HospitalInspections.org

Based on observation and interview, it was determined that the facility failed to maintain a common wall separation, including all components, with a fire resistance rating of at least two hours on one of three levels within this component.

Findings include:

1. Observation made on July 6, 2015 at 10:45 am, revealed that first floor glass corridor common wall fire doors, separating the MOB# 1 Building and the Cancer Center Building failed to close completely and positively latch when tested.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed doors require an adjustment to positive latch.

2. Observation made on July 6, 2015 at 9:50 am, revealed that located above first floor glass corridor, fire doors separating the MOB# 1 Building and the Cancer Center Building had an unsealed horizontal penetration around a 3" inch sprinkler main.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the penetration.

Based on observation and interview, it was determined that the facility failed to maintain a common wall separation, including all components, with a fire resistance rating of at least two hours on one of two levels within this component.

Findings include:

1. Observation made on July 6, 2015, at 10:45 am revealed that first floor common wall fire doors separating the MOB# 1 Building and the Cancer Center Building failed to close completely and positively latch when tested.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the doors require an adjustment to positively latch.

2. Observation made on July 6, 2015, at 9:50 am, revealed that located above fire doors separating the MOB# 1 Building and the Cancer Center Building there was an unsealed horizontal penetration around a 3" inch sprinkler main.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the penetration.

Based on observation and interview, it was determined that the facility failed to maintain the fire rating of the common walls in three of three smoke zones.

Findings include:

1. Observation on July 6, 2015, between 9:36 am and 11:22 am, revealed unsealed penetrations of the common walls at the following locations:

a. 9:36 am, first floor, above the ceiling in cubicle 13, a blue MC cable.
b. 10:36 am, second floor, Nuclear Medicine, conduit above the water pipe.
c. 11:22 am, third floor, 3C staff lounge, metal conduit and bundle of yellow wires.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed there were penetrations.

Based on observation and interview, it was determined that the facility failed to ensure that common fire walls are properly inspected and maintained free of unsealed penetrations in one of three levels within this component.

Finding include:

1. Observations made on July 6, 2015, between 11:42 am and 1:35 pm, revealed unsealed penetrations of common fire walls in the following locations:

a. 11:42 am, first floor above the ceiling of the double doors to Xray, circular hole with grey data wires.
b. 11:50 am, first floor above the ceiling of the double fire doors to Main that is by the Atrium, unsealed penetration.
c. 12:50 pm, first floor above the ceiling of the double fire doors to the MOB, unsealed penetration by a insulated pipe and a Armor cable and also unsealed conduit pipes near the sofit.
d. 1:35 pm, first floor above the double doors to X ray and Cat Scan, unsealed penetration of wall.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed unsealed penetrations of common fire walls in the above named locations.

Based on observation, document review and interview, it was determined that the facility failed to maintain the building construction requirements for the entire component.

Findings include:

1. Observation and document review made on July 8, 2015, between 9:00 am and 12:00 pm, revealed that the component is a three-story building, Type II (000) unprotected non-combustible construction. The story height exceeds the allowable height for unprotected noncombustible construction.

Interview at the exit conference with the Director of Plant Operations & Maintenance and the Executive Director on July 8, 2015, at 2:30 pm, confirmed the construction type and identified that the facility has an acceptable FSES reviewed on July 8, 2015 addressing this issue.

2. Observation made on July 6, 2015 at 10:34 am, revealed that the first floor MOB# 1 at elevator #8, there was a structural steel beam missing large sections of sprayed on fire proofing material.

Interview at the exit conference with the Director of Plant Operations & Maintenance and the Executive Director on July 8, 2015, at 2:30 pm, confirmed missing sprayed on fire proofing material.

Based on observation and interview, it was determined that the facility failed to maintain the building construction type in one of twelve smoke zones.

Findings include:

1. Observation made on July 8, 2015, between 1:20 pm and 1:44 pm, revealed the structural steel was not protected by a fire proofing material, at the following locations:

a. 1:20 pm, first floor, tele data closet at room 109, at the sprinkler head anchor.
b. 1:44 pm, first floor, above the corridor ceiling at Stair Tower 3, above the HVAC grille at the anchor for the conduit bank.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the steel was not protected.

Based on observation and interview, it was determined that the facility failed to maintain the fire rating of the structural steel in three of seven smoke zones.

Findings include:

1. Observation July 6, 2015, at 1:07 pm, revealed a section of the structural steel was missing the fire proofing material above the corridor ceiling between patient bays 6 and 7 on the third floor.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the steel was not protected.


2. Observation on July 7, 2015, between 9:24 am and 9:43 am, revealed sections of the structural steel was missing the fire proofing material in the following locations:

a. 9:24 am, first floor, about six feet from elevator 19, above the ceiling of the elevator lobby.
b. 9:43 am, first floor, at the back hall door to the conference rooms, at the device anchor.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the steel was not protected.

Based on observation and interview, it was determined that the facility failed to ensure that the fire resistive rating of structural steel beams are maintained on two of three levels within this component.

Findings include:

1. Observation made on July 6, 2015, between 9:27 am and 1:38 pm, revealed structural steel I beams that had missing spray on fire proofing material in the following locations:

a. 9:27 am, second floor shell space electrical room by stair tower # 1, beam missing fire proofing in two spots.
b. 1:38 pm, basement level large high voltage electrical room, missing fire proofing on the beam that is above the switch gear near the smoke detector and in a another spot along the same beam.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed missing spray on fire proofing material on the steel beams in the above named locations.

Based on observation and interview, it was determined that the facility failed to maintain the corridor smoke separation from the use area in one of eleven smoke zones.

Findings include:

Observation made on July 2, 2015, at 9:50 am, revealed a plastic open grate in the ceiling of the ER telecom room, on the first floor.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the ceiling was not smoke tight.

Based on observation and interview, it was determined that the facility failed to maintain the corridor smoke separation from use areas in one of three smoke zones.

Findings include:

Observation made on July 6, 2015, at 11:45 am, revealed a gap in the ceiling tile of room 3407, at the non-removable sprinkler escutcheon.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the ceiling tile was not smoke tight.

Based on observation and interview, it was determined that the facility failed to maintain the corridor smoke separation from use areas in one of twelve smoke zones.

Findings include:

Observation made on July 8, 2015, at 1:49 pm, revealed a penetration of a two inch sleeve for data wire in the corridor wall of the electrical room on the first floor, by Stair Tower 3.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed there was a penetration.

Based on observation and interview, it was determined that the facility failed to maintain doors protecting corridor openings, in other than hazardous areas, to close and positively latch into the frame in one of twelve smoke zones within this facility.

Findings include:

1. Observation made on July 8, 2015, between 10:10 am and 10:25 am, revealed that the following corridor doors failed to close completely and positively latch when tested.

a. 10:10 am, third floor south wing room 306.
b. 10:25 am, third floor south wing room 315.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the above doors require adjustment.

Based on observation and interview, it was determined that the facility failed to ensure the corridor doors positively latched into the door frame and remained closed in the frame in two of eleven smoke compartments.

Findings include:

1. Observation made on July 2, 2015, at 10:05 am, revealed on the fourth floor, the corridor door to room 4334 failed to close and positively latch into the door frame.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the door failed to close and positively latch.


2. Observation made on July 2, 2015, at 10:30 am, revealed the door to the radiology women's locker room failed to close and positively latch.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the door failed to close when tested.

Based on observation and interview, it was determined that the facility failed to ensure the corridor doors positively latched into the door frame and remained closed in the frame in two of fifteen smoke compartments within this component.

Findings include:

1. Observations made on July 6, 2015, between 11:45 am and 1:55 pm, revealed the corridor doors failed to positively latch at the following locations:

a. 11:45 am, third floor room 3325.
b. 1:55 pm, second floor single door to Pathology, the door was located across the corridor from the "slide block" storage room.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the doors failed to close properly.

Based on observation and interview, it was determined that the facility failed to maintain corridor doors free of obstructions in one of three smoke zones.

Findings include:

Observation made on July 6, 2015, at 11:37 am, revealed the inactive leaf of the door to third floor room 3415 was in the open position, and a trash can was placed in front of the active leaf.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the door was obstructed from closing.

Based on observation and interview, it was determined that the facility failed to maintain the corridor doors to be capable of positively latching in one of seven smoke zones.

Findings include:

Observation on July 7, 2015, at 9:29 am, revealed the strike plate of housekeeping 1201 door was stuffed to prevent it from latching.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the door failed to latch.

Based on observation and interview, it was determined that the facility failed to ensure that corridor doors are properly inspected and maintained to positively latch and are free of impediments to closing on two of three levels within this component.

Findings include:

1. Observations made on July 6, 2015, between 10:14 am and 2:23 pm, revealed corridor doors that failed to positively latch when tested in the following locations:

a. 10:14 am, first floor janitor's closet by the soiled room, strike plate taped over.
b. 10:57 am, first floor ER Pod # 1 bay # 4.
c. 11:11 am, first floor ER Pod # 2, treatment room # 24.
d. 2:23 pm, basement level main bio med room door.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the doors failed to positively latch when tested in the above named locations.

2. Observation made on July 6, 2015, at 2:07 pm, revealed that the basement level IT office door that is across from the wall mounted fire extinguisher was propped open by a computer hard drive column. The door is equipped with a self closer and exposes the exit access corridor. This condition was also observed in the morning on July 7, 2015.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the door was repeatedly propped open during the two day survey.

Based on observation and interview, it was determined that the facility failed to maintain vertical openings in one of twelve smoke zones within this facility.

Findings include:

Observation made on July 8, 2015, at 9:15 am, revealed that penthouse ventilation mechanical shaft for the generator by controls for AHU #3, had storage of miscellaneous building materials.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the shaft was being utilized for storage.

Based on observation and interview, it was determined that the facility failed to ensure that floor/ceiling slab assemblies are properly inspected and maintained free of unsealed penetrations in two of three levels within this component.

Findings include:

1. Observations made on July 6, 2015, between 10:02 am and 1:41 pm, revealed unsealed penetrations and cutouts of floor/ceiling slab assemblies in the following locations:

a. 10:02 am, first floor electrical room by the stair tower # 2, rectangular cut out of the ceiling slab assembly at the top of the two wall mounted electrical panels.
b. 1:41 pm, basement level medical air/vacuum pump room, three unsealed penetrations of the ceiling slab by pipes that are near med gas piping.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the cut out and unsealed penetrations of the ceiling slab assemblies in the above named locations.

Based on observation and interview, it was determined that the facility failed to maintain the proper fire resistance rating of the smoke barrier walls in four of fifteen smoke compartments within this component.

