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Based on observation, the facility failed to provide an approved method to ensure appliances that are protected under the hood, if they are moved, they are returned to the approved design location per the requirements of:

2012 NFPA 101, 19.3.2.5.1, and 9.2.3
2011 NFPA 96, 12.1.2.2, 12.1.2.3, 12.1.2.3.1, and 6.2.4.1

This deficiency affects the Kitchen.

Findings include:

During a tour of the facility, the surveyor observed the following:
1. The facility failed to provide an approved method to ensure appliances that are protected under the hood, if they are moved, they are returned to the approved design location.
2. The grease drip tray was missing from the center of the hood system.

A member of maintenance staff was present when this deficiency was identified.

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Based on observation and review of documentation, the facility failed to maintain the fire alarm system per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, Table 14.3.1(9)(h), and 21.9

This deficiency affects the fire alarm system.

Findings include:

During a review of documentation and tour of the facility, the surveyor observed the following:

1. The facility failed to provide documentation of conducting semi-annual visual inspections on the smoke detectors within the past 12 months

2. The Rear Exit of the Outpatient Building full time locked egress double doors failed to automatically unlock upon loss of power to the fire alarm system

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to provide information on the automatic sprinkler system per the requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.1.1(1)
2010 NFPA 13, 7.6.1.4, 7.6.1.5, TIA 10-2, and 8.6.4.1.1.1

This deficiency affects automatic sprinkler system.

Findings include:

During a tour of the facility, the surveyor observed the following:

A. The facility failed to provide the following:

1. The facility failed to have a placard mounted on the wet system riser feeding the remote antifreeze systems. This placard shall indicate the following:

a. The number of all remote antifreeze systems supplied by that riser

b. The location of all remote antifreeze systems supplied by that riser

2. The facility failed to have a placard mounted on the main valves of the antifreeze systems. This placard shall indicate the following:

a. The manufacture type and brand of the antifreeze solution

b. The volume of anti-freeze solution used in the system

B. Insulation from HVAC ductwork was sagging down and resting on top of an upright sprinkler in an unused Mechanical Room on the 2nd Floor.

A member of the maintenance staff was present when this deficiency was identified.

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45258

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Based on observation and review of documentation, the facility failed to maintain the automatic sprinkler system per requirements of:

2012 NFPA 101, 19.3.5.1, 9.7.5, and 9.7.8
2011 NFPA 25, 5.3.4, TIA 11-1, TIA 11-2, TIA 11-3, TIA 11-4, 5.1.1.2, Table 5.1.1.2, and 5.3.1.1,1.6

This deficiency affects the automatic sprinkler system.

Findings include:

During a tour of the facility, the surveyor observed the following:

1. The facility failed to provide documentation indicating the existing antifreeze solution had been drained and replaced with the new required premixed antifreeze solution during the last annual inspectionand testing conducted on

2. The facility failed to provide documentation that the 2001 fast-response sprinklers found randomly throughout the facility had been replaced or a representative sample tested within 20 years of installation

3. The surveyor could not verify the date of installation for the single dry head automatic sprinkler, located outside the back kitchen door, for replacement. It was connected to a 2010 standard head, inside the building.

A member of the maintenance staff was present when this deficiency was identified.

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45258

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Based on observation, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3, 8.5.1, and 8.5.6.2

This deficiency affects 2 of 6 smoke barriers.

Findings include:

During a tour of the facility, the surveyor observed the following unsealed penetrations in the following smoke barriers:

1. Multiple electrical conduits and cables were not sealed in the smoke barrier between Detox and Med Surgery

2. A 1/2" pipe with red, white, orange, black and two blue wires, was not sealed at the smoke barrier between the Lobby and the Dining Room

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the permitted smoking area per the requirements of:

2012 NFPA 101, 19.7.4 (6)

This deficiency affects the designated smoking area.

Findings include:

During a tour of the facility, the surveyor observed the designated smoking area's metal container with self-closing cover device contained other things, besides cigarette butts and ashes, such as a plastic bag and styrofoam cups.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and review of documentation, the facility failed to maintain the line isolation monitors (LIM) per the requirements of:

2012 NFPA 99, 6.3.4.1.4, and 6.3.2.6.3.6

This deficiency affects 2 of 2 LIMs.

Findings include:

During a tour of the facility:

1. The facility failed to provide documentation of monthly testing of the LIMs

2. When the surveyor operated the test switch for the LIM for Operation Room 2 the following deficiencies were observed:

a. The signal lamp failed to operate

b. The audible warning failed to operate

c. The meter failed to operate

A member of maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to provide a remote manual stop station for the emergency generator per the requirements of:

2012 NFPA 99, 6.4.4.1.1.3
2010 NFPA 110, 5.6.5.6, and 5.6.5.6.1

This deficiency affects the generator.

Findings include:

During a tour of the facility, the facility failed to provide a labeled, remote manual stop station for the 2002 emergency generator. This was required when this generator was installed, see 1999 NFPA 110, 3-5.5.6.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the electrical equipment per the requirements of:

2012 NFPA 99, 10.2.3.6, and 10.2.4
2011 NFPA 70, 400.8
S&C: 14-46-LCS

This deficiency affects the Break Room in the Emergency Dept.

Findings include:

During a tour of the facility, the surveyor observed a refrigerator and an ice machine plugged into a power strip in the Emergency Departments's Break Room.

A member of the maintenance staff was present when this deficiency was identified.

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