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Based upon observation and interview, the facility failed to ensure that aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7 and continuously maintained free of all obstructions to full use in care of an emergency as required by 19.2.1 and 7.1.10.1. This deficient practice could potentially affect all occupants of the affected smoke compartments on the 8th, 6th and 5th Floors by not allowing unobstructed egress in the event of an emergency. Findings include:

1. On 12/11/18, at approximately 11:50 AM, the following observation was made and confirmed by interview with Staff #3 that Webber 8th floor beds were stored in the service elevator lobby.

2. On 12/11/18, at approximately 2:20 PM, the following observation was made and confirmed by interview with Staff #3 that Webber 5th floor beds were stored in the service elevator lobby.



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3. On 12/11/18, at approximately 12:05 PM, the following observation was made and confirmed by interview with Staff #4 that Brush 6th floor exit egress corridor to the exit door by Patient Room #6608 was obstructed by the storage of a food tray service cart.

4. On 12/11/18, at approximately 2:58 PM, the following observation was made and confirmed by interview with Staff #4 that Brush 5th floor exit egress corridor was obstructed by the storage of two computers on wheels charging in the corridor.

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Based upon observation and interview, the facility failed to ensure that doors in a required means of egress are not equipped with a latch or lock that requires the use of a tool or key from the egress side unless meeting the special locking arrangements for clinical needs in accordance with 19.2.2.2.5.1 and 19.2.2.2.6, special needs locking arrangements in accordance with 19.2.2.2.5.2, delayed egress locking in accordance with 19.2.2.2.4, access-controlled egress doors in accordance with 19.2.2.2.4, or elevator lobby exit access in accordance with 19.2.2.2.4. This deficient practice could potentially affect all occupants of the Special Care Nursery but not allowing unobstructed egress in the event of an emergency. Findings include:

1. On 12/12/18, at approximately 11:35 AM, the following observation was made and confirmed by interview with Staff #4 that Brush 2nd floor rear exit door from the Special Care Nursery had a magnetic lock with card reader release installed for exiting. A remote control (emergency unlock) device must be installed and shall be centrally located at staff control stations (i.e. nurses stations) in the locked areas to simultaneously remove power directly from the locking mechanism independent of any other electronic controls.

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Based upon observation and interview, the facility failed to ensure that doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area were self-closing and kept in the closed position unless held open in accordance with 7.2.1.8.2 as required by 19.2.2.2.7 and 19.2.2.2.8. This deficient practice could potentially affect all occupants of the affected smoke compartments on the listed Floors in the event of a fire emergency that is not confined as designed as a result of unclosed doors. Findings include:

1. On 12/11/18, at approximately 11:40 AM, the following observation was made and confirmed by interview with Staff #1 that Stairwell 27 Door across from the Blood Bank Lower Ground Level did not self-close to a positive latch.

2. On 12/11/18, at approximately 12:20 PM, the following observation was made and confirmed by interview with Staff #1 that Brush Patient Technology Center Room 1426 door does not self-close to a positive latch.



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3. On 12/11/18, at approximately 11:10 AM, the following observation was made and confirmed by interview with Staff #3 that Webber 10th floor coordinator on the double doors by supply room 10511 did not function when checked.

4. On 12/11/18, at approximately 11:20 AM, the following observation was made and confirmed by interview with Staff #3 that Webber 10th floor coordinator on the double doors by supply room 10523 did not function when checked.

5. On 12/11/18, at approximately 2:25 PM, the following observation was made and confirmed by interview with Staff #3 that Webber 5th floor double doors into the corner unit by the public elevators did not close to latch.

6. On 12/11/18, at approximately 2:30 PM, the following observation was made and confirmed by interview with Staff #3 that Webber 5th floor door to soiled room 5524 did not close to positive latch.

7. On 12/11/18, at approximately 2:40 PM, the following observation was made and confirmed by interview with Staff #3 that Webber 4th floor smoke barrier doors by room 4442 had a detached closer arm and the door did not self-close.