Findings include:

1. Observation made on July 6, 2015, at 9:15 am, on the fourth floor revealed there was a partially sealed sprinkler pipe penetration in the smoke barrier wall located by room 4456.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the partially sealed sprinkler pipe penetration.

2. Observations made on July 7, 2015, between 9:00 am and 9:10 am, revealed at the following locations there were unsealed penetrations of the smoke barrier walls:

a. 9:15 am, second floor, above the ceiling at the service elevator lobby, unsealed sprinkler pipe penetration of the relocated smoke barrier.
b. 9:10 am, second floor above the ceiling, unsealed large conduit penetration on the smoke barrier wall located by room 2202.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the unsealed penetrations of the smoke barrier walls.

Based on observation and interview, it was determined that the facility failed to maintain the proper fire resistance rating of the smoke barrier walls in three of eleven smoke compartments.

Findings include:

1. Observations made on July 2, 2015, between 9:22 am and 10:38 am, revealed there were unsealed or partially sealed penetrations of the smoke barrier walls in the following locations:

a. 9:22 am, ground floor, Atrium, above the ceiling at the elevator, toward the smoke barrier doors, above the sprinkler pipe, there was a hole in the wall.
b. 9:25 am, fourth floor East smoke barrier near the public elevators, penetration of bundle of black colored cable, partially sealed.
c. 9:35 am, fourth floor smoke barrier by room 4033, penetration of two sets of insulated pipes, partially sealed.
d. 9:36 am, ground floor, metal detector room, Atrium wall, a data wire penetration.
e. 9:55 am, ground floor, minor care suite, data wire penetration and a duct not sealed to the wall.
f. 10:03 am, ground floor, at consultation room, unsealed coaxial cable.
g. 10:38 am, outside room 1900, data wire penetration.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the improperly sealed smoke wall penetrations.

Based on observation and interview, it was determined that the facility failed to maintain the fire rating of the smoke barrier walls in two of twelve smoke zones.

Findings include:

1. Observation made on July 8, 2015, between 9:55 am and 1:00 pm, revealed penetrations of the smoke barrier walls in the following locations:

a. 9:55 am, third floor above smoke doors for Moss Rehabilitation around cable tray.
b. 11:07 am, ground floor, by the elevator lobby at the wall to the 3Bs, there were 3 holes where piping had been removed.
c. 11:22 am, ground floor, outside Conference Room A, across from the drinking fountain, the duct work was not sealed or angled to the smoke barrier wall.
d. 11:49 am, ground floor, wall to the 3Bs, above the fire bell, the duct work was not sealed or angled to the smoke barrier wall.
e. 1:00 pm, ground floor, in the doctors office for three B's with HVAC, sprinkler piping.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed there were penetrations.

Based on observation and interview, it was determined that the facility failed to ensure that smoke barrier walls are properly inspected and maintained free of cutouts and unsealed penetrations on one of three levels within this component.

Findings include:

1. Observations made on July 6, 2015, between 10:26 am and 11:20 am, revealed unsealed penetrations of smoke barrier walls in the following locations:

a. 10:26 am, first floor smoke barrier wall above ceiling of double doors to Pod # 2, unsealed penetration by insulated pipe.
b. 10: 28 am, first floor above the the smoke barrier doors to main hallway, circular cut out of the wall with a Armor cable penetration.
c. 11:00 am, first floor smoke barrier above the double doors by the nurse station an room
#1, unsealed penetration by a Armor cable that is behind a ductwork.
d. 11:20 am, first floor smoke barrier above the ceiling between the two sets of double doors and the sofit, cutout around a conduit pipe.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the cut outs and unsealed penetrations of smoke barrier walls in the above named locations.

2. Observations made on July 7, 2015, between 8:00 am and 8:05 am, revealed unsealed penetrations of smoke barrier walls in the following locations:

a. 8:00 am, first floor ER treatment room # 26 A/B bathroom, the holes in the wall below the med gas pipes.
b. 8:05 am, first floor trauma room, smoke wall has penetrations on three sides, one hole above the double doors, left side wall penetrations by conduit pipes and holes on the right side by data cables penetrations.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the cut outs and unsealed penetrations of smoke barrier walls in the above named locations.

Based on observation and interview, it was determined that the facility failed to maintain door openings in smoke barriers in one of twelve smoke zones within this facility component.

Findings include:

Observation made on July 8, 2015, at 11:45 am, revealed the ground floor smoke barrier door within the conference room/administration suite lacked self-closing hardware and a fire rated glass assembly.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the rated door opening was not maintained properly.

Based on observation and interview, it was determined that the facility failed to ensure the doors in the smoke barrier walls properly closed and maintain at least a twenty minute fire protection rating in four of fifteen smoke compartments within this component.

Findings include:

1. Observation made on July 6, 2015, at 11:30 am, revealed on the third floor, when tested, the corridor door for room 3300, which was also located within the smoke barrier wall, failed to close and positively latch into the frame.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the door located in the smoke barrier wall failed to close properly.

2. Observation made on July 6, 2015, at 2:10 pm, revealed on the second floor there were no doors installed within the communicating opening of the smoke barrier wall located at the service elevator lobby. The smoke barrier wall had been relocated during construction and the wall now follows along the corridor and across the opening to the service elevator lobby.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed there were no smoke doors installed within the corridor opening of the smoke barrier wall.

Based on observation and interview, it was determined that the facility failed to maintain the smoke barrier doors to be capable of self-closing and resisting the passage of smoke in two of eleven smoke zones.

Findings include:

Observation made on July 2, 2015, at 9:30 am, revealed the door between the security room and the Atrium was held open with a wedge.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the smoke barrier door was held open by an unauthorized device.

Based on observation and interview, it was determined that the facility failed to ensure that smoke barrier doors are properly inspected and maintained to fully close and resist the passage of smoke on two of three levels within this component.

Findings Include:

1. Observations made on July 6, 2015, between 9:49 am and 2:03 pm, revealed smoke barrier doors that failed to fully close and resist the passage of smoke when tested in the following locations:

a. 9:49 am, second floor shell space smoke barrier door by the ramp.
b. 10:58 am, first floor Pod # 1, right side door leaf smoke door by the acute treatment room # 1.
c. 2:03 pm, basement level smoke barrier right side door leaf failed to fully close.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the smoke barrier doors failed to fully close when tested in the above named locations.

Based on observation and interview, it was determined that the facility failed to ensure the doors to hazardous areas were self-closing and remain closed within the door frame on one of three levels within this component.
Findings include:

Observation made on July 6, 2015, at 9:25 am, revealed that the third floor MOB #2 electrical closet by suite #303 was being held open by an unauthorized means, a piece of wood in the strike plate.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the door was blocked open.

Based on observation and interview, it was determined that the facility failed to ensure the doors to hazardous areas were self-closing and remain closed within the door frame in one of fifteen smoke compartments within this component.

Findings include:

Observation made on July 7, 2015, at 10:10 am, revealed on the second floor, the room next to the laboratory lounge was used to store numerous cardboard boxes and other combustibles. The corridor door lacked a self-closing device. The room was greater than 50 square feet in area.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the storage room door lacked a self-closing device.

Based on observation and interview, it was determined that the facility failed to ensure the doors to hazardous areas were self-closing and remain closed within the door frame in two of eleven smoke compartments.
Findings include:

1. Observation made on July 2, 2015, between 10:00 am and 11:05 am, revealed that the following hazardous area doors failed to close and positively latch when tested.

a. 10:00 am, fourth floor ICU infectious waste corridor door.
b. 11:05 am, first floor bed storage room corridor door.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the doors failed to close properly.

Based on observation and interview, it was determined that the facility failed to maintain hazardous area doors to close, positively latch, and be smoke tight in conjunction with the sprinkler system in two of twelve smoke zones.

Findings include:

1. Observation made on July 8, 2015, at 9:30 am, revealed the third floor mechanical room paint shop door lacks a self-closure, the room is greater than fifty square feet and contains paints and thinners.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the door to the paint shop lacked a self-closure.

2. Observation made on July 8, 2015, at 9:55 am, revealed a gap in the drop ceiling system where a tile had fallen due to water damage in the ground floor elevator machine room.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the ceiling was not smoke tight.

Based on observation and interview, it was determined that the facility failed to ensure that hazardous areas are properly inspected and maintained, that doors are self closing without obstructions, that fire rating labels are visible, and walls are free of unsealed penetrations on three of three levels within this component.

Findings include:

1. Observations made on July 6, 2015, between 9:37 am and 2:20 pm, revealed unsealed penetrations and cutouts of rated room walls and shell spaces in the following locations:

a. 9:37 am, second floor shell space one hour wall , unsealed penetration by a conduit pipe that is next to junction box and a green Armor cable that is behind a ductwork near the junction box.
b. 10:20 am, first floor electrical room by the residents office, cutout of the wall by a conduit pipe at the corner of the doorway.
c. 1:03 pm, first floor future elevator machine room that is next to the SLA equipped doors, unsealed penetration by a conduit pipe that is next to a I beam that has a yellow cut Romex cable protruding from the wall.
d. 2:01 pm, basement level corridor above the ceiling of the double doors to the boiler room, hole in the cinderblock wall for a Armor cable.
e. 2:20 pm, basement level bio med storage room, cutout of the one hour wall above the ceiling by the door side wall.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed cutouts and unsealed penetration of rated walls in the above named locations.

2. Observation made on July 6, 2015, at 9:28 am, revealed that on the second floor shell space, the door to the electrical room that is next to stair tower # 1, lacks a fire rating label. The floor plans provided by the facility indicate that the door is part of a one hour rated wall.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the lack of a fire rating label on the door.

3. Observation made on July 6, 2015, at 12:53 pm, revealed that at the first floor shell space, the door next to the Atrium failed to positively latch when tested due to a taped over strike plate.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the door requires adjustment.

4. Observation made on July 6, 2015, at 2:13 pm, revealed that the basement level conference room is being used for storage of rolls combustible paper floor plans and cardboard boxes. Both doors to the room lack a self closer. Additionally, the conference room walls have a cutout of the inner drywall at the floor level around the perimeter of the room.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the lack of self closer on the doors and openings in the partitions.

5. Observation made on July 6, 2015, at 2:21 pm, revealed that the basement level bio med storage room door was propped open by a box. The storage room is greater that fifty square feet and door is equipped with a self closer.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the storage room door was propped open.

6. Observations made on July 7, 2015, between 8:22 am and 8:29 am, revealed storage room doors that failed to latch when tested in the following locations:

a. 8:22 am, basement level carpenter's shop double doors.
b. 8:29 am, basement level paint shop.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the doors failed to latch when tested in the above named locations.

