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Based on observations during the survey walk of the facility on the morning of 2/6/2014, with the Safety Director and Maintenance Operator, the facility failed to maintain the integrity of the egress corridors. Positive latching hardware was not operational at many of the janitor closets throughout the facility.

Based on observations during the survey walk of the facility on the morning of 2/6/2014, with the Safety Director and Maintenance Operator, the facility failed to assure the doors in smoke barriers had the required smoke control amenities. At patient wing #40, opposite swing cross-corridor smoke doors did not have astragals installed to provide a smoke tight seal at the meeting edges of the doors when closed.

Based on observations during the survey walk of the facility on the morning of 2/6/2014, with the Safety Director and Maintenance Operator, the facility failed to assure the integrity of the one hour enclosure. Hazardous rooms must be separated from the rest of the facility by rated 1-hour fire walls that go up to the deck and a 45 minute door with closer and positive latch. Many soiled utility doors ' positive latching hardware was not latching in the door frame.



Based on observations during the survey walk of the facility on the morning of 2/6/2014, with the Safety Director and Maintenance Operator, the facility failed to assure the protection of a hazardous room. Both doors into the mallik file room were kept open. With this many files, the room becomes a hazardous room and the doors need to remain in a latched and closed position.

Based on observations during the survey walk of the facility on the afternoon of 2/6/2014, with the Safety Director and Maintenance Operator, the facility failed to maintain exiting. An exit sign existed above an exterior door. However the door could not be exited out. Emergency exit only sign would be acceptable as long as door remains able to be exited from the wellness center.



Based on observations during the survey walk of the facility on the morning of 2/6/2014, with the Safety Director and Maintenance Operator, the facility failed to provide egress direction. No exit sign existed at recovery department.



Based on observations during the survey walk of the facility on the morning of 2/6/2014, with the Safety Director and Maintenance Operator, the facility failed to provide egress direction near mallik office, which lead into wellness center ' s egress exit doors.

Based on observations during the survey walk of the facility on the afternoon of 2/6/2014, with the Safety Director and Maintenance Operator, the facility failed to maintain a clear and unobstructed egress path. The rear egress corridor, in dialysis department, contained boxes and carts which impeded egress path.

Based on observations during the survey walk of the facility on the morning of 2/6/2014, with the Safety Director and Maintenance Operator, the facility ' s fire sprinkler system did not comply with NFPA 13.
Paint was on sprinkler head at dietary ' s clean ware side.
Many sprinkler head escutcheons were missing.
NFPA 13, 2002: 6.2.6.4.4.... Sprinklers that have painted or coated shall be replaced in accordance with the requirements of 6.2.6.2.2 ....Where sprinklers have had paint applied by other than the sprinkler manufacturer, they shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

Based on observations during the survey walk of the facility on the morning of 2/6/2014, with the Safety Director and Maintenance Operator, the facility did not have reliable fire extinguishers. Pressure gauge reading or indicator was not in operable range or position at 1) #8 near dietary; 2) in kitchen; 3) at dialysis corridor; 4) at physical therapy near employee break room.

Based on observations during the survey walk of the facility on the morning of 2/6/2014, with the Safety Director and Maintenance Operator, the facility failed to securely store med gas cylinders. Med gas cylinders shall be individually secured in place to meet the requirements of NFPA 99, 2002, 5.1.3.3.2(7). ..... Locations for central supply systems and the storage of medical gases shall meet the following requirements: (7) Be provided with racks, chains, or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, from falling

Based on observations during the survey walk of the facility on the afternoon of 2/6/2014, with the Safety Director and Maintenance Operator, the facility failed to assure that the essential electrical system was in full compliance. Exit light circuit was supplied with power from wellness center ' s panel board E. It did not appear that this is a life safety panel board. Verify to ensure that no functions other than those listed below in items 1 through 7 are connected to the life safety branch. If so move exit lights to a life safety panel board.
The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions;
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.



Based on observations during the survey walk of the facility on the morning of 2/6/2014, with the Safety Director and Maintenance Operator, the facility failed to assure that the essential electrical system was in full compliance. Fire alarm pwr was supplied with power from the BL-CB2 panel board, which was stated to be a critical panel board. This needs to be powered by the life safety panel board. The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 3. Alarm and alerting systems including the following: a. Fire Alarms.



Based on observations during the survey walk of the facility on the morning of 2/6/2014, with the Safety Director and Maintenance Operator, the facility failed to ensure that the Type I essential electrical service (EES) is in accordance with NFPA 99. Critical branch panel board did not have a permanent label reading " Critical " at patient wing #40.
Additionally, in the wellness center, panel board E was stated to be on the Type 1 EES. However, it was not clear what circuiting it provided power to.
Ensure all panel boards powered by generator are labeled "LIFE SAFETY", "CRITICAL" or "EQUIPMENT", as applicable to identify which branch they serve. Additionally, the panel directories need to be labeled to legibly identify the purpose or use of each circuit.