HospitalInspections.org

Based on observation and interview, the facility failed to ensure the three hour barrier between the renovated emergency department area and the new medical office building and the two hour barrier between the emergency department area and the existing construction were free of penetrations. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/22/16 at 2:14 PM a tour was taken of the facility with Staff Q and M.

1.On 08/22/16 at 2:18 PM observation above the drop down ceiling of the three hour fire barrier between the new and existing health care occupancies revealed, as seen from a waiting area at coordinates d7, a one inch open conduit holding blue wires and one grey one.

On 08/22/16 at 2:18 PM in an interview, Staff Q confirmed the finding.

2. On 08/22/16 at 2:35 PM observation above the drop down ceiling of the three hour fire barrier between the renovated emergency department area and the new medical office building as seen from within the chief operating officer ' s office revealed an open junction box with an open conduit traveling to it.

On 08/22/16 at 2:35 PM in an interview, Staff Q confirmed the finding.

3. On 08/22/16 at 2:44 PM observation above the drop down ceiling of the three hour fire barrier between renovated emergency department area and the new medical office building as seen from within the women ' s bathroom within the medical office building revealed an eighth inch wide crack in the barrier extending from the drop down ceiling to the deck above.

On 08/22/16 at 2:44 PM in an interview, Staff Q confirmed the finding.

4. On 08/22/16 at 3:58 PM observation above the drop down ceiling of the three hour fire barrier between renovated emergency department area and the new medical office building, as seen from within an exam room located at coordinates d10, revealed a one inch conduit with an annular space.

On 08/22/16 at 3:58 PM in an interview, Staff Q confirmed the finding.

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

5. On 08/23/16 at 11:12 AM observation of the door to the radiology area located at coordinates h7 and within a two hour barrier that separated the medical office building that was renovated into an emergency department from the existing structure, revealed its latching hardware did not close and latch the doors.

On 08/23/16 at 11:12 AM in an interview, Staff Q confirmed the finding.

6. On 08/23/16 at 11:25 AM observation at the double doors at coordinates h9 and above the drop down ceiling of the two hour fire barrier that separates the medical office building that was renovated into an emergency department from the existing structure revealed-as seen from the west side of the doors-revealed an annular space around a sprinkler line and an open conduit holding multiple wires of a variety of colors.

On 08/23/16 at 11:25 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each corridor door with self-closing and latching hardware closed and latched the door. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

1.On 08/23/16 at 10:57 AM observation of the corridor door to the fire blanket room and located at coordinates h7 revealed its self-closing and latching hardware did not close and latch the door.

On 08/23/16 at 10:57 AM in an interview, Staff Q confirmed the finding.

2. On 08/23/16 at 11:34 AM the corridor door between two radiology rooms and located at coordinates j8 revealed its closing and latching hardware did not close and latch the door.

On 08/23/16 at 11:34 AM in an interview, Staff Q confirmed the finding.

3. On 08/23/16 at 12:00 PM observation of the room at coordinates j7 revealed it had a Dutch door between it and the corridor. The Dutch door was observed to only have latching hardware on the bottom half (and not the top).

On 08/25/16 at 9:30 AM in an interview, Staff Q confirmed the finding.

On 08/23/16 at 4:24 PM a tour of the lower level was taken with Staff Q and M.

4. On 08/23/16 at 4:24 PM observation of the corridor door having the sign female employees only revealed its self-closing and latching hardware did not close and latch the door.

On 08/23/16 at 4:24 PM in an interview, Staff Q confirmed the finding.

5. On 08/23/16 at 4:26 PM observation of the pass through door to the dish washing area and located in the corridor revealed its self-closing latching hardware did not close and latch the door.

On 08/23/16 at 4:26 PM in an interview, Staff Q confirmed the finding.

On 08/24/16 at 9:24 AM a tour was taken of the facility with Staff Q.

6. On 08/24/16 at 9:24 AM observation of the corridor door to the women ' s bathroom outside the outpatient surgical suite revealed its self-closing and latching hardware did not close and latch the door.

