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Based on observations, the facility failed to maintain the smoke and fire resistance rating for 2-hour and 3-hour rated fire barrier walls in accordance with NFPA 101, 2000 Edition, Section 8.2.3.2.4.2. These deficiencies affect 5 of 21 smoke compartments.

Findings include:

First Floor:

- During an observation on 12/1/15 at 1:50 p.m., the 3-hour wall near the horizontal sliding fire door (HSFD) was reviewed. There were two penetrations above the ceiling tile where the HSFD closes.¹ One was at a sprinkler pipe, and the remaining was around an I beam.

- During an observation on 12/1/15 at 2:00 p.m., the 3 hour wall above the exit door near the conference room was reviewed. There was a penetration for a large black wire which was not properly sealed.¹

- During an observation on 12/1/15 at 2:30 p.m., the 2-hour wall between the Maria Dean center and the existing hospital was reviewed. There were two unsealed conduits, 1 inch and 1.5 inch in size, which contained wiring to control doors.¹

Second Floor:

- During an observation on 12/1/15 at 10:48 a.m., the 2-hour barrier outside the IT training room was inspected. There were two conduits not sealed on either side, and a penetration with two IT cables running through which was not sealed on either side. There was also a bank of electrical conduits which were not sealed on one side of the barrier.¹

- During an observation on 12/1/15 at 11:36 a.m., the 2-hour barrier in the old OB department near room 2328 and the boiler room entrance was inspected. There was one penetration around a pipe which was not sealed.¹

- During an observation on 12/1/15 at 12:09 p.m., the 2-hour barrier above the double doors near room 2972 was inspected. There were two 2.5" conduits not sealed or plugged to fill the rest of space in the conduit.¹

- During an observation on 12/1/15 at 12:15 p.m., the 2-hour barrier across from 2972 electrical room was inspected. There was a penetration around a conduit which was not sealed on either side.¹

¹ NFPA 101, 2000 Edition, Section 8.2.3.2.4.2; Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observations, the facility failed to ensure that all corridor walls in the sprinkled building could resist the passage of smoke in accordance with NFPA 101, 2000 Edition, Section 19.3.6.1. The deficiency affects 4 of 21 smoke compartments, two on each floor.

Findings include:

First Floor:

- During an observation on 11/30/15 at 1:45 p.m., the 1-hour corridor wall of the F- Mechanical room in Informational Technology (IT)/Finance was reviewed. There were penetrations in the west wall of this room which is a corridor wall.¹

Second Floor:

- During an observation on 12/1/15 at 12:23 p.m., the 1-hour corridor wall near room 2978 was inspected, there were two electrical conduits going into room 2978 from the corridor which were not sealed on the corridor side.¹

¹ NFPA 101, 2000 Edition, Section 19.3.6.1; Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. (See also 19.2.5.9.)
Exception No. 1: Smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 shall be permitted to have spaces that are unlimited in size open to the corridor, provided that the following criteria are met:
(a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses ' station or similar space.
(d) The space does not obstruct access to required exits.

Based on observations, the facility failed to maintain a latching corridor door and to use acceptable hold open devices on a corridor door in accordance with NFPA 101, 2000 Edition, Sections 19.3.6.3.2, 19.3.6.3.3 and Annex Section A.19.3.6.3.3. This deficiency affects 2 of 21 smoke compartments.

Findings include:

- During an observation on 12/1/15 at 8:20 a.m., the corridor door to conference room 1584 was exercised. The south most door failed to latch.¹

- During an observation on 12/1/15 at 9:10 a.m., the corridor door to the Health Resource center was exercised. The door had a kick-down device installed on the door and could not be closed without first unlatching the kick-down device.²

¹ NFPA 101, 2000 Edition, Section 19.3.6.3.2, Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service.

² NFPA 101, 2000 Edition, Section 19.3.6.3.3, hold-open devices that release when the door is pushed or pulled shall be permitted. Annex A.19.3.6.3.3, doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Based on observation, the facility failed to maintain vertical openings between floors in accordance with NFPA 101,2000 Edition, Section 18.3.1.1.¹ The deficiency affects 1 of 2 smoke compartments on first and second floors.

Findings included:

- During an observation on 12/1/15 at 10:40 a.m., room 1243 was reviewed. The room contains two vertical chases for communication wiring for upper floors. The conduit chases were not sealed between floors to maintain the two hour fire resistance rating between floors.

¹ NFPA 101, 2000 Edition, Section 18.3.1.1, Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least two hours connecting four stories or more. (One hour for single story building and sprinkled buildings up to three stories in height.)

Based on observations, the facility failed to ensure openings between floors were enclosed with construction having a fire resistance rating of at least one hour per NFPA 101, 2000 Edition, Section 19.3.1.1. These deficiencies affect 1 of 10 first floor smoke compartments.

Findings include:

- During an observation on 11/30/15 at 1:35 p.m., the IT closet in Finance was reviewed. There were several conduits which were not sealed properly to maintain the fire resistance between floors.¹

- During an observation on 11/30/15 at 2:35 p.m., the IT Data room was reviewed.
a) There were 18 conduits which were not sealed properly to maintain the fire resistance between floors in the north east corner of the Data room.¹
b) There was one ceiling penetration in the middle data room which was not sealed to maintain the fire resistance between floors.¹

¹ NFPA 101, 2000 Edition, Section 19.3.1.1, Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
Exception No. 1: Unprotected vertical openings in accordance with 8.2.5.8 shall be permitted.
Exception No. 2: Exception No. 1 to 8.2.5.6(1) shall not apply to patient sleeping and treatment rooms.
Exception No. 3: Multilevel patient sleeping areas in psychiatric facilities shall be permitted without enclosure protection between levels, provided that all the following conditions are met:
(a) The entire normally occupied area, including all communicating floor levels, is sufficiently open and unobstructed so that a fire or other dangerous condition in any part is obvious to the occupants or supervisory personnel in the area.
(b) Egress capacity is sufficient to provide simultaneously for all the occupants of all communicating levels and areas, with all communicating levels in the same fire area being considered as a single floor area for purposes of determination of required egress capacity.
(c) The height between the highest and lowest finished floor levels shall not exceed 13 ft (4 m); the number of levels shall not be restricted.
Exception No. 4: Unprotected openings in accordance with 8.2.5.5 shall not be permitted.
Exception No. 5: Where a full enclosure of a stairway that is not a required exit is impracticable, the required enclosure shall be permitted to be limited to that necessary to prevent a fire originating in any story from spreading to any other story.

Based on observations, the facility failed to maintain the two-hour fire protection of the self-closing doors used as a horizontal exit in accordance with NFPA 101, 2000 Edition, Section 8.2.3.2.1 and NFPA 80, 1999 Edition, Section 2-4.1.4. These deficiencies affect 10 of 21 smoke compartments.

Findings include:

First Floor:

- During an observation on 12/1/15 at 8:10 a.m., the set of 1.5 hour fire rated doors were reviewed for the mechanical room (1500) on smoke compartment 1-C. The set of doors had louvers through the leaf of each door reducing the doors to less than smoke resisting. The set of doors were not rated for the 2-hour barrier wall which they were installed in.¹

- During an observation on 12/1/15 at 1:15 p.m., The set of fire rated doors between the Maria Dean building and the Main Hospital were exercised. The 1.5 hour rated fire doors failed to latch when exercised on three different tries.¹ ²


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Second Floor:

- During an observation on 11/30/15 at 3:41 p.m., the 2-hour doors between rooms 2550 and 2548 in same day services was exercised. The west leaf was found to have no automatic locking latch system.¹ ²

- During an observation on 11/30/15 at 3:45 p.m., the east 2-hour doors were exercised in same day services. The north leaf does not latch on its own.¹ ²

- During an observation on 11/30/15 at 4:57 p.m., the 3-hour doors near phlebotomy were exercised. The south leaf did not latch on its own.¹ ²

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 8.2.3.2.1; Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire doors and Fire Windows.

² NFPA 80 Standard for Fire Doors and Fire Windows, 1999 Edition, Section 2-4.1.4; All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Based on observation, the facility failed to ensure that access to exits was marked by approved, readily visible signs properly denoting the way to the means of egress in accordance with NFPA 101, 2000 Edition, Section 7.10.1.4. The deficiency affects 1 of 4 exits.

Findings include:

- During an observation on 12/2/15 at 10:27 a.m., the corridor area in the north east corner of the building leading to the northeast exit door was lacking an exit sign. The exit was not readily identifiable from both directions in the corridor.

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 7.10.1.4, Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

Based on observations, the facility failed to maintain smoke barriers per NFPA 101, 2000 Edition, Section 8.3.6.1. These deficiencies affect 2 of 10 first floor smoke compartments.

Findings include:

- During an observation on 11/30/15 at 1:50 p.m., the F-Mechanical room in IT/Finance was reviewed. A conduit on the north wall of the room was not properly sealed to maintain the smoke barrier wall.¹

- During an observation on 11/30/15 at 3:40 p.m., the E-Mechanical room near the Medical Staff Conference room was reviewed. There was wiring in the north east corner of the smoke barrier wall which was not sealed, along with other penetrations which included a three inch by three inch cut out in the wall and a two inch by four inch cut out which were not sealed properly.¹

- During an observation on 12/1/15 at 8:50 a.m., the electrical room (1504) was reviewed. There were three penetrations in the west smoke barrier wall near the ceiling which were not sealed to maintain the fire resistance for smoke barriers.¹

¹ NFPA 101, 2000 Edition, Section 8.3.6.1; Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observations, the facility failed to maintain the fire resistance rating of smoke barriers in accordance with NFPA 101, 2000 Edition, Section 8.3.6.1. The deficiency affects 2 of 2 smoke compartments on the fourth floor.

The findings include:

- During an observation on 12/1/15 at 1:10 p.m., the smoke barrier was reviewed for fourth floor of the towers. There was a single penetration of the barrier at a gray wire above the west smoke barrier doors.

¹ NFPA 101, 2000 Edition, Section 8.3.6.1; Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

Based on observation, the facility failed to ensure that all doors in smoke barriers were able to resist the passage of smoke in accordance with NFPA 101, 2000 Edition, Section 8.3.4.1¹ and Annex A.8.3.4.1². The deficiency affected 1 of 10 main floor smoke compartments.

Findings include:

- During an observation on 12/1/15 at 10:05 a.m., the north facing doors to the elevator lobby were exercised. The right most leaf drug on the floor and failed to close at all.¹ ² The elevator lobby doors were in a smoke barrier for the smoke compartment.

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 8.3.4.1; Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

² NFPA 101, 2000 Edition, Annex A.8.3.4.1; The clearance for proper operation of smoke doors is defined as 1/8 in. (0.3 cm). For additional information on the installation of smoke-control door assemblies, see NFPA 105, Recommended Practice for the Installation of Smoke-Control Door Assemblies, 1999 Edition.

Based on observation, the facility failed to maintain the one-hour rated construction of hazardous areas in accordance with NFPA 101, 2000 Edition, Sections 8.4.1.2 and 8.2.3.2.4.2. The deficiency could affect one room in 1 of 2 smoke compartments.

