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Based on observations, wall finishes do not meet minimum requirements. Noted locations are: Emergency Department (E.D.) Soiled Utility room, and the Old McCurdy Library. These conditions void the capability of meeting flame spread ratings.

Findings include:

While on tour August 24 at 9:00 a.m., the E.D. Utility room north wall has penetrations made from rolling carts impacting it.
On August 25 at 9:45 a.m., the McCurdy Library has disintegrating plaster wall finish, caused from water intrusion.

Based on observations, door assemblies are not in complete compliance as required. Sample noted areas are: Baby Place Soiled Utility room, Emergency Department (E.D.) Soiled Utility room, and the "A" building 1st floor Nursing Staff office. These conditions may allow smoke and/or fire to enter an exit corridor and make it untenable.

Findings include:

While on tour August 23 at 1:15 p.m., the Baby Place Utility room door was not capable of closing to a positive latch.
On August 24 at 9:00 a.m., the E.D. Utility room door is damaged, which negates its fire rating.
On August 25 at 11:15 a.m., the "A" building Nursing Staff office has an unused corridor door with paper boxes stacked against it.
Reference: NFPA 80--Standard for Fire Doors and Windows (1999 Edition)
15-1.1 "Where a door or window opening is no longer in use, the opening shall be filled with construction equivalent to that of the wall."

Based on an observation, a space in use for storage was not in accordance with approved Standards. The affected location is at the Cardiovascular Intensive Care Unit (CVICU) on the 2nd floor. This condition would allow smoke from a fire to enter adjoining spaces and endanger occupants.

Findings include:

While on tour August 25 at 10:00 a.m., a room identified as Clean Utility is being used for storing numerous combustible and flammable items. The room is over 100 square feet in size. It does not have a fire rated door, there is no automatic door closing device, and it appears the construction is not of a minimum one-hour fire rating.

Based on an observation, an area of the facility does not have a warning device. The affected location is in "B" building at the top of Stair #6. This condition would not allow notification to occupants, in the event of alarm activation.

Findings include:

While on tour August 24 at 3:15 p.m., within the mechanical rooms area, there was no audible/visible fire alarm device.

Based on observations, record review, and staff interview, the automatic sprinkler system was not fully maintained. Affected locations are: the Kitchen coolers and freezers, Receiving dock, and Dish Washing room, Main Hospital 4th floor south Nurse Station closet, the Dietary paper storage closet north of Stair #16, and the Basement Main Computer room. These conditions may impact capabilities of the suppression system in the event of a fire.

Findings include:

While on tour August 23 between 3:15 and 4:00 p.m., dry sprinklers in the coolers and freezers are dated 1993. This type of sprinkler is required to be tested or replaced every 10 years.
Reference: NFPA 25 Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
5.3.1.1.1.5 "Dry sprinklers that have been in service for 10 years shall be tested or replaced. If maintained and serviced, they shall be re-tested at 10 year intervals."
At the Receiving Dock, the anti-freeze system has not had the mixture solution tested for a specific gravity reading, as required annually.
In the Dish Washing room, ceiling sprinklers are heavily loaded with foreign matter.
On August 24 at 2:45 p.m., the 4th floor south Nurse Station closet has a ceiling sprinkler with foreign matter on it.
On August 25 between 10:30 and 11:00 a.m., in the Dietary paper storage closet, a light fixture is suspended from sprinkler piping, which is prohibited. In the Basement at the Main Computer room, 5 of 15 sprinklers are of the quick response type, and the remaining are standard response. Sprinklers with different response characteristics, are not permitted to be installed within the same compartment.

Based on an observation, ventilation of a space being used to store products of a Biohazardous nature was not provided. The affected area is in the basement opposite the Gift Gallery office. This condition may allow airborne pathogens and contaminants to enter adjoining spaces and endanger occupants.

Findings include:

While on tour August 25 at 1:15 p.m., the above described Biohazardous waste closet does not have any ventilation.
Exhaust ventilation direct to atmosphere is required (as examples) in Soiled Linen Storage and Handling, Laundry, Dish Washing, Decontamination or Soiled Workroom, Anesthesia Storage, Laboratories, Sterilizer equipment room, Toilets, Janitors Closets, Baths, Showers and Bed Pan rooms. The preceding list of occupancies is not all inclusive.

