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Based on observation, document review and staff interview, emergency lighting is not tested and maintained. This deficient practice could affect patients, staff and visitors if failure to test and maintain the installed emergency lighting system can result in failure of the system to perform when needed during loss of normal power.

The finding is:

On 06/04/2019 at 2:00pm, while in the company of the DSS during document review battery powered emergency lighting annual testing for the 1.5 hour duration was not recorded to comply with 7.9.3.1.1 (3).

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 and block exiting.

The findings are:

A. On 06/04/2019 at 11:25am while accompanied by the DSS construction debris was observed within the Lower Level Mechanical room adjacent to Receiving. The accumulation of construction debris throughout the mechanical space inpeeds the efficiency of the air handling unit and access to it. This condition does not comply with 19.3.2.

B. On 06/04/2019 at 10:25am while accompanied by the DSS a hole in the ceiling of the Sterilizer "Boiler" room located on the Upper Level was observed. This condition does not provide a smoke tight enclosure to a sprinklered hazardous area which does not comply with 19.3.2.

C. On 06/04/2019 at 10:45am while accompanied by the DSS several holes in the required 2-hour fire rated wall located adjacent to ATS B-L-EQ-2243-A were observed. This condition does comply with 19.3.2 and does not provide a fire rated enclosure to a hazardous area. Location observed: Generator room.

Base on observation the facility failed to separate the kitchen grease duct from environmental ventilation ducts. This deficient practice could result in the uncontrolled spread of fire and products of combustion during a kitchen hood/duct fire event, which may affect patients, staff and visitors.

The findings are:

A. On 06/04/2019 at 9:35am while accompanied by the DSS, the kitchen grease duct located within the rooftop mechanical penthouse was observed to lack close access for cleaning purposes. The grease duct appears to lack the following:

1. Existing access panel located near the bottom of the duct's vertical run lacks a U.L. listed label for this type of installation to comply with NFPA 96 2011, 7.1.5, 7.3 and ANSI/UL1978.

2. The same access panel referenced in comment A.1 lacks signage reading "access panel do not obstruct" to comply with NFPA 96 2011, 7.1.6.

3. The grease duct's change in direction and horizontal run lacks access for cleaning to comply with NFPA 96, 2011, 7.3.1

B. On 06/04/2019 at 9:45am while accompanied by the DSS, the kitchen grease duct appeared to be interconnected to the galvanized exhaust duct used by airhandlers which does not comply with NFPA 96 2011, 7.1.3.

C. On 06/04/2019 at 10:00am while accompanied by the DSS, the kitchen grease duct which is interconnected to galvanized exhaust duct does not comply with NFPA 96 2011, 7.1.2 for a duct leading directly to the exterior.

Based upon direct observation, corridor doors are not smoke tight. Failure to provide smoke tight corridor doors may compromise the effectiveness of the door to remain closed to prevent the passage of smoke from one side of the corridor wall to the other.

The finding is:

On 06/04/2019 at 11:00am while in the company of the DSS, a corridor door was observed which did not provide a smoke tight installation to comply with 19.3.6.3.1. Location observed: Upper Level Stress Room corridor door contains a hole.

Based on an observation, the facility failed to properly manage and maintain the existing Air-conditioning and Ventilating Systems. This deficient practice could affect patients, staff and visitors if components of the system build up with dust in quantities deemed hazardous which may contribute to the systems failure to limit the spread of fire/smoke during a fire event.

The findings are:

A. On 06/04/2019 at 2:45pm while accompanied by the DSS, review of the fire and smoke damper inspection dated 03/26/2019 contained no evidence to indicate all deficiencies cited in that inspection have been corrected to comply with NFPA 80 2010, 19.5.3 for fire dampers and combination fire/smoke dampers. Although work order\invoice information was reviewed to indicate that a portion of the cited damper deficiencies had been addressed, others could not be confirmed to be corrected. Those on the list which remain unresolved due to lack of access panel, or the damper was observed to be closed or needing repair, for example: "FD109-access door needed".

B. On 06/04/2019 at 9:20am while accompanied by the DSS, installed access panels located at ductwork, for the inspection and maintenance of fire dampers, lack labeling to identify if the damper is abandoned or active. This condition does not comply with NFPA 80-2010, 19.2.3. Example location: Mechanical Penthouse

Based upon direct observation during the survey walk-thru, electrical systems are not maintained in conformance with Code requirements. Failure to maintain the electrical system can lead to confusion when selected components require shut-down for maintenance and power circuits cannot be accurately identified.

Findings include:

A. On 06/04/2019 at 1:20pm while accompanied by the DSS, during staff interview and observation the height of the exterior bulk oxygen tank was not determined in order to require grounding of that system. However, the bonding to building steel for the med gas piping, and water piping systems within the building, were not located. Staff were not able to confirm compliance with NFPA 99-2012, 5.1 and NFPA 70-2011, 517 for a completely bonded system for healthcare.

B. On 06/04/2019 at 10:15am while accompanied by the DSS, during staff interview and observation an emergency calling device was not installed to comply with NFPA 99, 2012, 7.4.3.1.5.1. Location observed Main Level Patient Bath (located across from room #203).