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Based on observations and interview the facility failed to ensure that 1 stairwell door could completely close to a latched position.

Findings include:

Observations during tour on 12/16/15 between 10:30 a.m. and 11:00 a.m. with Staff A (Emergency Management Coordinator) and Staff B (Plant Engineer) revealed that 1 (one) stairwell door located in the lower level utility wing, labeled G-033, would not automatically close to a latched position when released from the magnetic hold open device. The bottom of the door slab strikes the bottom of the door frame, preventing the door from fully closing and latching.

Interview with Staff A and Staff B confirmed the above findings and location.

Based on observations and interviews the facility failed to ensure that smoke barriers are maintained to be continuous and prevent the passage of smoke.

Findings include:

Observations During tour on 12/17/15 between 10:00 a.m. and 1:00 p.m. with Staff A (Emergency Management Coordinator) and Staff B (Plant Engineer) revealed the following locations where the smoke barriers failed to be complete and could resist the passage of smoke. These areas have unprotected penetrations through the smoke barrier walls.

1. Above the suspended ceiling in the stairwell, outside the main Kitchen entrance has a section of HVAC (Heating, Ventilation, Air Conditioning) ductwork penetrating both sides of the stairwell walls. This ductwork has 2-3 inches of open wall space around all 4 sides of the ductwork in both walls. Both of these walls would not prevent the passage of smoke.
2. Above the suspended ceiling over the cafeteria doors there is a 3" inch unprotected penetration through the smoke barrier wall.
3. The "Air Handling Room" near the conference room on the 2nd floor (west wing) has a 4" hole through the concrete floor slab. This hole is located over the boiler room and will not resist the passage of smoke.

Interview with Staff A and Staff B confirmed the above findings and locations.

Based on observations and interview the facility failed to ensure that 3 doors protecting combustible storage rooms are equipped with automatic closing devices.

Findings include:

Observations during tour on 12/16/15 between 1:00 p.m. and 3:00 p.m. with Staff A (Emergency Management Coordinator) and Staff B (Plant Engineer) revealed the following 3 combustible storage rooms that exceed 50 square feet in size. These 3 rooms are not equipped with automatic door closing devices.

1. The "Bio-Hazard" room in the lower level Utility wing (over 50 sq.ft.) is not equipped with an automatic closing device.
2. The "Records" room ( G-062) in the lower level Utility wing (over 50 sq.ft.) is not equipped with an automatic closing device.
3. The "Dietary storage" room in the lower level Utility wing (over 50 sq.ft.) is not equipped with an automatic closing device.

Interview with Staff A and Staff B confirmed the above findings and locations.

Based on interview during record review the facility failed to ensure that Fire drills are held at unexpected and varying times for the 2nd shift.

Findings include:

Record review during tour on 12/15/15 between 12:30 p.m. and 1:30 p.m. with Staff A (Emergency Management Coordinator) revealed that the 2nd shift fire drills for the last 2 years were all held at the beginning of the shift and did not vary in the times that they were conducted.

These drills were as follows:

2nd shift (3:00 p.m. - 11:00 p.m.)

09/23/15 3:20 p.m.
08/03/15 3:15 p.m.
06/02/15 3:35 p.m.
02/26/15 3:20 p.m.
11/02/14 3:36 p.m.
08/28/14 3:09 p.m.
06/30/14 3:32 p.m.
03/03/14 3:37 p.m.

Interview with Staff A during the Exit conference confirmed the above findings.

Based on observation and interview the facility failed to ensure that 1 (one) room in the Medical Records department is equipped with sprinkler coverage.

Findings include:

Observation during tour on 12/16/15 between 11:00 a.m. and 1:00 p.m. with Staff A (Emergency Management Coordinator) and Staff B (Plant Engineer) revealed that inside the Medical Records department there is 1 room (1-076) without any sprinkler coverage installed. The room is approximately 7 feet x 12 feet.

Interview with Staff A and Staff B confirmed the findings and location.

Based on observation and interview the facility failed to ensure that medical gas cylinders are individually secured.

Findings include:

Observations during tour on 12/16/15 between 1:30 p.m. and 2:00 p.m. with Staff A (Emergency Management Coordinator) and Staff B (Plant Engineer) revealed that the Medical Gas Manifold room (Located outside of the loading dock) has 2 groups of medical gas cylinders (approximately 7 cylinders each). Each group of cylinders is secured with a single chain wrapped around the group.

Observations also revealed that the Medical Gas Storage room has a single chain securing all the cylinders together.

Interview with Staff A and Staff B confirmed the findings and locations.

Based on record review and interview the facility failed to ensure that both emergency generators are exercised under load monthly.

Findings include:

Record review during tour on 12/15/15 between 2:00 p.m. and 2:30 p.m. with Staff A (Emergency Management Coordinator) and Staff B (Plant Engineer) revealed that there are 2 emergency generators for the Facility.

Monthly load tests were performed on the following months as follows:

Generator #1:

January 2015
March 2015
April 2015
June 2015
July 2015
August 2015
October 2015
November 2015

Generator #2
January 2015
February 2015
March 2015
June 2015
July 2015
August 2015
September 2015
October 2015
November 2015

Interview with Staff A and Staff B revealed mechanical issues that prevented some load tests from being preformed.