Based on observation and interview, it was determined that the facility failed to ensure doors to exit stair towers were positive latching on one of three levels within this facility.

Findings include:

Observation made on July 6, 2015, at 9:40 am, revealed that the MOB #2 south stair tower access door failed to close completely and positively latch when tested.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the door required an adjustment to latch in the frame.

Based on observation and interview, it was determined that the facility failed to maintain the fire rating of the stair towers in one of one stair tower.

Findings include:

Observation made on July 6, 2015, at 10:44 am, revealed a partially sealed penetration by a sprinkler pipe into the stair tower in Nuclear IR Room 2316.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed there was a penetration.

Based on observation and interview, it was determined that the facility failed to maintain the fire rating of the stair towers in one of three stair towers.

Findings include:

Observation made on July 2, 2015, at 9:46 am, revealed a partially sealed penetration by a water pipe above the corridor ceiling into Stair Tower 1 inside the ER on the first floor.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed there was a penetration.

Based on observation and interview, it was determined that the facility failed to ensure that stair towers are properly inspected and maintained free of unsealed penetrations and that doors are self closing and positively latch when tested in two of three levels within this component.

Findings include:

1. Observation made on July 6, 2015, at 9:53 am, revealed that on the second floor shell space above stair tower # 2, there was an unsealed penetration of the stair tower wall by a conduit pipe.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the unsealed penetration of the stair tower wall.

2. Observation made on July 6, 2015, at 10:48 am, revealed that on the first floor ED, the exit access door to stair tower # 1 failed to positively latch when tested.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the stair tower exit access door failed to positively latch when tested.

Based on observation and interview, it was determined that the facility failed to ensure the stairways and smoke proof towers were free of obstructions on one of three levels within this component.

Findings include:

Observation made on July 6, 2015, at 10:17 am, revealed that the first floor MOB#1 west stair tower landing had a large commercial information sign stored inside the stairwell.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed there were items stored in the stair tower.

Based on observation and interview, it was determined that the facility failed to ensure that exit access and exit stairways are free from impediments and obstructions to egress on two of of six levels within this facility.

Findings include:

1. Observation made on July 2, 2015, at 9:35 am, revealed that the fifth floor west stair tower landing, there was storage of a chair and a step stool.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the impediments to egress.

2. Observation made on July 2, 2015, at 11:10 am, revealed that the second floor receiving/intravenous storage room door #2508, had a dead bolt lock installed.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the door was subject to locking.

Based on observation and interview, it was determined that the facility failed to ensure that exit access is properly inspected and maintained and that the use of padlocks does not interfere with egress on one of three levels within this component.

Findings include:

Observation made on July 6, 2015, at 9:31 am, revealed that on the second floor shell space there is a caged pen enclosure that has double doors secured by a pad lock which is not operational from the egress side of the pen enclose.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the use of the pad lock on the pen enclosure doors.

Based on observation and interview, it was determined that the facility failed to provide emergency lighting for at least 1½ hour duration in one of two smoke compartments.

Findings include:

Observation made on July 6, 2015, at 11:02 am, revealed that the second floor battery-operated emergency light fixture by elevator 2R, failed to illuminate when tested.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the emergency light did not work.

Based on observation and interview, it was determined that the facility failed to ensure that exit and directional signs are properly inspected and maintained on one of three levels within this component.

Findings include:

Observation made on July 6, 2015, at 10:44 am, revealed that on the first floor ED corridor that is at the corner by the soiled linen room, there is an exit sign with a directional arrow that directs you into a patient restroom. The stair tower down the corridor lacks an exit sign perpendicular to the stair tower exit access door.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the lack of a directional exit signs.

Based on document review and interview, it was determined that the facility failed to conduct fire drills once per shift per quarter within this facility component.

Findings include:

Document review made on July 8, 2015, between 1:00 pm and 1:45 pm, revealed that the first quarter third shift fire drill documentation was unavailable for review.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed that documentation was unavailable.

Based on document review and interview, it was determined that the facility failed to ensure that required inspections were conducted on one of one fire alarm system within this component.

Findings include:

Records reviewed on July 8, 2015, between 1:00 pm and 1:45 pm, revealed that documentation was unavailable indicating the semi-annual visual inspection of specific fire alarm system components had been conducted. The only records available were the annual functional test of fire alarm components conducted in March 2014 and March 2015.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the documentation was not available.

Based on document review and interview, it was determined that the facility failed to ensure that required inspections were conducted on one of one fire alarm system within this component.

Findings include:

Records reviewed on July 2, 2015, at 11:55 am, revealed that documentation was unavailable indicating the semi-annual visual inspection of specific fire alarm system components had been conducted. The only records available were the annual functional test of fire alarm components that had been conducted in April 2014 and April 2015.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the documentation was not available.

Based on document review and interview, it was determined that the facility failed to ensure that fire alarm semi annual inspections are conducted and documented within this component.

Findings include:

Document review made on July 7, 2015, between 11:00 am and 2:30 pm, revealed that the facility could not produce documentation of the semi annual fire alarm visual inspection during the time of the survey.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the lack of documentation for the semi annual fire alarm visual inspection.

Based on observation and interview, it was determined that the facility failed to maintain and inspect smoke detectors on one of three levels within this component.

Findings include:

1. Observation made on July 6, 2015, between 10:00 am and 10:20 am, revealed that the following area smoke detection devices were hanging by its wiring:

a. 10:00 am, MOB #2, second floor in the corridor by suite 215.
b. 10:20 am, MOB # 1, second floor in the corridor by suite 203 and the restroom.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the condition of the smoke detectors.

Based on observation and interview, it was determined that the facility failed to ensure new smoke detection devices were installed and operating properly in one of fifteen smoke compartments within this component.

Findings include:

1.Observation made on July 6, 2015 at 9:20 am, revealed on the fourth floor inside equipment room 4459, the suspended ceiling had been removed and there was a smoke detector hanging at the height of where the missing ceiling had been. The smoke detector was approximately three feet below the concrete deck/ceiling. The facility must verify if the smoke detector's current installation/location meets with the manufacturers installation recommendations.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the condition of the smoke detector.

2. Observation made on July 6, 2015, at 1:55 pm, revealed within the Main Building first floor IT room, the smoke detection device was hanging by its wiring.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the condition of the smoke detector.

Based on observation and interview, it was determined that the facility failed to ensure that buildings classified as fully sprinklered have sprinkler protection in all required areas in two of twelve smoke zones within this component.

Findings:

1. Observations made on July 8, 2015, between 9:25 am and 10:00 am, revealed that the third floor mechanical space area lacked sprinkler protection in the following locations:

a. Generator room.
b. ATS room.
c. Electrical room.
d. Both exhaust shafts that vent the generator radiators.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the above named areas lack sprinkler protection.

2. Observation made on July 8, 2015, between 10:20 am and 11:10 am, revealed missing sprinkler heads at the following locations:

a. 10:20 am, ground floor, kitchen, house keeping sink closet.
b. 10:33 am, ground floor, data room.
c. 10:56 am, ground floor, intern suite closet.
d. 11:10 am, ground floor, old physical therapy suite closets.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed these areas lacked sprinkler coverage.

Based on observation and interview, it was determined that the facility failed to maintain complete sprinkler coverage on one of three levels within this component.

Findings Include:

Observation made on July 6, 2015, at 10:48 am, revealed that the first floor MOB #1 Building, the outpatient registration front closet lacks automatic sprinkler protection.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the area lacks sprinkler protection.

Based on observation and interview, it was determined that the facility failed to ensure buildings that were classified as fully sprinklered had sprinkler protection in all required areas in one of fifteen smoke compartments within this component.

Findings:

Observation made on July 7, 2015, at 10:40 am, revealed that the third floor electrical closet located across from the OR locker rooms, lacked sprinkler protection. This is a repeat deficiency noted during the Relicensure Survey conducted on July 10, 2013.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the area lacked sprinkler protection.

Based on observation and interview, it was determined that the facility failed to ensure that sprinkler protection is properly inspected and maintained to provide complete coverage on one of three levels within this component.

Findings include:

Observation made on July 6, 2015, at 1:57 pm, revealed that in the basement level boiler room, there was an elevated HVAC air handler unit that was approximately eight feet by sixteen feet. The space below the air handler lacks sprinkler coverage and is being used for storage for two shelves with supplies.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed lack of sprinkler protection under the elevated air handler assembly.

Based on observation and interview, it was determined that the facility failed to maintain automatic sprinkler system components on one of three levels within this component.

Findings include:

1. Observation made on July 6, 2015, at 9:37 am, revealed on the third floor MOB #2 south stair tower, the stand pipe sprinkler pressure gauge was dated 2008. Verification that recalibration had occurred was not available.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed that the sprinkler system component was not maintained properly.

2. Observation made on July 6, 2015, at 10:40 am, revealed the first floor MOB #1 telecommunication/data room by mammography room #104, has a pendent sprinkler head installed instead of an upright sprinkler head due to a missing suspended ceiling assembly.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed sprinkler components were not maintained properly.

Based on observation and interview, it was determined that the facility failed to maintain the automatic fire sprinkler system components were in reliable operating condition in one of one smoke compartments within this facility.

Findings include:

Observation made on July 6, 2015 at 1:00 pm, revealed that within MRI equipment room, the pre-action sprinkler system (2) riser gauges were dated 2007.


Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the expired sprinkler gauges.

Based on observation and interview, it was determined that the facility failed to provide a continuously operating automatic sprinkler system with piping free of non-system components on one six levels within this component.

Findings include:

Observation made on July 2, 2015, at 11:20 am, revealed that the mechanical shaft inside the second floor receiving storage room, suspended ceiling assembly was supported off a 2" inch sprinkler branch.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed non-sprinkler system components supported off of the sprinkler system.

Based on observation and interview, it was determined that the facility failed to ensure the automatic sprinkler systems were maintained in a reliable operating condition, that there were no obstructions, and a smoke tight ceiling assembly was provided in of one of fifteen smoke compartments within this component.

Findings include:

1. Observation made on July 6, 2015, at 1:40 am, revealed on the second floor inside housekeeping room 2263, the ceiling mounted concealed sprinkler had been painted completely over and requires replacement.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the concealed sprinkler had been covered with paint.

2. Observation made on July 7, 2015, at 10:10 am, revealed in the storage room located next to the laboratory lounge, the ceiling mounted concealed sprinkler was missing it's cover.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the concealed sprinkler was missing it's cover.

