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Based on observation and interview, the facility did not have the proper construction type. The beams for the floor was missing the fireproofing. This is not in compliance with NFPA 101 (2012 edition) Table 19.1.6.1.

1. On 01/17/2017 at 10:10 AM, observation revealed on the lower level at the mechanical room (air handler room) next to the computer lab, that the fireproofing was missing on the structural beams, including underneath the electrical boxes and other locations. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Director).
2. On 01/17/2017 at 11:00 AM observation revealed on the lower level at storage room G 106, that there was wood attached to the ceiling. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Director).

Based on observation and interview, the facility failed to provide properly rated doors in a 1-hour rated fire barrier wall connected to the fire alarm system in accordance with NFPA 101 (2012 edition), 19.2.2.2.7 and 7.2.1.8.2. This deficient practice had the potential to affect 10 of 13 inpatients and an undeterminable number of outpatients as well as staff and visitors.

Findings include:

On 1/17/17 at 9:36 am, observation of the doors in the fire barrier wall by the staff elevator on the 2nd floor were held open with a locking device but were not connected to the fire alarm and would not close upon activation of the fire alarm system.

This deficient practice was confirmed by staff D at the time of discovery.

Based on observation and interview, the facility did not have a corridor with 2 exits. This observed situation was not compliant with NFPA 101 (2012 edition.), 19.2.5.4

FINDINGS INCLUDE:

1. On 01/17/2017 at 12:30 PM, observation revealed on the lower level at the corriddor next to the garage, that the corridor only had one exit. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Director).

Based on observation and interview, the facility failed to properly identify exit doors in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.2.2.2.4 and 7.10.1.2.1. This deficiency had the potential to affect an undetermined number of staff and visitors.

Findings include:

On 1/17/2017 at 2:05 PM, observation revealed that the exit door through the roof from the penthouse mechanical room was not identified with an "EXIT" sign. This deficient practice was confirmed by Staff C (Director of Environmental Services) at the time of discovery.

Based on observation and interview, the facility did not enclose vertical openings between floors with a 1 hour fire-rated assembly. This observed situation was not compliant with NFPA 101 (2012 edition), 19.3.1

FINDINGS INCLUDE:

1. On 01/17/2017 at 9:15 AM, observation revealed on the lower level at the stairway EG that the heater located in the cinderblock wall and the double layer of dry wall sticking out into the mechanical room was not a 1 hour rated assembly. In addition, the piping through the dry wall was not fire caulked. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Director).

2. On 01/17/2017 at 12:45 PM, observation revealed on the lower level at the stairway BG and exit passageway wall that the heater located in the cinderblock wall was not a 1 hour rated assembly. The cinderblock was cut away. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Director).

3. On 01/17/2017 at 3:10 PM, observation revealed on the lower level at the stairway AG that the stair enclosure contained wood instead of concrete. The wood does not make the assembly one hour fire rated. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Director).



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4. On 01/17/2017 at 10:20 PM, observation revealed on the first floor at the staff elevator shaft that the 1- hour rated shaft wall assembly did not extend to the underside of the beam directly above the wall. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Assistant Director EVS).

Based on observation and interview, the facility did not enclose hazardous rooms with a smoke-tight room enclosure in a sprinkled smoke zone and door closers were missing. This observed situation was not compliant with NFPA 101 (2012 ed.), 19.3.2.1

FINDINGS INCLUDE:

1. On 01/17/2017 at 9:23 AM, observation revealed on the lower level that the old cath lab was was converted to a storage room and did not have 3/4 hour rated door and did not have a closer. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. The storage area included 5 pallets, 10 to 15 boxes of paper storage and other miscellaneous combustible material. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E, (Safety Director).

2. On 1/17/2017 at 9:30 AM, observation revealed in the lower level locker 007, that the room was used as storage, and it was less than 100 square feet. The door did not have a closer on it. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E, (Safety Director).

3. On 1/17/2017 at 10:15 AM, observation revealed on the lower level mechanical room (L115) that the one hour rated wall had a cast iron pipe running the length of the pipe in the north wall (instead of penetrating the wall). This prevents the wall from being one hour rated as shown on the life safety plans. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E, (Safety Director).

