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Based on interview observation, the facility failed to ensure each fire wall was free of penetration and each door in the fire wall had an observable rating. This affected the fire wall on the second floor of the C building, in the credit union, in the staff bathroom located between the B and C building, on the fourth, third, second, and first floors of the D building, and the first floor of the A building. This affected the fire doors on the fifth floor of the D building and the third floor of the A building. This has the potential to affect all patients, visitors and staff who use the buidling. The capacity was 203 beds and the census was 98 patients.

Findings include:

On 01/23/13 between 8:30 A.M. and 4:30 P.M. tour of the facility was conducted with Staff YY. Observation on the second floor of the C building, above the ceiling tiles of a two hour fire rated barrier near the orthopaedic physician office, revealed a penetration surrounding three white pipes and two ducts. The floor decking above was not sealed in the same area.

Observation of a two hour fire rated barrier located in a leased space, revealed a penetration approximately six inches in length surrounding three conduits. The penetration was noted above the ceiling at the work desk in the student area.

Observation of a two hour fire rated barrier above the ceiling tiles within the credit union revealed a penetration surrounding electrical conduit. Located in the safe room, above the ceiling tiles, a penetration was observed surrounding a water pipe between the block and the floor decking above.

Observation of a two hour fire rated barrier above the ceiling tiles on the third floor in the staff bathroom, located between the B and C building revealed a a large portion of the fire barrier wall was missing. Staff CC verified a large portion of the fire barrier was not in place as noted on the building fire safety plans.









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On 01/23/13 at 9:45 A.M. a tour of the 5th floor of the D building was conducted with Staff XX. The fifth floor was a sleeping patient area consisting of orthopedic and medical surgical telemetry patients. During the tour stairwell D1 ' s fire door did not have an observable rating.

During the tour of the 5th floor, Staff XX confirmed the finding.

On 01/23/13 at 11:10 A.M. a tour of the fourth floor of the D building was conducted with Staff XX. The tour revealed a firewall that separated Building C from Building D. Observation above the drop down ceiling above the double doors opposite waiting area 4194 revealed an opening created by a two inch conduit.

Observation above the drop down ceiling revealed the fire wall separating corridor 4153 from corridor 4233 was comprised of two five eighths inch drywalls.

Observation above the drop down ceiling perpendicular to stairwell C2 revealed the fire wall to have a two inch penetration.

During the tour of the fourth floor Staff XX confirmed the observations.

On 01/23/13 at 2:50 P.M. a tour was conducted of the third floor with Staff XX. Observation above the dropdown ceiling between the single fire door in elevator lobby 3096 leading to stair C2 and the double doors leading to corridor 3128 revealed a two inch conduit open to air.

Observation above the dropdown ceiling above the double doors in elevator lobby 3096 leading to corridor 3128 revealed a five by 12 inch square missing from the drywall.

On 01/23/13 at 3:21 P.M. a tour was conducted of the second floor of the D building with Staff XX. During the tour a one inch conduit above the drop down ceiling above the single door leading to stair C2 was revealed to have an annular space in the fire wall.

During the tour a two inch conduit above the drop down ceiling above the double doors was observed to be in a fire wall and open to air.

During the tour, Staff XX confirmed the findings.

On 01/23/13 at 4:05 P.M. a tour of the first floor of the D building was conducted with Staff XX. During the tour the fire wall was observed to run from the northeast to the southeast in a zigzag like pattern. Observation of the firewall between the surgery waiting area and elevator lobby 1300 revealed, above the dropdown ceiling, three metallic channels each six inches wide by one inch deep and all open to air.

During the tour of the first floor of the D building revealed a fire door to stairwell C2 without an observable rating.

During the tour of the first floor of the D building, Staff XX confirmed the findings.

A second tour of the first floor of the D building was conducted with Staff XX on 01/24/13 at 8:40 A.M. During the tour, above the drop down ceiling above the double doors in corridor 1233 and parallel with stairway C2, a fist sized hole around a conduit holding blue wire was observed.

During the tour of the first floor of the D building, Staff XX confirmed the findings.