8. On 12/11/18, at approximately 2:45 PM, the following observation was made and confirmed by interview with Staff #3 that Webber 4th floor smoke barrier doors from Neuroscience to 4 Webber south did not close to latch preventing a smoke tight seal.

9. On 12/11/18, at approximately 2:50 PM, the following observation was made and confirmed by interview with Staff #3 that Webber 4th floor door to storage room 4521 did not close to latch.



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10. On 12/11/18, at approximately 11:11 AM, the following observation was made and confirmed by interview with Staff #4 that Brush 8th floor fire rated cross corridor doors from the ICU to Brush did not close to a positive latch when tested.

11. On 12/11/18, at approximately 03:03 PM, the following observation was made and confirmed by interview with Staff #4 that Brush 5th floor door to Soiled Utility #5729 did not close to a positive latch when tested.

12. On 12/11/18, at approximately 03:19 PM, the following observation was made and confirmed by interview with Staff #4 that Brush 5th floor fire rated cross corridor doors located by Clean Utility #5638 did not close to a positive latch when tested.

13. On 12/12/18, at approximately 10:58 AM, the following observation was made and confirmed by interview with Staff #4 that Brush 3rd floor rear exit door from the NICU did not close to a positive latch when tested.

14. On 12/12/18, at approximately 11:13 AM, the following observation was made and confirmed by Staff #4 that Brush 3rd floor door to Soiled Utility #3616 did not close to a positive latch when tested.

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Based upon observation and interview, the facility failed to ensure that stairways and smokeproof enclosures used as exits are in accordance with 7.2 as required by 19.2.2.3 and 19.2.2.4.7.2. This deficient practice could potentially affect all occupants of Brush Building 8th Floor by not allowing unobstructed egress in the stairwell. Findings include:

1. On 12/11/18, at approximately 11:16 AM, the following observation was made and confirmed by interview with Staff #4 that Brush 8th floor exit/egress stairway HUH-47 had a maintenance equipment/supply cart stored in the stairway enclosure.
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Based upon observation and interview, the facility failed to ensure that hazardous areas are protected by a fire barrier having a 1-hour fire-resistance rating or protected by an automatic extinguishing system in accordance with 8.7.1 as required by 19.3.2.1. This deficient practice could potentially affect all occupants of the affected smoke compartments on the listed Floors in the event of a fire emergency that is not confined to the hazard room. Findings include:

1. On 12/11/18, at approximately 11:51 AM, the following observation was made and confirmed by interview with Staff #4 that Brush 6th floor Patient Room #6705 was being used for bed storage. The door did not have a self-closing device installed to automatically close the door to a positive latch and reasonable smoke tight seal.

2. On 12/12/18, at approximately 11:22 AM, the following observation was made and confirmed by interview with Staff #4 that Brush 3rd floor Patient Room #3600 had been changed to a Storage Room and did not have a required automatic door closing device installed.

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Based upon records review and interview, the facility failed to ensure that cooking facilities are protected in accordance with NFPA 96 unless meeting the requirements of 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.4.4 as required by 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, and TIA 12-2. This deficient practice could affect all building occupants in the event of a fire which is not contained due to improper protection. Findings include:

1. On 12/12/18, at approximately 11:45, it was discovered by review of records and confirmed by interview with Staff #2, that Main Kitchen - 4 - Range Hood System had improper nozzle coverage and has not been remedied.

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Based upon observation and interview, the facility failed to ensure that ABHRs are protected in accordance with 8.7.3.1 unless meeting all conditions as required by 19.3.2.6 and 42 CFR Parts 403, 418, 460, 482, 483, and 485. This deficient practice could potentially affect all occupants of the smoke compartment in the event of fire resulting from non-compliant dispenser location. Findings include:

1. On 12/11/18, at approximately 1:50 PM, the following observation was made and confirmed by interview with Staff #1 that Brush in the corridor at Patient Room 2204 there was an alcohol based hand rub dispenser that was installed above an ignition source within a 1 inch horizontal distance from each side of the ignition source.