On 08/24/16 at 9:24 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure the rated, protective construction surrounding its stairways were free of penetrations. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

1.On 08/23/16 at 1:25 PM observation above the drop down ceiling of the one hour barrier surrounding the laboratory stair and seen from the east/west corridor revealed a one inch open conduit with an annular space.

On 08/23/16 at 1:25 PM in an interview, Staff Q confirmed the finding.

2. On 08/23/16 at 3:06 PM observation above the drop down ceiling of the north side of the one hour barrier protecting the med surg elevator revealed a half inch conduit with an annular space.

On 08/23/16 at 3:06 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure access to exits were clearly marked by approved, readily visible signs and doors likely to be mistaken for an exit had a sign designating they were not an exit. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

1.On 08/23/16 at 10:41 AM an exit sign was observed at coordinates f6 that had a chevron pointing to an outside door with windows that had a sign stating it was not a fire exit.

On 08/23/16 at 10:41 AM in an interview, Staff Q confirmed the finding.

2. On 08/23/16 at 3:17 PM observation of the outside window door located at coordinates h4 revealed it did not have a sign designating no exit.

On 08/23/16 at 3:17 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure penetrations in its smoke barriers were properly sealed. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/22/16 at 2:14 PM a tour was taken of the facility with Staff Q and M.

1.On 08/22/16 at 4:20 PM observation above the drop down ceiling of the one hour fire barrier to the right of the window above the television in the birthing room revealed a one foot by one foot opening in the seam between where the ceiling meets the deck.

On 08/22/16 at 4:20 PM in an interview, Staff Q confirmed the finding

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

2. On 08/23/16 at 10:05 AM observation above the drop down ceiling of the one hour barrier in the physician sleep area at coordinates E6 revealed eight one inch by six inch penetrations along the top of the barrier.

On 08/23/16 at 10:05 AM in an interview, Staff Q confirmed the finding.

3. On 08/23/16 at 10:16 AM observation above the drop down ceiling of the one hour barrier surrounding the nursing station at coordinates e6-as seen from within--revealed square annular spaces around each end of a heating, ventilation, and cooling duct running north/south.

On 08/23/16 at 10:16 AM in an interview, Staff Q confirmed the finding.

4. On 08/23/16 at 10:20 AM observation above the drop down ceiling of the one hour barrier surrounding the nursing station at coordinates e6 as seen from outside and just north of the door, revealed blue wiring surrounded by an annular space and a sprinkler line with an annular space.

On 08/23/16 at 10:20 AM in an interview, Staff Q confirmed the finding.

5. On 08/23/16 at 12:03 PM observation above the drop down ceiling of the one hour barrier as seen from within the room at coordinates k7 and on south side revealed an annular space around heating, ventilation, and cooling ducting.

On 08/23/16 at 12:03 PM in an interview, Staff Q confirmed the finding.

6. On 08/23/16 at 1:41 PM observation above the drop down ceiling of the two hour barrier located within the housekeeping closet 180 degrees from the double doors perpendicular to the west side of the laboratory stairs (coordinates k5) revealed a one foot by four foot cut-away in one layer of the drywall.

On 08/23/16 at 1:41 PM in an interview, Staff Q confirmed the finding.

7. On 08/23/16 at 2:00 PM observation above the drop down ceiling of the two hour barrier as seen from within the bathroom and over the shower stall of the preadmission testing room (coordinates k5) revealed plywood was covering what was once a window opening.

On 08/23/16 at 2:00 PM in an interview, Staff Q confirmed the finding.

8. On 08/23/16 at 2:05 PM observation above the drop down ceiling of the one hour barrier at coordinates l5 as seen from the north side revealed along the top third an open square with two conduits running through, and at the joint at the ceiling the penetration was filled with mineral wool but not sealed with firestop.

On 08/23/16 at 2:05 PM in an interview, Staff Q confirmed the finding.

9. On 08/23/16 at 2:10 PM observation above the drop down ceiling of the one hour barrier above the door at coordinates m5 revealed the joint between the wall and the deck was filled mineral wool but not sealed with firestop.

On 08/23/16 at 2:10 PM in an interview, Staff Q confirmed the finding.