Based on an observation, commercial cooking equipment was not installed by approved methods. The affected area is the deep fat fryers in the Main Kitchen. This condition may allow a grease fire to become uncontrolled.

Findings include:

While on tour August 23 at 3:15 p.m., 2 of 2 fryers are not located so that the suppression system nozzles are directly centered over the wells. The fryers were relocated due to a roof rain water leak. Staff placed a container to catch the water on a table, that required moving the fryers away from the nozzles.
Reference: NFPA 96--Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (1998 Edition)
11.1.6 "Cooking equipment shall not be operated while its fire-extinguishing system or exhaust system is nonoperational or otherwise impaired."

Based on an observation, the Medical Gas manifolds (3 of 3) at the "Farm" compound do not meet required installation standards. This condition may cause a system rupture and discontinuation of needed gases in the facility, endangering users.

Findings include:

While on tour August 25 at 11:15 a.m., each of the gas manifold pressure relief vents, do not have a screened covering. The discharge ports shall have protection from foreign object entry.
Reference: NFPA 99 Health Care Facilities
5.1.3.4.6 Relief Valves
5.1.3.4.6.1 (8) " Have the discharge terminal turned down and screened to prevent the entry of rain, snow, or vermin."

Based on an observation, emergency lighting at a generator did not meet the required Standard. The affected location is the Generator for the Heart Center. This condition would leave the area in darkness in the event of a loss of normal power.

Findings include:

While on tour August 23 at 2:45 p.m., the generator housing existing emergency lighting devices, do not provide a minimum amount of lumens. Per staff interview, their emergency lighting power source is taken from the generator starting batteries.
Reference: NFPA 110--Standard for Emergency and Standby Power Systems
7.3.3 "The intensity of illumination in the separate building or room housing the EPS equipment for level 1 shall be 3.0 foot candles, unless otherwise specified by a requirement recognized by the authority having jurisdiction."

Based on observations, wall finishes do not meet minimum requirements. Noted locations are: Emergency Department (E.D.) Soiled Utility room, and the Old McCurdy Library. These conditions void the capability of meeting flame spread ratings.

Findings include:

While on tour August 24 at 9:00 a.m., the E.D. Utility room north wall has penetrations made from rolling carts impacting it.
On August 25 at 9:45 a.m., the McCurdy Library has disintegrating plaster wall finish, caused from water intrusion.

Based on observations, door assemblies are not in complete compliance as required. Sample noted areas are: Baby Place Soiled Utility room, Emergency Department (E.D.) Soiled Utility room, and the "A" building 1st floor Nursing Staff office. These conditions may allow smoke and/or fire to enter an exit corridor and make it untenable.

Findings include:

While on tour August 23 at 1:15 p.m., the Baby Place Utility room door was not capable of closing to a positive latch.
On August 24 at 9:00 a.m., the E.D. Utility room door is damaged, which negates its fire rating.
On August 25 at 11:15 a.m., the "A" building Nursing Staff office has an unused corridor door with paper boxes stacked against it.
Reference: NFPA 80--Standard for Fire Doors and Windows (1999 Edition)
15-1.1 "Where a door or window opening is no longer in use, the opening shall be filled with construction equivalent to that of the wall."

Based on an observation, a space in use for storage was not in accordance with approved Standards. The affected location is at the Cardiovascular Intensive Care Unit (CVICU) on the 2nd floor. This condition would allow smoke from a fire to enter adjoining spaces and endanger occupants.

Findings include:

While on tour August 25 at 10:00 a.m., a room identified as Clean Utility is being used for storing numerous combustible and flammable items. The room is over 100 square feet in size. It does not have a fire rated door, there is no automatic door closing device, and it appears the construction is not of a minimum one-hour fire rating.

Based on an observation, an area of the facility does not have a warning device. The affected location is in "B" building at the top of Stair #6. This condition would not allow notification to occupants, in the event of alarm activation.

