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Based on observation and staff verification, it was determined the facility failed to maintain the integrity of the fire proofing of the steel structure in order to maintain the required building construction and type according to NFPA 101, 2012 edition Chapter 19.1.6.1. This finding has the potential to affect all patients receiving services from the facility. The facility census was 29.


Findings include:

Facility tour took place with Staff Y and Z on 08/13/19 to 08/14/19. Observation was made of areas where the fire proofing material had been dislodged or scraped away from the steel support beams in the following locations:

1. Four areas of fire proofing removed on beams above generators located on the fourth floor.

2. Fire proofing missing on steel beams in fourth floor switchgear room

3. An 8 inch section of exposed steel was observed on a structural beam above suspended ceiling of room 3010

These findings were verified by Staff Y and Z during facility tour.

Based on record review and staff interview it was determined the facility failed to perform the annual inspections of emergency and exit lights in accordance with NFPA 101 - 2012 Edition 7.9.3.1.2. This finding has the potential to affect all patients receiving services from the facility. The census was 29.

Findings include:

Based upon emergency light record review on 08/12/19 it was noted that monthly 30 second testing was completed on the facility emergency lights but no documentation could be found to verify the annual 90 minute testing.

A request was made of Staff Y and Z for the missing documentation on 08/12/19 but none was available.

Based on fire alarm documentation review and staff verification, it was determined the facility failed to ensure sensitivity testing of all smoke detectors according to NFPA 101 - 2012 Edition 9.6.1.3 and NFPA 72 - 2012 Edition Section 14.6.2.2 through 14.6.2.4. This finding has the potential to affect all patients receiving services from the facility. The census was 29.

Findings include:

Fire alarm documentation review for the offsite therapy facility took place on 08/12/19. During review it was noted that the facility had one smoke detector. Although the detector had been tested functionally on 03/12/19 by a professional company, no documentation was found to verify a sensitivity test had been performed on or near the same date. The last sensitivity test documented was dated for 03/17/17, greater than two years prior.

A request was made of Staff Y for the missing documentation at the time of the review but none was available. This finding was verified by Staff Y and Z on 08/13/19.

Based on documentation review and staff verification it was determined the facility failed to ensure the 5 year hydrostatic testing was performed on the components of the sprinkler system according to NFPA 25- 2011 Edition, Section 6.3.2.1. Additionally, the facility failed to have the fire department connection on the outer part of the building identified with proper signage according to NFPA 13.7. This finding has the potential to affect all 29 patients receiving services from the facility.

Findings include:

Sprinkler system documentation review for the offsite therapy facility took place on 08/12/19. During review it was noted the facility had not performed the required five year hydrostatic test between the fire department connection and the check valve and failed to have the fire department connection on the outer part of the building identified with proper signage according to NFPA 13.7.

This finding was verified by Staff Y and Z on 08/12/19.

Based on observations, documentation review and staff interview the facility failed to inspect test and maintain sprinkler system in accordance with NFPA 13-2010 edition and NFPA 25-2011 edition. This finding has the potential to affect all patients receiving services from the facility. The facility census was 29.

Findings include:

Review of life safety code documentation and interview with Staff Y and Staff Z on 08/12/19 revealed the following:

1. The facility failed to provide evidence that the dry sprinkler system piping had the integrity of the sprinkler pipe tested within the last three years.

2. The facility failed to provide evidence the hydrostatic test between the fire department connection and the check valve had been conducted within the last five years.

Tour with Staff Y and Staff Z on 08/13/19 through 08/14/19 included observations of the sprinkler system throughout the facility and revealed the following:

1. At 12:00 P.M. on 08/13/19 observation was made of the sprinkler heads in Intensive Care Unit (ICU) located above the nursing station and (ICU) employee break room being covered with dust.

2. At 2:25 P.M. on 08/13/19, observed a sprinkler head in 300 storage room blocked by ceiling light.

3. At 2:30 P.M. on 08/13/19, observed a small storage room located in back of therapy with various therapy equipment that did not have a suspended ceiling and did not have any sprinkler protection.

