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Based on document review and staff interview, the facility failed to maintain the means of egress in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain the means of egress could result in injury or death in the event of an emergency. The deficiency affected seven (7) of seven (7) smoke compartments.

The findings were:

Document review on 12/11/18 at 3:15 PM revealed that inspection of fire-rated door assemblies had been conducted in the last 12 months. The inspections are being conducted by the maintenance staff of the facility, however the staff has not received any training or certification to conduct the inspections.

Interview with the maintenance director at the time of the observation acknowledged the deficiency, but indicated he was unaware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 19.2.1, 7.2.1.15.2, 2010 NFPA 80 5.2.1

Based on observation and staff interview, the facility failed to provide horizontal exits in accordance with the 2012 NFPA 101, Life Safety Code. Failure to provide horizontal exits could result in injury or death in the event of an emergency. The deficiencies affected seven (7) of seven (7) smoke compartments.

The findings were:

Observation on 12/11/18 at 1:20 PM revealed a 2-hour fire barrier separating the new lobby/administration/ER addition and the remainder of the hospital. The 2-hour fire barrier is used as a horizontal exit for the existing building. Two sets of cross-corridor doors used as horizontal exits were labeled as 90 minute fire doors. However, observation of the crash bars revealed labels that stated "Panic Hardware". Typically hardware that is to be used for on fire rated doors has a label that reads "Fire Hardware". Observation of other similar doors that were also labeled as 90 minute fire doors did have crash bars with the label "Fire Hardware".

Interview with the maintenance director at the time of the observation acknowledged the deficiency, but indicated he was unaware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 19.2.2.5, 7.2.4.3.1


Observation on 12/11/18 at 1:30 PM revealed a 2-hour fire barrier separating the new lobby/administration/ER addition and the remainder of the hospital. A door within the 2-hour fire barrier that exited from the C.T. room was labled as 60-minute fire rating. Doors located in 2-hour fire barriers shall have a minimum 90 minute fire rating.

Interview with the maintenance director at the time of the observation acknowledged the deficiency, but indicated he was unaware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 19.2.2.5, 7.2.4.3.1, Table 8.3.4.2

Based on observation and staff interview, the facility failed to provide emergency lighting in accordance with the 2012 NFPA 101, Life Safety Code. Failure to provide emergency lighting could result in injury or death in the event of an emergency. The deficiency affected the basement.

The findings were:

Observation on 12/11/18 at 12:15 PM revealed combustible storage being kept in the basement emergency generator room. Only parts, tools, and manuals for routine maintenance and repair shall be permitted to be stored in the emergency generator room.

Interview with the maintenance director at the time of the observation acknowledged the deficiency, but indicated he was unaware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 19.2.9.1, 7.9.2.4; 2010 NFPA 110 7.11.1

Based on observation and staff interview, the facility failed to protect hazardous areas in accordance with the 2012 NFPA 101, Life Safety Code. Failure to protect hazardous areas could result in injury or death in the event of a fire. The deficiencies affected three (3) of seven (7) smoke compartments on the main floor and the basement.

The findings were:

Observation on 12/11/18 at 12:30 PM revealed a storage room in the administrative suite that had large quantities of paper. The room was greater than 50 square feet in size, and had no door closer. Rooms over 50 square feet in area used for the storage of combustible material must have self or automatic-closing doors.

Interview with the maintenance director at the time of the observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 19.3.2.1.3


Observation on 12/11/18 at 12:00 PM revealed multiple rooms in the basement of the facility used for storage of combustible material. These rooms had unprotected electrical and plumbing wall penetrations. Rooms over 50 square feet in area used for the storage of combustible material must be separated from other spaces by smoke partitions.

Interview with the maintenance director at the time of the observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 19.3.2.1.2


Observation on 12/11/18 at 12:10 PM revealed the old kitchen room in the basement being used for storage of combustible materials. The room had two entrance doors, and only one of the doors had an automatic door closer. Rooms over 50 square feet in area used for the storage of combustible material must have self or automatic-closing doors.

Interview with the maintenance director at the time of the observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 19.3.2.1.3


Observation on 12/11/18 at 1:42 PM revealed a storage room in the physical therapy suite with no automatic door closer. Rooms over 50 square feet in area used for the storage of combustible material must have self or automatic-closing doors.

Interview with the maintenance director at the time of the observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 19.3.2.1.3


Observation on 12/11/18 at 1:50 PM revealed the main floor mechanical room with no automatic door closer. Their was evidence that an automatic door closer had been removed from the door. Boiler and fuel-fired heater rooms must have self or automatic-closing doors.

Interview with the maintenance director at the time of the observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 19.3.2.1.3


Observation on 12/11/18 at 2:30 PM revealed that the house keeping office in the purchasing suite was being used to store combustible materials, but had no automatic door closer. Rooms over 50 square feet in area used for the storage of combustible material must have self or automatic-closing doors.

Interview with the maintenance director at the time of the observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 19.3.2.1.3


Observation on 12/11/18 at 1:00 PM revealed a set of doors separating the emergency room suite from the ambulance bay. The doors are part of a 1-hour fire barrier separating the ambulance bay from the hospital. The doors were labled as 90 minute fire doors. However, the crash bars had labels that read "Panic Hardware" instead of "Fire Hardware".

Interview with the maintenance director at the time of the observation acknowledged the deficiency, but indicated he was unaware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 8.3.3.1

Based on observation and staff interview, the facility failed to maintain utilities in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain utilities could result in injury or death in the event of an emergency. The deficiency affected one (1) of seven (7) smoke compartments on the main floor.

The findings were:

Observation on 12/11/18 at 2:20 PM revealed two electrical receptacles located near sinks that were non-GFCI protected. The receptacles were located in the med/surg patient room corridor's clean utility room and south nurses station.

Interview with the maintenance director at the time of the observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 19.5.1.1, 9.1.2; NFPA 70 210.8 (B)(6)

Based on document review and staff interview, the facility failed to conduct fire drills in accordance with the 2012 NFPA 101, Life Safety Code. Failure to conduct fire drills could result in injury or death in the event of an emergency. The deficiencies affected seven (7) out of seven (7) smoke compartments and the basement.

The findings were:

Document review on 12/11/18 at 2:10 PM revealed that the facility was conducting one fire drill per quarter, and rotating which shift the fire drill was being conducted. Fire drills must be conducted once a quarter on every shift.

Interview with the maintenance director at the time of the observation acknowledged the deficiency, but indicated he misunderstood the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 19.7.1.6

Based on observation and staff interview, the facility failed to utilize power strips in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to properly use power strips could result in injury or death. The deficiencies affected one (1) of seven (7) smoke compartments on the main floor.

The findings were:

Observation on 12/11/18 at 3:05 PM revealed an operating room in the surgical suite that had a power strip that used to power patient care equipment. The power strip was plugged into a wall outlet and laid out on the ground. The power strip did not meet one of the allowable UL listings for power strips used in patient care areas.

Interview with the maintenance director at the time of the observation acknowledged the deficiency, and indicated he believed that the power strip was of the correct UL listing.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 99 10.2.3.6, CMS S&C: 14-46-LSC