10. On 08/23/16 at 2:19 PM observation above the drop down ceiling of the one hour barrier along the perimeter of the nursing lounge and the physician dressing room (coordinate k3) and seen from the corridor revealed it did not consist of two layers of drywall between the drop down ceiling and the deck.

On 08/23/16 at 2:19 PM in an interview, Staff Q confirmed the finding.

11. On 08/23/16 at 2:52 PM observation above the drop down ceiling of the two hour barrier over the double doors located at coordinates j3 and seen on the south side, revealed blue wires traveling through and open one inch conduit.

On 08/23/16 at 2:52 PM in an interview, Staff Q confirmed the finding.

12. On 08/23/16 at 2:56 PM observation above the drop down ceiling of the north two hour barrier in the clean utility room located at coordinates k3 revealed (as seen from within) a corrugated conduit with an annular space and at the western two hour barrier a shoe box size penetration with sprinkler lines traveling through.

On 08/23/16 at 2:56 PM in an interview, Staff Q confirmed the finding.

13. On 08/23/16 at 3:28 PM observation above the drop down ceiling of the northern one hour barrier located at coordinates k2 in the operating room revealed a one inch penetration with one corrugated conduit traveling through.

On 08/23/16 at 3:28 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each door in a rated barrier could self-close. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

On 08/23/16 at 3:52 PM observation of the door to the room at coordinates f10 revealed it was in a one hour barrier but did not have a self-closer.

On 08/23/16 at 3:52 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure its doors located in rated barriers self-closed and where installed with latching hardware, latched. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

1.On 08/23/16 at 12:01 PM observation of the door to the room located at coordinates k7 revealed it to be in a one hour barrier but without a self-closer.

On 08/23/16 at 12:01 PM in an interview, Staff Q confirmed the finding.

2. On 08/23/16 at 1:31 PM observation of the double doors on the west side and perpendicular to the laboratory stairs (coordinates k5) revealed they were in a two hour barrier and had a quarter inch gap between the leaves.

On 08/23/16 at 1:31 PM in an interview, Staff Q confirmed the finding.

3. On 08/23/16 at 1:45 PM observation of the door in the two hour barrier and located at coordinates l5 revealed it was propped open with a block of concrete with no staff in the area.

On 08/23/16 at 1:45 PM in an interview, Staff Q confirmed the finding.

4. On 08/23/16 at 2:10 PM observation of the door in the one hour barrier located at m5 revealed its self-closing and latching hardware did not self-close and latch the door.

On 08/23/16 at 2:10 PM in an interview, Staff Q confirmed the finding.

5. On 08/23/16 at 2:11 PM observation of the door just south of the above door and located in a two hour barrier revealed is self-closing and latching hardware did not self-close and latch the door.

On 08/23/16 at 2:11pm in an interview, Staff Q confirmed the finding.

6. On 08/23/16 at 2:34 PM observation of the door in the one hour barrier and 180 degrees from the nursing lounge and located at coordinates k3 revealed its self-closing and latching hardware did not close and latch the door.

On 08/23/16 at 2:34 PM in an interview, Staff Q confirmed the finding.

7. On 08/23/16 at 3:28 PM observation of the door at coordinates k2 (northern one hour barrier in the operating room) revealed it did not have a self-closer.

On 08/23/16 at 3:28 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure the barrier protecting each hazardous area was free of penetrations and each door self-closed. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

1. On 08/23/16 at 3:56 PM observation of the door to the biohazard room at coordinates h10 revealed it was in a one hour barrier but did not have a self-closer.

On 08/23/16 at 3:56 PM in an interview, Staff Q confirmed the finding.

2. On 08/23/16 at 3:57 PM observation above the drop down ceiling of the one hour barrier above that door revealed at the corner 180 degrees from it there were three copper lines with annular spaces.

On 08/23/16 at 3:57 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure the rated construction protecting hazardous areas were free of penetrations and the doors self-closed. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

1.On 08/23/16 at 10:34 AM observation above the drop down ceiling of the one hour barrier surrounding the biohazard room at coordinates f5-as seen from within--revealed 180 degrees from the door and at the corner a one foot by six inch section single layer of missing drywall.

