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Based on observation and interview with staff, the facility failed to provide Exit access that is arranged so that exits are readily accessible at all times in accordance with section 7.1. The hospital was designed with Performance-Based Design that requires that any change in design for any part of the hospital ,the ownership or management of the building shall have a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions, Delayed Egress Locks (Magnetic Locks)7.2.1.6.1 Delayed-Egress Locks were not approved for application, locks were installed on double egress doors northeast of nurses station, delayed egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met. The doors did not unlock when force is applied for 15 seconds and there shall be an sign in accordance with 7.2.1.6.1. (d) PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS

1) Based on observation and interview with staff, the facility failed to install, test, and maintain a fire alarm system required for life safety in accordance with NFPA 70 National Electrical Code and NFPA 72. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

a) The combination fire and smoke damper that opens and closes on the activation of the fire alarm was not documented on the annual fire alarm inspection report, dated May 8, 2013.

b) The facility did not have a Directory of Points or had conducted an assessment of inspection that all devices were tested. No documentation of assessment, performance improvement, or evaluation of services provided by the Fire Alarm Contractor was made .

1) Based on observation and interview with staff, the facility failed to provide Heating, ventilating, and air conditioning that complies with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 9.2, 18.5.2.1, 18.5.2.2, NFPA 90A Findings include:

a) The manometers on the HVAC Air Handler were not being monitored

1) Based on observation and interview with staff, the facility failed to protect Anesthetizing locations that are protected in accordance with NFPA 99, Standard for Health Care Facilities: Findings include:

a) The Shutoff valves located for the endoscopy procedure rooms were located outside in the corridor. A shutoff valve shall be located immediately outside each Anesthetizing location and other vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency

b) The facility failed to provide a smoke evacuation system installed in accordance with NFPA chapter 12-4.1.2 and chapter 5-4.1 through 5-6.1 5-4.1* Ventilation-Anesthetizing Locations Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.

c) Based on observation and interview with staff, the facility failed to provide a program that includes periodic review of manufacturer's safety guidelines and usage requirements for electrosurgical units and similar appliances with all personnel concerned with the application and maintenance of electric appliances, including physicians, nurses, nurse aids, engineers, technicians, and orderlies, who shall be cognizant of the risks associated with their use. To achieve this end the hospital shall provide appropriate programs of continuing education for its personnel in accordance with Qualification and Training of Personnel NFPA 99 chapter 7-6.5.

1) Based on observation and interview with staff, the facility failed to provide Electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings include:

a) The facility did not provide written inspection procedures acceptable to the authority having jurisdiction, is continuously enforced by a designated individual at the hospital, to indicate that equipment-grounding conductors for 120-V, single-phase, 15- and 20 receptacles, equipment connected by cord and plug, and fixed electrical equipment are installed and maintained in accordance with NFPA 70, National Electrical Code, and applicable performance requirements of this chapter. The procedure shall include electrical continuity tests of all required equipment, grounding conductors, and their connections. The receptacles located in the Operating rooms were not on GFI or protected by an Line Isolation monitor.

Based on observation and interview with staff, the facility failed to provide Exit access that is arranged so that exits are readily accessible at all times in accordance with section 7.1. The hospital was designed with Performance-Based Design that requires that any change in design for any part of the hospital ,the ownership or management of the building shall have a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions, Delayed Egress Locks (Magnetic Locks)7.2.1.6.1 Delayed-Egress Locks were not approved for application, locks were installed on double egress doors northeast of nurses station, delayed egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met. The doors did not unlock when force is applied for 15 seconds and there shall be an sign in accordance with 7.2.1.6.1. (d) PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS

1) Based on observation and interview with staff, the facility failed to install, test, and maintain a fire alarm system required for life safety in accordance with NFPA 70 National Electrical Code and NFPA 72. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

a) The combination fire and smoke damper that opens and closes on the activation of the fire alarm was not documented on the annual fire alarm inspection report, dated May 8, 2013.

b) The facility did not have a Directory of Points or had conducted an assessment of inspection that all devices were tested. No documentation of assessment, performance improvement, or evaluation of services provided by the Fire Alarm Contractor was made .

1) Based on observation and interview with staff, the facility failed to provide Heating, ventilating, and air conditioning that complies with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 9.2, 18.5.2.1, 18.5.2.2, NFPA 90A Findings include:

a) The manometers on the HVAC Air Handler were not being monitored

1) Based on observation and interview with staff, the facility failed to protect Anesthetizing locations that are protected in accordance with NFPA 99, Standard for Health Care Facilities: Findings include:

a) The Shutoff valves located for the endoscopy procedure rooms were located outside in the corridor. A shutoff valve shall be located immediately outside each Anesthetizing location and other vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency

b) The facility failed to provide a smoke evacuation system installed in accordance with NFPA chapter 12-4.1.2 and chapter 5-4.1 through 5-6.1 5-4.1* Ventilation-Anesthetizing Locations Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.

c) Based on observation and interview with staff, the facility failed to provide a program that includes periodic review of manufacturer's safety guidelines and usage requirements for electrosurgical units and similar appliances with all personnel concerned with the application and maintenance of electric appliances, including physicians, nurses, nurse aids, engineers, technicians, and orderlies, who shall be cognizant of the risks associated with their use. To achieve this end the hospital shall provide appropriate programs of continuing education for its personnel in accordance with Qualification and Training of Personnel NFPA 99 chapter 7-6.5.

1) Based on observation and interview with staff, the facility failed to provide Electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings include:

a) The facility did not provide written inspection procedures acceptable to the authority having jurisdiction, is continuously enforced by a designated individual at the hospital, to indicate that equipment-grounding conductors for 120-V, single-phase, 15- and 20 receptacles, equipment connected by cord and plug, and fixed electrical equipment are installed and maintained in accordance with NFPA 70, National Electrical Code, and applicable performance requirements of this chapter. The procedure shall include electrical continuity tests of all required equipment, grounding conductors, and their connections. The receptacles located in the Operating rooms were not on GFI or protected by an Line Isolation monitor.