3. Observations made on July 7, 2015, between 10:15 am and 10:25 am, revealed in the following areas, the suspended ceiling assembly was missing or there were several missing ceiling tiles, which could delay sprinkler operation.

a. 10:15 am, second floor two data server rooms located across the corridor from the laboratory, the suspended ceiling was completely missing. Pendant sprinklers were installed in the rooms
b. 10:25 am, second floor radiology electrical room (power conditioner room) located next to room 1323, several ceiling tiles were missing from the ceiling assembly.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the condition of the suspended ceilings.

Based on observation and interview, it was determined that the facility failed to ensure that the automatic sprinkler system is properly inspected and maintained, that sprinkler heads are free of obstructions and the walls and ceiling tiles resist the passage of smoke on two of three levels within this component.

Findings include:

1. Observations made on July 6, 2015, between 2:17 pm and 2:22 pm, revealed storage on top shelves within eighteen inches of sprinkler heads in the following locations:

a. 2:17 pm, basement level main bio med room, storage on top shelf's all around room.
b. 2:22 pm, basement level main bio med storage room, storage on top shelf's.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the storage on the top shelves in the above named locations.

2. Observation made on July 6, 2015, between 9:45 am and 2:16 pm, revealed holes in walls and missing and displaced ceiling tiles in the following locations:

a. 9:45 am, second floor shell space electrical room near the double doors, rectangular cutout of the drywall above electrical panel labeled CT-1 480 Y227 V 3 Ph 4 W, and gaps around a ductwork.
b. 11:36 am, first floor former hallway now small room with electrical closet, missing ceiling tile assembly.
c. 11:40 am, former hallway now large room with two electrical closets, missing ceiling assembly.
d. 2:08 pm, basement level bathroom next to the storage room and the IT office, two displaced tiles.
e. 2:16 pm, basement level bio med room and the smaller office that is inside the room several missing and displaced ceiling tiles.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed missing, displaced ceiling tiles and holes in the walls in the above named locations.

Based on observation and interview, it was determined that the facility failed to ensure that automatic sprinkler system components are inspected and maintained at the required intervals in one of twelve smoke zones.

Findings include:

Observation made on July 8, 2015, at 10:12 am, revealed inside the second floor cath lab pre-action sprinkler closet, there were two sprinkler gauges that were dated "09". Sprinkler system gauges are to be replaced at five (5) year intervals.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the sprinkler gauges were beyond the five (5) year service interval.

Based on observation and interview, it was determined that the facility failed to inspect and maintain portable fire extinguishers in operable condition on one of six levels within this facility.

Findings include:

Observation made July 2, 2015, at 9:50 am, revealed that in the penthouse mechanical room by the roof access door there was a portable fire extinguisher pressure gauge that was reading undercharge.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the fire extinguisher was not maintained properly.

Based on observation and interview, it was determined that the facility failed to perform monthly extinguisher quick checks in one of seven smoke zones.

Findings include:

Observation on July 7, 2015, at 11:15 am, revealed the monthly quick checks were not performed on the fire extinguisher located in the first floor mechanical space, near the sprinkler main.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the quick checks had not been recorded on the tag.

Based on observation and interview, it was determined that the facility failed to ensure that portable fire extinguishers are properly inspected and maintained fully charged and that annual inspections and monthly quick checks are conducted and documented on three of three levels within this component.

Findings include:

1. Observations made on July 6, 2015, between 9:29 am and 10:37 am, revealed portable fire extinguishers that were indicating a recharge condition in the following locations:

a. 9:29 am, second floor shell space second wall mounted fire extinguisher that is next to the shell space.
b. 10:37 am, first floor ED main entrance vestibule, unsecured fire extinguisher that was indicating a recharge condition. Monthly quick checks were not conducted for the months of May 2015 and June 2015.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the extinguishers required recharging in the above named locations.

2. Observation made on July 6, 2015, at 1:34 am, revealed that the basement level elevator machine room had a wall mounted fire extinguisher that had an expired annual inspection tag dated April 2014. The tag also indicated that the fire extinguisher had under gone monthly quick checks for the months of May 2015 and June 2015.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the missed annual inspection of the fire extinguisher in the elevator machine room.

Based on observation and interview, it was determined that the facility did not perform the required owner's quick checks on the kitchen ansul system in one of one ansul system.

Findings include:

Observation on July 2, 2015, at 10:45 am, revealed the facility had not recorded the required monthly quick checks on the kitchen and cafeteria serving area ansul system.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the quick checks were not recorded on the ansul system tags.

Based on document review and interview, it was determined that the facility failed to inspect cooking facility equipment within this component.

Findings include:

Document review made on July 8, 2015, at 2:15 pm, revealed the facility could not provide documentation that semi-annual kitchen hood cleaning had occurred between April 2014 and April 2015.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the facility could not provide the required documentation.

Based on observation and interview, it was determined that the facility failed to maintain medical gas storage and administration areas and ensure medical gas piping and supports do not support non-system components in two of fifteen smoke compartments.

Findings include:

Observation made on July 7, 2015, at 10:45 am, revealed in the third floor corridor by room 3328, the medical air piping had a black colored wire bundle attached for approximately twenty feet.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the wiring attached to the medical gas pipes.

Based on document review and interview, it was determined that the facility failed to ensure that emergency generator sets were properly inspected and maintained within this component.

Findings include:

Document review made on July 8, 2015, between 1:00 pm and 1:45 pm, revealed that the facility could not produce documentation of the emergency generator battery inspection for electrolyte levels/specific gravity during the time of the survey.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 8, 2015 at 2:30 pm, confirmed the lack of documentation for the emergency generator battery testing/inspection.

Based on document review and interview, it was determined that the facility failed to ensure that emergency generator sets were properly inspected and maintained within this component.

Findings include:

Document review made on July 2, 2015, at 10:45 am, revealed that the facility could not produce documentation of the emergency generator battery inspection for electrolyte levels/specific gravity during the time of the survey.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 2, 2015 at 1:00 pm, confirmed the lack of documentation for the emergency generator battery testing/inspection.

Based on observation, document review and interview, it was determined that the facility failed to ensure that emergency generator sets are properly inspected and maintained within this component.

Findings Include:

1. Observation made on July 7, 2015, at 10:33 am, revealed that the exterior generator set that services the MOB has a plastic Armor cable that is broken in the center area and is exposing the inner wiring to the elements and possible damage. The wiring is spliced together and is running from the battery charger to the rest of the generator set.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the broken plastic Armor cable and the exposed inner wiring.

2. Document review made on July 7, 2015, between 11:00 am and 2:30 pm, revealed that the facility could not produce documentation of the emergency generator battery inspection for electrolyte levels/specific gravity during the time of the survey.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the lack of documentation for the emergency generator battery testing/inspection.

Based on observation, interview and document review, it was determined that the facility failed to ensure that generator sets were properly inspected and maintained that battery electrolyte levels were checked and documented on a weekly basis within this component.

Findings include:

Document review made on July 7, 2015 between 11:00 am and 2:30 pm, revealed that the facility could not produce documentation of the generator battery weekly checking of electrolyte levels and specific gravity during the time of the survey.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the lack of generator battery electrolyte specific gravity checks documentation during the time of the survey.

Based on observation and interview, it was determined that the facility failed to ensure that temporary wiring was not used in place of permanent wiring and that surge protectors were properly used in three of fifteen smoke compartments within this component.

Findings include:

1. Observations made on July 6, 2015, between 9:40 am and 1:00 pm, revealed the unauthorized use of extension cords and surge protectors in the following areas:

a. 9:40 am, fourth floor neuro ICU nurse station, extension cord powering a surge protector utilized to power office equipment.
b. 9:50 am, inside equipment room 4402, yellow extension cord powering television control equipment.
c. 1:00 pm, third floor lounge 3365, two coffee makers powered through a surge protector.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the unauthorized use of extension cords and surge protectors.

2. Observation made on July 7, 2015, at 10:10 am, revealed on the second floor physical therapy room at the nurse station, there was an extension cord powering a surge protector that was utilized to power computer equipment.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the unauthorized use of a surge protector.

Based on observation and interview, it was determined that the facility failed to monitor the use of electrical devices and maintain the electrical components to be secured in two of seven smoke zones.

Findings include:

1. Observation made on July 6, 2015, at 1:41 pm, revealed a surge protector was plugged into a surge protector inside infection control room 3516.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the surge protectors were being improperly used.

2. Observation on July 7, 2015, at 10:20 am, revealed an open junction box inside the fire alarm office, in the first floor mechanical space.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed there was an open junction box.

Based on observation and interview, it was determined that the facility failed to monitor the use of electrical equipment for improper use of electrical devices in one of eleven smoke zones.

Findings include:

1. Observation on July 2, 2015, between 10:07 am and 11:17 am, revealed the improper use of surge protectors and extension cords at the following locations:

a. 10:07 am, first floor, Director of Physicians Office, there was an extension cord in use.
b. 11:03 am, second floor, Pharmacy, there was a surge protector plugged into a surge protector.
c. 11:05 am, second floor, Pharmacy, there was a refrigerator plugged into a surge protector by the Pyxis Distributor.
d. 11:17 am, second floor, Locksmith Shop, there was a microwave plugged into a surge protector.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the improper use of electrical equipment.

Based on observation and interview, it was determined that the facility failed to ensure that electrical wiring and equipment is properly inspected and maintained and that the improper use of powerstrips is prohibited on one of three levels within this component.

Findings include:

Observation made on July 6, 2015, at 10:21 am, revealed that in the first floor ER Supervisors office, there was a refrigerator that was plugged into a powerstrip.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the refrigerator was plugged into a powerstrip.

Based on observation and interview, it was determined that the facility failed to ensure that electrical wiring is adequately protected in one of twelve smoke zones.

Findings include:

Observation made on July 8, 2015, at 12:45 pm, revealed in the first floor Emergency Department, there was a section of MC type electrical wring that was dead ended into wire nuts and not in a protective electrical junction box.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the electrical wiring was not terminated in a protective electrical junction box

Based on observation and interview, it was determined that the facility failed to maintain a common wall separation, including all components, with a fire resistance rating of at least two hours on one of three levels within this component.

Findings include:

1. Observation made on July 6, 2015 at 10:45 am, revealed that first floor glass corridor common wall fire doors, separating the MOB# 1 Building and the Cancer Center Building failed to close completely and positively latch when tested.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed doors require an adjustment to positive latch.

2. Observation made on July 6, 2015 at 9:50 am, revealed that located above first floor glass corridor, fire doors separating the MOB# 1 Building and the Cancer Center Building had an unsealed horizontal penetration around a 3" inch sprinkler main.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the penetration.