On 08/23/16 at 10:34 AM in an interview, Staff Q confirmed the finding.

2. On 08/23/16 at 10:56 AM a corridor door to the laboratory and located at coordinates h7 was observed to not have a self-closer.

On 08/23/16 at 10:56 AM in an interview, Staff Q confirmed the finding.

3. On 08/23/16 at 3:12 PM observation of the door to the biohazard room in the intensive care unit revealed it was located in a one hour barrier but did not have self-closing and latching hardware.

On 08/23/16 at 3:12 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure its corridors were free and clear of paraphernalia. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

1.On 08/23/16 at 11:25 AM a portable x-ray machine was observed parked in the corridor near the double doors at coordinates h9.

On 08/23/16 at 11:25 AM in an interview, Staff R stated that is where it is stored.

2. On 08/24/16 at 9:10 AM a C-arm was observed in place in an exit corridor containing sleeping patient rooms. The C-arm was located 6 feet from an exit discharge door.

On 08/24/16 at 9:10 AM in an interview, Staff Q confirmed the finding.

Based on document review and interview, the facility failed to include a transmission of a fire alarm signal during each of its fire drills. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/24/16 a review of the facility's fire drills was completed. The review revealed on 6/30/15 at 9:30 PM, on 6/25/15 at 5:30 AM, on 08/28/15 at 9:30 PM, and on 09/30/15 at 5:00 AM the fire drills did not include the transmission of a fire alarm signal.

On 08/24/16 at 4:55 PM in an interview, Staff Q confirmed the signal was not transmitted because to do so would trigger the audible alarms.

Based on observation, document review, and interview, the facility failed to have ceiling tiles in place in certain areas to allow for heat to reach the sprinkler head as soon as possible, to have hydraulic name plates in place at risers per NFPA 25, 1999 edition, 2-2.7, and to have signs on control valves per NFPA 25, 1999 edition, 9-3. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

1.On 08/23/16 at 11:56 AM observation of the ceiling of the room adjacent to the MRI room (coordinates k8) revealed approximately half the ceiling tiles were missing while the sprinkler heads and smoke detectors remained in place (on tiles) so that heat and smoke would be unable to travel horizontally to them and thereby delay their activation.

On 08/23/16 at 11:56 AM in an interview, Staff Q confirmed the tiles were removed.

On 08/24/16 a review of the facility ' s fire sprinkler system inspection documentation was completed.

2. The review revealed on 04/28/16 and on 07/21/16 the hydraulic nameplates for the emergency department canopy and the kitchen canopy were not securely attached to the respective risers. The reports did state that " calculations in maintenance office. "

On 08/24/16 at 4:55 PM in an interview, Staff Q explained the hydraulic nameplates were not on each of their referenced riser, but lumped together on one.

3. On 08/24/16 a review of the facility ' s fire sprinkler system inspection documentation revealed on 04/28/16 and on 07/21/16 that " all valves should have signs on them. "

On 08/24/16 at 4:55 PM in an interview, Staff Q stated no signs were put on the valves.

4. On 08/24/16 a review of the facility ' s fire sprinkler system inspection documentation revealed on 04/28/16 and on 07/21/16 the four inch system to the building without a name revealed at line A1e, the gauge on the quick-opening device does not indicate the same pressure as the gauge on the system side of the dry-pipe valve. The note to this line stated, " Drain valves should be mapped. "

On 08/24/16 at 4:55 PM in an interview, Staff Q said he did not know what that meant.

Based on observation and interview, the facility failed to ensure its emergency power system complied with NFPA 99 (1999 edition), specifically 3-4.1.1.15. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/24/16 at 11:13 AM a tour was taken of the facility's emergency power system with Staff Q.

During the tour the facility was observed to have two diesel generators, one of which was outside, each with an annunciator on them. An annunciator panel was observed within an enclosed office, but the office was not in constant attendance.

