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The facility failed to ensure exit access was readily accessible at all times.

During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open. 7.2.1.4.3.1

Observation determined numerous corridor doors throughout the facility opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.

Failure to maintain the means of egress to be available at all times increases the risk of death or injury due to fire.

The deficiency affected numerous corridor doors in the means of egress throughout the facility.

One or more battery-powered lighting units shall be provided within locations where deep sedation and general anesthesia is administered. NFPA 99, 6.3.2.2.11.1.

The facility failed to provide emergency lighting in all areas where general anesthesia is administered.

Observation determined the Endoscopy Suite Room 201 and the ESWL Room were areas where general anesthesia was administered and did not have battery-powered emergency lighting in the rooms.

Failure to provide emergency lighting in all required areas increases the risk of injury or death due to fire.

This deficiency affected two (2) of numerous rooms that require emergency lighting in the facility.

The facility failed to maintain the two-hour fire resistive rating of shaft enclosures throughout the building. 19.3.1.

Observation determined:

1) The corridor door to the mechanical chase near Elevator F did not have a fire rating tag on the door to document the required 90-minute fire rating of the door.
2) The corridor wall separating the exit corridor on the second floor from the mechanical chase in Mechanical Room 2467 had a wooden box recessed into the wall. The mechanical chase provided a vertical opening to floors above and below the second floor.

Failure to protect vertical openings with construction having a fire resistance rating of at least two hours increases the risk of death or injury due to fire.

This deficiency affected two (2) of numerous vertical openings in the facility.

Smoke detectors must not be located in a direct airflow nor closer than 3 ft. (1 m) from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1.

The facility failed to ensure the smoke detection system was in compliance with NFPA 72, National Fire Alarm and Signaling Code.

Observation determined smoke detectors throughout the facility were installed within 3 ft. of an air supply diffuser or air return vent.

Failure to install the smoke detection system as required increases the risk of death or injury due to fire.

This deficiency affected numerous smoke detectors in the facility. The smoke detection system serves the entire facility.

The facility failed to install the automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

Observation determined:

1) Elevator Equipment Room 544 in the basement did not have sprinkler coverage.
2) Two (2) sprinklers in ICU Breakroom 3433 were closer than 6 feet apart where a wall had been removed.
3) Mechanical Room 217 in the basement lacked sprinkler coverage below ductwork that was over 4 feet wide.
4) Mechanical Room 2306 on the second floor had one (1) sprinkler below the ductwork in the room and did not have sprinkler coverage above the ductwork within 12 inches of the floor deck.

Failure to install the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury or death due to fire.

This deficiency affected four (4) of numerous rooms in the facility. The automatic sprinkler system serves the entire facility.

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. 19.7.6, 4.6.12, NFPA 25, 13.2.7.1, 13.3.2.1.1

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

Observation determined three (3) sprinklers in Staff Lounge Room 2428 on the second floor had excessive corrosion on the sprinklers possibly causing a delay in the activation.

Failure to inspect, test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous rooms in the facility. The automatic sprinkler system serves the entire facility.

Portable fire extinguishers shall be provided in all health care occupancies. Extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 19.3.5.12, 9.7.4.1

The facility failed to maintain fire extinguishers in accordance with NFPA 10.

Observation determined:

1) Two (2) fire extinguishers located on the fourth floor near Clean Utility Room 4742 and on the third floor near the Kidney Dialysis unit entrance were last serviced in September 2016, exceeding 1 year from this survey.
2) One (1) fire extinguisher located in the exit corridor near Patient Room 4205 was last serviced in July 2016, exceeding 1 year from this survey.

Failure to maintain portable fire extinguishers in accordance with NFPA 10 increases the risk of death or injury due to fire.

This deficiency affected three (3) of numerous fire extinguishers in the facility.