Based on observation and interview, it was determined that the facility failed to maintain a common wall separation, including all components, with a fire resistance rating of at least two hours on one of two levels within this component.

Findings include:

1. Observation made on July 6, 2015, at 10:45 am revealed that first floor common wall fire doors separating the MOB# 1 Building and the Cancer Center Building failed to close completely and positively latch when tested.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the doors require an adjustment to positively latch.

2. Observation made on July 6, 2015, at 9:50 am, revealed that located above fire doors separating the MOB# 1 Building and the Cancer Center Building there was an unsealed horizontal penetration around a 3" inch sprinkler main.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the penetration.

Based on observation and interview, it was determined that the facility failed to maintain the fire rating of the common walls in three of three smoke zones.

Findings include:

1. Observation on July 6, 2015, between 9:36 am and 11:22 am, revealed unsealed penetrations of the common walls at the following locations:

a. 9:36 am, first floor, above the ceiling in cubicle 13, a blue MC cable.
b. 10:36 am, second floor, Nuclear Medicine, conduit above the water pipe.
c. 11:22 am, third floor, 3C staff lounge, metal conduit and bundle of yellow wires.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed there were penetrations.

Based on observation and interview, it was determined that the facility failed to ensure that common fire walls are properly inspected and maintained free of unsealed penetrations in one of three levels within this component.

Finding include:

1. Observations made on July 6, 2015, between 11:42 am and 1:35 pm, revealed unsealed penetrations of common fire walls in the following locations:

a. 11:42 am, first floor above the ceiling of the double doors to Xray, circular hole with grey data wires.
b. 11:50 am, first floor above the ceiling of the double fire doors to Main that is by the Atrium, unsealed penetration.
c. 12:50 pm, first floor above the ceiling of the double fire doors to the MOB, unsealed penetration by a insulated pipe and a Armor cable and also unsealed conduit pipes near the sofit.
d. 1:35 pm, first floor above the double doors to X ray and Cat Scan, unsealed penetration of wall.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed unsealed penetrations of common fire walls in the above named locations.

Based on observation, document review and interview, it was determined that the facility failed to maintain the building construction requirements for the entire component.

Findings include:

1. Observation and document review made on July 8, 2015, between 9:00 am and 12:00 pm, revealed that the component is a three-story building, Type II (000) unprotected non-combustible construction. The story height exceeds the allowable height for unprotected noncombustible construction.

Interview at the exit conference with the Director of Plant Operations & Maintenance and the Executive Director on July 8, 2015, at 2:30 pm, confirmed the construction type and identified that the facility has an acceptable FSES reviewed on July 8, 2015 addressing this issue.

2. Observation made on July 6, 2015 at 10:34 am, revealed that the first floor MOB# 1 at elevator #8, there was a structural steel beam missing large sections of sprayed on fire proofing material.

Interview at the exit conference with the Director of Plant Operations & Maintenance and the Executive Director on July 8, 2015, at 2:30 pm, confirmed missing sprayed on fire proofing material.

Based on observation and interview, it was determined that the facility failed to maintain the building construction type in one of twelve smoke zones.

Findings include:

1. Observation made on July 8, 2015, between 1:20 pm and 1:44 pm, revealed the structural steel was not protected by a fire proofing material, at the following locations:

a. 1:20 pm, first floor, tele data closet at room 109, at the sprinkler head anchor.
b. 1:44 pm, first floor, above the corridor ceiling at Stair Tower 3, above the HVAC grille at the anchor for the conduit bank.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the steel was not protected.

Based on observation and interview, it was determined that the facility failed to maintain the fire rating of the structural steel in three of seven smoke zones.

Findings include:

1. Observation July 6, 2015, at 1:07 pm, revealed a section of the structural steel was missing the fire proofing material above the corridor ceiling between patient bays 6 and 7 on the third floor.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the steel was not protected.


2. Observation on July 7, 2015, between 9:24 am and 9:43 am, revealed sections of the structural steel was missing the fire proofing material in the following locations:

a. 9:24 am, first floor, about six feet from elevator 19, above the ceiling of the elevator lobby.
b. 9:43 am, first floor, at the back hall door to the conference rooms, at the device anchor.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the steel was not protected.

Based on observation and interview, it was determined that the facility failed to ensure that the fire resistive rating of structural steel beams are maintained on two of three levels within this component.

Findings include:

1. Observation made on July 6, 2015, between 9:27 am and 1:38 pm, revealed structural steel I beams that had missing spray on fire proofing material in the following locations:

a. 9:27 am, second floor shell space electrical room by stair tower # 1, beam missing fire proofing in two spots.
b. 1:38 pm, basement level large high voltage electrical room, missing fire proofing on the beam that is above the switch gear near the smoke detector and in a another spot along the same beam.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed missing spray on fire proofing material on the steel beams in the above named locations.

Based on observation and interview, it was determined that the facility failed to maintain the corridor smoke separation from the use area in one of eleven smoke zones.

Findings include:

Observation made on July 2, 2015, at 9:50 am, revealed a plastic open grate in the ceiling of the ER telecom room, on the first floor.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the ceiling was not smoke tight.

Based on observation and interview, it was determined that the facility failed to maintain the corridor smoke separation from use areas in one of three smoke zones.

Findings include:

Observation made on July 6, 2015, at 11:45 am, revealed a gap in the ceiling tile of room 3407, at the non-removable sprinkler escutcheon.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the ceiling tile was not smoke tight.

Based on observation and interview, it was determined that the facility failed to maintain the corridor smoke separation from use areas in one of twelve smoke zones.

Findings include:

Observation made on July 8, 2015, at 1:49 pm, revealed a penetration of a two inch sleeve for data wire in the corridor wall of the electrical room on the first floor, by Stair Tower 3.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed there was a penetration.

Based on observation and interview, it was determined that the facility failed to maintain doors protecting corridor openings, in other than hazardous areas, to close and positively latch into the frame in one of twelve smoke zones within this facility.

Findings include:

1. Observation made on July 8, 2015, between 10:10 am and 10:25 am, revealed that the following corridor doors failed to close completely and positively latch when tested.

a. 10:10 am, third floor south wing room 306.
b. 10:25 am, third floor south wing room 315.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the above doors require adjustment.

Based on observation and interview, it was determined that the facility failed to ensure the corridor doors positively latched into the door frame and remained closed in the frame in two of eleven smoke compartments.

Findings include:

1. Observation made on July 2, 2015, at 10:05 am, revealed on the fourth floor, the corridor door to room 4334 failed to close and positively latch into the door frame.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the door failed to close and positively latch.


2. Observation made on July 2, 2015, at 10:30 am, revealed the door to the radiology women's locker room failed to close and positively latch.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the door failed to close when tested.

Based on observation and interview, it was determined that the facility failed to ensure the corridor doors positively latched into the door frame and remained closed in the frame in two of fifteen smoke compartments within this component.

Findings include:

1. Observations made on July 6, 2015, between 11:45 am and 1:55 pm, revealed the corridor doors failed to positively latch at the following locations:

a. 11:45 am, third floor room 3325.
b. 1:55 pm, second floor single door to Pathology, the door was located across the corridor from the "slide block" storage room.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the doors failed to close properly.

Based on observation and interview, it was determined that the facility failed to maintain corridor doors free of obstructions in one of three smoke zones.

Findings include:

Observation made on July 6, 2015, at 11:37 am, revealed the inactive leaf of the door to third floor room 3415 was in the open position, and a trash can was placed in front of the active leaf.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the door was obstructed from closing.

Based on observation and interview, it was determined that the facility failed to maintain the corridor doors to be capable of positively latching in one of seven smoke zones.

Findings include:

Observation on July 7, 2015, at 9:29 am, revealed the strike plate of housekeeping 1201 door was stuffed to prevent it from latching.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the door failed to latch.

Based on observation and interview, it was determined that the facility failed to ensure that corridor doors are properly inspected and maintained to positively latch and are free of impediments to closing on two of three levels within this component.

Findings include:

1. Observations made on July 6, 2015, between 10:14 am and 2:23 pm, revealed corridor doors that failed to positively latch when tested in the following locations:

a. 10:14 am, first floor janitor's closet by the soiled room, strike plate taped over.
b. 10:57 am, first floor ER Pod # 1 bay # 4.
c. 11:11 am, first floor ER Pod # 2, treatment room # 24.
d. 2:23 pm, basement level main bio med room door.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the doors failed to positively latch when tested in the above named locations.

2. Observation made on July 6, 2015, at 2:07 pm, revealed that the basement level IT office door that is across from the wall mounted fire extinguisher was propped open by a computer hard drive column. The door is equipped with a self closer and exposes the exit access corridor. This condition was also observed in the morning on July 7, 2015.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the door was repeatedly propped open during the two day survey.

Based on observation and interview, it was determined that the facility failed to maintain vertical openings in one of twelve smoke zones within this facility.

Findings include:

Observation made on July 8, 2015, at 9:15 am, revealed that penthouse ventilation mechanical shaft for the generator by controls for AHU #3, had storage of miscellaneous building materials.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the shaft was being utilized for storage.

Based on observation and interview, it was determined that the facility failed to ensure that floor/ceiling slab assemblies are properly inspected and maintained free of unsealed penetrations in two of three levels within this component.

Findings include:

1. Observations made on July 6, 2015, between 10:02 am and 1:41 pm, revealed unsealed penetrations and cutouts of floor/ceiling slab assemblies in the following locations:

a. 10:02 am, first floor electrical room by the stair tower # 2, rectangular cut out of the ceiling slab assembly at the top of the two wall mounted electrical panels.
b. 1:41 pm, basement level medical air/vacuum pump room, three unsealed penetrations of the ceiling slab by pipes that are near med gas piping.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the cut out and unsealed penetrations of the ceiling slab assemblies in the above named locations.

Based on observation and interview, it was determined that the facility failed to maintain the proper fire resistance rating of the smoke barrier walls in four of fifteen smoke compartments within this component.

Findings include:

1. Observation made on July 6, 2015, at 9:15 am, on the fourth floor revealed there was a partially sealed sprinkler pipe penetration in the smoke barrier wall located by room 4456.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the partially sealed sprinkler pipe penetration.

2. Observations made on July 7, 2015, between 9:00 am and 9:10 am, revealed at the following locations there were unsealed penetrations of the smoke barrier walls:

a. 9:15 am, second floor, above the ceiling at the service elevator lobby, unsealed sprinkler pipe penetration of the relocated smoke barrier.
b. 9:10 am, second floor above the ceiling, unsealed large conduit penetration on the smoke barrier wall located by room 2202.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the unsealed penetrations of the smoke barrier walls.