During the tour Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure the three hour barrier between the renovated emergency department area and the new medical office building and the two hour barrier between the emergency department area and the existing construction were free of penetrations. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/22/16 at 2:14 PM a tour was taken of the facility with Staff Q and M.

1.On 08/22/16 at 2:18 PM observation above the drop down ceiling of the three hour fire barrier between the new and existing health care occupancies revealed, as seen from a waiting area at coordinates d7, a one inch open conduit holding blue wires and one grey one.

On 08/22/16 at 2:18 PM in an interview, Staff Q confirmed the finding.

2. On 08/22/16 at 2:35 PM observation above the drop down ceiling of the three hour fire barrier between the renovated emergency department area and the new medical office building as seen from within the chief operating officer ' s office revealed an open junction box with an open conduit traveling to it.

On 08/22/16 at 2:35 PM in an interview, Staff Q confirmed the finding.

3. On 08/22/16 at 2:44 PM observation above the drop down ceiling of the three hour fire barrier between renovated emergency department area and the new medical office building as seen from within the women ' s bathroom within the medical office building revealed an eighth inch wide crack in the barrier extending from the drop down ceiling to the deck above.

On 08/22/16 at 2:44 PM in an interview, Staff Q confirmed the finding.

4. On 08/22/16 at 3:58 PM observation above the drop down ceiling of the three hour fire barrier between renovated emergency department area and the new medical office building, as seen from within an exam room located at coordinates d10, revealed a one inch conduit with an annular space.

On 08/22/16 at 3:58 PM in an interview, Staff Q confirmed the finding.

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

5. On 08/23/16 at 11:12 AM observation of the door to the radiology area located at coordinates h7 and within a two hour barrier that separated the medical office building that was renovated into an emergency department from the existing structure, revealed its latching hardware did not close and latch the doors.

On 08/23/16 at 11:12 AM in an interview, Staff Q confirmed the finding.

6. On 08/23/16 at 11:25 AM observation at the double doors at coordinates h9 and above the drop down ceiling of the two hour fire barrier that separates the medical office building that was renovated into an emergency department from the existing structure revealed-as seen from the west side of the doors-revealed an annular space around a sprinkler line and an open conduit holding multiple wires of a variety of colors.

On 08/23/16 at 11:25 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each corridor door with self-closing and latching hardware closed and latched the door. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

1.On 08/23/16 at 10:57 AM observation of the corridor door to the fire blanket room and located at coordinates h7 revealed its self-closing and latching hardware did not close and latch the door.

On 08/23/16 at 10:57 AM in an interview, Staff Q confirmed the finding.

2. On 08/23/16 at 11:34 AM the corridor door between two radiology rooms and located at coordinates j8 revealed its closing and latching hardware did not close and latch the door.

On 08/23/16 at 11:34 AM in an interview, Staff Q confirmed the finding.

3. On 08/23/16 at 12:00 PM observation of the room at coordinates j7 revealed it had a Dutch door between it and the corridor. The Dutch door was observed to only have latching hardware on the bottom half (and not the top).

On 08/25/16 at 9:30 AM in an interview, Staff Q confirmed the finding.

On 08/23/16 at 4:24 PM a tour of the lower level was taken with Staff Q and M.

4. On 08/23/16 at 4:24 PM observation of the corridor door having the sign female employees only revealed its self-closing and latching hardware did not close and latch the door.

On 08/23/16 at 4:24 PM in an interview, Staff Q confirmed the finding.

5. On 08/23/16 at 4:26 PM observation of the pass through door to the dish washing area and located in the corridor revealed its self-closing latching hardware did not close and latch the door.

On 08/23/16 at 4:26 PM in an interview, Staff Q confirmed the finding.

On 08/24/16 at 9:24 AM a tour was taken of the facility with Staff Q.

6. On 08/24/16 at 9:24 AM observation of the corridor door to the women ' s bathroom outside the outpatient surgical suite revealed its self-closing and latching hardware did not close and latch the door.

On 08/24/16 at 9:24 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure the rated, protective construction surrounding its stairways were free of penetrations. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

1.On 08/23/16 at 1:25 PM observation above the drop down ceiling of the one hour barrier surrounding the laboratory stair and seen from the east/west corridor revealed a one inch open conduit with an annular space.