Findings include:

First Floor:

- During an observation on 12/1/15 at 11:10 a.m., room 1293 (soiled linen room) was reviewed. The ceiling was not properly rated for a hazardous location, and the door to the room was not rated or self-closing.

NFPA 101, 2000 Edition, Section 8.4.1.2; In new construction, where protection is provided with automatic extinguishing systems without fire-resistive separation, the space protected shall be enclosed with smoke partitions in accordance with 8.2.4.

NFPA 101, 2000 Edition, Section 8.2.3.2.4.2; Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts and similar building service equipment that pass through fire barriers shall be protected as follows:

Based on observations, the facility failed to protect hazardous areas with a self closing door per NFPA 101, 2000 Edition, Section 19.3.2.1. These deficiencies affect 8 of 21 smoke compartments.

Findings include:

First Floor:

- During an observation on 11/30/15 at 3:10 p.m., the vault room near the 2-hour wall of the Maria Dean center was reviewed. The storeroom was larger than 100 sq ft, and contained combustible materials. The door to the storeroom (1526) was not self-closing.¹

- During an observation on 11/3/15 at 3:55 p.m., room 1733 in Radiation/Oncology was reviewed. The room was greater than 100 sq ft and contained combustible materials. The corridor door to the room was not self-closing.

- During an observation on 11/30/15 at 4:40 p.m., the storage room in Pediatrics was reviewed. The storeroom was greater than 100 sq ft and contained combustible materials. The corridor door to the storeroom was not self-closing.¹

- During an observation on 11/30/15 at 4:57 p.m., the D-15 Mechanical room was reviewed. This storeroom is greater than 100 sq ft and contained combustible storage. There was one penetration in the far west ceiling of the room.¹

- During an observation on 11/30/15 at 5:13 p.m., the laundry area was reviewed. There were two conduits in the south east wall of the room which were not properly sealed to maintain the fire/smoke resistance for a hazardous area.¹

Second Floor:

- During an observation on 12/1/15 at 7:47 a.m., room 2738 in the sleep center was inspected. The room is a storage room, over 50 square feet, it was lacking a self-closer on one of two doors to the room.¹

- During an observation on 12/1/15 at 8:04 a.m., storage room 2719 was inspected. The room is over 100 square feet and is lacking a self-closer.¹

¹ NFPA 101, 2000 Edition, Section 19.3.2.1; Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 square feet (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square feet (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based on observation, the facility failed to maintain clear pathways to the exit discharge in accordance with NFPA 101, 2000 Edition, Section 7.1.10.1¹ and CMS Policy S&C-10-18-LSC². The deficiency could affect 1 of 4 exits from the main level.

Findings include:

- During an observation on 12/1/15 at 11:20 a.m., the exit from Magnetic Resonance Imaging (MRI) to the loading dock was reviewed. There were carts blocking direct access to full instant use of the egress path in cases of emergency.

- During an observation on 12/3/15 at 6:30 a.m., the doors in the smoke barrier in the Diagnostic Imaging corridor were exercised during the testing of the fire alarm. The set of doors failed to release when tested causing an obstruction for all who would need to exit the interior spaces in case of emergency.

¹ NFPA 101, 2000 Edition, Section 7.1.10.1; Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Annex .7.1.10.1; A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

Based on observations and interview, the facility failed to provide means of egress that were free and clear of obstructions in accordance with NFPA 101, 2000 Edition, Sections 7.1.10.1. These deficiencies affect 4 of 9 exits on first floor, and 2 of 16 exits on second floor.

Findings include:

- During an observation on 11/30/15 at 4:26 p.m., the exit access to the public way was reviewed for the exit near Radiology/Oncology. The exit to the public way was not swept and had accumulations of ice and snow covering the walkway.¹

- During an observation on 12/1/15 at 7:20 a.m., the exit access to the public way was reviewed for the exit from Purchasing. The exit to the public way was not swept and had accumulations of ice and snow covering the walkway.¹

- During an observation on 12/1/15 at 9:00 a.m., the east exit through the courtyard was reviewed. The exit was not swept and had accumulations of ice and snow covering the walk-way.¹

- During an observation on 12/1/15 at 1:32 p.m., the exit access to the public way was reviewed for the exit near room 1929 near the 2-hour wall of the Maria Dean center.
a) The exit to the public way was not swept and had accumulations of ice and snow covering the walkway.¹
b) There was also a chair blocking access on the sidewalk to the public way.¹


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- During an observation on 12/1/15 at 11:36 a.m., the sidewalk from the outside exit in the old OB wing was not swept of snow.¹

- During an observation on 12/3/15 at 8:26 a.m., the sidewalk from the emergency exit out of medical records was not swept of snow.¹

¹ NFPA 101, 2000 Edition, Section 7.1.10.1; Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Annex A.7.1.10.1; A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

Based on observation, the facility failed to provide means of egress that were free and clear of obstructions in accordance with NFPA 101, 2000 Edition, Sections 7.1.10.1. This deficiency affects 1 of 4 exits.

Findings include:

- During an observation on 12/2/15 at 10:27 a.m., the sidewalk and stairway to the public way out of the north east exit was not cleared of the snow.¹

¹ NFPA 101, 2000 Edition, Section 7.1.10.1; Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on record review, the facility failed to hold fire drills at a minimum of quarterly on each shift per NFPA 101, 2000 Edition, Section 19.7.1.2. This deficiency could affect 21 of 21 smoke compartments.

Findings include:

Review of facility documents regarding fire drills reflected fire drills were not completed for the night shift in the first quarter of 2015.¹

¹ NFPA 101, 2000 Edition, Section 19.7.1.2; Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on observation, the facility failed to install the fire alarm system with all its components per NFPA 72, National Fire Alarm Code, 1999 Edition, Section 2-8.2.2. This deficiency could affect 2 of 8 smoke compartments in the patient tower.

Findings include:

- During an observation on 12/3/15 at 6:23 a.m., the building separation between the patient towers and the main hospital on the second floor was inspected. There was not a manual pull station for the fire alarm within 5 feet of the horizontal exit on the patient tower side of the 3-hour doors.¹

¹ NFPA 72, National Fire Alarm Code, 1999 Edition, Section 2-8.2.2; Manual fire alarm boxes shall be located within 5 ft (1.5 m) of the exit doorway opening at each exit on each floor.

Based on observation, the facility failed to identify the branch circuit for the Fire Alarm Control Panel (FACP) and failed to mark it in RED at the electrical panel. This deficiency affects all of the building.

Findings include:

- During an observation on 12/2/15 at 10:24 p.m., the FACP and the corresponding breaker were inspected. The circuit breaker for the FACP was not identified on the FACP and the breaker was not delineated in red.¹

¹ NFPA 72, National Fire Alarm Code, Section 1-5.2.5.2, Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Based on observation, the facility failed to identify the branch circuit for the Fire Alarm Control Panel (FACP) in RED at the electrical panel. This deficiency affects all three floors of the facility.

Findings include:

First Floor:

- During an observation on 12/1/15 at 4:17 p.m., the FACP and the corresponding breaker were inspected. The breaker was not delineated in red.

¹ NFPA 72, National Fire Alarm Code, Section 1-5.2.5.2, Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Based on record review and interview, the facility failed to conduct load voltage tests on the batteries of the fire alarm control panel (FACP) semi-annually, as required per NFPA 72, 1999 Edition, Table 7-3.2. The deficiency affects 21 of 21 smoke compartments.

Findings include:

Review of the alarm system test records reflected the annual maintenance of the panel was conducted on 6/19/15, and reflected the load voltage testing had been done on the sealed lead-acid batteries of the panel. There was no evidence the sealed-lead acid batteries have been voltage tested six-months prior to the annual alarm test.¹

During an interview on 8/10/15 at 11:15 a.m., staff member A, director of facilities, stated they were not aware of the semiannual testing requirement.

¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Table 7.3.2 (6)(d)(3), requires sealed lead-acid type batteries to have a "Load Voltage Test" upon initial installation and then semiannually thereafter.

Based on observations, the facility failed to provide a complete sprinkler system free of obstructions for complete sprinkler pattern coverage in accordance with NFPA 13, 1999 Edition, Sections 5-6.5.2.1 and 5-6.5.3.1. The deficiency affects 1 of 10 first floor smoke compartments.

Findings include:

- During an observation on 12/1/15 at 9:40 a.m., Mechanical room A in the professional wing was reviewed. The room had air handler units greater than 48 inches in width which were not sprinkled above and below the ducting.³

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.2.1, Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with this section. Regardless of the rules of this section, solid continuous obstructions shall meet the requirements of 5-6.5.1.2.

² NFPA 13 Standard for Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.3.1; Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.
Exception: Obstructions that are not fixed in place, such as conference tables.

Based on observation, the facility failed to maintain the sprinkler system in accordance to NFPA 13, 1999 Edition, Section 5-5.5.3. This deficiency affects 1 room in 1 of 2 smoke compartments.

- During an observation on 12/1/15 at 11:00 a.m., room 1268 was reviewed. The privacy curtain for the room did not have mesh at the top to allow full sprinkler coverage for the lone sprinkler head.

NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-5.5.3; Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 5-5.5.3.

Based on observations and interview, the facility failed to maintain components of the sprinkler system in accordance with NFPA 13, 1998 Edition, Section 5-1.1. This deficiency affects the second floor.

Findings include:

During an observation on 12/2/15 at 7:20 a.m., room 2128 was observed. The privacy curtain used to screen the corridor door did not have mesh at the top, so the lone sprinkler head could provide protection to that portion of the room.¹

¹ NFPA 13 Standard for the Installation of Sprinkler Systems 1999 Edition, Section 5-1.1; The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.

Based on observation, the facility failed to continuously maintain the automatic sprinkler system in accordance with NFPA 25, 1998 Edition, Section 2-2.1.1. The deficiency affects one head of the sprinkler system.

Findings include:

- During an observation on 12/2/15 at 10:20 a.m., the hearing booth room was inspected. There was an escutcheon ring which was down from the ceiling of the booth approximately 3/8 of an inch, exposing a gap around the sprinkler pipe.¹

¹ NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 Edition, Section 2-2.1.1; Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1*: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Based on observations, the facility failed to maintain the automatic sprinkler system per NFPA 13, 1999 Edition, Sections 5-1.1, 5-6.3.4 & 5-6.5.1.2 and NFPA 25, 1998 Edition, Section 2-2.1.1. These deficiencies affect 13 of 21 first and second floor smoke compartments.

Findings include:

First Floor:

- During an observation on 11/30/15 at 2:45 p.m., the data/mechanical room in IT/Finance was reviewed. A sprinkler head near the south wall would spray directly into a beam.¹

- During an observation on 11/30/15 at 3:25 p.m., the Quality Manager's office was reviewed. One ceiling tile had been removed and not reinstalled to maintain the integrity of the rated ceiling.

