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Based upon observation and interview, the facility failed to ensure that hazardous areas are protected by a fire barrier having a 1-hour fire-resistance rating or protected by an automatic extinguishing system in accordance with 8.7.1 as required by 19.3.2.1. This deficient practice could affect 8 patients and 5 staff in the event of a fire not being contained to the hazardous area.

Findings Include:
On 1/23/17 at approximately 12:04pm, Room 301 in ICU was observed to be used for storage of equipment. The door was not equipped with a self-closing device and had an inactive leaf that also was not equipped with latching hardware as required by Section 8.7.3.1.

On 1/23/17 at approximately 12:04pm, an interview with Maint #1 and Maint #2 revealed that the room was being used for storage and that the door was not properly equipped.

On 1/23/17 at approximately 2:45pm, the door to Mechanical Room 10 Nitrous Oxide Storage Room failed to self-close and latch when tested as required by Section 8.7.1.3.

On 1/23/17 at approximately 2:45pm, in an interview, Maintenance #1 confirmed that the door did not self-close and latch.

Based upon observation and interview, the facility failed to ensure that the fire alarm system was tested and maintained in accordance with an approved program complying with NFPA 70 and NFPA 72 and records were readily available as required by 19.3.4.1, 9.6.1.5, NFPA 70, and NFPA 72. This deficient practice could affect 1 occupant in the event of a fire not being detected in the incipient stage.

Findings Include:
On 1/23/17 at approximately 11:54am, the Elevator Machine Control Room smoke detector was observed to be covered by a plastic bag rendering it unable to operate in violation of NFPA 72, Section 14.3.4.

On 1/23/17 at approximately 11:54am, an interview with Maint #1 revealed that the bag was in place during routine maintenance and not removed. Maint #1 removed the bag at that time.

Based upon observation and interview, the facility failed to ensure that hospitals were required by construction type are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13 as required by 19.3.5.1 through 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, and 9.7.1.1(1). This deficient practice could affect 1 occupant in the event of a fire not being controlled in a sprinkler protected area.

Findings Include:
On 1/23/17 at approximately 12:45pm, the Attic Elevator Control Room was observed to not be equipped with a sprinkler head. The remainder of the attic is protected throughout by automatic sprinkler heads.

On 1/23/17 at approximately 12:45pm, an interview with Maint #1 confirmed that no sprinklers were installed in the room.

Based upon observation and interview, the facility failed to ensure that smoke barriers were constructed to a minimum 1/2-hour fire resistance rating in accordance with 8.5 as required by 19.3.7.3 and 8.6.7.1(1). This deficient practice could affect 20 patients in the event of smoke not being contained to the smoke compartment of origin.

Findings Include:
On 1/23/17 at approximately 1:20pm, penetration consisting of a wire in smoke barrier wall above the cross-corridor doors by Room 216 was observed to not be protected in accordance with Section 8.5.6.2.

On 1/23/17 at approximately 1:20pm, an interview with Maint #1 and Maint #2 confirmed that the wall was a smoke barrier and the penetrations were not protected with an approved firestop assembly.

Based upon observation and interview, the facility failed to ensure that ventilating or heat-producing equipment was installed in compliance with the provisions of Section 9.2.2. This deficient practice could affect 1 staff in the event of a fire in the dryer vent not being contained.

Findings Include:
On 1/23/17 at approximately 12:35pm, the 3 North Soiled Utility Room dryer vent was observed to be constructed of vinyl material and not of rigid sheet metal or other smooth, non-combustible material as required by Section 10.7.3.6 of NFPA 211.

On 1/23/17 at approximately 12:35pm, an interview with Maint #1 and Maint #2 confirmed that the dryer vent was not of non-combustible material.

Based upon observation and interview, the facility failed to ensure that electrical wiring was installed in accordance with NFPA 70 as required by Section 9.1.2. This deficient practice could affect 5 occupants in the event of an electrical fault causing a fire.

Findings Include:
On 1/23/17 at approximately 12:26pm, wiring above the fire doors for 3 South wing was observed to not have the cover plate in place as required by NFPA 70, Article 314.25.

On 1/23/17 at approximately 12:26pm, an interview with Maint #1 and Maint #2 confirmed that the wiring observed was active and not covered. Maint #1 replaced the cover at that time.

Based upon observation and interview, the facility failed to ensure that extension cords are placed in use only temporarily as required by 10.2.4 of NFPA 99 and 590.3(D) of NFPA 70. This deficient practice could affect 1 staff in the event of an electrical overload of the extension cord leading to a fire.

Findings Include:
On 1/23/17 at approximately 12:10pm, the refrigerator in Nourishment Room 3 West was observed to be connected to the electrical outlet with an extension cord. The refrigerator cord was capable of reaching the outlet.

On 1/23/17 at approximately 12:10pm, an interview with Maint #1 and Maint #2 confirmed that the cord was not in temporary use as permitted by Section 10.2.4 of NFPA 99. Maint #1 removed the cord and plugged the refrigerator into the outlet directly.