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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, 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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.