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Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. Failure to provide exit signs to identify exit access can prevent occupants from reaching a required exit if the primary exit is blocked by a fire/smoke condition.

The finding is:

On 03/22/2022 at 10:48am accompanied by MP1 a corridor lacks exit signage leading to an exterior exit discharge. This condition does not comply with 19.2.4.4. Location observed: corridor adjacent to Hazardous Waste room and the Water Heater room contains a door leading directly outside.

Based upon observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material to block exiting.

The finding is:

On 03/22/2022 at 11:00am while in the company of MP1 a non-sprinkler protected storage room failed to be provided with 1-hour rated separation to comply with 19.3.2.1 due to a hole in the wall near the ceiling. Location observed: Hazardous Waste room.

Based on document review and staff interview record of inspection and cleaning activity is not documented for the kitchen grease hood and duct system. Failure to inspect and clean this system may affect the safety of patients, staff and visitors.

Findings include:

A. On 03/22/2022 at 9:50am in the company of MP1 and MP2 written documentation of the inspection and cleaning activities for the kitchen grease hood and duct system could not be provided. Only a sticker located on the hood was presented for this activity. NFPA 96, 2011, 11.6.15 is not complied with and the sticker does not qualify as a report of area cleaned or not and is not a certificate of inspection. Further there is no indication that 11.6 section is adhered to.

B. On 03/22/2022 at 9:45am in the company of MP1 and MP2, The inspection, testing and maintenance of the fire-extinguishing system of grease hood did not comply with NFPA 96, 2011, 11.2.5.1 for the provision of an inspection tag attached to the system. There is no provision for the monthly inspection and signature/initial by the installer/inspector of the system to further comply with NFPA 17 2009, 11.2.4/ NFPA 17A 2009, 7.2.5.

Based upon observation during the survey walk-thru, fire alarm systems are not installed in accordance with Code requirements. Failure to install the fire alarm system in accordance with Code requirements can result in disruption of the system to not function as required.

the finding is:

On 03/22/2022 at 11:30am while in the company of MP1, it was observed, at the Basement level storage room contained an electrical panel labeled emergency power. The fire alarm circuit was provided with a mechanical lock-on device but does not comply with NFPA 72-2010, 10.5.5.3 for protection against physical damage.
The panel housing the fire alarm circuit lacks a door, the door was observed laying to the side. The panel requires a door, and the door is missing from the installation which does not comply with NEC 70, 2011 110.

Based on observation, not all electrical receptacles are installed as required. this deficient practice could affect patients, staff, and visitors in the building because electrical power may not be available for use when required if they are not installed properly.

The finding is::

On 03/22/2022 at 9:15am while accompanied by MP1, observation determined that electrical receptacles, served by the emergency power system, are not labeled as to electrical panel and circuit as required by NFPA 70 2011 517-19(A). Location observed:Emergency Department Trauma and Treatment/Exam rooms.