On 08/23/16 at 1:25 PM in an interview, Staff Q confirmed the finding.

2. On 08/23/16 at 3:06 PM observation above the drop down ceiling of the north side of the one hour barrier protecting the med surg elevator revealed a half inch conduit with an annular space.

On 08/23/16 at 3:06 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure access to exits were clearly marked by approved, readily visible signs and doors likely to be mistaken for an exit had a sign designating they were not an exit. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

1.On 08/23/16 at 10:41 AM an exit sign was observed at coordinates f6 that had a chevron pointing to an outside door with windows that had a sign stating it was not a fire exit.

On 08/23/16 at 10:41 AM in an interview, Staff Q confirmed the finding.

2. On 08/23/16 at 3:17 PM observation of the outside window door located at coordinates h4 revealed it did not have a sign designating no exit.

On 08/23/16 at 3:17 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure penetrations in its smoke barriers were properly sealed. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/22/16 at 2:14 PM a tour was taken of the facility with Staff Q and M.

1.On 08/22/16 at 4:20 PM observation above the drop down ceiling of the one hour fire barrier to the right of the window above the television in the birthing room revealed a one foot by one foot opening in the seam between where the ceiling meets the deck.

On 08/22/16 at 4:20 PM in an interview, Staff Q confirmed the finding

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

2. On 08/23/16 at 10:05 AM observation above the drop down ceiling of the one hour barrier in the physician sleep area at coordinates E6 revealed eight one inch by six inch penetrations along the top of the barrier.

On 08/23/16 at 10:05 AM in an interview, Staff Q confirmed the finding.

3. On 08/23/16 at 10:16 AM observation above the drop down ceiling of the one hour barrier surrounding the nursing station at coordinates e6-as seen from within--revealed square annular spaces around each end of a heating, ventilation, and cooling duct running north/south.

On 08/23/16 at 10:16 AM in an interview, Staff Q confirmed the finding.

4. On 08/23/16 at 10:20 AM observation above the drop down ceiling of the one hour barrier surrounding the nursing station at coordinates e6 as seen from outside and just north of the door, revealed blue wiring surrounded by an annular space and a sprinkler line with an annular space.

On 08/23/16 at 10:20 AM in an interview, Staff Q confirmed the finding.

5. On 08/23/16 at 12:03 PM observation above the drop down ceiling of the one hour barrier as seen from within the room at coordinates k7 and on south side revealed an annular space around heating, ventilation, and cooling ducting.

On 08/23/16 at 12:03 PM in an interview, Staff Q confirmed the finding.

6. On 08/23/16 at 1:41 PM observation above the drop down ceiling of the two hour barrier located within the housekeeping closet 180 degrees from the double doors perpendicular to the west side of the laboratory stairs (coordinates k5) revealed a one foot by four foot cut-away in one layer of the drywall.

On 08/23/16 at 1:41 PM in an interview, Staff Q confirmed the finding.

7. On 08/23/16 at 2:00 PM observation above the drop down ceiling of the two hour barrier as seen from within the bathroom and over the shower stall of the preadmission testing room (coordinates k5) revealed plywood was covering what was once a window opening.

On 08/23/16 at 2:00 PM in an interview, Staff Q confirmed the finding.

8. On 08/23/16 at 2:05 PM observation above the drop down ceiling of the one hour barrier at coordinates l5 as seen from the north side revealed along the top third an open square with two conduits running through, and at the joint at the ceiling the penetration was filled with mineral wool but not sealed with firestop.

On 08/23/16 at 2:05 PM in an interview, Staff Q confirmed the finding.

9. On 08/23/16 at 2:10 PM observation above the drop down ceiling of the one hour barrier above the door at coordinates m5 revealed the joint between the wall and the deck was filled mineral wool but not sealed with firestop.

On 08/23/16 at 2:10 PM in an interview, Staff Q confirmed the finding.