- During an observation on 11/30/15 at 4:20 p.m., the storeroom between Radiology and Oncology was reviewed. Three escutcheon rings were loose and dangling from the sprinkler heads.

- During an observation on 11/30/15 at 4:30 p.m., room 1738 Neuropsychiatry was reviewed. There was a missing ceiling tile which had not been reinstalled to maintain the integrity of the rated ceiling.

- During an observation on 11/30/15 at 4:47 p.m., the kitchen and dietary areas were reviewed.
a) There were two lint filled sprinkler heads above the Convotherm equipment.²
b) There was one lint filled sprinkler head above the salad bar in the cafeteria.²

- During an observation on 11/30/15 at 5:00 p.m., the laundry area was reviewed.
a) Room 1332 (back of dryers) had lint buildup on several sprinkler heads.²
b) Room housing washing machines had a drop ceiling which was not enclosed at one portion, allowing smoke to filter above the level of protection.4
c) Also, in the laundry area, one light fixture prevented one sprinkler head from developing a full sprinkler pattern.¹

- During an observation on 12/1/15 at 7:30 a.m., in room 1632 (Morgue), there was one escutcheon ring down from the ceiling tile and one escutcheon for a scale chain which was not smoke tight at the ceiling tile.4

- During an observation on 12/1/15 at 8:20 a.m, the print shop was reviewed. A sprinkler head had been installed within three inches of a drop ceiling interfering with the spray pattern for the head.¹

During an observation on 12/1/15 at 8:30 a.m., the steam room in smoke compartment 1-C was reviewed. There was a drop ceiling which was not complete at a side wall, allowing smoke to accumulate above the level of protection.4

Second Floor:

-During an observation on 11/30/15 at 1:18 p.m., the med gas store room on the second floor was inspected. The sprinkler head on the ceiling was measured to be approximately four inches from the ceiling mounted light fixture. The light fixture was also lower than the deflector of the sprinkler head.¹

- During an observation on 11/30/15 at 3:02 p.m., the public relations coordinator's office 2866 was inspected. The sprinkler head in the room was totally covered in dust and lint.²

- During an observation on 11/30/15 at 3:30 p.m., room 2501 was inspected. The sprinkler head in the room was covered in dust and lint.²

- During an observation on 11/30/15 at 3:35 p.m., the scope cleaning room was inspected. The sprinkler head in the room was covered in dust and lint.²

- During an observation on 12/1/15 at 7:44 a.m., the room across from 2725 was inspected. There were two sprinkler heads only about one foot apart.³

- During an observation on 12/1/15 at 8:34 a.m., soiled utility room 2268 was inspected. There were two sprinkler heads only four feet apart.³

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.1.2; Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).
Exception No. 1: Sprinklers shall be permitted to be spaced on opposite sides of obstructions not exceeding 4 ft (1.2 m) in width provided the distance from the centerline of the obstruction to the sprinklers does not exceed one-half the allowable distance permitted between sprinklers.
Exception No. 2: Obstructions located against the wall and that are not over 30 in. (762 mm) in width shall be permitted to be protected in accordance with Figure 5-6.5.1.2(b).
Distance from Sprinklers to Side of Obstruction (A) Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.) (B)
Less than 1 ft 0
1 ft to less than 1 ft 6 in. 2 1/2
1 ft 6 in. to less than 2 ft 3 1/2
2 ft to less than 2 ft 6 in. 5 1/2
2 ft 6 in. to less than 3 ft 7 1/2
3 ft to less than 3 ft 6 in. 9 1/2
3 ft 6 in. to less than 4 ft 12
4 ft to less than 4 ft 6 in. 14
4 ft 6 in. to less than 5 ft 16 1/2
5 ft and greater 18
For SI units, 1 in. = 25.4 mm; 1 ft = 0.3048 m.
Note: For (A) and (B), refer to Figure 5-6.5.1.2(a).

² NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 Edition, Section 2-2.1.1; Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1*: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

³ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-6.3.4; Minimum Distance Between Sprinklers. Sprinklers shall be spaced not less than 6 ft (1.8 m) on center.
Exception No. 1: Sprinklers shall be permitted to be placed less than 6 ft (1.8 m) on center where the following conditions are satisfied:
(a) Baffles shall be installed and located midway between sprinklers and arranged to protect the actuating elements.
(b) Baffles shall be of noncombustible or limited-combustible material that will stay in place before and during sprinkler operation.
(c) Baffles shall be not less than 8 in. (203 mm) wide and 6 in. (152 mm) high. The tops of baffles shall extend between 2 in. and 3 in. (51 mm and 76 mm) above the deflectors of upright sprinklers. The bottoms of baffles shall extend downward to a level at least even with the deflectors of pendent sprinklers.
Exception No. 2: In-rack sprinklers shall be permitted to be placed less than 6 ft (1.8 m) on center.
Exception No. 3: Old-style sprinklers protecting fur storage vaults shall be permitted to be placed less than 6 ft (1.8 m) on center.

4 NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5.1.1; The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.

Based on observations, the facility failed to place portable fire extinguishers at proper heights per NFPA 10, Section 1-6.10 and failed to inspect all portable fire extinguishers at least every 30 days in accordance with NFPA 10, 1998 Edition, Section 4-3.1. These deficiencies affect two fire extinguishers.

Findings include:

- During an observation on 12/2/15 at 10:15 a.m., the portable fire extinguisher located in diagnostic imaging was mounted above 60 inches.¹


32381

- During an observation on 12/2/15 at 10:18 a.m., the fire extinguisher in the fire equipment room was found to be missing the initials for monthly inspections for October and November of 2015.²

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 1-6.10; Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

² NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 4-3.1 Frequency; Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

Based on observation, the facility failed to inspect all portable fire extinguishers at least every 30 days in accordance with NFPA 10, 1998 Edition, Section 4-3.1. This deficiency affects one fire extinguisher on first floor.

Findings include:

- During an observation on 12/1/15 at 4:02 p.m., the portable fire extinguisher next to the pharmacy was inspected. It was found to be missing the initials for having been inspected in November of 2015.¹

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 4-3.1 Frequency; Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

Based on observations, the facility failed to document the inspection of a portable fire extinguisher in accordance with the standards of NFPA 10, 1998 Edition, Section 4-4.4.1. The deficiency affected 1 extinguisher 1 of 11 second floor smoke compartments.

Findings include:

- During an observation on 11/30/15 at 2:40 p.m., the lab was inspected. The portable fire extinguisher in the southeast corner of the lab, #09-08, did not have a 6-year maintenance sticker on the back of the extinguisher.¹

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 4-4.4.1*; Fire extinguishers that pass the applicable 6-year requirement of 4-4.3 shall have the maintenance information recorded on a suitable metallic label or equally durable material having a minimum size of 2 in. 3 1/2 in. (5.1 cm 8.9 cm).
The new label shall be affixed to the shell by a heatless process, and any old maintenance labels shall be removed. These labels shall be of the self-destructive type when removal from a fire extinguisher is attempted. The label shall include the following information:
(a) Month and year the maintenance was performed, indicated by a perforation such as is done by a hand punch
(b) Name or initials of person performing the maintenance and name of agency performing the maintenance.

² NFPA 10, 1998 Edition, Section 5-6.4 Low-Pressure Cylinders; Fire extinguisher shells of the low-pressure type that pass a hydrostatic test shall have the test information recorded on a suitable metallic label or equally durable material with a minimum size of 2 in. 3 1/2 in. (5.1 cm 8.9 cm). The label shall be affixed to the shell by means of a heatless process and all old hydrostatic test labels shall be removed. These labels shall be of the type that self-destructs when removal from a fire extinguisher shell is attempted. The label shall include the following information:
(a) Month and year the test was performed, indicated by a perforation, such as is done by a hand punch
(b) Test pressure used
(c) Name or initials of person performing the test, and name of agency performing the test

Based on observation and interview, the facility failed to maintain the means of egress free of all obstruction for instant use in accordance with NFPA 101, 2000 Edition, Section 7.1.10.1 and Annex A.7.1.10.1. These deficiencies affect 1 of 9 exits and 2 of 10 first floor smoke compartments.

Findings include:

- During an observation on 11/30/15, the exit corridor near facilities leading toward the boiler room was reviewed. There were stored items in the corridor including, pallets of delivered supplies, building supplies, lighting, and combustible materials. The isle toward the exit was not free and clear for proper means of egress which allows unobstructed travel at all times.¹

¹ NFPA 101, 2000 Edition, Section 7.1.10.1; Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Annex Section A.7.1.10.1; A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

Based on observation, the facility failed to store a nitrous oxide compressed gas cylinder in accordance with the standards of NFPA 99, 1999 Edition, Section 4-3.5.2.1.¹ This deficiency affects the second floor.

Findings include:

During an observation on 12/2/15 at 8:10 a.m., procedure room 2020 was observed. The nitrous cylinder was not secured to prevent it from tipping over.¹

¹ NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 4-3.5.2.1, Gases in Cylinders and Liquefied Gases in Containers - Level 1, (a) Handling of Gases; requires administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility. (b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed: 27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on observation, the facility failed to store oxygen cylinders in accordance with the standards of NFPA 99, 1999 Edition, Sections 4-3.1.1.2 (a) (4). This deficiency affects 1 of 11 second floor smoke compartments.

Findings include:

- During an observation on 11/30/15 at 1:18 p.m., the second floor med gas room was inspected. There were two light switches and 3 wall outlets which were not a minimum of 60 inches from the floor.¹

¹ NFPA 99, 1999 Edition, Section 4-3.1.1.2 (a) (4); The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

Based on observations, interview and record review, the facility failed to ensure that the piped medical gas system met the standards of NFPA 99, 1999 Edition, Section 4-3.5.4.2. These deficiencies affect 2 of 21 first and second floor smoke compartments.

Findings include:

First Floor:

- During an observation on 11/30/15 at 4:28 p.m., the shut off valve for the med gas in room 1704 was reviewed. The shut off valve was labeled incorrectly and did not reflect that it was now room 1704.¹

- During an observation on 11/30/15 at 4:32 p.m., the shut off valve for the med gas in room 1742 of Neuropsychiatry was reviewed. The cover for the control valve was not labeled to reflect the room number that was controlled by the shut of valve.¹

Second Floor:

- During an observation on 11/30/15 at 4:30 p.m., OR 3 and OR 4 were inspected. The gas shutoffs outside the rooms were not labeled to which room was controlled by the shutoff valve.¹

¹ NFPA 99 Health Care Facilities, 1999 Edition, Section 4-3.5.4.2; The shutoff valves described in 4-3.1.2.3, 4-3.1.2.3(m), and 4-3.1.2.3(n) shall be labeled to reflect the rooms that are controlled by such valves. Labeling shall be kept current from initial construction through acceptance. Valves shall be labeled in substance as follows:
CAUTION:
(NAME OF MEDICAL GAS) VALVE DO NOT CLOSE EXCEPT IN EMERGENCY THIS VALVE CONTROLS SUPPLY TO . . . .