Based on observation and interview, it was determined that the facility failed to maintain the proper fire resistance rating of the smoke barrier walls in three of eleven smoke compartments.

Findings include:

1. Observations made on July 2, 2015, between 9:22 am and 10:38 am, revealed there were unsealed or partially sealed penetrations of the smoke barrier walls in the following locations:

a. 9:22 am, ground floor, Atrium, above the ceiling at the elevator, toward the smoke barrier doors, above the sprinkler pipe, there was a hole in the wall.
b. 9:25 am, fourth floor East smoke barrier near the public elevators, penetration of bundle of black colored cable, partially sealed.
c. 9:35 am, fourth floor smoke barrier by room 4033, penetration of two sets of insulated pipes, partially sealed.
d. 9:36 am, ground floor, metal detector room, Atrium wall, a data wire penetration.
e. 9:55 am, ground floor, minor care suite, data wire penetration and a duct not sealed to the wall.
f. 10:03 am, ground floor, at consultation room, unsealed coaxial cable.
g. 10:38 am, outside room 1900, data wire penetration.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the improperly sealed smoke wall penetrations.

Based on observation and interview, it was determined that the facility failed to maintain the fire rating of the smoke barrier walls in two of twelve smoke zones.

Findings include:

1. Observation made on July 8, 2015, between 9:55 am and 1:00 pm, revealed penetrations of the smoke barrier walls in the following locations:

a. 9:55 am, third floor above smoke doors for Moss Rehabilitation around cable tray.
b. 11:07 am, ground floor, by the elevator lobby at the wall to the 3Bs, there were 3 holes where piping had been removed.
c. 11:22 am, ground floor, outside Conference Room A, across from the drinking fountain, the duct work was not sealed or angled to the smoke barrier wall.
d. 11:49 am, ground floor, wall to the 3Bs, above the fire bell, the duct work was not sealed or angled to the smoke barrier wall.
e. 1:00 pm, ground floor, in the doctors office for three B's with HVAC, sprinkler piping.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed there were penetrations.

Based on observation and interview, it was determined that the facility failed to ensure that smoke barrier walls are properly inspected and maintained free of cutouts and unsealed penetrations on one of three levels within this component.

Findings include:

1. Observations made on July 6, 2015, between 10:26 am and 11:20 am, revealed unsealed penetrations of smoke barrier walls in the following locations:

a. 10:26 am, first floor smoke barrier wall above ceiling of double doors to Pod # 2, unsealed penetration by insulated pipe.
b. 10: 28 am, first floor above the the smoke barrier doors to main hallway, circular cut out of the wall with a Armor cable penetration.
c. 11:00 am, first floor smoke barrier above the double doors by the nurse station an room
#1, unsealed penetration by a Armor cable that is behind a ductwork.
d. 11:20 am, first floor smoke barrier above the ceiling between the two sets of double doors and the sofit, cutout around a conduit pipe.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the cut outs and unsealed penetrations of smoke barrier walls in the above named locations.

2. Observations made on July 7, 2015, between 8:00 am and 8:05 am, revealed unsealed penetrations of smoke barrier walls in the following locations:

a. 8:00 am, first floor ER treatment room # 26 A/B bathroom, the holes in the wall below the med gas pipes.
b. 8:05 am, first floor trauma room, smoke wall has penetrations on three sides, one hole above the double doors, left side wall penetrations by conduit pipes and holes on the right side by data cables penetrations.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the cut outs and unsealed penetrations of smoke barrier walls in the above named locations.

Based on observation and interview, it was determined that the facility failed to maintain door openings in smoke barriers in one of twelve smoke zones within this facility component.

Findings include:

Observation made on July 8, 2015, at 11:45 am, revealed the ground floor smoke barrier door within the conference room/administration suite lacked self-closing hardware and a fire rated glass assembly.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the rated door opening was not maintained properly.

Based on observation and interview, it was determined that the facility failed to ensure the doors in the smoke barrier walls properly closed and maintain at least a twenty minute fire protection rating in four of fifteen smoke compartments within this component.

Findings include:

1. Observation made on July 6, 2015, at 11:30 am, revealed on the third floor, when tested, the corridor door for room 3300, which was also located within the smoke barrier wall, failed to close and positively latch into the frame.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the door located in the smoke barrier wall failed to close properly.

2. Observation made on July 6, 2015, at 2:10 pm, revealed on the second floor there were no doors installed within the communicating opening of the smoke barrier wall located at the service elevator lobby. The smoke barrier wall had been relocated during construction and the wall now follows along the corridor and across the opening to the service elevator lobby.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed there were no smoke doors installed within the corridor opening of the smoke barrier wall.

Based on observation and interview, it was determined that the facility failed to maintain the smoke barrier doors to be capable of self-closing and resisting the passage of smoke in two of eleven smoke zones.

Findings include:

Observation made on July 2, 2015, at 9:30 am, revealed the door between the security room and the Atrium was held open with a wedge.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the smoke barrier door was held open by an unauthorized device.

Based on observation and interview, it was determined that the facility failed to ensure that smoke barrier doors are properly inspected and maintained to fully close and resist the passage of smoke on two of three levels within this component.

Findings Include:

1. Observations made on July 6, 2015, between 9:49 am and 2:03 pm, revealed smoke barrier doors that failed to fully close and resist the passage of smoke when tested in the following locations:

a. 9:49 am, second floor shell space smoke barrier door by the ramp.
b. 10:58 am, first floor Pod # 1, right side door leaf smoke door by the acute treatment room # 1.
c. 2:03 pm, basement level smoke barrier right side door leaf failed to fully close.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the smoke barrier doors failed to fully close when tested in the above named locations.

Based on observation and interview, it was determined that the facility failed to ensure the doors to hazardous areas were self-closing and remain closed within the door frame on one of three levels within this component.
Findings include:

Observation made on July 6, 2015, at 9:25 am, revealed that the third floor MOB #2 electrical closet by suite #303 was being held open by an unauthorized means, a piece of wood in the strike plate.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the door was blocked open.

Based on observation and interview, it was determined that the facility failed to ensure the doors to hazardous areas were self-closing and remain closed within the door frame in one of fifteen smoke compartments within this component.

Findings include:

Observation made on July 7, 2015, at 10:10 am, revealed on the second floor, the room next to the laboratory lounge was used to store numerous cardboard boxes and other combustibles. The corridor door lacked a self-closing device. The room was greater than 50 square feet in area.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the storage room door lacked a self-closing device.

Based on observation and interview, it was determined that the facility failed to ensure the doors to hazardous areas were self-closing and remain closed within the door frame in two of eleven smoke compartments.
Findings include:

1. Observation made on July 2, 2015, between 10:00 am and 11:05 am, revealed that the following hazardous area doors failed to close and positively latch when tested.

a. 10:00 am, fourth floor ICU infectious waste corridor door.
b. 11:05 am, first floor bed storage room corridor door.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the doors failed to close properly.

Based on observation and interview, it was determined that the facility failed to maintain hazardous area doors to close, positively latch, and be smoke tight in conjunction with the sprinkler system in two of twelve smoke zones.

Findings include:

1. Observation made on July 8, 2015, at 9:30 am, revealed the third floor mechanical room paint shop door lacks a self-closure, the room is greater than fifty square feet and contains paints and thinners.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the door to the paint shop lacked a self-closure.

2. Observation made on July 8, 2015, at 9:55 am, revealed a gap in the drop ceiling system where a tile had fallen due to water damage in the ground floor elevator machine room.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the ceiling was not smoke tight.

Based on observation and interview, it was determined that the facility failed to ensure that hazardous areas are properly inspected and maintained, that doors are self closing without obstructions, that fire rating labels are visible, and walls are free of unsealed penetrations on three of three levels within this component.

Findings include:

1. Observations made on July 6, 2015, between 9:37 am and 2:20 pm, revealed unsealed penetrations and cutouts of rated room walls and shell spaces in the following locations:

a. 9:37 am, second floor shell space one hour wall , unsealed penetration by a conduit pipe that is next to junction box and a green Armor cable that is behind a ductwork near the junction box.
b. 10:20 am, first floor electrical room by the residents office, cutout of the wall by a conduit pipe at the corner of the doorway.
c. 1:03 pm, first floor future elevator machine room that is next to the SLA equipped doors, unsealed penetration by a conduit pipe that is next to a I beam that has a yellow cut Romex cable protruding from the wall.
d. 2:01 pm, basement level corridor above the ceiling of the double doors to the boiler room, hole in the cinderblock wall for a Armor cable.
e. 2:20 pm, basement level bio med storage room, cutout of the one hour wall above the ceiling by the door side wall.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed cutouts and unsealed penetration of rated walls in the above named locations.

2. Observation made on July 6, 2015, at 9:28 am, revealed that on the second floor shell space, the door to the electrical room that is next to stair tower # 1, lacks a fire rating label. The floor plans provided by the facility indicate that the door is part of a one hour rated wall.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the lack of a fire rating label on the door.

3. Observation made on July 6, 2015, at 12:53 pm, revealed that at the first floor shell space, the door next to the Atrium failed to positively latch when tested due to a taped over strike plate.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the door requires adjustment.

4. Observation made on July 6, 2015, at 2:13 pm, revealed that the basement level conference room is being used for storage of rolls combustible paper floor plans and cardboard boxes. Both doors to the room lack a self closer. Additionally, the conference room walls have a cutout of the inner drywall at the floor level around the perimeter of the room.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the lack of self closer on the doors and openings in the partitions.

5. Observation made on July 6, 2015, at 2:21 pm, revealed that the basement level bio med storage room door was propped open by a box. The storage room is greater that fifty square feet and door is equipped with a self closer.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the storage room door was propped open.

6. Observations made on July 7, 2015, between 8:22 am and 8:29 am, revealed storage room doors that failed to latch when tested in the following locations:

a. 8:22 am, basement level carpenter's shop double doors.
b. 8:29 am, basement level paint shop.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the doors failed to latch when tested in the above named locations.

Based on observation and interview, it was determined that the facility failed to ensure doors to exit stair towers were positive latching on one of three levels within this facility.

Findings include:

Observation made on July 6, 2015, at 9:40 am, revealed that the MOB #2 south stair tower access door failed to close completely and positively latch when tested.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the door required an adjustment to latch in the frame.

Based on observation and interview, it was determined that the facility failed to maintain the fire rating of the stair towers in one of one stair tower.

Findings include:

Observation made on July 6, 2015, at 10:44 am, revealed a partially sealed penetration by a sprinkler pipe into the stair tower in Nuclear IR Room 2316.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed there was a penetration.