10. On 08/23/16 at 2:19 PM observation above the drop down ceiling of the one hour barrier along the perimeter of the nursing lounge and the physician dressing room (coordinate k3) and seen from the corridor revealed it did not consist of two layers of drywall between the drop down ceiling and the deck.

On 08/23/16 at 2:19 PM in an interview, Staff Q confirmed the finding.

11. On 08/23/16 at 2:52 PM observation above the drop down ceiling of the two hour barrier over the double doors located at coordinates j3 and seen on the south side, revealed blue wires traveling through and open one inch conduit.

On 08/23/16 at 2:52 PM in an interview, Staff Q confirmed the finding.

12. On 08/23/16 at 2:56 PM observation above the drop down ceiling of the north two hour barrier in the clean utility room located at coordinates k3 revealed (as seen from within) a corrugated conduit with an annular space and at the western two hour barrier a shoe box size penetration with sprinkler lines traveling through.

On 08/23/16 at 2:56 PM in an interview, Staff Q confirmed the finding.

13. On 08/23/16 at 3:28 PM observation above the drop down ceiling of the northern one hour barrier located at coordinates k2 in the operating room revealed a one inch penetration with one corrugated conduit traveling through.

On 08/23/16 at 3:28 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each door in a rated barrier could self-close. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

On 08/23/16 at 3:52 PM observation of the door to the room at coordinates f10 revealed it was in a one hour barrier but did not have a self-closer.

On 08/23/16 at 3:52 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure its doors located in rated barriers self-closed and where installed with latching hardware, latched. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

1.On 08/23/16 at 12:01 PM observation of the door to the room located at coordinates k7 revealed it to be in a one hour barrier but without a self-closer.

On 08/23/16 at 12:01 PM in an interview, Staff Q confirmed the finding.

2. On 08/23/16 at 1:31 PM observation of the double doors on the west side and perpendicular to the laboratory stairs (coordinates k5) revealed they were in a two hour barrier and had a quarter inch gap between the leaves.

On 08/23/16 at 1:31 PM in an interview, Staff Q confirmed the finding.

3. On 08/23/16 at 1:45 PM observation of the door in the two hour barrier and located at coordinates l5 revealed it was propped open with a block of concrete with no staff in the area.

On 08/23/16 at 1:45 PM in an interview, Staff Q confirmed the finding.

4. On 08/23/16 at 2:10 PM observation of the door in the one hour barrier located at m5 revealed its self-closing and latching hardware did not self-close and latch the door.

On 08/23/16 at 2:10 PM in an interview, Staff Q confirmed the finding.

5. On 08/23/16 at 2:11 PM observation of the door just south of the above door and located in a two hour barrier revealed is self-closing and latching hardware did not self-close and latch the door.

On 08/23/16 at 2:11pm in an interview, Staff Q confirmed the finding.

6. On 08/23/16 at 2:34 PM observation of the door in the one hour barrier and 180 degrees from the nursing lounge and located at coordinates k3 revealed its self-closing and latching hardware did not close and latch the door.

On 08/23/16 at 2:34 PM in an interview, Staff Q confirmed the finding.

7. On 08/23/16 at 3:28 PM observation of the door at coordinates k2 (northern one hour barrier in the operating room) revealed it did not have a self-closer.

On 08/23/16 at 3:28 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure the barrier protecting each hazardous area was free of penetrations and each door self-closed. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

1. On 08/23/16 at 3:56 PM observation of the door to the biohazard room at coordinates h10 revealed it was in a one hour barrier but did not have a self-closer.

On 08/23/16 at 3:56 PM in an interview, Staff Q confirmed the finding.

2. On 08/23/16 at 3:57 PM observation above the drop down ceiling of the one hour barrier above that door revealed at the corner 180 degrees from it there were three copper lines with annular spaces.

On 08/23/16 at 3:57 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure the rated construction protecting hazardous areas were free of penetrations and the doors self-closed. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

1.On 08/23/16 at 10:34 AM observation above the drop down ceiling of the one hour barrier surrounding the biohazard room at coordinates f5-as seen from within--revealed 180 degrees from the door and at the corner a one foot by six inch section single layer of missing drywall.