Based on observation, record review, and staff interviews, all of the anesthetizing locations were not held above 35% humidity per NFPA 99, Section 5-4.1.1. This deficiency could affect 5 of 7 operating rooms.

Finding include:

During an interview on 12/2/15 at 11:25 a.m., staff member A stated operating rooms (ORs) 5, 6, and 7 are humidified and the humidifiers are set at 25%. He stated the facility does not have a categorical waiver to allow the humidity to be below 35%.

In the same interview, it was discovered operating rooms 1, 2, 3, and 4 are not humidified. Rooms 2 and 3 are not used for anything but storage. ORs 1 and 4 are not humidified.¹

During an observation of the facility's automatic monitoring system, the humidity was recorded to be hovering slightly above or below 25% in ORs 5, 6, and 7. The automated system was recording humidity levels of 9 or 10% in ORs 1 and 4. This appeared to be in error, as a local humidity device in the OR read the humidity to be 30%.¹

In an interview on 12/2/15 at 2:00 p.m., staff member B stated the humidities have been running around 30% on the reports she gets. Staff member B, stated all the ORs are used interchangeably, there are no special surgeries in the ORs with no humidification. She also stated, she was not aware of CMS humidity requirements, and that with the categorical waiver, humidity could be as low as 20%.²

¹ NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 5-4.1.1*; The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

² CMS S&C-13-25-LSC and ASC: Relative Humidity (RH): Waiver of Life Safety Code (LSC) Anesthetizing Location Requirements; Discussion of Ambulatory Surgical Center (ASC) Operation Room Requirements, Issued April 29, 2013.

Based on observation, the facility failed to ensure interior walls were constructed and finished to be noncombustible in accordance with NFPA 101, Life Safety Code, 2000 Edition, Section 18.1.6.3. The deficiency could affect 1 of 2 smoke compartments on the third floor of the patient tower.

Findings include:

Second Floor:

- During an observation on 12/1/15 at 1:15 p.m., the third floor of the patient tower was inspected. The corridor wall outside room 2164 had a one foot by two feet cutout of the 1-hour separated interior wall.¹

¹ In accordance with NFPA 101 and Section 19.1.6.3; all interior walls and partitions in buildings of Type I or Type II construction shall be of noncombustible or limited-combustible materials.
Exception*: Listed, fire-retardant-treated wood studs shall be permitted within non-load bearing 1-hour fire-rated partitions. Further, Annex A.19.1.6.3 Exception states that there is a finish capacity in a 1-hour fire-rated partition that would be expected to prevent the generation of smoke and gases from fire retardant-treated wood studs for an extended time during fire exposure. This Code does not intend to permit the use of fire-retardant wood studs and partitions of only 20-minute fire resistance.

Based on observation, the facility failed to ensure that smoke dampers, interconnected to the facility fire alarm system, closed upon testing per NFPA 72, 1999 Edition, Section 3-9.5.2. This deficiency could effect 2 of 2 smoke compartments on the second floor of the patient towers.

Findings include:

Second Floor:

- During an observation on 12/1/15 at 1:23 p.m., the damper over the double doors in the west corridor on the second floor of the patient towers was inspected. Upon being tested by removal of the air line from the damper, it failed to close.¹

¹ NFPA 72 National Fire Alarm Code®, 1999 Edition, Section 3-9.5.2; If connected to the fire alarm system serving the protected premises, all detection devices used to cause the operation of HVAC (Heating, Ventilation, and Air-Conditioning) systems smoke dampers, fire dampers, fan control, smoke doors, and fire doors shall be monitored for integrity in accordance with 1-5.8.

Based on observations, the facility failed to ensure that smoke dampers, interconnected to the facility fire alarm system, closed upon testing per NFPA 72, 1999 Edition, Section 3-9.5.2., and failed to ensure that fire dampers were exercised once in four years time per NFPA 90A, 1999 Edition, Section 3-4.7¹. These deficiencies affect 21 of 21 first and second floor smoke compartments.

Findings include:

- During an interview on 11/30/15 at 8:30 a.m., staff member A stated they were testing the dampers on a 6-year interval and they were not aware of the waiver.¹ ²

- During an observation on 12/1/15 at 10:48 a.m., the damper outside the case management office was tested by pulling the air line off the damper. The damper failed to close.³

- During an observation on 12/1/15 at 11:15 a.m., the damper near the Administrator of the day office was tested by pulling the air line off the damper. The damper failed to function.³

¹ NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems,1999 Edition, Section 3-4.7 Maintenance, At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

² Hospitals can qualify for a six year damper test interval per CMS S&C Policy S&C-10-04-LSC Waiver to Allow Hospitals to Use the NFPA 6-Year Damper Testing Interval, Issued 10/30/09.

² NFPA 72 National Fire Alarm Code®, 1999 Edition, Section 3-9.5.2; If connected to the fire alarm system serving the protected premises, all detection devices used to cause the operation of HVAC (Heating, Ventilation, and Air-Conditioning) systems smoke dampers, fire dampers, fan control, smoke doors, and fire doors shall be monitored for integrity in accordance with 1-5.8.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC and NFPA 70, 1999 Edition. These deficiencies affected the second floor.

Findings include:

- During an observation on 12/2/15 at 7:15 a.m., room 2216 was inspected. A floor heater was plugged into a power strip.¹

- During an observation on 12/2/15 at 7:25 a.m., room 2070 was inspected. A refrigerator was plugged into a power strip.¹

- During an observation on 12/2/15 at 7:40 a.m., the Audiology 2-E office was inspected. A white extension cord was found in-use.²

- During an observation on 12/2/15 at 7:50 a.m., room 2050 was inspected. A white extension cord was found in-use.²

- During an observation on 12/2/15 at 8:02 a.m., room 2038 was inspected. A multi-plug adaptor was found in-use.²

- During an observation on 12/2/15 at 8:07 a.m., the 2-A nurse's station was inspected. A white extension cord was found in-use.²

- During an observation on 12/2/15 at 8:20 a.m., room 2156 was inspected. A yellow extension cord was found which supplied power to a camera which had been installed. The extension cord was still in-use for the camera.²

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

² NFPA 70 National Electrical Code, 1999 Edition, Article 305-2(b); All Wiring Installations (a) Other Articles. Except as specifically modified in this article, all other requirements of this Code for permanent wiring shall apply to temporary wiring installations.
(b) Approval. Temporary wiring methods shall be acceptable only if approved based on the conditions of use and any special requirements of the temporary installation.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with NFPA 70, 1999 Edition, Article 400-8. These deficiencies affect the entire building.

Findings include:

- During an observation on 12/2/15 at 9:42 a.m., the physician's dictation room by exam room 54 was inspected. A refrigerator power cord was run through a sliding glass door and plugged into a wall outlet. Power cords can not be run under or through open door ways.¹

- During an observation on 12/2/15 at 9:47 a.m., in the alcove next to exam room 41, there were three power strips triple daisy chained together under the desk.²

¹ NFPA 70 National Electric Code, 1999 Edition, Article 400-8; Flexible cords shall not be run through doorways, windows or similar openings.

² CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

Based on observation, the facility failed to utilize power strips in accordance with CMS Survey & Certification Policy S&C-14-46-LSC. This deficiency could affects 1 of 2 floors.

Findings include:

During an observation on 12/2/15 at 1:30 p.m., there was a dangling power strip unsupported in room 1929.¹

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC. This deficiency could affect 1 of 1 smoke compartments.

Findings include:

Third Floor:

- During an observation on 12/1/15 at 10:09 a.m., room 3177 on the third floor of the patient tower was inspected. There was a power strip hanging and unsupported in the room.

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC and NFPA 70, 1999 Edition, Articles 305-2(b) and 370.28(c). These deficiencies affect 12 of 21 first and second floor smoke compartments.

Findings include:

First Floor:

- During an observation on 11/30/15 at 1:20 p.m., IT/Finance area was reviewed.
a.) There were several power strips found in series (piggy backed together).¹

b.) A microwave oven was found plugged into a power strip.¹

- During an observation on 11/30/15 at 3:00 p.m., the Vault room, had two covers missing on electrical conduit greater than 110 volts.²

- During an observation on 11/30/15 at 3:20 p.m., in office #1530, the power strip was dangling and unsupported.¹

- During an observation on 11/30/15 at 3:45 p.m., in Oncology
a) an white extension cord was found in-use.³
b) a refrigerator was plugged into a power strip.¹
c) in room #1712, an extension cord was found in-use for a computer.³
d) In room 1716, a power strip was unsupported and a microwave was plugged into a power strip.¹

- During an observation on 11/30/15 at 5:05 p.m., in room 1325 of the laundry, a microwave oven was plugged into a power strip.¹

- During an observation on 12/3/15 at 7:00 a.m., wiring which was attached to two by six inch construction lumber over the coffee shop pay counter was not enclosed in conduit.³

Second Floor:

- During an observation on 11/30/15 at 1:43 p.m., the ER registration office was inspected. There was a microwave plugged into a power strip and a power strip hanging by the cords that were plugged into it under the desk in the office.¹

- During an observation on 11/30/15 at 1:43 p.m., the Cath Lab was inspected. There was a power strip hanging by the cords that were plugged into it.¹

- During an observation on 11/30/15 at 2:34 p.m., room 2811 was inspected. There was a power strip hanging by the the cords plugged into it.¹

- During an observation on 11/30/15 at 2:48 p.m., room 2803A was inspected. The was a power strip hanging by the the cords plugged into it.¹

- During an observation on 11/30/15 at 2:54 p.m., the administration offices were inspected. There was a power strip under the Executive Assistant's desk hanging by the cords plugged into it.¹

- During an observation on 11/30/15 at 2:57 p.m., office 2846 was inspected. There were two power strips daisy chained together.¹

- During an observation on 11/30/15 at 4:51 p.m., the case manager's office, room 2445, was inspected. There was a microwave plugged into a power strip.¹

- During an observation on 12/1/15 at 8:16 a.m., the molecular lab was inspected. There were two refrigerators plugged into a multi-plug adapter that did not have circuit protection.¹ ²

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

² NFPA 70 National Electric Code, 1999 Edition, Article 370.28(c); All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Article 250-110.

³ NFPA 70 National Electrical Code, 1999 Edition, Article 305-2(b); All Wiring Installations (a) Other Articles. Except as specifically modified in this article, all other requirements of this Code for permanent wiring shall apply to temporary wiring installations.
(b) Approval. Temporary wiring methods shall be acceptable only if approved based on the conditions of use and any special requirements of the temporary installation.

Based on observations, the facility failed to ensure that alcohol-based hand rub (ABHR) dispensers were not installed directly over or adjacent to an ignition source per CMS Survey & Certification Policy S&C-05-33. This deficiency affects 2 of 11 second floor smoke compartments.