4. On 1/17/2017 at 11:10 AM, observation revealed in the lower level storage room (G207) that 2 pipes with insulation penetrated the rated wall and did not have fire caulk around them. This prevents the wall from being one hour rated as shown on the life safety plans. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E, (Safety Director).

5. On 1/17/2017 at 11:20 AM, observation revealed in the lower level garage storage room that there was no fire caulk on pipes that penetrated the north wall. This prevents the wall from being one hour rated as shown on the life safety plans. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E, (Safety Director).

6. On 1/17/2017 at 2:30 PM, observation revealed in the lower level storage in the corridor by a storage room, that the medical gas zone valve (a box greater than 100 square inches ) prevented that wall from maintaining the 1 hour fire rated wall as shown on the life safety plans. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E, (Safety Director).


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7. On 1/17/2017 at 9:25 AM, observation revealed on the first floor in the corridor by the central storage room (1432) that (2) 4 " sleeves, conduit and plumbing pipes penetrated the rated wall and were not sealed and did not have fire caulk around them. This prevents the wall from being one hour rated as shown on the life safety plans. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A, (Maintenance 3).
8. On 1/17/2017 at 9:30 AM, observation revealed on the first floor in the corridor by the trash room that a 6 " plumbing pipe, 8 " x 36 " opening in the concrete masonry wall, 4 " x 6 " opening with multiple conduit pipes, as well as 4 " and 5 " openings penetrated the rated wall and were not sealed and did not have fire caulk around them. This prevents the wall from being one hour rated as shown on the life safety plans. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A, (Maintenance 3).
9. On 1/17/2017 at 9:33 AM, observation revealed on the first floor in the corridor by the storage room (1436) that a 12 " x 24 " duct penetrating the concrete masonry rated wall was not sealed and did not have a sleeve installed around the duct. This prevents the wall from being one hour rated as shown on the life safety plans. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A, (Maintenance 3).
10. On 1/17/2017 at 9:37 AM, observation revealed on the first floor in the corridor by the clean linen storage room that a 10 " x 20 " transfer duct penetrating the concrete masonry rated wall was not sealed and did not have a sleeve installed around the duct as well as an 8 " diameter hole, (2) 4 " pipe sleeves and (2) 5 " pipe sleeves. This prevents the wall from being one hour rated as shown on the life safety plans. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A, (Maintenance 3).
11. On 1/17/2017 at 9:41 AM, observation revealed on the first floor in the corridor by the central storage room (1432) that an 8 " diameter hole and multiple pipes penetrated the rated wall and a transfer duct and were not sealed and did not have fire caulk around them. This prevents the wall from being one hour rated as shown on the life safety plans. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A, (Maintenance 3).
12. On 1/17/2017 at 9:45 AM, observation revealed on the first floor in the corridor by the dietary storage room that a 3 " diameter hole with multiple wires and a 10 " x 20 " transfer duct through the rated wall, were not sealed and the duct was not sleeved. This prevents the wall from being one hour rated as shown on the life safety plans. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A, (Maintenance 3).
13. On 1/17/2017 at 9:47 AM, observation revealed on the first floor in the corridor by the staff kitchen entrance near door (165) that a 12 " x 12 " patch above the ceiling in the rated wall was not sealed and the edges pulled away from the wall. This prevents the wall from being one hour rated as shown on the life safety plans. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A, (Maintenance 3).
14. On 1/17/2017 at 9:49 AM, observation revealed on the first floor in the corridor by the staff kitchen entrance near door (165) that a 2 " wide gap in the gypsum board above the ceiling in the rated wall was not sealed. This prevents the wall from being one hour rated as shown on the life safety plans. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A, (Maintenance 3).
15. On 1/17/2017 at 9:51 AM, observation revealed on the first floor in the corridor by the vending and dining entrance near door (166) that a 6 " square hole with (3) conduit pipes in the gypsum board above the ceiling in the rated wall were not sealed. This prevents the wall from being one hour rated as shown on the life safety plans. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A, (Maintenance 3).
16. On 1/17/2017 at 9:59 AM, observation revealed on the first floor in the utility clean up room (161) that (2) 6 " diameter pipes, a 10 " duct and a 2 " vent pipe penetrated the gypsum board above the ceiling in the rated wall and were not sealed. This prevents the wall from being one hour rated as shown on the life safety plans. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A, (Maintenance 3).
17. On 1/17/2017 at 10:16 AM, observation revealed on the first floor in the storage room (142) that (2) 6 " diameter pipes penetrated the gypsum board above the ceiling in the rated wall and were not sealed. This prevents the wall from being one hour rated as shown on the life safety plans. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A, (Maintenance 3).
18. On 1/17/2017 at 10:51 AM, observation revealed on the first floor in the soiled utility room (1126) that the top of the rated wall above the ceiling as well as an opening was closed off with a 14 " square piece of sheet metal in the rated wall and was not fire sealed. This prevents the wall from being one hour rated as shown on the life safety plans. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B, (Assistant Director EVS).