On 08/23/16 at 10:34 AM in an interview, Staff Q confirmed the finding.

2. On 08/23/16 at 10:56 AM a corridor door to the laboratory and located at coordinates h7 was observed to not have a self-closer.

On 08/23/16 at 10:56 AM in an interview, Staff Q confirmed the finding.

3. On 08/23/16 at 3:12 PM observation of the door to the biohazard room in the intensive care unit revealed it was located in a one hour barrier but did not have self-closing and latching hardware.

On 08/23/16 at 3:12 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure its corridors were free and clear of paraphernalia. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

1.On 08/23/16 at 11:25 AM a portable x-ray machine was observed parked in the corridor near the double doors at coordinates h9.

On 08/23/16 at 11:25 AM in an interview, Staff R stated that is where it is stored.

2. On 08/24/16 at 9:10 AM a C-arm was observed in place in an exit corridor containing sleeping patient rooms. The C-arm was located 6 feet from an exit discharge door.

On 08/24/16 at 9:10 AM in an interview, Staff Q confirmed the finding.

Based on document review and interview, the facility failed to include a transmission of a fire alarm signal during each of its fire drills. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/24/16 a review of the facility's fire drills was completed. The review revealed on 6/30/15 at 9:30 PM, on 6/25/15 at 5:30 AM, on 08/28/15 at 9:30 PM, and on 09/30/15 at 5:00 AM the fire drills did not include the transmission of a fire alarm signal.

On 08/24/16 at 4:55 PM in an interview, Staff Q confirmed the signal was not transmitted because to do so would trigger the audible alarms.

Based on observation, document review, and interview, the facility failed to have ceiling tiles in place in certain areas to allow for heat to reach the sprinkler head as soon as possible, to have hydraulic name plates in place at risers per NFPA 25, 1999 edition, 2-2.7, and to have signs on control valves per NFPA 25, 1999 edition, 9-3. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/23/16 at 10:05 AM a tour was taken of the facility with Staff Q and M.

1.On 08/23/16 at 11:56 AM observation of the ceiling of the room adjacent to the MRI room (coordinates k8) revealed approximately half the ceiling tiles were missing while the sprinkler heads and smoke detectors remained in place (on tiles) so that heat and smoke would be unable to travel horizontally to them and thereby delay their activation.

On 08/23/16 at 11:56 AM in an interview, Staff Q confirmed the tiles were removed.

On 08/24/16 a review of the facility ' s fire sprinkler system inspection documentation was completed.

2. The review revealed on 04/28/16 and on 07/21/16 the hydraulic nameplates for the emergency department canopy and the kitchen canopy were not securely attached to the respective risers. The reports did state that " calculations in maintenance office. "

On 08/24/16 at 4:55 PM in an interview, Staff Q explained the hydraulic nameplates were not on each of their referenced riser, but lumped together on one.

3. On 08/24/16 a review of the facility ' s fire sprinkler system inspection documentation revealed on 04/28/16 and on 07/21/16 that " all valves should have signs on them. "

On 08/24/16 at 4:55 PM in an interview, Staff Q stated no signs were put on the valves.

4. On 08/24/16 a review of the facility ' s fire sprinkler system inspection documentation revealed on 04/28/16 and on 07/21/16 the four inch system to the building without a name revealed at line A1e, the gauge on the quick-opening device does not indicate the same pressure as the gauge on the system side of the dry-pipe valve. The note to this line stated, " Drain valves should be mapped. "

On 08/24/16 at 4:55 PM in an interview, Staff Q said he did not know what that meant.

Based on observation and interview, the facility failed to ensure its emergency power system complied with NFPA 99 (1999 edition), specifically 3-4.1.1.15. This has the potential to affect all patients and visitors to the facility. The facility had a census of 22 patients.

Findings include:

On 08/24/16 at 11:13 AM a tour was taken of the facility's emergency power system with Staff Q.

During the tour the facility was observed to have two diesel generators, one of which was outside, each with an annunciator on them. An annunciator panel was observed within an enclosed office, but the office was not in constant attendance.

During the tour Staff Q confirmed the observation.