required for storage location of nonflammable medical gasses greater than 3,000 cubic feet.
· Room 1290A stored 21 H tanks of oxygen (21 x 300 cf/tank = 6,300 cubic feet)

The Facility Engineer was present when the deficiency was identified.

Failure to store medical gasses as required increases the risk of death or injury due to fire.

The deficiency affected one of six smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.2.4; 1999 NFPA 99 Section 4-3.1.1.2(b)4

Based on observation and interview, the facility failed to provide medical gas systems as required.

Findings include:

On 8/6/14 the medical gas inspection report dated 1/21/14 indicated:
· The carbon monoxide monitor for the medical air did not indicate with a 20% input. Indication is required at greater than 10 ppm.
Ref: 2000 NFPA 101 Section 19.3.2.4; 1999 NFPA 99 Section 4-3.1.2.2(d)3.
· The nitrous oxide and oxygen manifold did not have duplex final line regulators as required.
Ref: 2000 NFPA 101 Section 19.3.2.4; 1999 NFPA 99 Section 4-3.1.1.8(g)
· Medical gas was being provided to the endo and surgery cleaning room. Medical gas is only permitted to be piped to patient care areas.
Ref: 2000 NFPA 101 Section 19.3.2.4; 1999 NFPA 99 Section 4-3.1.1.8

The Facility Engineer was present when the deficiency was identified.

Failure to provide medical gas systems as required increases the risk of death or injury due to fire.

The deficiency affected two locations and two of numerous medical gas functions.

Based on observation and interview, the facility failed to provide an essential electrical system as required.

Findings include:

On 8/6/14, the generator providing emergency power did not have a remote manual stop outside of the room housing the prime mover (diesel motor) or elsewhere on the premises where the prime mover located outside of the building as required.

Ref: 2000 NFPA 101 Section 19.3.2.3; 1999 NFPA 99 Section 12-3.2.3, 3-4.1.1.4(a); 1999 NFPA 110 Section 3-5.5.6

On 8/6/14, the generator providing emergency power did not have a remote alarm annunciator outside of the generating room in a location readily observable by operating personnel as required.

Ref: 2000 NFPA 101 Section 19.3.2.3; 1999 NFPA 99 Section 12-3.2.3, 3-4.1.1.15

The Facility Engineer was present when the deficiencies were identified.

Failure to provide an essential electrical system as required increases the risk of death or injury due to fire.

The deficiency affected two of numerous requirements of the essential electrical system.

Based on observation and interview, the facility failed to maintain medical gas master alarm panels as required.

Findings include:

On 8/6/14 the medical gas inspection report dated 1/21/14 indicated:
· The medical gas alarm did not have a visual indicator for high pressure as required for the Oxygen, Nitrous Oxide and Medical air as required.
· The medical gas alarms panel did not alarm for high or low pressure for medical air as required.

Ref: 2000 NFPA 101 Section 19.3.2.4; 1999 NFPA 99 Section 4-3.1.2.2(b)3.e.

The Facility Engineer was present when the deficiency was identified.

Failure to provide medical gas master alarms as required increases the risk of death or injury due to fire.

The deficiency affected two of numerous function required of the medical gas master alarms.

Based on observation and interview, the facility failed to maintain 2 hour fire resistance rated barriers as required.

Findings include:

On 8/5/14 the fire doors located at the following locations did not close and latch as required when released from the open position.
· Next to CT scan room 1556, one of two leaves dragging on floor
· Between hospital and 2 story building in main corridor, one of two leaves dragging on floor
· Between hospital and 2 story building corridor to procurement, one of two leaves dragging on floor, one of two leaves not self-latching as required.

Fire doors located in fire barriers are required to swing easily and freely and shall be equipped with a closing device that cause the door to close and latch each time it is opened.

Ref: 2000 NFPA 101 Section 19.1.1.4.2, 8.2.3.2.1, 1999 NFPA 80 Section 2-1.4.1, 2-4.1.4
Ref: 2000 NFPA 101 Section 19.1.1.4.2, 8.2.3.2.1, 1999 NFPA 80 Section 2-4.4.5 (self-latching, auto flush bolts)

The Facility Engineer was present when the deficiency was identified.

Failure to maintain fire barriers as required increases the risk of death or injury due to fire.

The deficiency affected three of an estimated ten locations where fire doors are required.

Based on observation and interview, the facility failed to maintain corridor doors as required.

Findings include:

On 8/5/14 the following corridor doors were not provided with a suitable means for keeping the doors closed where the door would resist a force of 5 lbs. applied at the latch edge as required. The latches were malfunctioning.
· Room 245, patient room, inpatient ward
· Room 259, patient room, inpatient ward
· Room 263, patient room, inpatient ward
· Room 1202, storage room, inpatient ward

The Facility Engineer was present when the deficiency was identified.

Failure to maintain corridor doors as required increases the risk of death or injury due to fire.

