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Based on observation and staff interview, the facility failed to maintain exits in accordance with the 2012 NFPA 101, Life Safety Code. The deficiency affected 1 of 2 exits. The findings were:

Observation on 3/28/2018 at 11:40 AM at the entrance on the west side of the building revealed the stairs leading to the public way lacked handrails on either side. Failure to provide handrails as required could result in an injury or death from a fall. Interview with the head nurse at the time of the observation acknowledged the lack of handrails, and indicated she was unaware handrails were required on those particular stairs.

REF: 2012 NFPA 101 Sections: 39.2.1.1; 7.2.2.4.1.1

Based on observation and staff interview, the facility failed to maintain means of egress in accordance with the 2012 NFPA 101, Life Safety Code. The deficiency affected 2 of 16 smoke compartments. The findings were:

1. Observation on 3/29/2018 at 7:57 AM located adjacent to the bio-med rooms revealed a corridor that was congested with an exercise bike, patient bed, dolly, and a pallet full of boxes. Failure to maintain means of egress could result in injury or death during an emergency. Interview with the facility maintenance manager at the time of the observation acknowledged the congested corridor, and that he was aware of the requirement.

REF: 2012 NFPA 101, Sections: 19.2.1; 7.1.10.1; 4.5.3.2

2. Observation on 3/29/2018 at 7:17 AM located at the cancer suite exit sidewalk to the public way revealed a snow covered path that had not been shoveled. Failure to maintain means of egress could result in injury or death during an emergency. Interview with the facility maintenance manager at the time of the observation acknowledged the snow packed sidewalk, and that he was aware of the requirement.

REF: 2012 NFPA 101, Sections: 19.2.1; 7.1.10.1; 4.5.3.2

3. Observation on 3/29/2018 at 8:01 AM located in the exit stairwell adjacent to the bio-med area revealed access-controlled egress door that did not release until someone pushed the button to exit. Further observation revealed that there was no electronic sensor to unlock the door upon approach. Interview with the facility maintenance manager at the time of the observation acknowledged the lack of the sensor, and indicated he was unaware of the requirement.

REF: 2012 NFPA 101, Section: 7.2.1.6.2

Based on observation and staff interview the facility failed to maintain doors at hazardous area enclosures in accordance with the 2012 NFPA 101, Life Safety Code. The deficiency affected 5 of 5 floors. The findings were:

1. Observation on 3/28/2018 at 3:50 PM at storage room 1204 revealed that the door was provided with a self-closing device, but would not latch into the door frame. Further observation at storage rooms 1109, 1194, 1199, and storage rooms throughout the facility revealed doors with self closing devices that failed to latch. Failure to maintain doors as required could result in fire spread resulting in injury or death. Interview with the facility maintenance manager at the time of the observations acknowledged the doors failed to latch, and indicated he was aware of the requirement.

REF: 2012 NFPA101, Sections: 19.3.2.1.3; 7.2.1.8.2

2. Observation on 3/29/2018 at 8:12 AM located in the bio-med room revealed a door that was open to the corridor. Further observation revealed the door had a door closer, but only shut manually and was not interconnected to any emergency system. The room contained combustible storage and was larger than 100 square feet. Failure to maintain doors at hazardous enclosures as required could allow fire spread resulting in injury or death. Interview with the facility maintenance manager at the time of the observation acknowledged the deficiency, and indicated he was unaware of the requirement.

REF: 2012 NFPA 101 Sections: 19.3.2.1; 8.7.1.1
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Based on observation and staff interview, the facility failed to maintain emergency lighting in accordance with the 2012 NFPA 101, Life Safety Code. The deficiency affected 1 of 1 smoke compartments. The findings were:

Observation on 3/28/2018 at 11:30 AM in the waiting room revealed that the emergency lighting failed to operated when tested. Further observation revealed that all emergency lighting in the facility failed to operate when tested. Failure to maintain emergency lighting as required could delay egress resulting in injury or death. Interview with the head nurse at the time of the observation acknowledged the deficiency, and indicated she was unaware of the requirement.

