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Based on observation, the facility failed to maintain the means of egress per the requirements of:

2012 NFPA 101, 19.2.1, and 7.2.1.9.1.3

This deficiency affects 1 of 2 Operating Room (O.R.) area means of egress.

Findings include:

During a tour of the facility, the surveyor observed the O.R. egress door (across the hall from the O.R. Waiting Room) did not have a sign on the egress side that reads, "IN EMERGENCY, PUSH TO OPEN".

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the magnetic hold open devices for a set of cross-corridor fire doors per the requirements of:

2012 NFPA 101, 19.2.2.2.7, and 7.2.1.8.2(4)

This deficiency affects 1 set of cross-corridor fire doors.

Findings include:

During a tour of the facility, the surveyor observed the magnetic hold open devices for the pair of cross-corridor fire doors between the Intensive Care Unit Hall and Hall 1, failed to release during loss of power to the fire alarm system.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain a horizontal exit per the requirements of:

2012 NFPA 101, 19.2.2.5, 7.2.4.3.1, and 8.3.5.1

This deficiency affects 1 horizontal exit.

Findings include:

During a tour of the facility, the surveyor observed an unsealed opening of a 3" conduit, used as a chase, for multiple cables in the 2-hour fire barrier above the ceiling over the cross corridor doors between Obstetrics and Radiology.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to provide continuous illumination of the means of egress per the requirements of:

2012 NFPA 101, 19.2.8, and 7.8.1.4

This deficiency affects both Education Center exits.

Findings include:

During a tour of the facility, the surveyor observed a single wall mounted fixture with a single bulb (no continuous illumination of the means of egress) at the two Education Center exits.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and review of documentation, the facility failed to maintain the automatic sprinkler system per requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.5
2011 NFPA 25, 5.3.1.1.1.3

This deficiency affects entire facility

Findings include:

During a tour of the facility, the facility failed to provide documentation that the 1999 fast-response sprinkler heads found throughout the facility had been replaced or a representative sample tested within 20 years of installation.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain areas open to the corridor per the requirements of:

2012 NFPA 101, 19.3.6.1 (1) (c)

This deficiency affects 1 alcove.

Findings include:

During a tour of the facility, the surveyor observed file cabinets in an alcove open to the corridor (without an electrically supervised automatic smoke detection system) on Hall 1 next to the Case Management Office. This space did not allow direct supervision by the facility staff from a Nurses' Station or similar space.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain a corridor door per the requirements of:

2012 NFPA 101, 19.3.6.3.5
42 CFR 482.41 (b) (1) (ii)
S&C-07-18

This deficiency affects 1 corridor door.

Findings include:

During a tour of the facility, the surveyor observed the Business Office Break Room's corridor door had a 3/4" gap between the door and door frame when the door was closed and latched, prohibiting the door from being smoke resistive.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3, 8.5.1, 8.5.6.2, and 8.5.6.3

This deficiency affects 1 smoke barrier.

Findings include:

During a tour of the facility, the surveyor observed an unsealed penetration of a 1/2" copper oxygen pipe above the ceiling, over the cross-corridor doors of the smoke barrier between the Emergency Department and Radiology.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the permitted smoking area per the requirements of:

2012 NFPA 101, 19.7.4, (6)

This deficiency affects 2 of 2 designated smoking areas.

Findings include:

During a tour of the facility, the surveyor observed the two permitted smoking areas failed to have metal containers with self-closing cover devices.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to prohibit a portable space heating device per the requirements of:

2012 NFPA 101, 19.7.8

This deficiency affects 1 of 2 on-call sleeping rooms.

Findings include:

During a tour of the facility, the surveyor observed a portable space heating device on the carpeted floor in the Doctors On-call Room in the Operating Room Area. This was located in a sleeping smoke compartment and the facility was unable to provide documentation that the heating element did not exceeding 212 degrees.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the oxygen cylinders per the requirements of:

2012 NFPA 99, 11.3.2.3

This deficiency affects 1 of 1 outside oxygen cylinder storage.

Findings include:

During a tour of the facility, the surveyor observed the outside oxygen storage roof frame was made out of wood and was within 5 feet of the oxygen cylinders.

A member of the maintenance staff was present when this deficiency was identified.