The deficiency affected four of numerous corridor doors in the building.

Ref: 2000 NFPA 101 Section 19.3.6.3.2

Based on observation and interview, the facility failed to provide smoke barrier doors as required.

Findings include:

On 8/5/14 the following smoke barrier doors were not self-closing as required.
· Cross corridor doors near office 1200, one leaf drags on floor, doors do not fully close leaving ¾ inch gap that would not resist the passage of smoke

The Facility Engineer was present when the deficiency was identified.

Failure to provide smoke barrier doors as required increases the risk of death or injury due to fire.

The deficiency affected two of six smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.7.6

Based on observation and interview, the facility failed to protect hazardous areas as required.

Findings include:

On 8/5/14, the following storage rooms were found to have doors that were not self-closing.
· Room 1272, Kitchen (closer pulled out of frame)
· Physical Therapy fabrication/ storage, 10 ft x 25 ft= 250 square feet (sq)

Storage rooms that exceed 50 sf in size and contain combustible materials are considered hazardous areas. Doors to hazardous areas are required to be self-closing.

The Facility Engineer was present when the deficiency was identified.

Failure to protect hazardous areas as required increases the risk of death or injury due to fire.

The deficiency affected two of numerous hazardous areas in the building.

Ref: 2000 NFPA 101 Section 19.3.2.1

Based on observation and interview, the facility failed to maintain the means of egress a required.

Findings include:

On 8/5/14 deadbolt locks were mounted at a height of 57 inches above the finished floor at 2 operating rooms. Locks and latches on doors are required to be located between 32 inches and 48 inches above the floor.

Ref: 2000 NFPA 101 Section 19.2.1, 7.2.1.5.4

On 8/5/14 the following doors would not open when an excess of 50 lbs. force was applied. The opening for existing doors in existing buildings shall not exceed 50 lbs. applied to the latch style.
· Exit door near room 253, inpatient ward
· Room 247 anti-room

Ref: 2000 NFPA 101 Section 19.2.1, 7.2.1.4.5 exception #1

On 8/5/14 the following doors were equipped with two locking/latching devices where two releasing operations were required to operate the door. Doors in the means of egress are required to be operable with not more than one releasing operation.
· Administration conference room

Ref: 2000 NFPA 101 Section 19.2.1, 7.2.1.5.4

The Facility Engineer was present when the deficiency was identified.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

The deficiency affected four of numerous doors in the means of egress serving the building.

Based on observation and interview, the facility failed to maintain the means of egress a required.

Findings include:

On 8/5/14, the door leading to the behavioral health offices was equipped with a lock that required a key in the direction of egress. Doors in the means of egress are not permitted to be equipped with a lock or latch that requires the use of a key in the direction of egress. This means of egress is required so that common path of travel does not exceed 75 feet for areas outside of the behavioral health offices. Areas more than 75 feet from the central stair are affected.

Ref 2000 NFPA 101 Section 39.2.2.2.1, 7.2.1.5.1, 39.2.5.3

The Facility Engineer was present when the deficiency was identified.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous doors in the means of egress serving the building.

Based on observation and interview, the facility failed to provide a fire plan as required.

Findings include:

On 8/6/14 the fire plan did provide for evacuation of smoke compartment as required.
The Facility Engineer was present when the deficiency was identified.

Failure to provide a fire plan as required increases the risk of death or injury due to fire.

The deficiency affected one of eight required components.

Ref: 2000 NFPA 101 Section 19.7.1.1, 19.7.2.2

Based on observation and interview, the facility failed to install automatic fire sprinklers as required.

Findings include:

On 8/5/14 the following locations were not protected with automatic fire sprinklers as required:
· Walk in refrigerator and freezer, kitchen

Ref: 2000 NFPA 101 Section 19.1.6.2, 19.3.5.1, 9.7.1.1; 1999 NFPA 13 Section 5-1.1

On 8/5/14 the following stairway did not have a sprinkler below the first landing at the bottom of the shaft as required.
· Stair 1 door 1504

Ref: 2000 NFPA 101 Section 19.3.5.3, 9.7.1.1; 1999 NFPA 13 Section 5-13.3.2

On 8/5/14 the following location did not maintain 18 inches or more clearance between the sprinkler deflector and storage as required.
· Room 1204, Inpatient Ward, soiled utility, 12 inches to shelf

Ref: 2000 NFPA 101 Section 31.3.5.1, 9.7.1.1; 1999 NFPA 13 Section 5-6.6

On 8/5/14 concealed sprinklers at the following location were not installed as required by their listing:
· Room 1186 - concealed sprinkler cover painted between sprinkler and ceiling.

Concealed sprinklers are required to maintain a 1/8 inch air gap between the lip of concealing plate and the ceiling to allow heat flow above the cover plate. Paint is not permitted to seal off any of the air gap.

