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Based on observation and interview, the facility had alcohol-based hand rub dispensers located in an exit enclosure and there was a glove dispenser mounted on the wall in an exit enclosure. This is not in compliance with NFPA 101 (2012 edition), 8.7.3.2, 7.1.3.2.1, 19.3.2.6 and 7.1.4.

FINDINGS INCLUDE:

1. On 01/9/2017 at 12:45 PM, observation revealed on the lower level at the stair exit enclosure by the Board room, there was a a glove dispenser mounted on the wall and there was a alcohol-base hand-rub dispenser also mounted on the wall. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Facilities).

Based on observation and interview, the facility did not properly separate the nursing home from the hospital by a 2 hour wall. This in not in compliance with NFPA 101 (2012 edition), 19.1.1.4.2. to separate the nursing home from the hospital.

1. On 01/9/2017 at 2:52 PM, observation revealed on the lower level at the door from the kitchen into the nursing home, the double door did not close and latch when one of the doors was interrupted in the closing process. It was missing a door coordinator. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Facilities).

Based on observation and interview, the facility did not have the proper construction type. The ceiling was made of wood which makes the building a Type V (combustible (0,0,0) building. This is not in compliance with NFPA 101 (2012 edition), Table 19.1.6.1.

1. On 01/10/2017 at 10:10 AM, observation revealed on the lower level at the mechanical (air handler room) the ceiling in the old bathroom was made out of plywood. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Facilities).

Based on observation and interview, the facility did not have proper exit signage and an egress door could be locked and then be unable to unlock on the egress side. The observed situation was not compliant with NFPA 101 (2012 edition), 7.10.8.3, 7.10.2 and 7.2.1.5.3.

FINDINGS INCLUDE:

1. On 01/9/2017 at 2:22 PM, observation revealed on the lower level at the discharge of the Southwest stairs into the 'old' main entrance, that the exit signage was not correct. The door out of the stair into the main entrance is not an exit but it had an exit sign on it. A 'no exit' is required on the door. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Facilities).
2. On 01/9/2017 at 2:24 PM, observation revealed on the lower level at the discharge of the southwest stairs into the 'old' main entrance, that the exit signage was not correct. The door out of the stair to the outside is the exit, but there was no lit exit sign directing one to the exit when coming down the stairs. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Facilities).
3. On 1/10/2017 at 11:59 AM, observation revealed at room 114, that the door could be locked from the outside (corridor side) and there was no means on the inside of the room to unlock it. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Facilities)

Based on observation and interview, the facility did not maintain a corridor originally designed for 8 feet clear width. This is not permitted per NFPA 101 (2012 edition), 19.4.5.1.1.

1. On 01/10/2017 at 3:30 PM, observation revealed in the Emergency department that a 'insta-med machine' was in place in the corridor leading to the waiting area and to one of the exits out of the Emergcy Department Suite. The machine reduced the corridor width to approximately 6 feet. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Facilities).

Based on observation and interview, the facility did not enclose stairs with rated doors that latched. This observed situation was not compliant with NFPA 101 (2012 edition), 8.3.3.1

FINDINGS INCLUDE:

1. On 01/9/2017 at 1:15 PM, observation revealed on the lower level at the stair exit enclosure by the Board room, that one out of the 4 doors from the corridor into the exit enclosure did not latch. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Facilities).

Based on observation and interview, the facility did not enclose hazardous rooms with a smoke-tight room enclosure in a sprinkled smoke zone. This observed situation was not compliant with NFPA 101 (2012 edition), 19.3.2.1

FINDINGS INCLUDE:

1. On 01/9/2017 at 2:00 PM, observation revealed on the lower level at the door to the storage room near the Board Room that the door did not have a closer on it. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Facilities).

2. On 01/09/2017 at 3:23 PM, observation revealed on the upper level that the old nursery which was converted to a clean storage after 2003, did not have 1 hour rated walls and the door was not rated. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. The storage area included 2 1/2 carts of clean linens and other miscellaneous combustible material. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D, (Director of Facilities).

3. On 01/9/2017 at 3:40 PM, observation revealed on the upper level dirty utility room did not have a 45 minute labeled door. The room is in the 1994 building which required at the time of construction to be protected with one hour walls, 45 minute doors and be sprinklered. By definition a room being used as a soiled utility shall meet the previous requirements. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D, Director of Facilities.

4. On 1/10/2017 at 9 am, observation revealed on the lower level in the X ray storage, that the 1 hour rated walls had an access panel in the rated wall that was not rated. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D, Director of Facilities.

Based on observation and interview, the fire alarm pull station was located too high. This observed situation was not compliant with NFPA 72 (2010 ed.), 17.14.2.

FINDINGS INCLUDE:

1. On 01/10/2017 at 9:15 AM, observation revealed on the upper level at the stairs (between the 1952 and 1994 buildings) that the fire alarm pull station was located at 5 feet above the floor. It is required to be between 42 and 48 inches above the floor. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Facilities).

Based on record review and interview, the facility did not know how long the batteries of the fire alarm system would last. The situation was not compliant with NFPA 72 (2010 ed.), 10.5.6.

