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The inspector observed, while accompanied by the Chief Diagnostic Service Officer during the hours of the inspection from 1:00 pm to 4:00 pm on 5/15/2017 that there were the following issues. Documentation was not available showing that fire doors were being inspected per the following requirements.
Fire-rated door assemblies and certain other doors in the means of egress shall be tested annually or per an accepted performance-based evaluation schedule approved by the authority having jurisdiction (AHJ) per NFPA 80, 2010, Ch. 5.2. A written record of the inspections and testing shall be signed and kept for inspection by the AHJ. NFPA101, 7.2.1.15

The inspector observed, while accompanied by the Chief Diagnostic Service Officer during the hours of the inspection from 1:00 pm to 4:00 pm on 5/15/2017 that there were the following issues. In the central supply breakdown room, there was a sprinkler head that was missing its escutcheon plate.
"Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of the listed sprinkler assembly." -NFPA 13, 2010, 6.2.7.2

The inspector observed, while accompanied by the Chief Diagnostic Service Officer during the hours of the inspection from 1:00 pm to 4:00 pm on 5/15/2017 that there were the following issues. In the exterior fire riser room the spare sprinkler head box was missing the required sprinkler wrench.
Red Head Box: "A supply of at least six spare sprinklers shall be maintained on the premises so that any sprinklers that have been operated or damaged in any way can be replaced promptly. A minimum of two sprinklers of each type and temperature rating should be provided. For protected facilities having 300 to 1000 sprinklers, no fewer than 12 sprinklers shall be provided, and for over 1000 sprinklers, no fewer than 24 sprinklers. One sprinkler wrench shall be kept in the cabinet for each sprinkler type." - NFPA 13, 2002: 6.2.9 and Appendix

The inspector observed, while accompanied by the Chief Diagnostic Service Officer during the hours of the inspection from 1:00 pm to 4:00 pm on 5/15/2017 that there were the following issues. The rated double doors located near the central supply area were missing an astragal, or the equivalent.
Rabbets, bevels, or astragals are at meeting edges, and stops are at the head and sides of door frames. Center mullions are prohibited in smoke barrier door openings 20.3.7.9, 20.3.7.10, 20.3.7.13, 20.3.7.14

The inspector observed, while accompanied by the Chief Diagnostic Service Officer during the hours of the inspection from 1:00 pm to 4:00 pm on 5/15/2017 that there were the following issues. The documentation failed to include the signatures of the participants in the fire drills.
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7

The inspector observed, while accompanied by the Chief Diagnostic Service Officer during the hours of the inspection from 1:00 pm to 4:00 pm on 5/15/2017 that there were the following issues. The cubicle curtains in the surgical area did not have a label indicating that they meet the following requirements.
"A copy of documentation indicating that draperies, curtains (including cubicle curtains), and other similar loosely hanging furnishings and decorations are flame-resistant as demonstrated by passing both the small and large-scale tests of NFPA 701, Standard Methods of Fire Tests for Flame-Resistant Textiles and Films, 1999 edition as required by NFPA 101, §18-7.5

The inspector observed, while accompanied by the Chief Diagnostic Service Officer during the hours of the inspection from 1:00 pm to 4:00 pm on 5/15/2017 that there were the following issues. In the fire riser room there were electrical panel boards that had stored materials blocking the required clear space in front of them.
"Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage." - NFPA 70, 2012, 110.26(E)

The inspector observed, while accompanied by the Chief Diagnostic Service Officer during the hours of the inspection from 1:00 pm to 4:00 pm on 5/15/2017 that there were the following issues. The electrical room located near admissions had an open j-box which exposed the wiring. Cover plates must be installed.

The inspector observed, while accompanied by the Chief Diagnostic Service Officer during the hours of the inspection from 1:00 pm to 4:00 pm on 5/15/2017 that there were the following issues.
In the medical gas cylinder storage area, the cylinders were not secured per the following requirements.
All medical gas cylinders (including E cylinders) must be physically supported, either in a stand or rack or chained or strapped to the wall. This requirement is intended to prevent mechanical hazards caused by a sudden release of gas if a tank falls over. Here, cylinders secured by chains shall not be secured more than two per section of chain.
In the medical gas storage area there were some copper gas lines that needed to be isolated from touching dissimilar metals (support brackets) per the following requirements.
"Copper medical gas piping shall be separated or insulated from dissimilar metal piping and supports to prevent bimetallic electrolyte action." - NFPA 99, 2002: 5.1.10.6.4

The inspector observed, while accompanied by the Chief Diagnostic Service Officer during the hours of the inspection from 1:00 pm to 4:00 pm on 5/15/2017 that there were the following issues. Documentation was not available showing that the following features of fire protection and fire loss prevention was being performed for the facility's operating rooms.
Periodic evaluations are made of hazards that could be encountered during surgical procedures, and fire prevention procedures are established.
Procedures are established for operating room emergencies including alarm activation, evacuation, equipment shutdown, and control operations. Emergency procedures include the control of chemical spills, and extinguishment of drapery, clothing and equipment fires. Training is provided to new OR personnel (including surgeons), continuing education is provided, incidents are reviewed monthly, and procedures are reviewed annually. 15.13 (NFPA 99)