On 01/24/13 at 3:17 P.M. a tour was conducted of the third floor of the A building with Staff XX. During the tour the fire doors to stairway A4 and A1 was observed without an observable rating.

During the tour, Staff XX confirmed the finding.

On 01/25/13 at 10:00 A.M. a tour was conducted of the first floor with Staff XX. Observation of the firewall above the drop down ceiling near stairwell A1 revealed three three inch electrical conduits open to air.

During the tour, in an interview Staff XX confirmed the finding.

Based on interview and observation, the facility failed to ensure each waiting area was protected by a smoke detection system or had direct supervision by the staff. This affected waiting area 4194 in the D building and 324A in the A building. This has the potential to affect all patients, staff, and visitors who use the A and D buildings. The capacity was 203 beds and the facility census was 98.
Findings include:
On 01/23/13 at 11:10 A.M. a tour was conducted of the fourth floor of the D building with Staff XX. During the tour waiting area 4194 was observed to have neither smoke detection nor sprinkler protection. It was also observed to be without any human supervision.

During the tour Staff XX confirmed the observation in an interview.

On 01/24/13 at 3:17 P.M. a tour was conducted of the third floor of the A building. Observation of waiting area 324A revealed the door propped open to the corridor and no one was in attendance to view the room. The room was observed without sprinklers and smoke detectors.

On 01/24/13 at 3:20 P.M. Staff BB stated the door was left open so that patients could come and sit early in the morning, before staff arrived.

Based on facility tour and staff interview and verification, the facility failed to ensure that doors in sprinklered buildings were only required to resist the passage of smoke. There was no impediment to the closing of the doors. Doors were to be provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 were permitted but not provided. The facility had capacity for 203 beds with a census of 98 patients at the time of the survey.

Findings included;

On 01/24/13 tour of the laboratory area located on the ground floor was conducted with Staff YY. Observation of the outpatient lab area revealed the presence of Dutch doors. The Dutch doors were located within a one hour fire rated smoke/fire barrier corridor wall. The outpatient lab and the corridor were provided with automatic sprinkler protection.

Observation of the wood Dutch doors revealed there was no closing device on either the top or bottom portions of the door. There was no astragal noted at the door separation. Staff present in the area stated the bottom portion of the Dutch door was typically kept closed and was used for patients to check in at the lab prior to going to the waiting area.

Staff present on tour verified there was no closing devices on the upper or lower halves of the Dutch door.

Based on observation and interview, the facility failed to ensure each access to an exit on the sixth, second, and ground floor of the D building were marked by approved, readily visible exit signs. This has the potential to affect all patients, staff, and visitors of the facility. The capacity was 203 beds, and the census was 98 patients.

Findings include:

A second tour of the sixth floor of the D building was conducted with Staff XX on 01/23/13 at 8:30 A.M. The tour revealed the floor to consist of two locked units for psychiatric care.

During the tour, a path of egress defined by the evacuation plan posted at stairwell D2, revealed a path of egress from the stairwell traveling northeast along the corridor past the double doors bridging rooms 609 and 622E, then turning right at the patient lounge.

Observation of the exit sign before approaching the double doors, however, revealed a chevron directing occupants into room 609.

During the tour of 01/23/13 at 8:30 A.M., Staff XX confirmed the observation.

During the tour, a path of egress defined by the evacuation plan posted at the northeast corner of the floor revealed a path of egress going down the corridor and turning left at the patient lounge. However, observation of the exit sign prior to the double doors bridging rooms 609 and 622E did not reveal an chevron pointing to the left to direct occupants to go left at the patient lounge.

During the tour of 01/23/13 at 8:30 A.M., Staff XX confirmed the observation.

On 01/23/13 at 3:21 P.M. a tour was conducted of the second floor of the D building with Staff XX. Within the tour of the floor a physical therapy suite was observed. From the most eastern portion of the room, an exit sign along the path of egress was not observed.

During the tour Staff XX confirmed the finding.

On 01/24/13 at 10:40 A.M. a tour was conducted of the ground floor of the D building with Staff XX. During the tour, corridor 327 was observed to be on a path of egress. However, observation from the most northeast portion of the corridor down to the southwest portion did not reveal an exit sign above the door between rooms 334 and 335.