Findings include:

- During an observation on 12/1/15 at 7:15 a.m., the dialysis reception area was inspected. There was an ABHR (Alcohol-Based Hand Rub) dispenser positioned over a wall outlet.¹

- During an observation on 12/1/15 at 7:58 a.m., the nutrition conference room was inspected. The ABHR dispenser was within an inch of the light switch.¹

¹ CMS interpretations under Survey & Certification (S&C)-05-33 policy issued on June 9, 2005, states ABHR dispensers shall meet the NFPA amendment to the 2000 Life Safety Code regarding the installation of ABHR dispensers in exit corridors and on interior walls. The Certification Bureau enforces that ABHR dispensers be offset by at least one inch and not mounted directly above any electrical source.

Based on observations, the facility failed to maintain the smoke and fire resistance rating for 2-hour and 3-hour rated fire barrier walls in accordance with NFPA 101, 2000 Edition, Section 8.2.3.2.4.2. These deficiencies affect 5 of 21 smoke compartments.

Findings include:

First Floor:

- During an observation on 12/1/15 at 1:50 p.m., the 3-hour wall near the horizontal sliding fire door (HSFD) was reviewed. There were two penetrations above the ceiling tile where the HSFD closes.¹ One was at a sprinkler pipe, and the remaining was around an I beam.

- During an observation on 12/1/15 at 2:00 p.m., the 3 hour wall above the exit door near the conference room was reviewed. There was a penetration for a large black wire which was not properly sealed.¹

- During an observation on 12/1/15 at 2:30 p.m., the 2-hour wall between the Maria Dean center and the existing hospital was reviewed. There were two unsealed conduits, 1 inch and 1.5 inch in size, which contained wiring to control doors.¹

Second Floor:

- During an observation on 12/1/15 at 10:48 a.m., the 2-hour barrier outside the IT training room was inspected. There were two conduits not sealed on either side, and a penetration with two IT cables running through which was not sealed on either side. There was also a bank of electrical conduits which were not sealed on one side of the barrier.¹

- During an observation on 12/1/15 at 11:36 a.m., the 2-hour barrier in the old OB department near room 2328 and the boiler room entrance was inspected. There was one penetration around a pipe which was not sealed.¹

- During an observation on 12/1/15 at 12:09 p.m., the 2-hour barrier above the double doors near room 2972 was inspected. There were two 2.5" conduits not sealed or plugged to fill the rest of space in the conduit.¹

- During an observation on 12/1/15 at 12:15 p.m., the 2-hour barrier across from 2972 electrical room was inspected. There was a penetration around a conduit which was not sealed on either side.¹

¹ NFPA 101, 2000 Edition, Section 8.2.3.2.4.2; Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observations, the facility failed to ensure that all corridor walls in the sprinkled building could resist the passage of smoke in accordance with NFPA 101, 2000 Edition, Section 19.3.6.1. The deficiency affects 4 of 21 smoke compartments, two on each floor.

Findings include:

First Floor:

- During an observation on 11/30/15 at 1:45 p.m., the 1-hour corridor wall of the F- Mechanical room in Informational Technology (IT)/Finance was reviewed. There were penetrations in the west wall of this room which is a corridor wall.¹

Second Floor:

- During an observation on 12/1/15 at 12:23 p.m., the 1-hour corridor wall near room 2978 was inspected, there were two electrical conduits going into room 2978 from the corridor which were not sealed on the corridor side.¹

¹ NFPA 101, 2000 Edition, Section 19.3.6.1; Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. (See also 19.2.5.9.)
Exception No. 1: Smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 shall be permitted to have spaces that are unlimited in size open to the corridor, provided that the following criteria are met:
(a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses ' station or similar space.
(d) The space does not obstruct access to required exits.

Based on observations, the facility failed to maintain a latching corridor door and to use acceptable hold open devices on a corridor door in accordance with NFPA 101, 2000 Edition, Sections 19.3.6.3.2, 19.3.6.3.3 and Annex Section A.19.3.6.3.3. This deficiency affects 2 of 21 smoke compartments.

Findings include:

- During an observation on 12/1/15 at 8:20 a.m., the corridor door to conference room 1584 was exercised. The south most door failed to latch.¹

- During an observation on 12/1/15 at 9:10 a.m., the corridor door to the Health Resource center was exercised. The door had a kick-down device installed on the door and could not be closed without first unlatching the kick-down device.²

¹ NFPA 101, 2000 Edition, Section 19.3.6.3.2, Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service.

² NFPA 101, 2000 Edition, Section 19.3.6.3.3, hold-open devices that release when the door is pushed or pulled shall be permitted. Annex A.19.3.6.3.3, doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Based on observation, the facility failed to maintain vertical openings between floors in accordance with NFPA 101,2000 Edition, Section 18.3.1.1.¹ The deficiency affects 1 of 2 smoke compartments on first and second floors.

Findings included:

- During an observation on 12/1/15 at 10:40 a.m., room 1243 was reviewed. The room contains two vertical chases for communication wiring for upper floors. The conduit chases were not sealed between floors to maintain the two hour fire resistance rating between floors.

¹ NFPA 101, 2000 Edition, Section 18.3.1.1, Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least two hours connecting four stories or more. (One hour for single story building and sprinkled buildings up to three stories in height.)

Based on observations, the facility failed to ensure openings between floors were enclosed with construction having a fire resistance rating of at least one hour per NFPA 101, 2000 Edition, Section 19.3.1.1. These deficiencies affect 1 of 10 first floor smoke compartments.

Findings include:

- During an observation on 11/30/15 at 1:35 p.m., the IT closet in Finance was reviewed. There were several conduits which were not sealed properly to maintain the fire resistance between floors.¹

- During an observation on 11/30/15 at 2:35 p.m., the IT Data room was reviewed.
a) There were 18 conduits which were not sealed properly to maintain the fire resistance between floors in the north east corner of the Data room.¹
b) There was one ceiling penetration in the middle data room which was not sealed to maintain the fire resistance between floors.¹

¹ NFPA 101, 2000 Edition, Section 19.3.1.1, Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
Exception No. 1: Unprotected vertical openings in accordance with 8.2.5.8 shall be permitted.
Exception No. 2: Exception No. 1 to 8.2.5.6(1) shall not apply to patient sleeping and treatment rooms.
Exception No. 3: Multilevel patient sleeping areas in psychiatric facilities shall be permitted without enclosure protection between levels, provided that all the following conditions are met:
(a) The entire normally occupied area, including all communicating floor levels, is sufficiently open and unobstructed so that a fire or other dangerous condition in any part is obvious to the occupants or supervisory personnel in the area.
(b) Egress capacity is sufficient to provide simultaneously for all the occupants of all communicating levels and areas, with all communicating levels in the same fire area being considered as a single floor area for purposes of determination of required egress capacity.
(c) The height between the highest and lowest finished floor levels shall not exceed 13 ft (4 m); the number of levels shall not be restricted.
Exception No. 4: Unprotected openings in accordance with 8.2.5.5 shall not be permitted.
Exception No. 5: Where a full enclosure of a stairway that is not a required exit is impracticable, the required enclosure shall be permitted to be limited to that necessary to prevent a fire originating in any story from spreading to any other story.

Based on observations, the facility failed to maintain the two-hour fire protection of the self-closing doors used as a horizontal exit in accordance with NFPA 101, 2000 Edition, Section 8.2.3.2.1 and NFPA 80, 1999 Edition, Section 2-4.1.4. These deficiencies affect 10 of 21 smoke compartments.

Findings include:

First Floor:

- During an observation on 12/1/15 at 8:10 a.m., the set of 1.5 hour fire rated doors were reviewed for the mechanical room (1500) on smoke compartment 1-C. The set of doors had louvers through the leaf of each door reducing the doors to less than smoke resisting. The set of doors were not rated for the 2-hour barrier wall which they were installed in.¹

- During an observation on 12/1/15 at 1:15 p.m., The set of fire rated doors between the Maria Dean building and the Main Hospital were exercised. The 1.5 hour rated fire doors failed to latch when exercised on three different tries.¹ ²


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Second Floor:

- During an observation on 11/30/15 at 3:41 p.m., the 2-hour doors between rooms 2550 and 2548 in same day services was exercised. The west leaf was found to have no automatic locking latch system.¹ ²

- During an observation on 11/30/15 at 3:45 p.m., the east 2-hour doors were exercised in same day services. The north leaf does not latch on its own.¹ ²

- During an observation on 11/30/15 at 4:57 p.m., the 3-hour doors near phlebotomy were exercised. The south leaf did not latch on its own.¹ ²

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 8.2.3.2.1; Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire doors and Fire Windows.

² NFPA 80 Standard for Fire Doors and Fire Windows, 1999 Edition, Section 2-4.1.4; All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Based on observation, the facility failed to ensure that access to exits was marked by approved, readily visible signs properly denoting the way to the means of egress in accordance with NFPA 101, 2000 Edition, Section 7.10.1.4. The deficiency affects 1 of 4 exits.

Findings include:

- During an observation on 12/2/15 at 10:27 a.m., the corridor area in the north east corner of the building leading to the northeast exit door was lacking an exit sign. The exit was not readily identifiable from both directions in the corridor.

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 7.10.1.4, Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

Based on observations, the facility failed to maintain smoke barriers per NFPA 101, 2000 Edition, Section 8.3.6.1. These deficiencies affect 2 of 10 first floor smoke compartments.

Findings include:

- During an observation on 11/30/15 at 1:50 p.m., the F-Mechanical room in IT/Finance was reviewed. A conduit on the north wall of the room was not properly sealed to maintain the smoke barrier wall.¹

- During an observation on 11/30/15 at 3:40 p.m., the E-Mechanical room near the Medical Staff Conference room was reviewed. There was wiring in the north east corner of the smoke barrier wall which was not sealed, along with other penetrations which included a three inch by three inch cut out in the wall and a two inch by four inch cut out which were not sealed properly.¹

- During an observation on 12/1/15 at 8:50 a.m., the electrical room (1504) was reviewed. There were three penetrations in the west smoke barrier wall near the ceiling which were not sealed to maintain the fire resistance for smoke barriers.¹

¹ NFPA 101, 2000 Edition, Section 8.3.6.1; Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observations, the facility failed to maintain the fire resistance rating of smoke barriers in accordance with NFPA 101, 2000 Edition, Section 8.3.6.1. The deficiency affects 2 of 2 smoke compartments on the fourth floor.

The findings include:

- During an observation on 12/1/15 at 1:10 p.m., the smoke barrier was reviewed for fourth floor of the towers. There was a single penetration of the barrier at a gray wire above the west smoke barrier doors.

¹ NFPA 101, 2000 Edition, Section 8.3.6.1; Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

Based on observation, the facility failed to ensure that all doors in smoke barriers were able to resist the passage of smoke in accordance with NFPA 101, 2000 Edition, Section 8.3.4.1¹ and Annex A.8.3.4.1². The deficiency affected 1 of 10 main floor smoke compartments.

Findings include:

- During an observation on 12/1/15 at 10:05 a.m., the north facing doors to the elevator lobby were exercised. The right most leaf drug on the floor and failed to close at all.¹ ² The elevator lobby doors were in a smoke barrier for the smoke compartment.

