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Based on observation and staff interview, the facility failed to maintain self-closing corridor doors in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain self-closing corridor doors as required could delay or prevent egress resulting in injury or death during an emergency. The deficiency affected one (1) of numerous self-closing corridor doors within the facility. The findings were:

Observation on 3/5/2020 at 8:45 AM at the administration office door (room 4616) revealed the rated smoke door with self closing device was held open with a door stop.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101: Section 7.2.1.8.1

Based on observation and staff interview, the facility failed to provide a self-closing door that latched in accordance with the 2012 NFPA 101, Life Safety Code. Failure to provide a latching self-closing door as required could delay egress resulting in injury or death during an emergency. The deficiency affected three (3) of numerous doors within the facility. The findings were:

Observation on 3/5/2020 at 1:24 PM in the 2nd floor waiting room in the atrium revealed a door that failed to latch when released with no initial movement. Additional observation found the doors adjacent to room 2107 and the soiled holding operating room also failed to latch when tested.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101: Section 7.2.1.8.2
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Based on observation and staff interview, the facility failed to maintain hazardous areas in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain hazardous areas as required could delay egress resulting in injury or death during an emergency. The deficiency affected one (1) of three (3) stairwells in the facility. The findings were:

Observation on 3/5/2020 at 10:03 AM in stairwell B (stairs by elevator) revealed combustibles stored in between the 4th floor and roof landing.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101: Section 19.2.2.3; 7.2.2.1.1; 7.1.3.2.1 (9)(c)(ii)
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Based on observation and staff interview, the facility failed to provide emergency lighting in accordance with the 2010 NFPA 110, Standard for Emergency and Standby Power Systems. Failure to provide emergency lighting as required could result in injury or death during an emergency. The deficiency affected three (3) of three (3) battery back-up lights in the facility. The findings were:

Observation on 3/5/2020 at 1:51 PM in the emergency generator transfer switch room revealed that the battery powered light failed when put into test mode. In an emergency where the transfer switch failed to operate the battery powered emergency lighting would provide illumination at the transfer switch. Further observation found that the remaining battery back-up lights throughout the facility failed when tested. Upon review of the maintenance records, no inspection had been carried out within the previous year.

Interview with the facility maintenance manager at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2010 NFPA 110, Section: 7.3.1
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Based on observation and staff interview, the facility failed to maintain exit signs in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain exit signs as required could delay egress resulting in injury or death during an emergency. The deficiency affected one (1) of numerous exits signs in the facility. The findings were:

Observation on 3/5/2020 at 9:45 AM of the exit sign at the corridor door by rooms 4505 and 4507 was missing.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101: Section 19.2.10.1; 7.10
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Based on observation and staff interview, the facility failed to maintain hazardous areas in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain hazardous areas as required could delay egress resulting in injury or death during an emergency. The deficiency affected one (1) of numerous rooms in the facility. The findings were:

Observation on 3/5/2020 at 9:14 AM in room 4606 revealed an excessive amount of paper product scraps, cardboard boxes and other combustibles in a non-rated room. The room was sprinkled, but doors were not self-closing.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101: Section 19.3.2
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Based on observation and staff interview, the facility failed to maintain fire alarm systems in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain fire detection systems as required could result in injury or death during an emergency. The deficiency affected one (1) of numerous testing requirements for the fire alarm system. The findings were:

Observation on 3/5/2020 at 1:51 PM at the fire annunciator panel revealed that the Underwriter's Laboratory (UL) certification for the fire alarm expired on March 31, 2019. Further observation revealed that a current certification was not in the fire alarm system documentation.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 19.3.4.1; 9.6.1.3
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Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the 2010 NFPA 13, Standard for the Installation of Sprinklers. Failure to properly maintain the fire sprinkler system could result in injury or death in the event of a fire. The deficiency was in one (1) of numerous rooms. The findings were:

Observation on 3/5/2020 at 9:21 AM in room 4605 revealed an obstruction directly next to the sprinkler head. The obstruction was an air deflector, with a height of approximately 2 inches, within 3" to sprinkler head.