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Based upon observation and interview, the facility failed to ensure that occupant notification is provided automatically in accordance with 9.6.3 by audible and visual signals as required by 19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, and 9.6.4. This deficient practice could potentially affect all occupants of the affected rooms by delaying their awareness of a potential fire emergency. Findings include:

1. On 12/11/18, at approximately 12:01 PM, the following observation was made and confirmed by interview with Staff #4 that Brush 6th floor Visitors Lounge #6613 did not have a required fire alarm notification device installed.

2. On 12/12/18, at approximately 11:09 AM, the following observation was made and confirmed by interview with Staff #4 that Brush 3rd floor Patient Room #3717 had been changed to a Waiting Room and did not have a required fire alarm notification device installed.

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Based upon observation, records review and interview, the facility failed to ensure that the fire alarm system was tested and maintained in accordance with an approved program complying with NFPA 70 and NFPA 72 and records were readily available as required by 19.3.4.1, 9.6.1.5, NFPA 70, and NFPA 72. This deficient practice could potentially affect all occupants of the building in the event of delayed or no operation of the building fire alarm system warning of a fire emergency. Findings include:

1. On 12/12/18, at approximately 11:00 AM, it was discovered by review of records and confirmed by interview with Staff #2, that Kitchen Hall by Electrical Room 846 - 171 - smoke detector had a broken cover and has not been remedied.

2. On 12/12/18, at approximately 11:08 AM, it was discovered by review of records and confirmed by interview with Staff #2, that Energy Center Parking Deck Stair - 690 - Control Valve was not wired in to the fire alarm control panel and has not been remedied.

3. On 12/12/18, at approximately 11:16 AM, it was discovered by review of records and confirmed by interview with Staff #2, that the following control valves had not been inspected during the most recent system inspection:
Webber Core by Stair HUH-27 - 164 - Control Valve
Webber Core by Stair HUH-27 - 276 - Control Valve

4. On 12/12/18, at approximately 11:23 AM, it was discovered by review of records and confirmed by interview with Staff #2, that the following preaction battery tests failed, and have not been remedied:
MRI Hall Room G029 - 243 - Preaction battery test failed
MRI Hall Room G029 - 244 - Preaction battery test failed
MRI Hall System 5 Room G025 - 264 - Preaction battery test failed
MRI Hall System 5 Room G025 - 265 - Preaction battery test failed
Webber Ground Cath Lab 5 - 199 - Preaction battery test failed
Webber Ground Cath Lab 5 - 200 - Preaction battery test failed

5. On 12/12/18, at approximately 11:35, it was discovered by review of records and confirmed by interview with Staff #2, that the following Pre-action heat detectors were not tested during the most recent inspection:
MRI Hall System 1 Skylight 1 - 177 - Preaction Heat Detector
MRI Hall System 1 Skylight 1 - 178 - Preaction Heat Detector
MRI Hall System 1 Skylight 2 - 179 - Preaction Heat Detector
MRI Hall System 1 Skylight 2 - 180 - Preaction Heat Detector
MRI Hall System 1 Skylight ROC - 312 - Preaction Heat Detector
MRI Hall System 1 Skylight ROC - 313 - Preaction Heat Detector
MRI Hall System 1 Skylight ROC - 314 - Preaction Heat Detector



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6. On 12/12/18, at approximately 11:05 AM, the following observation was made and confirmed by interview with Staff #4 that Brush 3rd floor smoke detector located in the exit egress corridor by Patient Room #3701 had been installed within three foot of a diffuser.

7. On 12/12/18, at approximately 11:15 AM, the following observation was made and confirmed by interview with Staff #4 that Brush 3rd floor smoke detector located in the exit egress corridor by Patient Room #3610 had been installed within three foot of a diffuser.