Findings include:

While on tour August 24 at 3:15 p.m., within the mechanical rooms area, there was no audible/visible fire alarm device.

Based on observations, record review, and staff interview, the automatic sprinkler system was not fully maintained. Affected locations are: the Kitchen coolers and freezers, Receiving dock, and Dish Washing room, Main Hospital 4th floor south Nurse Station closet, the Dietary paper storage closet north of Stair #16, and the Basement Main Computer room. These conditions may impact capabilities of the suppression system in the event of a fire.

Findings include:

While on tour August 23 between 3:15 and 4:00 p.m., dry sprinklers in the coolers and freezers are dated 1993. This type of sprinkler is required to be tested or replaced every 10 years.
Reference: NFPA 25 Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
5.3.1.1.1.5 "Dry sprinklers that have been in service for 10 years shall be tested or replaced. If maintained and serviced, they shall be re-tested at 10 year intervals."
At the Receiving Dock, the anti-freeze system has not had the mixture solution tested for a specific gravity reading, as required annually.
In the Dish Washing room, ceiling sprinklers are heavily loaded with foreign matter.
On August 24 at 2:45 p.m., the 4th floor south Nurse Station closet has a ceiling sprinkler with foreign matter on it.
On August 25 between 10:30 and 11:00 a.m., in the Dietary paper storage closet, a light fixture is suspended from sprinkler piping, which is prohibited. In the Basement at the Main Computer room, 5 of 15 sprinklers are of the quick response type, and the remaining are standard response. Sprinklers with different response characteristics, are not permitted to be installed within the same compartment.

Based on an observation, ventilation of a space being used to store products of a Biohazardous nature was not provided. The affected area is in the basement opposite the Gift Gallery office. This condition may allow airborne pathogens and contaminants to enter adjoining spaces and endanger occupants.

Findings include:

While on tour August 25 at 1:15 p.m., the above described Biohazardous waste closet does not have any ventilation.
Exhaust ventilation direct to atmosphere is required (as examples) in Soiled Linen Storage and Handling, Laundry, Dish Washing, Decontamination or Soiled Workroom, Anesthesia Storage, Laboratories, Sterilizer equipment room, Toilets, Janitors Closets, Baths, Showers and Bed Pan rooms. The preceding list of occupancies is not all inclusive.

Based on an observation, commercial cooking equipment was not installed by approved methods. The affected area is the deep fat fryers in the Main Kitchen. This condition may allow a grease fire to become uncontrolled.

Findings include:

While on tour August 23 at 3:15 p.m., 2 of 2 fryers are not located so that the suppression system nozzles are directly centered over the wells. The fryers were relocated due to a roof rain water leak. Staff placed a container to catch the water on a table, that required moving the fryers away from the nozzles.
Reference: NFPA 96--Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (1998 Edition)
11.1.6 "Cooking equipment shall not be operated while its fire-extinguishing system or exhaust system is nonoperational or otherwise impaired."

Based on an observation, the Medical Gas manifolds (3 of 3) at the "Farm" compound do not meet required installation standards. This condition may cause a system rupture and discontinuation of needed gases in the facility, endangering users.

Findings include:

While on tour August 25 at 11:15 a.m., each of the gas manifold pressure relief vents, do not have a screened covering. The discharge ports shall have protection from foreign object entry.
Reference: NFPA 99 Health Care Facilities
5.1.3.4.6 Relief Valves
5.1.3.4.6.1 (8) " Have the discharge terminal turned down and screened to prevent the entry of rain, snow, or vermin."

Based on an observation, emergency lighting at a generator did not meet the required Standard. The affected location is the Generator for the Heart Center. This condition would leave the area in darkness in the event of a loss of normal power.

Findings include:

While on tour August 23 at 2:45 p.m., the generator housing existing emergency lighting devices, do not provide a minimum amount of lumens. Per staff interview, their emergency lighting power source is taken from the generator starting batteries.
Reference: NFPA 110--Standard for Emergency and Standby Power Systems
7.3.3 "The intensity of illumination in the separate building or room housing the EPS equipment for level 1 shall be 3.0 foot candles, unless otherwise specified by a requirement recognized by the authority having jurisdiction."