Interview with the maintenance director at the time of observations acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2010 NFPA 13, Sections: 8.6.5

Based on observation and staff interview, the facility failed to to maintain the fire sprinkler system in accordance with the 2010 NFPA 13, Standard for the Installation of Sprinklers. Failure to properly maintain the fire sprinkler system could result in injury or death in the event of a fire. The deficiency was throughout the facility. The findings were:

Observation on 3/5/2020 at 9:31 AM in room 4509 revealed fire sprinkler heads with a missing escutcheon plate, exposing the annular space. Further observation revealed missing escutcheon plates in room 4108 and throughout the remainder of the facility.

Interview with the maintenance director at the time of observations acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2010 NFPA 13, Sections: 6.2.7.1

Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the 2010 NFPA 13, Standard for the Installation of Sprinklers. Failure to properly maintain the fire sprinkler system could result in injury or death in the event of a fire. The deficiency was in one (1) of numerous rooms. The findings were:

Observation on 3/5/2020 at 10:13 AM in the IT (suite 4200) storage area revealed fire sprinkler escutcheon plate had been soldered back together, making the cover plate no longer a part of the listed assembly, and potentially preventing the cover plate and sprinkler from working correctly in the event of a fire.

Interview with the maintenance director at the time of observations acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2010 NFPA 13, Sections: 6.2.7.3
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Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the 2011 NFPA 25, Standard for the Installation of Sprinklers. Failure to properly maintain the fire sprinkler system could result in injury or death in the event of a fire. The deficiency was in one (1) of numerous rooms. The findings were:

Observation on 3/5/2020 at 9:31 AM in room 4605 revealed a fire sprinkler head had been painted.

Interview with the maintenance director at the time of observations acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2011 NFPA 25, Section: 5.2.1

Based on observation and staff interview, the facility failed to to maintain the fire sprinkler system in accordance with the 2011 NFPA 25, Standard for the Installation of Sprinklers. Failure to properly maintain the fire sprinkler system could result in injury or death in the event of a fire. The deficiency was for one (1) of numerous rooms. The findings were:

Observation on 3/5/2020 at 1:33 PM in the main mechanical room revealed the fire sprinkler gauges have not been replaced or recalibrated in greater than 5 years.

Interview with the maintenance director at the time of observations acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2011 NFPA 25, Section: 5.2.1
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Based on observation and staff interview, the facility failed to to maintain the fire sprinkler system in accordance with the 2011 NFPA 25, Standard for the Installation of Sprinklers. Failure to properly maintain the fire sprinkler system could result in injury or death in the event of a fire. The deficiency was for one (1) of numerous rooms. The findings were:

Observation on 3/6/2020 between 8:15 AM and 9:15 AM at the building fire riser revealed that fire sprinkler gauges have not been replaced or recalibrated in greater than 5 years.

Interview with the maintenance director at the time of the observations acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2011 NFPA 25, Section: 5.2.1
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Based on observation and staff interview, the facility failed to conduct fire extinguisher inspections in accordance with the 2010 NFPA 10, Standard for Portable Fire Extinguishers. Failure to conduct fire extinguisher inspections as required may lead to injury or death during an emergency. The deficiencies affected all fire extinguishers in the facility. The findings were:

Observation on 3/5/2020 at 10:00 AM in the 4th floor elevator lobby found the fire extinguisher had not been inspected since June of 2019. Further observation found all fire extinguishers throughout the facility in the same state. Upon review of the records, no inspection had been completed since June of 2019.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2010 NFPA 10: Sections 7.2.1; 7.2.4

Based on observation and staff interview, the facility failed to provide access to fire extinguishers in accordance with the 2010 NFPA 10, Standard for Portable Fire Extinguishers and the 2012 NFPA 101, Life Safety Code. Failure to provide access to a fire extinguisher as required may lead to injury or death during an emergency. The deficiencies affected two (2) of numerous fire extinguishers in the facility. The findings were:

Observation on 3/5/2020 at 11:39 AM at the OB/Nursery operating room exterior found the fire extinguisher obstructed from view and access due to a cart being placed in front of it. Further observation found the fire extinguisher in the kitchen obstructed by several garbage cans.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 9.7.4.1
2010 NFPA 10: Sections 6.1.3.1; 6.1.3.3.1
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Based on observation and staff interview, the facility failed to conduct fire extinguisher inspections in accordance with the 2010 NFPA 10, Standard for Portable Fire Extinguishers. Failure to conduct fire extinguisher inspections as required may lead to injury or death during an emergency. The deficiency affected all fire extinguishers in the facility. The findings were:

Observation on 3/6/2020 between 8:15 AM and 9:15 AM found the fire extinguisher in the lobby had not been inspected since June of 2019. Further observation found all fire extinguishers throughout the facility in the same state. Upon review of the records no inspection had been completed since June of 2019.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 10: Sections 7.2.1; 7.2.4

Based on observation and staff interview, the facility failed to use portable space-heaters with low temperature heating elements in accordance with the 2012 NFPA, Life Safety Code. Failure to use approved portable space-heaters as required could lead to a fire resulting in injury or death. The deficiencies were found throughout the first floor of the facility. The findings were:

Observation on 5/6/2020 starting at 5:38 PM in the first floor reception/information desk revealed portable space heaters that were found to contain heating elements that when turned on would exceed 212°F.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section 19.7.8
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Based on observation and staff interview, the facility failed to provide ground-fault circuit interrupting receptacles in accordance with the 2012 NFPA 99, Health Care Facilities. Failure to provide ground fault circuit interrupting (GFCI) receptacles as required may lead to injury or death. The deficiency affected two (2) of numerous rooms in the facility. The findings were:

Observation on 3/5/2020 at 11:56 AM in the nursery nurses station sink used for the bathing of newborns found the emergency power outlets next to the sink to not be equipped with GFCI receptacles.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA Section 9.1.2
2011 NFPA 70 Section 210.8
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Based on observation and staff interview, the facility failed to maintain electrical equipment in accordance with the 2012 NFPA 101, Life Safety Code and 2011 NFPA 70, National Electrical Code. Failure to maintain electrical equipment as required could result in injury or death. The deficiency affected two (2) of numerous electrical panels in the facility. The findings were:

Observation on 3/5/2020 at 11:38 AM at the OB/Nursery operating room exterior revealed an obstructions in front of an electrical panel. A working space of three (3) feet in front of the panel is to be maintained. Further observation in the kitchen revealed a second panel with obstructions located within three (3) feet.

Interview with the maintenance director at time of observation acknowledged the obstructions, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section 9.1.2
2011 NFPA 70, Section 110.26
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Based on observation and staff interview, the facility failed to maintain electrical equipment in accordance with the 2012 NFPA 101, Life Safety Code and 2011 NFPA 70, National Electrical Code. Failure to maintain electrical equipment as required could result in injury or death. The deficiency affected three (3) of numerous rooms in the facility. The findings were:

Observation on 3/5/2020 at 9:38 AM in room 4319 revealed a power strip plugged into another power strip creating a daisy chain. Additional observations found daisy chained power strips in rooms 1403 and at the registration/admission desk on the 2nd floor.

Interview with the maintenance director at time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section 9.1.2
2011 NFPA 70, Section 400.8

Based on observation and staff interview, the facility failed to maintain electrical equipment in accordance with the 2012 NFPA 101, Life Safety Code and 2011 NFPA 70, National Electrical Code. Failure to maintain electrical equipment as required could result in injury or death during an emergency. The deficiency affected four (4) of numerous areas in the facility. The findings were:

Observation on 3/5/2020 at 10:38 AM, revealed that room 3304 had an extension cord. Further observation found extension cords in rooms 2104, 2131 (two extension cords), and outside by the BBQ cooking units.

Interview with the maintenance director at time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section 9.1.2
2011 NFPA 70, Section 400.8
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Based on observation and staff interview, the facility failed to store oxygen in an enclosure in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to enclose excess oxygen as required may contribute to the acceleration of a fire, and result in injury or death. The deficiency affected one (1) of multiple smoke compartments in the facility. The findings were:

Observation on 3/5/2020 at 11:38 AM at the OB/Nursery operating room exterior found 14 bottles of oxygen listed as 25 cubic feet each, for a total of 350 cubic feet, secured on a cart.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 99: Sections 11.3.2

Based on observation and staff interview, the facility failed to secure carbon dioxide cylinders in use or storage in accordance with the 2010 NFPA 55, Compressed Gases and Cryogenic Fluids Code. Failure to secure compressed gas cylinders as required may result in injury or death. The deficiency affected one (1) of numerous rooms in the facility. The findings were:

Observation on 3/5/2020 at 6:33 PM in the main kitchen pantry found 3 bottles of carbon dioxide unsecured on the floor, with one of the bottles used to prop open the door between the kitchen and the pantry.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2010 NFPA 55: Sections 7.1.8.4