4. At 2:45 P.M. on 08/13/19, observed a sprinkler head mounted directly above a wall mounted cabinet in nutrition room behind 3 north nursing station. There was not 18 inches between the sprinkler deflector and cabinet.

5. At 10:04 A.M. on 08/14/19 observed that room #1503 lacked any sprinkler protection. Additional observations above suspended ceiling revealed the sprinkler was installed above suspended ceiling but not mounted in the suspended ceiling.

6. At 2:56 P.M. on 08/14/19, observed two sprinkler heads in the chapel located 24 inches below the ceiling. This was 12 inches beyond the requirement of 12 inches.

7. At 4:35 P.M. on 08/14/19, observed multiple sprinkler heads in the laboratory covered with dirt.

8. At 8:45 A.M. on 08/14/19 observed rooms 7, 8 and 9 having sprinkler heads covered with dirt.

9. At 11:20 A.M. on 08/14/19, observed a sprinkler head blocked by books in the administration room closet.

10. At 2:25 P.M. on 08/14/19, observed a sprinkler located within 18 inches of the top of a locker in maintenance.

11. At 2:30 P.M. on 08/14/19, observed a concealed sprinkler located in the men's restroom in the hall outside administration with missing cover plate. Additional observation revealed the sprinkler deflector was dropped and was located at the level of the ceiling tile which blocks the full development of spray from the head.

Interview with Staff Y and Staff Z verified the findings at time of review and observation.

Based on observations and staff interview the facility failed to inspect, test and maintain fire extinguishers in accordance with NFPA 10-2010 edition. These findings had the potential to affect all 29 patients.

Findings include:

Tour with Staff Y and Staff Z on 08/13/19 to 08/14/19 revealed observations of the fire extinguishers throughout the facility being improperly mounted.

1. 10 pound ABC dry powder fire extinguishers was observed and revealed the fire extinguishers located in the south door of education hallway fire extinguisher was mounted at 5 foot 4 inches.

2. Located in the vacant surgery area was mounted at 5 foot 2 1/2 inches

3. Within the Obstetrics (OB) across from room 328 fire extinguisher was mounted at 5 foot 3 inches.

Fire extinguishers are not to be mounted above 5 feet above floor level.

4. Additional observation revealed the K type extinguisher located in the kitchen did not have the required placard posted above the extinguisher.

These findings were verified by Staff Y and Z during tour.

Based on observation and staff verification it was determined the facility failed to ensure the integrity of all smoke/fire barriers and smoke partitions by maintaining the required fire/smoke resistance rating according to NFPA 101, 2012 edition Chapter 8.5. These findings have the potential to affect all patients receiving services from the facility. The census was 29.

Findings include:

Facility tour took place with Staff Y and Z on 08/13/19 to 08/14/19. Observation was made of several penetrations located in the fire resistive smoke/fire barriers above the ceiling tiles and in the ceiling tiles in the following locations:

08/13/19

1. Observation of an opening in ceiling tile outside stairwell across from sleep lab.

2. The wall above door to utility room outside education has a section drywall not fastened and sealed below ceiling around some piping. This was approximately 16 X 6 inches.

3. At 4:00 PM observation in the pharmacy area had a section of suspended ceiling mounted at an angle and extended upwards, had a section of ceiling tile 18 inches by 2 foot missing. This was located to the right side of a camera.

08/14/19

4. At 8:45 AM a 1 1/2" hole above the cross corridor ED entrance double doors was observed.

5. Within ED bay 14, observation was made of one open end conduit, ED bay 17 has 3 open end conduits.

6. At 9:12 within the ED waiting area above a single door, observation was made of a 4 inch opening in the end of conduit.

7. At 9:20 AM observed above electrical room door 1111 a one inch conduit not sealed around the annular space, from within room 1111 an open end conduit was observed.

8. At 10:45 AM observed an approximate 14 x 24 inch section of drywall missing in the electrical room in Women's Health behind communication cabinet.