Based on observations and interview the facility failed to ensure that 1 stairwell door could completely close to a latched position.

Findings include:

Observations during tour on 12/16/15 between 10:30 a.m. and 11:00 a.m. with Staff A (Emergency Management Coordinator) and Staff B (Plant Engineer) revealed that 1 (one) stairwell door located in the lower level utility wing, labeled G-033, would not automatically close to a latched position when released from the magnetic hold open device. The bottom of the door slab strikes the bottom of the door frame, preventing the door from fully closing and latching.

Interview with Staff A and Staff B confirmed the above findings and location.

Based on observations and interviews the facility failed to ensure that smoke barriers are maintained to be continuous and prevent the passage of smoke.

Findings include:

Observations During tour on 12/17/15 between 10:00 a.m. and 1:00 p.m. with Staff A (Emergency Management Coordinator) and Staff B (Plant Engineer) revealed the following locations where the smoke barriers failed to be complete and could resist the passage of smoke. These areas have unprotected penetrations through the smoke barrier walls.

1. Above the suspended ceiling in the stairwell, outside the main Kitchen entrance has a section of HVAC (Heating, Ventilation, Air Conditioning) ductwork penetrating both sides of the stairwell walls. This ductwork has 2-3 inches of open wall space around all 4 sides of the ductwork in both walls. Both of these walls would not prevent the passage of smoke.
2. Above the suspended ceiling over the cafeteria doors there is a 3" inch unprotected penetration through the smoke barrier wall.
3. The "Air Handling Room" near the conference room on the 2nd floor (west wing) has a 4" hole through the concrete floor slab. This hole is located over the boiler room and will not resist the passage of smoke.

Interview with Staff A and Staff B confirmed the above findings and locations.

Based on observations and interview the facility failed to ensure that 3 doors protecting combustible storage rooms are equipped with automatic closing devices.

Findings include:

Observations during tour on 12/16/15 between 1:00 p.m. and 3:00 p.m. with Staff A (Emergency Management Coordinator) and Staff B (Plant Engineer) revealed the following 3 combustible storage rooms that exceed 50 square feet in size. These 3 rooms are not equipped with automatic door closing devices.

1. The "Bio-Hazard" room in the lower level Utility wing (over 50 sq.ft.) is not equipped with an automatic closing device.
2. The "Records" room ( G-062) in the lower level Utility wing (over 50 sq.ft.) is not equipped with an automatic closing device.
3. The "Dietary storage" room in the lower level Utility wing (over 50 sq.ft.) is not equipped with an automatic closing device.

Interview with Staff A and Staff B confirmed the above findings and locations.

Based on interview during record review the facility failed to ensure that Fire drills are held at unexpected and varying times for the 2nd shift.

Findings include:

Record review during tour on 12/15/15 between 12:30 p.m. and 1:30 p.m. with Staff A (Emergency Management Coordinator) revealed that the 2nd shift fire drills for the last 2 years were all held at the beginning of the shift and did not vary in the times that they were conducted.

These drills were as follows:

2nd shift (3:00 p.m. - 11:00 p.m.)

09/23/15 3:20 p.m.
08/03/15 3:15 p.m.
06/02/15 3:35 p.m.
02/26/15 3:20 p.m.
11/02/14 3:36 p.m.
08/28/14 3:09 p.m.
06/30/14 3:32 p.m.
03/03/14 3:37 p.m.

Interview with Staff A during the Exit conference confirmed the above findings.

Based on observation and interview the facility failed to ensure that 1 (one) room in the Medical Records department is equipped with sprinkler coverage.

Findings include:

Observation during tour on 12/16/15 between 11:00 a.m. and 1:00 p.m. with Staff A (Emergency Management Coordinator) and Staff B (Plant Engineer) revealed that inside the Medical Records department there is 1 room (1-076) without any sprinkler coverage installed. The room is approximately 7 feet x 12 feet.

Interview with Staff A and Staff B confirmed the findings and location.

Based on observation and interview the facility failed to ensure that medical gas cylinders are individually secured.

Findings include:

Observations during tour on 12/16/15 between 1:30 p.m. and 2:00 p.m. with Staff A (Emergency Management Coordinator) and Staff B (Plant Engineer) revealed that the Medical Gas Manifold room (Located outside of the loading dock) has 2 groups of medical gas cylinders (approximately 7 cylinders each). Each group of cylinders is secured with a single chain wrapped around the group.

Observations also revealed that the Medical Gas Storage room has a single chain securing all the cylinders together.

Interview with Staff A and Staff B confirmed the findings and locations.

Based on record review and interview the facility failed to ensure that both emergency generators are exercised under load monthly.

Findings include:

Record review during tour on 12/15/15 between 2:00 p.m. and 2:30 p.m. with Staff A (Emergency Management Coordinator) and Staff B (Plant Engineer) revealed that there are 2 emergency generators for the Facility.

Monthly load tests were performed on the following months as follows:

Generator #1:

January 2015
March 2015
April 2015
June 2015
July 2015
August 2015
October 2015
November 2015

Generator #2
January 2015
February 2015
March 2015
June 2015
July 2015
August 2015
September 2015
October 2015
November 2015

Interview with Staff A and Staff B revealed mechanical issues that prevented some load tests from being preformed.