During the tour Staff XX confirmed the finding.

Based on observation and interview, the facility failed to ensure each smoke barrier was free of penetrations. This affected the smoke wall in the cafeteria, the sixth and fifth floor of the D building, the fourth floor of the C building, and the ground floor of the heart center. This has the potential to affect all visitors, staff, and patients who use the facility. The capacity was 203 beds and the census was 98 patients.
Findings include:

On 01/22/13 at 2:30 P.M. tour of building C , fourth floor was conducted with Staff YY. Observation of the one hour fire rated smoke barriers revealed a penetration approximately one inch in diameter located above the fire rated door next to the restroom. Staff present on tour filled the penetration with fire rated caulking material.

On 01/23/13 between 11:50 A.M. and 4:30 P.M., observation above the ceiling tiles of a one hour fire rated fire barrier was conducted with Staff YY. A penetration was noted in the one hour fire/smoke barrier located at the continuous care room 5-8. The penetration surrounded a duct and a conduit.

Observation above the ceiling tiles of the one hour fire rated barrier located in the cafeteria revealed a large penetration in the floor decking. The open area in the floor decking was estimated by the staff to be approximately one square foot. Wood, wire and lathe could be seen through the open area.

On 01/24/13 tour of the one hour fire rated barrier located on the ground floor near the heart center was conducted with Staff YY. Observation at the "Mountain Landscape" picture, above the ceiling tiles, revealed a penetration through two sheets of gypsum boards. Steel studs were exposed in the one hour fire rated barrier. Staff CC, a contractor , was present and verified the observation did not meet the construction requirement for a one hour fire rated barrier.






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On 01/22/13 at 2:42 P.M. a tour was conducted of the sixth floor of the D building with Staff XX. The tour revealed the floor to consist of two locked units for psychiatric care. Review of the schematic for the sixth floor of the D building, and observation during tour, revealed the unit to be divided into two smoke compartments by a smoke barrier running from the northwest to the southeast, beginning at room 609 and finishing at the nurses lounge.

At 3:45 P.M. observation above the drop-down ceiling of the wall dividing room 609 from 610 revealed it to be pierced by part of a smoke damper.

Observation above the drop-down ceiling over the double doors that bridged room 609 with 622E revealed it to be pierced with a two inch conduit which ran grey wires around which was an annular space. The corrugations of the corrugated ceiling were also observed to be without fire stopping material.

In an interview during the tour of 01/22/13 at 2:42 P.M., Staff XX confirmed the findings.

On 01/23/13 at 9:45 A.M. a tour of the 5th floor of the D building was conducted with Staff XX. The fifth floor was a sleeping patient area consisting of orthopedic and medical surgical telemetry patients. The floor was bisected by a smoke wall running from the northwest to the southeast. Observation of the doors to the conference room (room 5039) and to the family waiting (room 5040) did not reveal a rating.

In an interview during the tour of 01/23/13 at 9:45 A.M., Staff XX confirmed the findings.

Observation of the smoke wall as it divided the staff lockers room (5041) and conference room (5039), revealed a finger sized penetration.

Based on facility tour and staff interview and verification, the facility failed to ensure that one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected a hazardous area. The facility had capacity for 203 beds with a census of 98 patients at the time of the survey.

Findings include:

1. On 01/23/13 at 10:40 A.M. tour with Staff YY was conducted of the psychiatric occupational therapy corridor. Observation of the area revealed the presence of a mechanical room. Observation inside the locked mechanical room revealed a narrow room about ten feet in length. Contents of the room included a large air conditioning (AC) unit. Observation of the mechanical room also revealed a large penetration in the wall surrounding the AC unit.

Staff YY opened the room located in the corridor next to the mechanical room to reveal an occupational therapy office. Immediately inside the room, to the left, was the large AC unit. There was no wall surrounding the unit which allowed the AC unit be open and exposed in the office. Staff YY verified the AC unit was functional and provided cooling to the entire corridor and the offices in the area.

Staff CC, a contractor, was summoned to the room and verified the office was once part of a mechanical room which housed the AC unit. The mechanical room was renovated by expansion and made into an office. Staff YY and CC verified no wall was constructed to separate the office from the mechanical room.

