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Based on observation and interview, the facility failed to maintain an elevator shaft per the requirements of:

2012 NFPA 101, 19.3.1, and 8.6

Findings include:

On 11/14/2018, during a tour of the facility from 8:00 am to 3:30 pm, the surveyor observed several unsealed penetrations in Elevator Shaft "D", between floors one and two.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to provide separation from a hazardous area per the requirements of:

42 CFR 483.90 (a) (1) (ii)
2012 NFPA 101, 19.3.2.1.3

Findings include:

On 11/14/2018, during a tour of the facility from 8:00 am to 3:30 pm, the surveyor observed the door to the Box Storage Room, located on Ground Floor (this room is used for the storage of combustible items and is over 50 sq. ft.) failed to positive latch.

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

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Based on observation and interview, the facility failed to maintain a magnetic locked egress door per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, 21.9

Findings include:

On 11/15/2018, during a tour of the facility from 8:00 am to 2:00 pm, the surveyor observed that the exit door on the Cath Lab Hall near the Electrical Room, failed to release from the magnetic lock under the activation of the fire alarm system.

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

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

2012 NFPA 101, 19.4.2, and 9.7.1.1(1)
2010 NFPA 13, 8.5.1, 8.5.4.2, 8.16.4.1, and 8.11.5.3

Findings include:

On 11/14/2018, during a tour of the facility from 8:00 am to 3:30 pm, the following was observed:
1. Four sections of lay-in ceiling were missing in the Cardiac Rehab A/H Room
2. Heat cord wrap around sprinkler pipe outside the Oxygen Storage Area
3. Sprinkler coverage was obstructed by an approximately 4'-0" HVAC duct in the Box Room on the Ground Floor

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

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

2012 NFPA 101, 19.4.2, and 9.7.5
2011 NFPA 25, 5.3.1.1.1.6, and 5.2.4.1

Findings include:

On 11/14/2018, during a tour of the facility from 8:00 am to 3:30 pm, the facility failed to provide documentation on the following:
1. The three dry sprinklers dated 2006 in the kitchen freezer had been replaced or a representative sample tested within 10 years of installation
2. The monthly inspections for the automatic sprinkler system wet riser gauges

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

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Based on observation and interview, the facility failed to maintain a corridor door per the requirements of:

2012 NFPA 101, 19.3.6.3.2 (2)

Findings include:

On 11/14/2018, during a tour of the facility from 8:00 am to 3:30 pm, in the Senior Behavioral Unit the surveyor observed the Laundry's Room's corridor door had approximately two 1/4" unsealed penetrations around the door handle (the door handle had been changed).

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain a smoke barrier 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

Findings include:

On 11/14/2018, during a tour of the facility from 8:00 am to 3:30 pm, the surveyor observed the following unsealed penetrations above the ceiling in the following smoke barriers:
1. An approximately two inch penetration around one green flex cord on the 1st floor at ICU
2. An approximately two inch penetration around one green flex cord and three blue wires on the 3rd floor at the Senior Behavioral Unit (SBU)

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

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Based on observation and interview, the facility failed to maintain the smoke barrier doors per the requirements of:

2012 NFPA 101, 19.3.7.8, and 8.5.4.1

Findings include:

On 11/14/2018, during a tour of the facility from 8:00 am to 3:30 pm, the surveyor observed the smoke barrier doors located on the 1st Floor at the Elevator Lobby and the West Stairs failed to fully close leaving a four inch gap during activation of the fire alarm system.

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

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Based on observation and interview, the facility failed to prohibit portable space heating devices per the requirements of:

2012 NFPA 101, 19.7.8

Findings include:

On 11/14/2018, during a tour of the facility from 8:00 am to 3:30 pm, the surveyor observed portable space heating devices in the following locations:
1. The Central Supply Office was plugged in and turned on
2. The Nurse Manager Office in Labor and Delivery located in a smoke compartment with sleeping rooms

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

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Based on review of documentation and interview, the facility failed to provide documentation of testing the diesel generators fuel per the requirements of:

2012 NFPA 99, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 1.3, 8.3.8

Findings include:

On 11/15/2018, during a tour of the facility from 8:00 am to 2:00 pm, the facility failed to provide documentation that a fuel quality test was performed within the past twelve months using tests approved by ASTM standards on all diesel fuel tanks.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to prohibit the use of extension cords per the requirements of:

2012 NFPA 99, 10.2.3.6, and 10.2.4
2011 NFPA 70, 400-8
S&C 14-46-LSC

On 11/14/2017, during a tour of the facility from 8:00 am to 3:30 pm, the surveyor observed a monitoring device plugged into a 25' extension cord in the MRI Equipment Room.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain the oxygen cylinders per the requirements of:

2012 NFPA 99, 11.6.2.3 (11)

Findings include:

On 11/13/2018, during a tour of the facility from 9:30 am to 6:00 pm, the surveyors observed unsecured oxygen cylinders in the following locations:
1. Several empty and full in the Outside Oxygen Storage Area near the Maintenance Shop


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2. One inside the Forms Room in the Material Management's Room
3. One in the Operating Rooms' (OR) Storage Room

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