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Based upon observation and interview, the facility failed to ensure that nursing homes and hospitals were required by construction type are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13 as required by 19.3.5.1 through 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, and 9.7.1.1(1). This deficient practice could potentially affect all occupants of the building in the event of a fire that is not contained due to improper sprinkler system installation. Findings include:

1. On 12/11/18, at approximately 11:32 AM, the following observation was made and confirmed by interview with Staff #1 that in the corridor at Pharmacy G504 there was an OR Pharmacy directional sign that was blocking the fire sprinkler spray pattern.



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2. On 12/12/18, at approximately 11:15 AM, the following observation was made and confirmed by interview with Staff #3 that CVI 3rd floor mechanical room insulation on the ductwork for Air Handler 4 had dropped and was obstructing the fire suppression heads.


3. On 12/12/18, at approximately 11:25 AM, the following observation was made and confirmed by interview with Staff #3 that CVI 3rd floor mechanical room insulation on the ductwork for Air Handler 4 supply by room 31007 had dropped and was obstructing the fire suppression heads.



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4. On 12/11/18, at approximately 03:08 PM, the following observation was made and confirmed by interview with Staff #4 that Brush 5th floor Blood Gas Lab did not have fire suppression sprinklers installed in the room.


5. On 12/11/18, at approximately 03:10 PM, the following observation was made and confirmed by interview with Staff #4 that Brush 5th floor alcove in the exit egress corridor next to Patient Room #5601 did not have adequate fire suppression sprinkler coverage installed.

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Based upon records review and interview, the facility failed to ensure that automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 and records are readily available as required by 9.7.5, 9.7.7, 9.7.8, and NFPA 25. This deficient practice could potentially affect all occupants of the building in the event of a fire that cannot be contained due to an improperly maintained sprinkler system. Findings include:

1. On 12/12/18, at approximately 11:20 AM, it was discovered by review of records and confirmed by interview with Staff #2, that the following hydraulic names plates were not attached to their respective sprinkler risers:
MRI Hall System 2 - 277 - Preaction Hydraulic Nameplate
MRI Hall System 3 - 278 - Preaction Hydraulic Nameplate
MRI Hall Room G023 - 281 - Preaction Hydraulic Nameplate
MRI Hall Room G001 - 271 - Preaction Hydraulic Nameplate

2. On 12/12/18, at approximately 11:26 AM, it was discovered by review of records and confirmed by interview with Staff #2, that MRI Hall Room G025 - 266 - Preaction Main Drain Test was not performed.

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Based upon observation, records review and interview, the facility failed to ensure that portable fire extinguishers are selected, installed, inspected and maintained in accordance with NFPA 10 as required by 19.3.5.12. This deficient practice could potential affect all occupants of the building in the event of a fire emergency that cannot be controlled with an improperly maintained fire extinguisher. Findings include:

1. On 12/11/18, at approximately 11:05 AM, the following observation was made and confirmed by interview with Staff #1 that at OR 18 the portable fire extinguisher cabinet door was dented and door handle was loose, resulting in lack of readiness for extinguisher access.

2. On 12/11/18, at approximately 11:45 AM, the following observation was made and confirmed by interview with Staff #1 that in G018 MRI 2 room there was a trash can blocking access to the portable fire extinguisher.

3. On 12/12/18, at approximately 11:48, it was discovered by review of records and confirmed by interview with Staff #2, that the following fire extinguishers were due for hydrostatic test:
1st floor CVI Cath Lab 5 1016 CO2 portable fire extinguisher
1st floor CVI Cath Lab 6A 866 CO2 portable fire extinguisher
1st floor CVI Cath Lab 6B 867 CO2 portable fire extinguisher
4th floor Brush Room 4628 515 Dry Chemical portable fire extinguisher
4th floor Brush Room 4612 518 Dry Chemical portable fire extinguisher
9th floor Webber Stair HUH 17 cabinet 32 Dry Chemical portable fire extinguisher
Ground Floor Webber Pump Room by AHU1-C 328 CO2 portable fire extinguisher

4. On 12/12/18, at approximately 11:52, it was discovered by review of records and confirmed by interview with Staff #2, that 4th floor Brush Mechanical Room 4828 1032 Dry Chemical portable fire extinguisher is due for 6 year maintenance.