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 8.3.4.1; Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

² NFPA 101, 2000 Edition, Annex A.8.3.4.1; The clearance for proper operation of smoke doors is defined as 1/8 in. (0.3 cm). For additional information on the installation of smoke-control door assemblies, see NFPA 105, Recommended Practice for the Installation of Smoke-Control Door Assemblies, 1999 Edition.

Based on observation, the facility failed to maintain the one-hour rated construction of hazardous areas in accordance with NFPA 101, 2000 Edition, Sections 8.4.1.2 and 8.2.3.2.4.2. The deficiency could affect one room in 1 of 2 smoke compartments.

Findings include:

First Floor:

- During an observation on 12/1/15 at 11:10 a.m., room 1293 (soiled linen room) was reviewed. The ceiling was not properly rated for a hazardous location, and the door to the room was not rated or self-closing.

NFPA 101, 2000 Edition, Section 8.4.1.2; In new construction, where protection is provided with automatic extinguishing systems without fire-resistive separation, the space protected shall be enclosed with smoke partitions in accordance with 8.2.4.

NFPA 101, 2000 Edition, Section 8.2.3.2.4.2; Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts and similar building service equipment that pass through fire barriers shall be protected as follows:

Based on observations, the facility failed to protect hazardous areas with a self closing door per NFPA 101, 2000 Edition, Section 19.3.2.1. These deficiencies affect 8 of 21 smoke compartments.

Findings include:

First Floor:

- During an observation on 11/30/15 at 3:10 p.m., the vault room near the 2-hour wall of the Maria Dean center was reviewed. The storeroom was larger than 100 sq ft, and contained combustible materials. The door to the storeroom (1526) was not self-closing.¹

- During an observation on 11/3/15 at 3:55 p.m., room 1733 in Radiation/Oncology was reviewed. The room was greater than 100 sq ft and contained combustible materials. The corridor door to the room was not self-closing.

- During an observation on 11/30/15 at 4:40 p.m., the storage room in Pediatrics was reviewed. The storeroom was greater than 100 sq ft and contained combustible materials. The corridor door to the storeroom was not self-closing.¹

- During an observation on 11/30/15 at 4:57 p.m., the D-15 Mechanical room was reviewed. This storeroom is greater than 100 sq ft and contained combustible storage. There was one penetration in the far west ceiling of the room.¹

- During an observation on 11/30/15 at 5:13 p.m., the laundry area was reviewed. There were two conduits in the south east wall of the room which were not properly sealed to maintain the fire/smoke resistance for a hazardous area.¹

Second Floor:

- During an observation on 12/1/15 at 7:47 a.m., room 2738 in the sleep center was inspected. The room is a storage room, over 50 square feet, it was lacking a self-closer on one of two doors to the room.¹

- During an observation on 12/1/15 at 8:04 a.m., storage room 2719 was inspected. The room is over 100 square feet and is lacking a self-closer.¹

¹ NFPA 101, 2000 Edition, Section 19.3.2.1; Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 square feet (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square feet (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based on observation, the facility failed to maintain clear pathways to the exit discharge in accordance with NFPA 101, 2000 Edition, Section 7.1.10.1¹ and CMS Policy S&C-10-18-LSC². The deficiency could affect 1 of 4 exits from the main level.

Findings include:

- During an observation on 12/1/15 at 11:20 a.m., the exit from Magnetic Resonance Imaging (MRI) to the loading dock was reviewed. There were carts blocking direct access to full instant use of the egress path in cases of emergency.

- During an observation on 12/3/15 at 6:30 a.m., the doors in the smoke barrier in the Diagnostic Imaging corridor were exercised during the testing of the fire alarm. The set of doors failed to release when tested causing an obstruction for all who would need to exit the interior spaces in case of emergency.

¹ NFPA 101, 2000 Edition, Section 7.1.10.1; Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Annex .7.1.10.1; A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

Based on observations and interview, the facility failed to provide means of egress that were free and clear of obstructions in accordance with NFPA 101, 2000 Edition, Sections 7.1.10.1. These deficiencies affect 4 of 9 exits on first floor, and 2 of 16 exits on second floor.

Findings include:

- During an observation on 11/30/15 at 4:26 p.m., the exit access to the public way was reviewed for the exit near Radiology/Oncology. The exit to the public way was not swept and had accumulations of ice and snow covering the walkway.¹

- During an observation on 12/1/15 at 7:20 a.m., the exit access to the public way was reviewed for the exit from Purchasing. The exit to the public way was not swept and had accumulations of ice and snow covering the walkway.¹

- During an observation on 12/1/15 at 9:00 a.m., the east exit through the courtyard was reviewed. The exit was not swept and had accumulations of ice and snow covering the walk-way.¹

- During an observation on 12/1/15 at 1:32 p.m., the exit access to the public way was reviewed for the exit near room 1929 near the 2-hour wall of the Maria Dean center.
a) The exit to the public way was not swept and had accumulations of ice and snow covering the walkway.¹
b) There was also a chair blocking access on the sidewalk to the public way.¹


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- During an observation on 12/1/15 at 11:36 a.m., the sidewalk from the outside exit in the old OB wing was not swept of snow.¹

- During an observation on 12/3/15 at 8:26 a.m., the sidewalk from the emergency exit out of medical records was not swept of snow.¹

¹ NFPA 101, 2000 Edition, Section 7.1.10.1; Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Annex A.7.1.10.1; A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

Based on observation, the facility failed to provide means of egress that were free and clear of obstructions in accordance with NFPA 101, 2000 Edition, Sections 7.1.10.1. This deficiency affects 1 of 4 exits.

Findings include:

- During an observation on 12/2/15 at 10:27 a.m., the sidewalk and stairway to the public way out of the north east exit was not cleared of the snow.¹

¹ NFPA 101, 2000 Edition, Section 7.1.10.1; Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on record review, the facility failed to hold fire drills at a minimum of quarterly on each shift per NFPA 101, 2000 Edition, Section 19.7.1.2. This deficiency could affect 21 of 21 smoke compartments.

Findings include:

Review of facility documents regarding fire drills reflected fire drills were not completed for the night shift in the first quarter of 2015.¹

¹ NFPA 101, 2000 Edition, Section 19.7.1.2; Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on observation, the facility failed to install the fire alarm system with all its components per NFPA 72, National Fire Alarm Code, 1999 Edition, Section 2-8.2.2. This deficiency could affect 2 of 8 smoke compartments in the patient tower.

Findings include:

- During an observation on 12/3/15 at 6:23 a.m., the building separation between the patient towers and the main hospital on the second floor was inspected. There was not a manual pull station for the fire alarm within 5 feet of the horizontal exit on the patient tower side of the 3-hour doors.¹

¹ NFPA 72, National Fire Alarm Code, 1999 Edition, Section 2-8.2.2; Manual fire alarm boxes shall be located within 5 ft (1.5 m) of the exit doorway opening at each exit on each floor.

Based on observation, the facility failed to identify the branch circuit for the Fire Alarm Control Panel (FACP) and failed to mark it in RED at the electrical panel. This deficiency affects all of the building.

Findings include:

- During an observation on 12/2/15 at 10:24 p.m., the FACP and the corresponding breaker were inspected. The circuit breaker for the FACP was not identified on the FACP and the breaker was not delineated in red.¹

¹ NFPA 72, National Fire Alarm Code, Section 1-5.2.5.2, Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Based on observation, the facility failed to identify the branch circuit for the Fire Alarm Control Panel (FACP) in RED at the electrical panel. This deficiency affects all three floors of the facility.

Findings include:

First Floor:

- During an observation on 12/1/15 at 4:17 p.m., the FACP and the corresponding breaker were inspected. The breaker was not delineated in red.

¹ NFPA 72, National Fire Alarm Code, Section 1-5.2.5.2, Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Based on record review and interview, the facility failed to conduct load voltage tests on the batteries of the fire alarm control panel (FACP) semi-annually, as required per NFPA 72, 1999 Edition, Table 7-3.2. The deficiency affects 21 of 21 smoke compartments.

Findings include:

Review of the alarm system test records reflected the annual maintenance of the panel was conducted on 6/19/15, and reflected the load voltage testing had been done on the sealed lead-acid batteries of the panel. There was no evidence the sealed-lead acid batteries have been voltage tested six-months prior to the annual alarm test.¹

During an interview on 8/10/15 at 11:15 a.m., staff member A, director of facilities, stated they were not aware of the semiannual testing requirement.

¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Table 7.3.2 (6)(d)(3), requires sealed lead-acid type batteries to have a "Load Voltage Test" upon initial installation and then semiannually thereafter.

Based on observations, the facility failed to provide a complete sprinkler system free of obstructions for complete sprinkler pattern coverage in accordance with NFPA 13, 1999 Edition, Sections 5-6.5.2.1 and 5-6.5.3.1. The deficiency affects 1 of 10 first floor smoke compartments.

Findings include:

- During an observation on 12/1/15 at 9:40 a.m., Mechanical room A in the professional wing was reviewed. The room had air handler units greater than 48 inches in width which were not sprinkled above and below the ducting.³

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.2.1, Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with this section. Regardless of the rules of this section, solid continuous obstructions shall meet the requirements of 5-6.5.1.2.

² NFPA 13 Standard for Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.3.1; Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.
Exception: Obstructions that are not fixed in place, such as conference tables.

Based on observation, the facility failed to maintain the sprinkler system in accordance to NFPA 13, 1999 Edition, Section 5-5.5.3. This deficiency affects 1 room in 1 of 2 smoke compartments.

- During an observation on 12/1/15 at 11:00 a.m., room 1268 was reviewed. The privacy curtain for the room did not have mesh at the top to allow full sprinkler coverage for the lone sprinkler head.

NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-5.5.3; Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 5-5.5.3.

Based on observations and interview, the facility failed to maintain components of the sprinkler system in accordance with NFPA 13, 1998 Edition, Section 5-1.1. This deficiency affects the second floor.

Findings include:

During an observation on 12/2/15 at 7:20 a.m., room 2128 was observed. The privacy curtain used to screen the corridor door did not have mesh at the top, so the lone sprinkler head could provide protection to that portion of the room.¹

¹ NFPA 13 Standard for the Installation of Sprinkler Systems 1999 Edition, Section 5-1.1; The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.

Based on observation, the facility failed to continuously maintain the automatic sprinkler system in accordance with NFPA 25, 1998 Edition, Section 2-2.1.1. The deficiency affects one head of the sprinkler system.

Findings include:

- During an observation on 12/2/15 at 10:20 a.m., the hearing booth room was inspected. There was an escutcheon ring which was down from the ceiling of the booth approximately 3/8 of an inch, exposing a gap around the sprinkler pipe.¹

¹ NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 Edition, Section 2-2.1.1; Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1*: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Based on observations, the facility failed to maintain the automatic sprinkler system per NFPA 13, 1999 Edition, Sections 5-1.1, 5-6.3.4 & 5-6.5.1.2 and NFPA 25, 1998 Edition, Section 2-2.1.1. These deficiencies affect 13 of 21 first and second floor smoke compartments.