Based on observation and interview, it was determined that the facility failed to maintain the fire rating of the stair towers in one of three stair towers.

Findings include:

Observation made on July 2, 2015, at 9:46 am, revealed a partially sealed penetration by a water pipe above the corridor ceiling into Stair Tower 1 inside the ER on the first floor.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed there was a penetration.

Based on observation and interview, it was determined that the facility failed to ensure that stair towers are properly inspected and maintained free of unsealed penetrations and that doors are self closing and positively latch when tested in two of three levels within this component.

Findings include:

1. Observation made on July 6, 2015, at 9:53 am, revealed that on the second floor shell space above stair tower # 2, there was an unsealed penetration of the stair tower wall by a conduit pipe.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the unsealed penetration of the stair tower wall.

2. Observation made on July 6, 2015, at 10:48 am, revealed that on the first floor ED, the exit access door to stair tower # 1 failed to positively latch when tested.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the stair tower exit access door failed to positively latch when tested.

Based on observation and interview, it was determined that the facility failed to ensure the stairways and smoke proof towers were free of obstructions on one of three levels within this component.

Findings include:

Observation made on July 6, 2015, at 10:17 am, revealed that the first floor MOB#1 west stair tower landing had a large commercial information sign stored inside the stairwell.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed there were items stored in the stair tower.

Based on observation and interview, it was determined that the facility failed to ensure that exit access and exit stairways are free from impediments and obstructions to egress on two of of six levels within this facility.

Findings include:

1. Observation made on July 2, 2015, at 9:35 am, revealed that the fifth floor west stair tower landing, there was storage of a chair and a step stool.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the impediments to egress.

2. Observation made on July 2, 2015, at 11:10 am, revealed that the second floor receiving/intravenous storage room door #2508, had a dead bolt lock installed.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the door was subject to locking.

Based on observation and interview, it was determined that the facility failed to ensure that exit access is properly inspected and maintained and that the use of padlocks does not interfere with egress on one of three levels within this component.

Findings include:

Observation made on July 6, 2015, at 9:31 am, revealed that on the second floor shell space there is a caged pen enclosure that has double doors secured by a pad lock which is not operational from the egress side of the pen enclose.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the use of the pad lock on the pen enclosure doors.

Based on observation and interview, it was determined that the facility failed to provide emergency lighting for at least 1½ hour duration in one of two smoke compartments.

Findings include:

Observation made on July 6, 2015, at 11:02 am, revealed that the second floor battery-operated emergency light fixture by elevator 2R, failed to illuminate when tested.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the emergency light did not work.

Based on observation and interview, it was determined that the facility failed to ensure that exit and directional signs are properly inspected and maintained on one of three levels within this component.

Findings include:

Observation made on July 6, 2015, at 10:44 am, revealed that on the first floor ED corridor that is at the corner by the soiled linen room, there is an exit sign with a directional arrow that directs you into a patient restroom. The stair tower down the corridor lacks an exit sign perpendicular to the stair tower exit access door.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the lack of a directional exit signs.

Based on document review and interview, it was determined that the facility failed to conduct fire drills once per shift per quarter within this facility component.

Findings include:

Document review made on July 8, 2015, between 1:00 pm and 1:45 pm, revealed that the first quarter third shift fire drill documentation was unavailable for review.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed that documentation was unavailable.

Based on document review and interview, it was determined that the facility failed to ensure that required inspections were conducted on one of one fire alarm system within this component.

Findings include:

Records reviewed on July 8, 2015, between 1:00 pm and 1:45 pm, revealed that documentation was unavailable indicating the semi-annual visual inspection of specific fire alarm system components had been conducted. The only records available were the annual functional test of fire alarm components conducted in March 2014 and March 2015.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the documentation was not available.

Based on document review and interview, it was determined that the facility failed to ensure that required inspections were conducted on one of one fire alarm system within this component.

Findings include:

Records reviewed on July 2, 2015, at 11:55 am, revealed that documentation was unavailable indicating the semi-annual visual inspection of specific fire alarm system components had been conducted. The only records available were the annual functional test of fire alarm components that had been conducted in April 2014 and April 2015.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the documentation was not available.

Based on document review and interview, it was determined that the facility failed to ensure required testing was conducted for the fire alarm system within this component.

Findings include:

Document review made on July 7, 2015, between 11:00 am and 2:30 pm, revealed that the facility could not produce documentation of the semi annual fire alarm visual inspection during the time of the survey.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the lack of documentation for the semi annual fire alarm visual inspection.

Based on document review and interview, it was determined that the facility failed to ensure required testing was conducted for the fire alarm sytem within this component.

Findings include:

Document review made on July 7, 2015, between 11:00 am and 2:30 pm, revealed that the facility could not produce documentation of the semi annual fire alarm visual inspection during the time of the survey.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the lack of documentation for the semi annual fire alarm visual inspection.

Based on document review and interview, it was determined that the facility failed to ensure that fire alarm semi annual inspections are conducted and documented within this component.

Findings include:

Document review made on July 7, 2015, between 11:00 am and 2:30 pm, revealed that the facility could not produce documentation of the semi annual fire alarm visual inspection during the time of the survey.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the lack of documentation for the semi annual fire alarm visual inspection.

Based on observation and interview, it was determined that the facility failed to maintain and inspect smoke detectors on one of three levels within this component.

Findings include:

1. Observation made on July 6, 2015, between 10:00 am and 10:20 am, revealed that the following area smoke detection devices were hanging by its wiring:

a. 10:00 am, MOB #2, second floor in the corridor by suite 215.
b. 10:20 am, MOB # 1, second floor in the corridor by suite 203 and the restroom.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the condition of the smoke detectors.

Based on observation and interview, it was determined that the facility failed to ensure new smoke detection devices were installed and operating properly in one of fifteen smoke compartments within this component.

Findings include:

1.Observation made on July 6, 2015 at 9:20 am, revealed on the fourth floor inside equipment room 4459, the suspended ceiling had been removed and there was a smoke detector hanging at the height of where the missing ceiling had been. The smoke detector was approximately three feet below the concrete deck/ceiling. The facility must verify if the smoke detector's current installation/location meets with the manufacturers installation recommendations.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the condition of the smoke detector.

2. Observation made on July 6, 2015, at 1:55 pm, revealed within the Main Building first floor IT room, the smoke detection device was hanging by its wiring.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the condition of the smoke detector.

Based on observation and interview, it was determined that the facility failed to ensure that buildings classified as fully sprinklered have sprinkler protection in all required areas in two of twelve smoke zones within this component.

Findings:

1. Observations made on July 8, 2015, between 9:25 am and 10:00 am, revealed that the third floor mechanical space area lacked sprinkler protection in the following locations:

a. Generator room.
b. ATS room.
c. Electrical room.
d. Both exhaust shafts that vent the generator radiators.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the above named areas lack sprinkler protection.

2. Observation made on July 8, 2015, between 10:20 am and 11:10 am, revealed missing sprinkler heads at the following locations:

a. 10:20 am, ground floor, kitchen, house keeping sink closet.
b. 10:33 am, ground floor, data room.
c. 10:56 am, ground floor, intern suite closet.
d. 11:10 am, ground floor, old physical therapy suite closets.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed these areas lacked sprinkler coverage.

Based on observation and interview, it was determined that the facility failed to maintain complete sprinkler coverage on one of three levels within this component.

Findings Include:

Observation made on July 6, 2015, at 10:48 am, revealed that the first floor MOB #1 Building, the outpatient registration front closet lacks automatic sprinkler protection.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the area lacks sprinkler protection.

Based on observation and interview, it was determined that the facility failed to ensure buildings that were classified as fully sprinklered had sprinkler protection in all required areas in one of fifteen smoke compartments within this component.

Findings:

Observation made on July 7, 2015, at 10:40 am, revealed that the third floor electrical closet located across from the OR locker rooms, lacked sprinkler protection. This is a repeat deficiency noted during the Relicensure Survey conducted on July 10, 2013.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the area lacked sprinkler protection.

Based on observation and interview, it was determined that the facility failed to ensure that sprinkler protection is properly inspected and maintained to provide complete coverage on one of three levels within this component.

Findings include:

Observation made on July 6, 2015, at 1:57 pm, revealed that in the basement level boiler room, there was an elevated HVAC air handler unit that was approximately eight feet by sixteen feet. The space below the air handler lacks sprinkler coverage and is being used for storage for two shelves with supplies.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed lack of sprinkler protection under the elevated air handler assembly.

Based on observation and interview, it was determined that the facility failed to maintain automatic sprinkler system components on one of three levels within this component.

Findings include:

1. Observation made on July 6, 2015, at 9:37 am, revealed on the third floor MOB #2 south stair tower, the stand pipe sprinkler pressure gauge was dated 2008. Verification that recalibration had occurred was not available.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed that the sprinkler system component was not maintained properly.

2. Observation made on July 6, 2015, at 10:40 am, revealed the first floor MOB #1 telecommunication/data room by mammography room #104, has a pendent sprinkler head installed instead of an upright sprinkler head due to a missing suspended ceiling assembly.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed sprinkler components were not maintained properly.

Based on observation and interview, it was determined that the facility failed to maintain the automatic fire sprinkler system components were in reliable operating condition in one of one smoke compartments within this facility.

Findings include:

Observation made on July 6, 2015 at 1:00 pm, revealed that within MRI equipment room, the pre-action sprinkler system (2) riser gauges were dated 2007.


Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the expired sprinkler gauges.

Based on observation and interview, it was determined that the facility failed to provide a continuously operating automatic sprinkler system with piping free of non-system components on one six levels within this component.

Findings include:

Observation made on July 2, 2015, at 11:20 am, revealed that the mechanical shaft inside the second floor receiving storage room, suspended ceiling assembly was supported off a 2" inch sprinkler branch.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed non-sprinkler system components supported off of the sprinkler system.

Based on observation and interview, it was determined that the facility failed to ensure the automatic sprinkler systems were maintained in a reliable operating condition, that there were no obstructions, and a smoke tight ceiling assembly was provided in of one of fifteen smoke compartments within this component.

Findings include:

1. Observation made on July 6, 2015, at 1:40 am, revealed on the second floor inside housekeeping room 2263, the ceiling mounted concealed sprinkler had been painted completely over and requires replacement.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the concealed sprinkler had been covered with paint.

2. Observation made on July 7, 2015, at 10:10 am, revealed in the storage room located next to the laboratory lounge, the ceiling mounted concealed sprinkler was missing it's cover.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the concealed sprinkler was missing it's cover.