5. On 12/12/18, at approximately 11:54, it was discovered by review of records and confirmed by interview with Staff #2, that 5th floor Hudson/Webber Room 523 81 Dry Chemical portable fire extinguisher is not mounted off the floor.

6. On 12/12/18, at approximately 11:58 PM, it was discovered by review of records and confirmed by interview with Staff #2, that the following fire extinguishers had not been inspected:
Ground Floor Brush Stairwell by Room 712 461 Dry Chemical portable fire extinguisher
Penthouse Webber Desk near Stair HUH 28 814 Dry Chemical portable fire extinguisher

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Based upon observation and interview, the facility failed to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, resist the passage of smoke, equipped with a means suitable for keeping the door closed, and there is no impediment to the closing of doors as required by 19.3.6.3 and 42 CFR 403, 418, 460, 482, 483, and 485. This deficient practice could potentially affect all occupants of the affected smoke compartments on the listed Floors in the event of a fire emergency that cannot be contained to the room of origin due to non-latching doors. Findings include:

1. On 12/11/18, at approximately 11:29 AM, the following observation was made and confirmed by interview with Staff #4 that Brush 8th floor door to the Staff Lounge #8707 did not close to a positive latch to provide a reasonable smoke tight seal when tested.

2. On 12/11/18, at approximately 2:10 PM, the following observation was made and confirmed by interview with Staff #4 that Brush 5-Center wing had the occupancy use changed from Healthcare (patient rooms) to Business Occupancy for I.T. Department relocation. The patient rooms were being used for storage, work stations and repair. Door latching hardware had been removed from patient rooms with pad locks installed, ceiling tiles missing throughout and items left in the exit egress corridor.

3. On 12/12/18, at approximately 1:20 PM, the following observation was made and confirmed by interview with Staff #4 that Brush Ground floor door to the Kitchen did not close to a positive latch to provide a reasonable smoke tight seal when tested.

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Based upon records review and interview, the facility failed to ensure that generators or other alternative power sources and associated equipment is capable of supplying service within 10 seconds, is maintained, inspected, tested and exercised in accordance with NFPA 110, and records are readily available as required by 6.4.4, 6.5.4, and 6.6.4 of NFPA 99, NFPA 110, NFPA 111 and 700.10 of NFPA 70. This deficient practice could potentially affect all occupants of the building in the event of need of generator power which could be affected by improper maintenance. Findings include:

1. On 12/12/18, at approximately 10:50 AM, it was discovered by review of records and confirmed by interview with Staff #2, that Generator #3 Battery #2 voltage reported as failed and not been remedied.

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Based upon observation and interview, the facility failed to ensure that power strips are listed for the area in which they are used as required by 10.2.3.6 of NFPA 99 and 400-8 of NFPA 70, and TIA 12-5 and that extension cords are placed in use only temporarily as required by 10.2.4 of NFPA 99 and 590.3(D) of NFPA 70. This deficient practice could potentially affect all occupants of the affected smoke compartment in the event of an electrical failure due to improper extension cord use. Findings include:

1. On 12/12/18, at approximately 10:10 AM, the following observation was made and confirmed by interview with Staff #2, that in Brush Room 5817 there was an extension cord placed through the ceiling tile being used in place of permanent wiring.

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Based upon observation and interview, the facility failed to ensure that storage of nonflammable gasses meet all requirements of 11.3.1 through 11.3.4 and 11.6.5 of NFPA 99. This deficient practice could potentially affect all occupants of the affected smoke compartment in the event of a failure of the unsecured compressed gas cylinder. Findings include:

1. On 12/11/18, at approximately 11:20 AM, the following observation was made and confirmed by interview with Staff #1 that in Gas Cylinders Room G535 there was a compressed gas cylinder that was not secured from tipping over.