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Based on observation and interview the facility failed to ensure exit and directional signs were displayed in accordance with 7.10 as required.

Findings:

On 06/15/17 at 11:45 am the facility's designated east exit was observed to lead to an enclosed corridor which has no directional exit signage to indicate travel path of egress. The corridor has two doors and a pathway that leads into an adjoined building which houses administrative staff. Staff, patients and/ or visitors could confuse the path and enter into the adjoined building office area which does not have exit signage displayed. The facility is a one story existing occupancy with over 30 occupants and the line of exit travel is not obvious. The maintenance manager was asked if the east exit would or could be used by hospital patients or staff close to it and he stated yes. The maintenance manager stated he would install exit signage since the path of exit was not obvious.

Based on record review and interview the facility failed to ensure fire rated door assemblies were tested, inspected and maintained annualy as required in NFPA 80, Section 5.2.3, 5.3, and 5.4. Also, that hazardous area doors shall be self-closing or automatic-closing as required in Chapter 19.3.2.1.

Findings:

On 06/14/17 at 11:43 am hazardous areas, soiled utility closets and biohazard waste room doors were observed to not have self-closing hardware installed. The maintenance manager was asked why they were not installed, and he said the contractor must have missed those.

On 06/14/17 at 2:56 pm four penetrations were observed in the hazardous area server room.

Based on record review and interview the facility failed to ensure fire rated door assemblies were tested, inspected and maintained annualy as required in NFPA 80, Section 5.2.3, 5.3, and 5.4.

Findings:

On 06/14/17 at 10:03 am during record review the maintenance manager was asked for the annual documentation for the facility fire rated door assemblies testing, inspection and maintanance. He said they do not have fire rated door documentation and were not aware of the requirement.

Based on observation and interview the facility failed to ensure all electrical wiring and equipment were in accordance with the National Electrical Code NFPA 70 standards of compliance.

Findings:

On 06/14/17 at 3:24 pm a three receptacle multiplug was observed to be in use in the dining room of the facility.

On 06/14/17 at 3:28 pm a refrigerator was observed to be plugged into a power tap.

on 06/14/17 at 3:32 pm a Thermo Scientist located in the laboratory was observed to be plugged into a powertap.

The maintenance manager acknowledged the extension cord and the hydroculator plugged into a non-GFCI receptacle and stated he would remove them as soon as possible.

National Electrical Code, NFPA 70, NFPA 99- 2012 Edition, NFPA 101- 2012 Edition.

Based on observation and interview the facility failed to ensure space heaters in use in waking employee areas had a heating element that did not exceed 212 degrees Fahrenheit as required.

Findings:

On 06/15/17 at 12:10 pm three space heaters were observed in the facility. One was located in the doctor's dictation room, a second one was located at the front reception area, and the third one was in the business accounts receivable managers office. The facility maintenance manager stated the facility has a policy of no space heaters so they will be removed.

Based on record review and interview the facility failed to ensure completing building systems risk assessment for their medical gas systems as required in NFPA 99, 2012 Edition, Chapter 4.

Findings:

On 06/14/17 at 11:01 am during an interview the maintenance manager was asked for their building systems risk assessments to include medical gas systems. During record review the maintenance manager failed to provide the medical gas risk assessment.

Based on observation and interview the facility failed to ensure eletrical receptacles with i9n 6 feet of a countertop water source are GFCI receptacles.

Findings:

On 06/14/17 at 3:12 pm the hydroculator in the physical therapy department was observed to be plugged into a non-GCFI eletrical receptacle. Each of the facility patient rooms were observed to have a non-GFCI eletrical receptacle at the countertop to be within 6 feet of a water source and not. The facility electrical engineer stated those particular electrical receptacles should be GFCI.

Based on record review and interview the facility failed to ensure completing building systems risk assessments for the facility essential electric system as required in NFPA 99, 2012 Edition, Chapter 4.

Findings:

On 06/14/17 at 10:17 am during an interview the maintenance manager was asked for their building systems risk assessments to include their essential electric system categories. The maintenance manager failed to provide the essential electric system risk assessment.