3. Observations made on July 7, 2015, between 10:15 am and 10:25 am, revealed in the following areas, the suspended ceiling assembly was missing or there were several missing ceiling tiles, which could delay sprinkler operation.

a. 10:15 am, second floor two data server rooms located across the corridor from the laboratory, the suspended ceiling was completely missing. Pendant sprinklers were installed in the rooms
b. 10:25 am, second floor radiology electrical room (power conditioner room) located next to room 1323, several ceiling tiles were missing from the ceiling assembly.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the condition of the suspended ceilings.

Based on observation and interview, it was determined that the facility failed to ensure that the automatic sprinkler system is properly inspected and maintained, that sprinkler heads are free of obstructions and the walls and ceiling tiles resist the passage of smoke on two of three levels within this component.

Findings include:

1. Observations made on July 6, 2015, between 2:17 pm and 2:22 pm, revealed storage on top shelves within eighteen inches of sprinkler heads in the following locations:

a. 2:17 pm, basement level main bio med room, storage on top shelf's all around room.
b. 2:22 pm, basement level main bio med storage room, storage on top shelf's.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the storage on the top shelves in the above named locations.

2. Observation made on July 6, 2015, between 9:45 am and 2:16 pm, revealed holes in walls and missing and displaced ceiling tiles in the following locations:

a. 9:45 am, second floor shell space electrical room near the double doors, rectangular cutout of the drywall above electrical panel labeled CT-1 480 Y227 V 3 Ph 4 W, and gaps around a ductwork.
b. 11:36 am, first floor former hallway now small room with electrical closet, missing ceiling tile assembly.
c. 11:40 am, former hallway now large room with two electrical closets, missing ceiling assembly.
d. 2:08 pm, basement level bathroom next to the storage room and the IT office, two displaced tiles.
e. 2:16 pm, basement level bio med room and the smaller office that is inside the room several missing and displaced ceiling tiles.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed missing, displaced ceiling tiles and holes in the walls in the above named locations.

Based on observation and interview, it was determined that the facility failed to ensure that automatic sprinkler system components are inspected and maintained at the required intervals in one of twelve smoke zones.

Findings include:

Observation made on July 8, 2015, at 10:12 am, revealed inside the second floor cath lab pre-action sprinkler closet, there were two sprinkler gauges that were dated "09". Sprinkler system gauges are to be replaced at five (5) year intervals.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the sprinkler gauges were beyond the five (5) year service interval.

Based on observation and interview, it was determined that the facility failed to inspect and maintain portable fire extinguishers in operable condition on one of six levels within this facility.

Findings include:

Observation made July 2, 2015, at 9:50 am, revealed that in the penthouse mechanical room by the roof access door there was a portable fire extinguisher pressure gauge that was reading undercharge.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the fire extinguisher was not maintained properly.

Based on observation and interview, it was determined that the facility failed to perform monthly extinguisher quick checks in one of seven smoke zones.

Findings include:

Observation on July 7, 2015, at 11:15 am, revealed the monthly quick checks were not performed on the fire extinguisher located in the first floor mechanical space, near the sprinkler main.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the quick checks had not been recorded on the tag.

Based on observation and interview, it was determined that the facility failed to ensure that portable fire extinguishers are properly inspected and maintained fully charged and that annual inspections and monthly quick checks are conducted and documented on three of three levels within this component.

Findings include:

1. Observations made on July 6, 2015, between 9:29 am and 10:37 am, revealed portable fire extinguishers that were indicating a recharge condition in the following locations:

a. 9:29 am, second floor shell space second wall mounted fire extinguisher that is next to the shell space.
b. 10:37 am, first floor ED main entrance vestibule, unsecured fire extinguisher that was indicating a recharge condition. Monthly quick checks were not conducted for the months of May 2015 and June 2015.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the extinguishers required recharging in the above named locations.

2. Observation made on July 6, 2015, at 1:34 am, revealed that the basement level elevator machine room had a wall mounted fire extinguisher that had an expired annual inspection tag dated April 2014. The tag also indicated that the fire extinguisher had under gone monthly quick checks for the months of May 2015 and June 2015.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the missed annual inspection of the fire extinguisher in the elevator machine room.

Based on observation and interview, it was determined that the facility did not perform the required owner's quick checks on the kitchen ansul system in one of one ansul system.

Findings include:

Observation on July 2, 2015, at 10:45 am, revealed the facility had not recorded the required monthly quick checks on the kitchen and cafeteria serving area ansul system.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the quick checks were not recorded on the ansul system tags.

Based on document review and interview, it was determined that the facility failed to inspect cooking facility equipment within this component.

Findings include:

Document review made on July 8, 2015, at 2:15 pm, revealed the facility could not provide documentation that semi-annual kitchen hood cleaning had occurred between April 2014 and April 2015.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the facility could not provide the required documentation.

Based on observation and interview, it was determined that the facility failed to maintain medical gas storage and administration areas and ensure medical gas piping and supports do not support non-system components in two of fifteen smoke compartments.

Findings include:

Observation made on July 7, 2015, at 10:45 am, revealed in the third floor corridor by room 3328, the medical air piping had a black colored wire bundle attached for approximately twenty feet.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the wiring attached to the medical gas pipes.

Based on document review and interview, it was determined that the facility failed to ensure that emergency generator sets were properly inspected and maintained within this component.

Findings include:

Document review made on July 8, 2015, between 1:00 pm and 1:45 pm, revealed that the facility could not produce documentation of the emergency generator battery inspection for electrolyte levels/specific gravity during the time of the survey.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 8, 2015 at 2:30 pm, confirmed the lack of documentation for the emergency generator battery testing/inspection.

Based on document review and interview, it was determined that the facility failed to ensure that emergency generator sets were properly inspected and maintained within this component.

Findings include:

Document review made on July 2, 2015, at 10:45 am, revealed that the facility could not produce documentation of the emergency generator battery inspection for electrolyte levels/specific gravity during the time of the survey.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 2, 2015 at 1:00 pm, confirmed the lack of documentation for the emergency generator battery testing/inspection.

Based on document review and interview, it was determined that the facility failed to ensure that emergency generator sets were properly inspected and maintained within this component.

Findings include:

Document review made on July 7, 2015, between 11:00 am and 2:30 pm, revealed that the facility could not produce documentation of the emergency generator battery inspection for electrolyte levels/specific gravity during the time of the survey.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the lack of documentation for the emergency generator battery testing/inspection.

Based on observation, document review and interview, it was determined that the facility failed to ensure that emergency generator sets are properly inspected and maintained within this component.

Findings Include:

1. Observation made on July 7, 2015, at 10:33 am, revealed that the exterior generator set that services the MOB has a plastic Armor cable that is broken in the center area and is exposing the inner wiring to the elements and possible damage. The wiring is spliced together and is running from the battery charger to the rest of the generator set.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the broken plastic Armor cable and the exposed inner wiring.

2. Document review made on July 7, 2015, between 11:00 am and 2:30 pm, revealed that the facility could not produce documentation of the emergency generator battery inspection for electrolyte levels/specific gravity during the time of the survey.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the lack of documentation for the emergency generator battery testing/inspection.

Based on observation, interview and document review, it was determined that the facility failed to ensure that generator sets were properly inspected and maintained that battery electrolyte levels were checked and documented on a weekly basis within this component.

Findings include:

Document review made on July 7, 2015 between 11:00 am and 2:30 pm, revealed that the facility could not produce documentation of the generator battery weekly checking of electrolyte levels and specific gravity during the time of the survey.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the lack of generator battery electrolyte specific gravity checks documentation during the time of the survey.

Based on observation and interview, it was determined that the facility failed to ensure that temporary wiring was not used in place of permanent wiring and that surge protectors were properly used in three of fifteen smoke compartments within this component.

Findings include:

1. Observations made on July 6, 2015, between 9:40 am and 1:00 pm, revealed the unauthorized use of extension cords and surge protectors in the following areas:

a. 9:40 am, fourth floor neuro ICU nurse station, extension cord powering a surge protector utilized to power office equipment.
b. 9:50 am, inside equipment room 4402, yellow extension cord powering television control equipment.
c. 1:00 pm, third floor lounge 3365, two coffee makers powered through a surge protector.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the unauthorized use of extension cords and surge protectors.

2. Observation made on July 7, 2015, at 10:10 am, revealed on the second floor physical therapy room at the nurse station, there was an extension cord powering a surge protector that was utilized to power computer equipment.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the unauthorized use of a surge protector.

Based on observation and interview, it was determined that the facility failed to monitor the use of electrical devices and maintain the electrical components to be secured in two of seven smoke zones.

Findings include:

1. Observation made on July 6, 2015, at 1:41 pm, revealed a surge protector was plugged into a surge protector inside infection control room 3516.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed the surge protectors were being improperly used.

2. Observation on July 7, 2015, at 10:20 am, revealed an open junction box inside the fire alarm office, in the first floor mechanical space.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015 at 2:45 pm, confirmed there was an open junction box.

Based on observation and interview, it was determined that the facility failed to monitor the use of electrical equipment for improper use of electrical devices in one of eleven smoke zones.

Findings include:

1. Observation on July 2, 2015, between 10:07 am and 11:17 am, revealed the improper use of surge protectors and extension cords at the following locations:

a. 10:07 am, first floor, Director of Physicians Office, there was an extension cord in use.
b. 11:03 am, second floor, Pharmacy, there was a surge protector plugged into a surge protector.
c. 11:05 am, second floor, Pharmacy, there was a refrigerator plugged into a surge protector by the Pyxis Distributor.
d. 11:17 am, second floor, Locksmith Shop, there was a microwave plugged into a surge protector.

Interview with the Clinical Associate Executive Director and the Supervisor Plant Operations on July 2, 2015, at 1:00 pm, confirmed the improper use of electrical equipment.

Based on observation and interview, it was determined that the facility failed to ensure that electrical wiring and equipment is properly inspected and maintained and that the improper use of powerstrips is prohibited on one of three levels within this component.

Findings include:

Observation made on July 6, 2015, at 10:21 am, revealed that in the first floor ER Supervisors office, there was a refrigerator that was plugged into a powerstrip.

Interview with the Senior Director of Safety, Maintenance Manager, and the Plant Supervisor on July 7, 2015, at 2:45 pm, confirmed the refrigerator was plugged into a powerstrip.

Based on observation and interview, it was determined that the facility failed to ensure that electrical wiring is adequately protected in one of twelve smoke zones.

Findings include:

Observation made on July 8, 2015, at 12:45 pm, revealed in the first floor Emergency Department, there was a section of MC type electrical wring that was dead ended into wire nuts and not in a protective electrical junction box.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the electrical wiring was not terminated in a protective electrical junction box