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Based on observation and staff interview, the facility did not ensure that sprinkler protection is installed and maintained in all areas as required per NFPA 101 Life Safety Code (2012 edition) 39.3, and NFPA 13 (2010 edition). These conditions could affect an undetermined number of outpatients, staff, and visitors.

Findings include:

On 03-22-2017 between 8:00 a.m. and 9:30a.m., observation revealed that an escutcheon ring was missing from a sprinkler head located in the following rooms: Blood Draw Room (1), X-ray Room (2), Diagnostic Radiology Room (1), and area near the back double doors (1). The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff "B".

Based on observation and staff interview, the facility did not ensure that Alcohol Based Hand Rub (ABHR) dispensers are installed a safe distance from an ignition source in accordance with NFPA 101-Life Safety Code, LSC 19.3.2.6. This condition could affect an undetermined number of outpatients, staff, and visitors within the Emergency Department Suite.

Findings include:

On 03-21-2017 at 11:09 a.m., observation revealed that a wall mounted Alcohol Based Hand Rub (ABHR) dispenser was installed approximately one inch above a light switch in Emergency Room 1613, within the Emergency Department Suite. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff "B".

Based on observation and staff interview, the facility did not ensure that the smoke detectors, for the fire alarm system, are installed per NFPA 101 (2012 edition), 9.6 and NFPA 72 (2010 edition), 17.7.4.1. This condition could affect all 9 inpatients, staff, and visitors.

Findings include:

On 03-21-2017 at 1:16 p.m., observation revealed that a smoke detector was installed within 36 " of an air supply diffuser in Lounge #1403. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff "B". The condition was corrected on the same day by the end of the tour by hospital maintenance staff.

Based on observation and staff interview, the facility did not ensure that sprinkler protection is installed in all areas as required per NFPA 101 Life Safety Code (2012 edition) 19.3.5 & 9.7.1, and NFPA 13 (2010 edition). This condition could affect an undetermined number of staff and visitors.

Findings include:

On 03-21-2017 at 11:38 a.m., observation revealed that the area below the overhead door of Radiology Storage Room # 1244 was not also protected by a fire sprinkler head, when the overhead door is in the open position. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff "B".

Based on observation and staff interview, the facility did not ensure that the automatic sprinkler fire suppression system is properly maintained in accordance with NFPA 101 (2012 edition) 9.7.5, and NFPA 25 (2011 edition), 4.7, 5.2.1, and 5.3.2.1. These conditions could affect all 9 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 03-21-2017 at 1:49 p.m., observation revealed that the sprinkler head, located in Dialysis Work Room # 1462 had a foreign material, similar to taping compound, on the deflector & bulb. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff "B".

2. On 03-21-2017 at 2:07 p.m., observation revealed that approximately 120 sq. ft. of the 460 sq. ft. Mechanical Equipment Room # 1467 was not protected by a fire sprinkler head. This area is where a floor mounted HVAC air handler Unit had been previously removed. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff "B".

3. On 03-21-2017 at 2:23 p.m., observation revealed that an escutcheon ring was missing from a sprinkler head located in the Physical Therapy Office # 1442. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff "B".

Based on observation and staff interview, the facility did not ensure that the fire resistance rating and smoke tightness of smoke barrier walls with sealed penetrations were maintained in accordance with NFPA 101 (2012 edition), 19.3.7.3 and 8.5. This condition could affect all 9 inpatients and an undetermined number of staff and visitors.

Findings include:

On 03-21-2017 at 9:18 a.m., observation revealed that the 1 hour fire rated smoke barrier wall, separating Lab #1179 from corridor #1183, was penetrated by an 8" round ventilation duct without the annular space around the ductwork being properly sealed in accordance with approved materials and methods. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff "B". The condition was corrected on the same day by the end of the tour by hospital maintenance staff.