REF: 2012 NFPA 101, Sections: 39.2.9.1; 7.9.1

Based on observation and staff interview, the facility failed to maintain hazardous area enclosures in accordance with the 2012 NFPA 101, Life Safety Code. The deficiency affected 1 of 16 smoke compartments. The findings were:

Observation on 3/29/2018 at 10:16 AM located in the Northwest corridor in smoke compartment B1 revealed shelving units containing large amounts of combustible material stored in the corridor. Failure to maintain hazardous enclosures as required could allow fire spread resulting in injury or death. Interview with the facility maintenance manager at the time of the observation acknowledged the deficiency, and indicated he was aware of the requirement.

REF: 2012 NFPA 101, Sections: 19.3.2.1; 8.7.1.1

Based on observation and staff interview, the facility failed to install fire detection systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 72, National Fire Alarm and Signaling Code. The deficiency affected 1 of 1 fire alarm panels. The findings were:

Observation on 3/28/2018 at 2:10 PM located in the imaging center adjacent to the entrance for the waiting area revealed a room with a fire alarm control panel. Further observation indicated no smoke detector in the room. Failure to provide fire detection systems as required could cause injury or death during an emergency. Interview with the facility maintenance manager at the time of the observation acknowledged the lack of a smoke detector in the room, and indicated he was aware of the requirement.

REF: 2012 NFPA 101, Section: 9.6
2010 NFPA 72, Section 10.15

Based on document review and staff interview the facility failed to maintain fire alarm systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 72, National Fire Alarm and Signaling Code. The deficiency affected 5 of 5 floors. The findings were:

Document review on 3/29/2018 at 4:28 PM revealed the facility could not verify that the required annual testing of audible and visible devices of the fire alarm system had been performed during the previous 12 months. Device test results are required to be itemized with the following information: device type, address, location, and test result. Failure to maintain fire alarm systems as required could cause system failure resulting in injury or death. Interview with the facility maintenance manager at the time of the observation acknowledged the deficiency, and indicated he was unaware of the requirement.

REF: 2012 NFPA 101, Sections: 19.3.4.1; 9.6.1.5
2010 NFPA 72, Sections: 14.4.5; 14.6.2.4

Based on observation and staff interview, the facility failed to maintain electric systems in accordance with the 2011 NFPA 70, National Electric Code. The deficiency affected 2 of 4 operating rooms. The findings were:

Observation on 3/28/2018 at 3:30 PM in operating room #2 revealed a PYXIS medical cabinet placed in front of an electrical panel. Further observation revealed another PYXIS medical cabinet in front of an electrical panel in operating room #4. Failure to maintain clearance around electrical panels as required for service and maintenance could result in injury or death. Interview with the facility maintenance manager at the time of the observation acknowledged the obstructed service clearance for the electrical panels, and indicated he was aware of the requirement.

REF: 2011 NFPA 70, Section 110-26

Based on observation and staff interview, the facility failed to maintain smoking regulations in accordance with the 2012 NFPA 101, Life Safety Code. The deficiency affected 1 of 8 entrances. The findings were:

Observation on 3/29/2018 at 7:03 AM at the entrance door from the parking garage to the hospital catwalk revealed the facility did not post a no smoking sign. Further observation revealed the catwalk to the building was fully ducted with HVAC equipment that entered into the main building. Interview with the facility maintenance manager at the time of the observation acknowledged the deficiency, and that he was aware of the requirement.

REF: 2012 NFPA 101 Section 19.7.4

Based on observation and staff interview, the facility failed to maintain electrical system in accordance with the 2012 NFPA 101, Life Safety Code. The deficiency affected 1 of 8 entrances. The findings were:

Observation on 3/29/2018 at 7:04 AM located at the entrance/exit doors from the main building to the catwalk revealed the cover for the electronic power assist device on top of the door was removed, with wires hanging down in the path of egress. Interview with the facility maintenance manager at the time of the observation indicated he was unaware the doors condition, but acknowledged the deficiency.

REF: 2012 NFPA 101, Section: 9.1.2