FINDINGS INCLUDE:

1. On 01/10/2017 at 9:30 AM, record review revealed that the annual test of the fire alarm indicated that it was unknown how long the battery backup would last for the fire alarm system. In addition, the record did not indicate that the fire system was on the life safety branch of the emergency system of the hospital. This condition was confirmed at the time of discovery by a concurrent interview with staff D (Director of Facilities).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (2010 edition) requirements, with no obstructions near the sprinkler. This situation was not compliant with NFPA 13 (2010 ed.), 8.6.5.2.1.1 (Table 8.6.5.2.1; NFPA 101 (2012 ed.), 19.3.5.1.

FINDINGS INCLUDE:

1. On 1/9/2017 at 4:02 PM, observation revealed on the upper floor in the bathroom of room 194, that the light fixture on the ceiling blocked the sprinkler coverage. The light fixture was located 6 inches away and 2 inches below the adjacent sprinkler deflector. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Facilities).

Based on observation and interview, the facility did not have corridor doors that were smoke tight. This observed situation was not compliant with NFPA 101 (2012 ed.), 19.3.6.3

FINDINGS INCLUDE:

1. On 1/9/2017 at 4:15 PM, observation revealed on the lower level at the two doors to the Medical Records Office, that the door had a 3/8 inch gap around the top and sides of the door. This type of door, with the same gap, exists directly above on the next floor above. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Facilities).

Based on observation and interview, the facility did not maintain a written evacuation plan that contained all the elements with staff trained on the extinguishment of fires. This observed situation was not compliant with NFPA 101 (2012 ed.), 19.7.1.8.

FINDINGS INCLUDE:

1. On 1/9/2017 at 3:00 PM, observation revealed on the lower level floor in the kitchen, that staff were not familiar with what class of fire extinguisher to use on cooking fires, such as a kitchen grease fire. During an interview, staff H (cook), could not identify the type of portable extinguisher, either the red Class ABC or stainless Class K type, to use on cooking fires. In addition, staff H (cook) did not know how the fire extinguish system worked on the cooking stove. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (Cook) and staff D, (Director of Facilities).

Based on observation and staff interview, the facility did store soiled linen and/or trash collection receptacles greater than 32 gallons capacity within any 64 square foot area. This does not conform to NFPA 101 - 2012 edition section 19.7.5.7.(2)

FINDINGS INCLUDE:

1. On 01/10/2017 at 2:00 PM, observation revealed on the upper level in the emergency department in exam room 8 and trauma room 2, that a 32 gallon soiled linen container and 32 gallon trash container where next to each other and together they exceeded 32 gallons in a 64 square foot area. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Facilities).

Based on record review of the testing of the medical gas system, a leaking oxygen zone valve was not replaced and the surgical department used it "for blowing off instruments in the surgery department by scope cleaning". This situation was not compliant with NFPA 101 (2012 ed.), 19.3.2.4. and this situation was not compliant with NFPA 101 (2012 ed.), 19.3.2.4. and NFPA 99, 2010 ed., 5.1.3.6.2.

FINDINGS INCLUDE:

1. On 01/10/2017 at 7:30 AM, a review of the annual medical gas testing report dated 12/27/2016 revealed that a leaking gas zone valve had been observed and had not yet been replaced in the surgery area. This condition was confirmed at the time of discovery by a concurrent interview with staff D (Director of Facilities).

2. On 01/10/2017 at 7:40 AM, a review of the annual medical gas testing report dated 12/27/2016 revealed that the surgical department used medical air "for blowing off instruments in the surgery department by scope cleaning". The hose and nose was still attached to the medical air, but Staff R, Director of Surgery, indicated that the technicians had been told to stop using medical air for cleaning. This condition was confirmed at the time of discovery by a concurrent interview with staff D (Director of Facilities) and Staff R, Director of Surgery.

Based on observation and interview, the facility had a power cord plugged into a wall outlet and went above the lay-in ceiling tile to a piece of equipment which was not visible from the floor below, and electrical boxes where not whole. This is not in compliance with NFPA 70.

FINDINGS INCLUDE:

1. On 01/9/2017 at 12:50 PM, observation revealed on the lower level in the stairwell next to the Board Room that a power cord was plugged into a wall outlet and then went above the lay-in ceiling tile to a piece of equipment which was not visible from the floor below. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Facilities).

2. On 01/9/2017 at 12:51 PM, observation revealed on the lower level in the stairwell next to the Board Room that a electrical box above the lay-in ceiling had several knock outs open and the wires inside were exposed. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Facilities).

Based on record review and interview, the facility did not provide testing of their emergency lights in the operating rooms. This is not compliant with NFPA 101 (2012 edition), 7.9.3.1.

1. On 01/10/2017 at 2:30 PM, record review revealed that in the Operating Rooms there was battery back up lights but there was no record that the batteries of the lights had been tested per NFPA 101, 7.9.3.1. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff D (Director of Facilities) and Staff R, (Director of Surgery).

Based on observation and interview, the facility did not have emergency power in Operating Room #2 which is a critical care location and two outside emergency generators did not have a remote stop switch as required by NFPA 110 (2010 edition), 5.6.5.6.

1. On 01/10/2017 at 2:22 PM, observation revealed in Operating Room #2 that there was no critical power available in the room. Nitrous Oxide is used in the room. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Facilities) and Staff R, (Director of Surgery).

2. On 01/10/2017 at 4:00 PM, observation revealed that the two outside emergency generators did not have a remote stop switch. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Director of Facilities).