Ref: 2000 NFPA 101 Section 19.1.6.2, 19.3.5.1, 9.7; 1999 NFPA 13 Section 5-3.1.1

The Facility Engineer was present when the deficiency was identified.

Failure to install automatic fire sprinklers as required increases the risk of death or injury due to fire.

The deficiency affected four of numerous locations requiring sprinkler protection.

Based on observation and interview, the facility failed to inspect and maintain the automatic fire sprinkler system as required.

Findings include:

On 8/5/14 sprinklers in the following location were not free of foreign material as required.
· The frangible element of 5 of 10 sprinklers in the basement medical records storage room were coated with what appeared to be dust from sanding of joint compound.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.5, 1998 NFPA 25 Section 2-2.1.1

The Facility Engineer was present when the deficiency was identified.

Failure to maintain automatic sprinklers as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous rooms with automatic sprinkler protection.

Based on observation and interview, the facility failed to protect cooking facilities as required.

Findings include:

On 8/6/14 the facility engineer verified that the hood ventilation system ductwork had never been inspected for cleaning or cleaned as required. Kitchen hood systems as used in this facility are required to be inspected semiannually to determine if they are contaminated with deposits from grease-laden vapors. If contaminated, the entire exhaust system is required to be cleaned to bare metal.

The Facility Engineer was present when the deficiency was identified.

Failure to protect cooking facilities as required increases the risk of death or injury due to fire.

The deficiency affected one of six smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.2.6, 9.2.3; 1998 NFPA 96 Section 8-3.1.1, 8-3.1.2

Based on observation and interview, the facility failed to store medical gasses as required.

Findings include:

On 8/5/14 the following room did not have dedicated mechanical ventilation or a natural vent opening measuring 72 square inches to the outside as required for storage location of nonflammable medical gasses greater than 3,000 cubic feet.
· Room 1290A stored 21 H tanks of oxygen (21 x 300 cf/tank = 6,300 cubic feet)

The Facility Engineer was present when the deficiency was identified.

Failure to store medical gasses as required increases the risk of death or injury due to fire.

The deficiency affected one of six smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.2.4; 1999 NFPA 99 Section 4-3.1.1.2(b)4

Based on observation and interview, the facility failed to provide medical gas systems as required.

Findings include:

On 8/6/14 the medical gas inspection report dated 1/21/14 indicated:
· The carbon monoxide monitor for the medical air did not indicate with a 20% input. Indication is required at greater than 10 ppm.
Ref: 2000 NFPA 101 Section 19.3.2.4; 1999 NFPA 99 Section 4-3.1.2.2(d)3.
· The nitrous oxide and oxygen manifold did not have duplex final line regulators as required.
Ref: 2000 NFPA 101 Section 19.3.2.4; 1999 NFPA 99 Section 4-3.1.1.8(g)
· Medical gas was being provided to the endo and surgery cleaning room. Medical gas is only permitted to be piped to patient care areas.
Ref: 2000 NFPA 101 Section 19.3.2.4; 1999 NFPA 99 Section 4-3.1.1.8

The Facility Engineer was present when the deficiency was identified.

Failure to provide medical gas systems as required increases the risk of death or injury due to fire.

The deficiency affected two locations and two of numerous medical gas functions.

Based on observation and interview, the facility failed to provide an essential electrical system as required.

Findings include:

On 8/6/14, the generator providing emergency power did not have a remote manual stop outside of the room housing the prime mover (diesel motor) or elsewhere on the premises where the prime mover located outside of the building as required.

Ref: 2000 NFPA 101 Section 19.3.2.3; 1999 NFPA 99 Section 12-3.2.3, 3-4.1.1.4(a); 1999 NFPA 110 Section 3-5.5.6

On 8/6/14, the generator providing emergency power did not have a remote alarm annunciator outside of the generating room in a location readily observable by operating personnel as required.

Ref: 2000 NFPA 101 Section 19.3.2.3; 1999 NFPA 99 Section 12-3.2.3, 3-4.1.1.15

The Facility Engineer was present when the deficiencies were identified.

Failure to provide an essential electrical system as required increases the risk of death or injury due to fire.

The deficiency affected two of numerous requirements of the essential electrical system.

Based on observation and interview, the facility failed to maintain medical gas master alarm panels as required.

Findings include:

On 8/6/14 the medical gas inspection report dated 1/21/14 indicated:
· The medical gas alarm did not have a visual indicator for high pressure as required for the Oxygen, Nitrous Oxide and Medical air as required.
· The medical gas alarms panel did not alarm for high or low pressure for medical air as required.

Ref: 2000 NFPA 101 Section 19.3.2.4; 1999 NFPA 99 Section 4-3.1.2.2(b)3.e.

The Facility Engineer was present when the deficiency was identified.

Failure to provide medical gas master alarms as required increases the risk of death or injury due to fire.

The deficiency affected two of numerous function required of the medical gas master alarms.