Findings include:

First Floor:

- During an observation on 11/30/15 at 2:45 p.m., the data/mechanical room in IT/Finance was reviewed. A sprinkler head near the south wall would spray directly into a beam.¹

- During an observation on 11/30/15 at 3:25 p.m., the Quality Manager's office was reviewed. One ceiling tile had been removed and not reinstalled to maintain the integrity of the rated ceiling.

- During an observation on 11/30/15 at 4:20 p.m., the storeroom between Radiology and Oncology was reviewed. Three escutcheon rings were loose and dangling from the sprinkler heads.

- During an observation on 11/30/15 at 4:30 p.m., room 1738 Neuropsychiatry was reviewed. There was a missing ceiling tile which had not been reinstalled to maintain the integrity of the rated ceiling.

- During an observation on 11/30/15 at 4:47 p.m., the kitchen and dietary areas were reviewed.
a) There were two lint filled sprinkler heads above the Convotherm equipment.²
b) There was one lint filled sprinkler head above the salad bar in the cafeteria.²

- During an observation on 11/30/15 at 5:00 p.m., the laundry area was reviewed.
a) Room 1332 (back of dryers) had lint buildup on several sprinkler heads.²
b) Room housing washing machines had a drop ceiling which was not enclosed at one portion, allowing smoke to filter above the level of protection.4
c) Also, in the laundry area, one light fixture prevented one sprinkler head from developing a full sprinkler pattern.¹

- During an observation on 12/1/15 at 7:30 a.m., in room 1632 (Morgue), there was one escutcheon ring down from the ceiling tile and one escutcheon for a scale chain which was not smoke tight at the ceiling tile.4

- During an observation on 12/1/15 at 8:20 a.m, the print shop was reviewed. A sprinkler head had been installed within three inches of a drop ceiling interfering with the spray pattern for the head.¹

During an observation on 12/1/15 at 8:30 a.m., the steam room in smoke compartment 1-C was reviewed. There was a drop ceiling which was not complete at a side wall, allowing smoke to accumulate above the level of protection.4

Second Floor:

-During an observation on 11/30/15 at 1:18 p.m., the med gas store room on the second floor was inspected. The sprinkler head on the ceiling was measured to be approximately four inches from the ceiling mounted light fixture. The light fixture was also lower than the deflector of the sprinkler head.¹

- During an observation on 11/30/15 at 3:02 p.m., the public relations coordinator's office 2866 was inspected. The sprinkler head in the room was totally covered in dust and lint.²

- During an observation on 11/30/15 at 3:30 p.m., room 2501 was inspected. The sprinkler head in the room was covered in dust and lint.²

- During an observation on 11/30/15 at 3:35 p.m., the scope cleaning room was inspected. The sprinkler head in the room was covered in dust and lint.²

- During an observation on 12/1/15 at 7:44 a.m., the room across from 2725 was inspected. There were two sprinkler heads only about one foot apart.³

- During an observation on 12/1/15 at 8:34 a.m., soiled utility room 2268 was inspected. There were two sprinkler heads only four feet apart.³

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.1.2; Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).
Exception No. 1: Sprinklers shall be permitted to be spaced on opposite sides of obstructions not exceeding 4 ft (1.2 m) in width provided the distance from the centerline of the obstruction to the sprinklers does not exceed one-half the allowable distance permitted between sprinklers.
Exception No. 2: Obstructions located against the wall and that are not over 30 in. (762 mm) in width shall be permitted to be protected in accordance with Figure 5-6.5.1.2(b).
Distance from Sprinklers to Side of Obstruction (A) Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.) (B)
Less than 1 ft 0
1 ft to less than 1 ft 6 in. 2 1/2
1 ft 6 in. to less than 2 ft 3 1/2
2 ft to less than 2 ft 6 in. 5 1/2
2 ft 6 in. to less than 3 ft 7 1/2
3 ft to less than 3 ft 6 in. 9 1/2
3 ft 6 in. to less than 4 ft 12
4 ft to less than 4 ft 6 in. 14
4 ft 6 in. to less than 5 ft 16 1/2
5 ft and greater 18
For SI units, 1 in. = 25.4 mm; 1 ft = 0.3048 m.
Note: For (A) and (B), refer to Figure 5-6.5.1.2(a).

² NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 Edition, Section 2-2.1.1; Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1*: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

³ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-6.3.4; Minimum Distance Between Sprinklers. Sprinklers shall be spaced not less than 6 ft (1.8 m) on center.
Exception No. 1: Sprinklers shall be permitted to be placed less than 6 ft (1.8 m) on center where the following conditions are satisfied:
(a) Baffles shall be installed and located midway between sprinklers and arranged to protect the actuating elements.
(b) Baffles shall be of noncombustible or limited-combustible material that will stay in place before and during sprinkler operation.
(c) Baffles shall be not less than 8 in. (203 mm) wide and 6 in. (152 mm) high. The tops of baffles shall extend between 2 in. and 3 in. (51 mm and 76 mm) above the deflectors of upright sprinklers. The bottoms of baffles shall extend downward to a level at least even with the deflectors of pendent sprinklers.
Exception No. 2: In-rack sprinklers shall be permitted to be placed less than 6 ft (1.8 m) on center.
Exception No. 3: Old-style sprinklers protecting fur storage vaults shall be permitted to be placed less than 6 ft (1.8 m) on center.

4 NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5.1.1; The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.

Based on observations, the facility failed to place portable fire extinguishers at proper heights per NFPA 10, Section 1-6.10 and failed to inspect all portable fire extinguishers at least every 30 days in accordance with NFPA 10, 1998 Edition, Section 4-3.1. These deficiencies affect two fire extinguishers.

Findings include:

- During an observation on 12/2/15 at 10:15 a.m., the portable fire extinguisher located in diagnostic imaging was mounted above 60 inches.¹


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- During an observation on 12/2/15 at 10:18 a.m., the fire extinguisher in the fire equipment room was found to be missing the initials for monthly inspections for October and November of 2015.²

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 1-6.10; Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

² NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 4-3.1 Frequency; Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

Based on observation, the facility failed to inspect all portable fire extinguishers at least every 30 days in accordance with NFPA 10, 1998 Edition, Section 4-3.1. This deficiency affects one fire extinguisher on first floor.

Findings include:

- During an observation on 12/1/15 at 4:02 p.m., the portable fire extinguisher next to the pharmacy was inspected. It was found to be missing the initials for having been inspected in November of 2015.¹

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 4-3.1 Frequency; Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

Based on observations, the facility failed to document the inspection of a portable fire extinguisher in accordance with the standards of NFPA 10, 1998 Edition, Section 4-4.4.1. The deficiency affected 1 extinguisher 1 of 11 second floor smoke compartments.

Findings include:

- During an observation on 11/30/15 at 2:40 p.m., the lab was inspected. The portable fire extinguisher in the southeast corner of the lab, #09-08, did not have a 6-year maintenance sticker on the back of the extinguisher.¹

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 4-4.4.1*; Fire extinguishers that pass the applicable 6-year requirement of 4-4.3 shall have the maintenance information recorded on a suitable metallic label or equally durable material having a minimum size of 2 in. 3 1/2 in. (5.1 cm 8.9 cm).
The new label shall be affixed to the shell by a heatless process, and any old maintenance labels shall be removed. These labels shall be of the self-destructive type when removal from a fire extinguisher is attempted. The label shall include the following information:
(a) Month and year the maintenance was performed, indicated by a perforation such as is done by a hand punch
(b) Name or initials of person performing the maintenance and name of agency performing the maintenance.

² NFPA 10, 1998 Edition, Section 5-6.4 Low-Pressure Cylinders; Fire extinguisher shells of the low-pressure type that pass a hydrostatic test shall have the test information recorded on a suitable metallic label or equally durable material with a minimum size of 2 in. 3 1/2 in. (5.1 cm 8.9 cm). The label shall be affixed to the shell by means of a heatless process and all old hydrostatic test labels shall be removed. These labels shall be of the type that self-destructs when removal from a fire extinguisher shell is attempted. The label shall include the following information:
(a) Month and year the test was performed, indicated by a perforation, such as is done by a hand punch
(b) Test pressure used
(c) Name or initials of person performing the test, and name of agency performing the test

Based on observation and interview, the facility failed to maintain the means of egress free of all obstruction for instant use in accordance with NFPA 101, 2000 Edition, Section 7.1.10.1 and Annex A.7.1.10.1. These deficiencies affect 1 of 9 exits and 2 of 10 first floor smoke compartments.

Findings include:

- During an observation on 11/30/15, the exit corridor near facilities leading toward the boiler room was reviewed. There were stored items in the corridor including, pallets of delivered supplies, building supplies, lighting, and combustible materials. The isle toward the exit was not free and clear for proper means of egress which allows unobstructed travel at all times.¹

¹ NFPA 101, 2000 Edition, Section 7.1.10.1; Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Annex Section A.7.1.10.1; A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

Based on observation, the facility failed to store a nitrous oxide compressed gas cylinder in accordance with the standards of NFPA 99, 1999 Edition, Section 4-3.5.2.1.¹ This deficiency affects the second floor.

Findings include:

During an observation on 12/2/15 at 8:10 a.m., procedure room 2020 was observed. The nitrous cylinder was not secured to prevent it from tipping over.¹

¹ NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 4-3.5.2.1, Gases in Cylinders and Liquefied Gases in Containers - Level 1, (a) Handling of Gases; requires administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility. (b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed: 27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on observation, the facility failed to store oxygen cylinders in accordance with the standards of NFPA 99, 1999 Edition, Sections 4-3.1.1.2 (a) (4). This deficiency affects 1 of 11 second floor smoke compartments.

Findings include:

- During an observation on 11/30/15 at 1:18 p.m., the second floor med gas room was inspected. There were two light switches and 3 wall outlets which were not a minimum of 60 inches from the floor.¹

¹ NFPA 99, 1999 Edition, Section 4-3.1.1.2 (a) (4); The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

Based on observations, interview and record review, the facility failed to ensure that the piped medical gas system met the standards of NFPA 99, 1999 Edition, Section 4-3.5.4.2. These deficiencies affect 2 of 21 first and second floor smoke compartments.

Findings include:

First Floor:

- During an observation on 11/30/15 at 4:28 p.m., the shut off valve for the med gas in room 1704 was reviewed. The shut off valve was labeled incorrectly and did not reflect that it was now room 1704.¹

- During an observation on 11/30/15 at 4:32 p.m., the shut off valve for the med gas in room 1742 of Neuropsychiatry was reviewed. The cover for the control valve was not labeled to reflect the room number that was controlled by the shut of valve.¹

Second Floor:

- During an observation on 11/30/15 at 4:30 p.m., OR 3 and OR 4 were inspected. The gas shutoffs outside the rooms were not labeled to which room was controlled by the shutoff valve.¹

¹ NFPA 99 Health Care Facilities, 1999 Edition, Section 4-3.5.4.2; The shutoff valves described in 4-3.1.2.3, 4-3.1.2.3(m), and 4-3.1.2.3(n) shall be labeled to reflect the rooms that are controlled by such valves. Labeling shall be kept current from initial construction through acceptance. Valves shall be labeled in substance as follows:
CAUTION:
(NAME OF MEDICAL GAS) VALVE DO NOT CLOSE EXCEPT IN EMERGENCY THIS VALVE CONTROLS SUPPLY TO . . . .

