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Based on observation and staff interview it was determined that the facility failed to maintain exit discharges in accordance with NFPA 101 Life Safety Code 2012 Edition and CMS S&C Letter 05-38.

Findings:

It was observed 10/24/17 at 11:45 AM that the exit discharge located at 1 South Catheterization Lab, did not safely discharge to a public way. After leaving the building from the exit a person would have to navigate down a steep hill before reaching the sidewalk and road below. This finding was confirmed with Staf MM at the time of observation.

It was observed 10/24/17 at 12:30 PM during a tour of the outside of the facility that the exit discharge located at the Operating Room Suite did not safely discharge to a public way. Specifically it did not discharge to a level all-weather travel surface. The exit discharged outside to a concrete slab, with an approximately 2 foot drop on the left leading to a steep grassy hill. Straight ahead was grass that also declined to the left. The grass did not provide a level surface and would be dangerous in inclement weather. There were also no markings indicating the direction to the public way. This finding was confirmed by Staff KK at the time of the observation.

Based on observation and staff interview, the facility failed to maintain proper illumination of the exit discharge from the operating room suite, in accordance with the NFPA 101 Life Safety Code 2012 Edition.

Findings:

On 10/24/17, at approximately 12:30 PM, during a tour of the outside of the building, it was observed that there was no light above the exit door from the operating suite stairway.

This finding was confirmed by Staff KK at the time of the observation.

Based on staff interview, and document review it was determined that the facility failed to conduct a functional test on every required battery-powered emergency light. Testing was performed for less than 30 seconds monthly, and less than 1 1/2 hours annually, which does not meet the requirements of NFPA 101 Life Safety Code 2012 Edition.

Findings:

On 10/24/17 at 10:30 AM two of the facility's preventive maintenance logs were reviewed with Staff MM. The log from March 2017 listed twelve lights that were tested. The log documented eleven of twelve lights tested had a test duration of only one hour. One light was documented to need replacement. The log from October 2017 documented eleven lights that were tested, ten of which were tested for only one hour. There was no documentation on either log of monthly testing being conducted. The instructions for testing, printed at the bottom of the log sheet read, "turn off breakers for 90 minutes".

During the log review, Staff MM could not explain why the tests were only being done for one hour. When asked if there was any monthly testing being done, he said no.

NFPA 101 Life Safety Code 2012 Edition requires monthly testing for not less than 30 seconds, and annual testing for not less than 1 1/2 hours.

Based on observation and staff interview, the Facility did not ensure that automatic smoke detection is installed at each fire alarm control unit, in areas not continuously occupied, in accordance with NFPA 101 Life Safety Code 2012 Edition.

Findings:

On 10/25/17 at 1:35 PM it was observed that there was no smoked detector in the MRI mechanical room where a Fire Alarm Control Unit is located.

This finding was confirmed by Staff LL at the time of the observation.

Based on observation, interview, and document review, the facility failed to ensure that the fire alarm system is tested and maintained in accordance with NFPA72, National Fire Alarm Code.

Findings:

On 10/24/17, the Alarm & Suppression Company Inspection Report was reviewed with Staff MM. The report documented 26 smoke detectors on the 3rd floor as "no access", and 1 beam detector in the cafeteria as being tested and failed, with no documentation of correction.

Staff MM stated the detectors were inaccessible, as they were taped off during construction. He stated the beam detector in the cafeteria had not worked since it was installed.

On 10/25/2017 at approximately 2:30PM, during a tour with Staff MM, it was observed that three smoke detectors in the hallway outside the Women's Imaging Center were wrapped with tape. The tape impaired the ability of the detectors to detect smoke, rendering them ineffective. Another detector was hanging from the ceiling by it's wires. Staff MM said that the construction workers did not remove the tape when they were done working in that area.

Based on observation, staff interview, and document review, it was determined that the facility did not ensure that all sprinkler heads are maintained free of dust and foreign materials. Additionally, sprinkler system gauge testing, and sprinkler piping obstruction investigation was not conducted every five years in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-based Fire Protection systems.

Findings:

On 10/23/17 at 2:45 PM, during the tour of the Sleep Lab, it was observed that several sprinkler heads were loaded with a coating of dust. These included the sprinkler heads in the hall outside of rooms #1, #2 and #4, the head outside the mechanical room, and the head in sleeping room #1. On 10/23/17 at 3:30 PM, it was observed that at least 4 sprinkler heads in the hall outside of Conference Room A were loaded with a coating of dust. These findings were confirmed by Staff MM at the time of the observation.

On 10/24/17 at 11:35 AM, during the tour of the kitchen, it was observed that a sprinkler head in the dishwashing room had what appeared to be an air freshener hung from it. This finding was confirmed by Staf NN, and Staff KK at the time of observation.

On 10/24/17 at 11:00 AM, the Sprinkler Inspection Reports were reviewed with Staff MM. Reports dated 1/12/17, 5/22/17, and 9/29/17 all documented that the 5-year inspection had not been done. Staff MM acknowledged the 5-year inspection had not been done.