Based on record review and interview, the facility failed to maintain and test emergency lights in anesthetizing locations in accordance with the requirements of NFPA 101 (2012 edition), Section 19.3.2.3 and NFPA 99 (2012 edition), Section 6.3.2.2.11.5 .

Findings include:

On 1/17/2017 at 12:38 PM, during review of the facility emergency light testing records it was discovered that tests were not conducted for the emergency lights located inside the four first floor operating rooms for a minimum of 30 seconds each month and 30 minutes annually within the last year. This deficient practice was confirmed by Staff C (Director of Environmental Services) at the time of discovery.

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (2010 edition) requirements, with no obstructions near the sprinkler, and areas that did not have sprinkler coverage. This situation was not compliant with NFPA 13 (2010 ed.), 8.6.5.2.1.1; Table 8.6.5.2.1(b); 8.6.4.1.2; NFPA 101 (2012 edition), 19.3.5.1.

FINDINGS INCLUDE:

1. On 1/17/2017 at 9:20 AM, observation revealed on the lower level of Stairwell EG that the bulkhead interrupted the flow of the sprinkler. The sprinkler was located 24 inches down from the head and 39 inches away from the head. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Director).
2. On 1/17/2017 at 9:35 AM, observation revealed on the lower level in Hazardous waste storage room, that the sprinkler was located 40 inches down from (below) the ceiling. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E, (Safety Director).
3. On 1/17/2017 at 9:50 AM observation revealed on the lower level in the corridor,that the sign (to the sleep disorder) blocks the sprinkler. The bottom of the sprinkler is 13 inches down and 5 inches away from the sprinkler. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E, (Safety Director).
4. On 1/17/2017 at 10:30 AM, observation revealed on the lover level at the Rehab reception area and the Rehab waiting area, that there was no sprinkler coverage in those areas. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Director).
5. On 01/17/2017 at 10:45 AM, observation revealed on the lower level at Stairway G128 that the stairs did not have sprinkler coverage beneath the stairs. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Director).
6. On 1/17/2017 at 12:20 PM observation revealed that the electrical switch gear room and the electrical transformer room were not sprinkler. The sprinkler code allows this area to not be sprinklered if enclosed in 2 hour walls. The rooms did not have a 1-1/2 hour rated door with frame and door closer as required by the 2 hour enclosure. In addition, the electrical transformer room had metal in the ceiling. This could not be confirmed that this metal was a 2 hour floor/ceiling assembly. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Director).
7. On 01/17/2017 at 12:38 PM, observation revealed on the lower level at Stairway BG that the stairs did not have sprinkler coverage beneath the stairs. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Director).
8. On 01/17/2017 at 12:50 PM, observation revealed on the lower level at the telecom room that the room did not have sprinkler coverage. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Director).
9. On 01/17/2017 at 12:57 PM, observation revealed on the lower level at storage room G10 that ducts greater than 4 feet wide did not have sprinkler coverage beneath the ducts. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Director).
10. On 01/17/2017 at 1:45 PM, observation revealed on the lower level at Stairway G01 that the stairs did not have full sprinkler coverage. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Director).
11. On 01/17/2017 at 3:10 PM, observation revealed on the lower level at Stairway AG that the stairs did not have full sprinkler coverage. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Director).