9. At 10:45 AM Women's Health electric room 1415 has 6 inch duct not sealed.

10. Ceiling in room 1720 electrical room has 7 conduits penetrating ceiling not sealed around ceiling tile.

11. At 11:35 AM located in the hall smoke barrier door next to director of marketing and communication room observed penetration above suspended ceiling above double doors.

12. At 4:00 PM north side closet by the quality office has electrical conduit fire stopped with drywall mud and 4 inch conduit not fire stopped around the annular space.

Staff Y and Z verified these findings during facility tour.

Based on fire door inspection reports and observation during tour and staff verification it was determined the facility failed to ensure the integrity and operations of smoke/fire doors according to NFPA 101 2012 edition Chapter 19.3 and NFPA 80 and NFPA 105. These findings have the potential to affect all patients receiving services from the facility. The census was 29.

Findings include:

Facility tour took place with Staff Y and Z on 08/13/19 to 08/14/19. Observation was made of several doors that had penetrations, latching hardware that was not operating properly and gaps between the door leafs that were greater than one eighth inch. Observations were as follows:

08/13/19

1. Double fire doors (FD074) by vending at entrance to 3 North connector has excess of 1/8 inch gap between doors.

2. Single stairwell fire rated door failed to close, located northwest stairwell between rooms 308 and 309.

3. At 8:30 AM observation of the 1 1/2 hour fire rated door in stairwell M4, (north stairwell door), had four penetrations.

4. At 3:40 PM double corridor doors (FD007) outside Behavior Health has over 1/8 inch gap between door leafs when in the closed position.

5. At 4:45 PM observation was made of a single non rated wood door with a self-closing device (located in the file room of the lab) with a rubber wedge holding the door open. The door latch was taped to keep the latch from operating and the frame was also taped over where the door latch would normally engage into the frame.

08/14/19

6. At 9:15 AM the door to room 1105 fails to latch when closed from the full open position.

7. Single door in front of the nurses station within the emergency room area failed to latch after multiple attempts to close.

8. At 11:15 AM a double 45 minute door outside the administration area failed to latch when closed. The door was equipped with a door closer and latching hardware.

9. At 2:20 PM a double rated fire door in laundry area had holes in both doors that need repaired. Additionally, a single door at the back side of the laundry had small holes.

These findings were verified by both Staff Y and Z during facility tour.

Based on observations and staff interview, the facility failed to provide ground-fault circuit-interrupter protection for personnel where receptacles are installed within 1.8 m (6 ft) of the outside edge of the sink in accordance with NFPA 99-2012 edition and NFPA 70-2011 Edition. This finding had the potential to affect all 29 patients.

Findings include:

During tour with Staff Y and Staff Z on 08/13/19 to 08/14/19 observations were made of the electrical installation throughout the facility. Observations were as follows:

1. In the call center a power strip was observed plugged into another power strip.

2. Observed and tested outlets within six feet of sinks located in room 4013 soiled utility, room 326 and room 328; when tested they failed to provide Ground-fault circuit-interruption for personnel.

Interview with Staff Y and Staff Z verified these findings at the time of discovery.

Based on observations and staff interview the facility failed to ensure storage of oxygen cylinders in accordance with NFPA 99- 2012 Edition. These findings have the potential to affect all 29 patients receiving services from the facility.

Findings include:

Tour with Staff Y and Staff Z on 08/13/19 to 08/14/19 revealed the following findings related to storage of oxidizing gases in the facility:

1. Observations of a room containing seven stored oxygen cylinders was also noted to have combustible items and the door was not locked to prevent unauthorized access.

2. Observations within the medical gas room revealed sources of ignition within five feet of the floor. All light switches and electrical outlets shall be protected or located at least five feet from the floor.

3. Observation of the oxygen storage room door was not identified with the required signage which is
"Caution Oxidizing Gases Stored Within, No Smoking."

Interview with Staff Y and Staff Z verified the findings at the time of observation.