Based on observation, record review, and staff interviews, all of the anesthetizing locations were not held above 35% humidity per NFPA 99, Section 5-4.1.1. This deficiency could affect 5 of 7 operating rooms.

Finding include:

During an interview on 12/2/15 at 11:25 a.m., staff member A stated operating rooms (ORs) 5, 6, and 7 are humidified and the humidifiers are set at 25%. He stated the facility does not have a categorical waiver to allow the humidity to be below 35%.

In the same interview, it was discovered operating rooms 1, 2, 3, and 4 are not humidified. Rooms 2 and 3 are not used for anything but storage. ORs 1 and 4 are not humidified.¹

During an observation of the facility's automatic monitoring system, the humidity was recorded to be hovering slightly above or below 25% in ORs 5, 6, and 7. The automated system was recording humidity levels of 9 or 10% in ORs 1 and 4. This appeared to be in error, as a local humidity device in the OR read the humidity to be 30%.¹

In an interview on 12/2/15 at 2:00 p.m., staff member B stated the humidities have been running around 30% on the reports she gets. Staff member B, stated all the ORs are used interchangeably, there are no special surgeries in the ORs with no humidification. She also stated, she was not aware of CMS humidity requirements, and that with the categorical waiver, humidity could be as low as 20%.²

¹ NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 5-4.1.1*; The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

² CMS S&C-13-25-LSC and ASC: Relative Humidity (RH): Waiver of Life Safety Code (LSC) Anesthetizing Location Requirements; Discussion of Ambulatory Surgical Center (ASC) Operation Room Requirements, Issued April 29, 2013.

Based on observation, the facility failed to ensure interior walls were constructed and finished to be noncombustible in accordance with NFPA 101, Life Safety Code, 2000 Edition, Section 18.1.6.3. The deficiency could affect 1 of 2 smoke compartments on the third floor of the patient tower.

Findings include:

Second Floor:

- During an observation on 12/1/15 at 1:15 p.m., the third floor of the patient tower was inspected. The corridor wall outside room 2164 had a one foot by two feet cutout of the 1-hour separated interior wall.¹

¹ In accordance with NFPA 101 and Section 19.1.6.3; all interior walls and partitions in buildings of Type I or Type II construction shall be of noncombustible or limited-combustible materials.
Exception*: Listed, fire-retardant-treated wood studs shall be permitted within non-load bearing 1-hour fire-rated partitions. Further, Annex A.19.1.6.3 Exception states that there is a finish capacity in a 1-hour fire-rated partition that would be expected to prevent the generation of smoke and gases from fire retardant-treated wood studs for an extended time during fire exposure. This Code does not intend to permit the use of fire-retardant wood studs and partitions of only 20-minute fire resistance.

Based on observation, the facility failed to ensure that smoke dampers, interconnected to the facility fire alarm system, closed upon testing per NFPA 72, 1999 Edition, Section 3-9.5.2. This deficiency could effect 2 of 2 smoke compartments on the second floor of the patient towers.

Findings include:

Second Floor:

- During an observation on 12/1/15 at 1:23 p.m., the damper over the double doors in the west corridor on the second floor of the patient towers was inspected. Upon being tested by removal of the air line from the damper, it failed to close.¹

¹ NFPA 72 National Fire Alarm Code®, 1999 Edition, Section 3-9.5.2; If connected to the fire alarm system serving the protected premises, all detection devices used to cause the operation of HVAC (Heating, Ventilation, and Air-Conditioning) systems smoke dampers, fire dampers, fan control, smoke doors, and fire doors shall be monitored for integrity in accordance with 1-5.8.

Based on observations, the facility failed to ensure that smoke dampers, interconnected to the facility fire alarm system, closed upon testing per NFPA 72, 1999 Edition, Section 3-9.5.2., and failed to ensure that fire dampers were exercised once in four years time per NFPA 90A, 1999 Edition, Section 3-4.7¹. These deficiencies affect 21 of 21 first and second floor smoke compartments.

Findings include:

- During an interview on 11/30/15 at 8:30 a.m., staff member A stated they were testing the dampers on a 6-year interval and they were not aware of the waiver.¹ ²

- During an observation on 12/1/15 at 10:48 a.m., the damper outside the case management office was tested by pulling the air line off the damper. The damper failed to close.³

- During an observation on 12/1/15 at 11:15 a.m., the damper near the Administrator of the day office was tested by pulling the air line off the damper. The damper failed to function.³

¹ NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems,1999 Edition, Section 3-4.7 Maintenance, At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

² Hospitals can qualify for a six year damper test interval per CMS S&C Policy S&C-10-04-LSC Waiver to Allow Hospitals to Use the NFPA 6-Year Damper Testing Interval, Issued 10/30/09.

² NFPA 72 National Fire Alarm Code®, 1999 Edition, Section 3-9.5.2; If connected to the fire alarm system serving the protected premises, all detection devices used to cause the operation of HVAC (Heating, Ventilation, and Air-Conditioning) systems smoke dampers, fire dampers, fan control, smoke doors, and fire doors shall be monitored for integrity in accordance with 1-5.8.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC and NFPA 70, 1999 Edition. These deficiencies affected the second floor.

Findings include:

- During an observation on 12/2/15 at 7:15 a.m., room 2216 was inspected. A floor heater was plugged into a power strip.¹

- During an observation on 12/2/15 at 7:25 a.m., room 2070 was inspected. A refrigerator was plugged into a power strip.¹

- During an observation on 12/2/15 at 7:40 a.m., the Audiology 2-E office was inspected. A white extension cord was found in-use.²

- During an observation on 12/2/15 at 7:50 a.m., room 2050 was inspected. A white extension cord was found in-use.²

- During an observation on 12/2/15 at 8:02 a.m., room 2038 was inspected. A multi-plug adaptor was found in-use.²

- During an observation on 12/2/15 at 8:07 a.m., the 2-A nurse's station was inspected. A white extension cord was found in-use.²

- During an observation on 12/2/15 at 8:20 a.m., room 2156 was inspected. A yellow extension cord was found which supplied power to a camera which had been installed. The extension cord was still in-use for the camera.²

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

² NFPA 70 National Electrical Code, 1999 Edition, Article 305-2(b); All Wiring Installations (a) Other Articles. Except as specifically modified in this article, all other requirements of this Code for permanent wiring shall apply to temporary wiring installations.
(b) Approval. Temporary wiring methods shall be acceptable only if approved based on the conditions of use and any special requirements of the temporary installation.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with NFPA 70, 1999 Edition, Article 400-8. These deficiencies affect the entire building.

Findings include:

- During an observation on 12/2/15 at 9:42 a.m., the physician's dictation room by exam room 54 was inspected. A refrigerator power cord was run through a sliding glass door and plugged into a wall outlet. Power cords can not be run under or through open door ways.¹

- During an observation on 12/2/15 at 9:47 a.m., in the alcove next to exam room 41, there were three power strips triple daisy chained together under the desk.²

¹ NFPA 70 National Electric Code, 1999 Edition, Article 400-8; Flexible cords shall not be run through doorways, windows or similar openings.

² CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

Based on observation, the facility failed to utilize power strips in accordance with CMS Survey & Certification Policy S&C-14-46-LSC. This deficiency could affects 1 of 2 floors.

Findings include:

During an observation on 12/2/15 at 1:30 p.m., there was a dangling power strip unsupported in room 1929.¹

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC. This deficiency could affect 1 of 1 smoke compartments.

Findings include:

Third Floor:

- During an observation on 12/1/15 at 10:09 a.m., room 3177 on the third floor of the patient tower was inspected. There was a power strip hanging and unsupported in the room.

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC and NFPA 70, 1999 Edition, Articles 305-2(b) and 370.28(c). These deficiencies affect 12 of 21 first and second floor smoke compartments.

Findings include:

First Floor:

- During an observation on 11/30/15 at 1:20 p.m., IT/Finance area was reviewed.
a.) There were several power strips found in series (piggy backed together).¹

b.) A microwave oven was found plugged into a power strip.¹

- During an observation on 11/30/15 at 3:00 p.m., the Vault room, had two covers missing on electrical conduit greater than 110 volts.²

- During an observation on 11/30/15 at 3:20 p.m., in office #1530, the power strip was dangling and unsupported.¹

- During an observation on 11/30/15 at 3:45 p.m., in Oncology
a) an white extension cord was found in-use.³
b) a refrigerator was plugged into a power strip.¹
c) in room #1712, an extension cord was found in-use for a computer.³
d) In room 1716, a power strip was unsupported and a microwave was plugged into a power strip.¹

- During an observation on 11/30/15 at 5:05 p.m., in room 1325 of the laundry, a microwave oven was plugged into a power strip.¹

- During an observation on 12/3/15 at 7:00 a.m., wiring which was attached to two by six inch construction lumber over the coffee shop pay counter was not enclosed in conduit.³

Second Floor:

- During an observation on 11/30/15 at 1:43 p.m., the ER registration office was inspected. There was a microwave plugged into a power strip and a power strip hanging by the cords that were plugged into it under the desk in the office.¹

- During an observation on 11/30/15 at 1:43 p.m., the Cath Lab was inspected. There was a power strip hanging by the cords that were plugged into it.¹

- During an observation on 11/30/15 at 2:34 p.m., room 2811 was inspected. There was a power strip hanging by the the cords plugged into it.¹

- During an observation on 11/30/15 at 2:48 p.m., room 2803A was inspected. The was a power strip hanging by the the cords plugged into it.¹

- During an observation on 11/30/15 at 2:54 p.m., the administration offices were inspected. There was a power strip under the Executive Assistant's desk hanging by the cords plugged into it.¹

- During an observation on 11/30/15 at 2:57 p.m., office 2846 was inspected. There were two power strips daisy chained together.¹

- During an observation on 11/30/15 at 4:51 p.m., the case manager's office, room 2445, was inspected. There was a microwave plugged into a power strip.¹

- During an observation on 12/1/15 at 8:16 a.m., the molecular lab was inspected. There were two refrigerators plugged into a multi-plug adapter that did not have circuit protection.¹ ²

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

² NFPA 70 National Electric Code, 1999 Edition, Article 370.28(c); All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Article 250-110.

³ NFPA 70 National Electrical Code, 1999 Edition, Article 305-2(b); All Wiring Installations (a) Other Articles. Except as specifically modified in this article, all other requirements of this Code for permanent wiring shall apply to temporary wiring installations.
(b) Approval. Temporary wiring methods shall be acceptable only if approved based on the conditions of use and any special requirements of the temporary installation.