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12. On 1/17/2017 at 11:00 AM observation revealed in the first floor file room that the sprinkler heads were obstructed. The bottom of the sprinkler heads is 10 " away from the movable file storage system. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B, (Assistant Director EVS).


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13. On 01/17/2017 at 9:54 AM observation revealed in the 2nd floor equipment room by the nurse station that the sprinkler was 40 inches from the ceiling surface above. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D at the time of discovery.

Based on observation and interview the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 (2012 edition) Sections 19.3.5 and 9.7.5, and NFPA 25 (2011 edition) Sections 5.2.1, and 5.2.1.1.1.

Findings include:

1. On 1/17/2016 at 10:48 am, observation revealed in the first floor break room in suite 1-K that an escutcheon ring was missing in the ceiling tile. This deficient practice was confirmed by staff B, (Assistant Director EVS) at the time of discovery.

2. On 1/17/2016 at 12:20 pm, observation revealed a 2 feet by 4 feet missing section of ceiling tile in the first floor closet outside room (1151). This deficient practice was confirmed by staff B, (Assistant Director EVS) at the time of discovery.


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3. On 1/17/2016 at 1:45 PM, observation revealed that two sprinkler heads in the Kitchen area had lint and other foreign materials on the heads. This deficient practice was confirmed by Staff C (Director of Environmental Services) at the time of discovery.



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4. On 1/17/2016 at 9:57 am, observation revealed a 2 feet by 2 feet missing section of ceiling tile in the 2nd floor record storage room by the HIS area. This deficient practice was confirmed by Staff D at the time of discovery.

Based on observation and interview, the facility did not have smoke barrier walls constructed to 1/2 hour fire resistance rating. This observed situation was not compliant with NFPA 101 (2012 edition), 19.3.7.3

FINDINGS INCLUDE:

1. On 01/17/2017 at 2:15 PM, observation revealed on the lower level at the smoke barrier's corridor doors, by the men's public toilet, L148, that the wall above the door at the corners of the wall, were not constructed to meet the required fire rating assembly. There were gaps in the dry wall assembly. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Director).


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2. On 01/17/2017 at 9:37 AM observation revealed the 1-hour fire barrier wall by the staff elevators on the 2nd floor was not continuous to the deck above. There was a 1-inch gap between the top of the wall and the deck above that was not fire stopped. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D at the time of discovery.

3. On 01/17/2017 at 9:45 AM observation revealed the smoke barrier wall above the ceiling tiles by room 201 was not continuous to the deck above. There was a 1-inch gap between the top of the wall and the deck above that was not fire stopped. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D at the time of discovery.

4. On 01/17/2017 at 9:59 AM observation revealed the smoke barrier wall above the ceiling tiles on the 2nd floor by the record storage room was not continuous to the deck above. There was a 1-inch gap between the top of the wall and the deck above that was not fire stopped. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D at the time of discovery.

5. On 01/17/2017 at 10:47 AM observation revealed the smoke barrier wall above the ceiling tiles on the 2nd floor by room 2515 was not continuous to the deck above. There was a 1-inch gap between the top of the wall and the deck above that was not properly fire stopped. There appeared to be an expandable foam type material within the gap and expandable foams are not recognized as compliant fire stop material. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D at the time of discovery.

Based on observation and interview, the facility failed to provide smoke barrier doors in accordance with NFPA 101 (2012 edition), sections 19.3.7.8 and 19.3.7.9.

Findings include:

On 1/17/17 at 9:36 AM observation of the double doors in the 1-hour rated fire barrier wall on the 2nd floor by the staff elevator was not fire rated. This deficient practice was confirmed by staff D at the time of discovery.

Based on observations and staff interview, the facility did not provide fixed electrical wiring in accordance with NFPA 99 (2012 edition) and NFPA 70 (2011 edition).

Findings include:

1. On 1/17/17 at 9:50 AM observation revealed in the 2nd floor employee lounge that a toaster, hot plate, and a microwave oven were all plugged into a single power strip. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff D.

2. On 1/17/17 at 10:05 AM observation revealed in the 2nd floor suite 2-C sleep lab that a refrigerator and a microwave oven were all plugged into a single power strip. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff D.