2. On 01/23/13 observation of the first floor, building C, revealed a leased room used by the tenant to store files. The file room contained a significant number of cardboard boxes. The file storage room had no automatic sprinkler system. There was no door to secure the room.

3. On 01/24/13 tour of the basement area was conducted with Staff YY. Observation of a physician office, Suite LL100, revealed a storage area, TB190. The storage area contained various combustible items which included boxes. The storage area had no automatic sprinkler system. Observation above the ceiling tiles revealed there was no one hour fire rated construction as evidenced by large sections of wall missing. The door to the storage area was a wooden door with no noted fire rating and no closing device.

Staff YY present at the observation, verified the findings.

Based on facility observation and staff interview and verification, the facility failed to ensure that exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1 and 19.2 This affected the exits on the locked behavioral units, including the sixth floor of the D building. The facility had capacity for 203 beds with a census of 98 patients at the time of the survey.

Findings include:

On 01/23/13 between 9:15 A.M. and 10:10 A.M. tour of the second floor of the C building was initiated with Staff YY. Observation of an exit stairwell (Stair M1) revealed that exit discharge was inside a courtyard. The courtyard was snow covered and the path to the courtyard exit was snow covered. At the courtyard exit discharge observation revealed a grassy snow covered area approximately ten feet in length to another snow covered paved public way.

Interview of Staff YY verified the courtyard did not have a cleared pathway to the courtyard discharge opening. Staff YY further verified the exit discharge from the courtyard was an uneven grassy area under the snow.

Tour of the locked behavioral units located throughout the facility on 01/22 through 01/25/13 with Staff XX, and YY revealed that five of six units had two sets of locked doors at the entrance/exits of the units. The sets of doors were noted to have magnetic locks which prevented the doors from opening. Staff present at tour revealed that a swipe card or a key was required to override the magnetic locks and disengage the doors to enter or leave the units.

Staff XX and YY were interviewed regarding the release of the doors in the event of a fire alarm. Both staff revealed that if a pull station or an alarm was activated in that area then the doors would release. If the alarm was activated on another floor or in another area of the facility then the doors would not release without use of a key or swipe card.

On 01/25/13 at 10:30 A.M. review of facility fire alarm documentation with Staff YY revealed an alarm was pulled for a fire drill in July 2012 at 2:20 P.M.. Documentation of the fire drill revealed the magnetic locks released for doors to the secured behavioral unit located on D building, sixth floor. There was no additional information regarding the disengagement of the other doors for other secured units in the facility.



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A second tour of the sixth floor of the D building was conducted with Staff XX on 01/23/13 at 8:30 A.M. The tour revealed the floor to consist of two locked units for psychiatric care.

During the tour, a path of egress defined by the evacuation plan posted at the northeast corner of the floor revealed a path of egress going down the corridor through locked doors and turning left at the patient lounge. The path then proceeded to a second locked door at the stairway.

On 01/25/13 at 3:00 P.M. in an interview Staff XX stated if an alarm local to the 6th floor is sounded, all locked door will release. However, he/she stated if a central alarm is sounded, or an alarm is sounded on another floor, the locked doors would each need to be keyed open.

On 01/25/13 at 9:30 A.M. a tour was conducted of the second floor of the A building with Staff XX. During the tour the path of egress as defined by the evacuation plan posted near stairwell A4 revealed the path took occupants through a psychiatric area that included two delayed egress doors.

During the tour, Staff XX confirmed the finding.

Based on facility observation ands staff interview and verification, the facility failed to ensure that patient room doors were arranged so that the patients could open the door from inside without using a key. The facility had capacity for 203 beds with a census of 98 patients at the time of the survey. At least two of five locked patient care units were affected. One patient surgical area was affected.

Findings include:

1. On 01/22/13 between 2:30 P.M. and 4:30 P.M. tour of the facility was conducted with Staff YY. Observation of building C, fourth floor, revealed a locked behavioral health unit. The unit was noted to have a capacity of ten patient beds with a census of six patients.

Observation of the patient bedrooms revealed a deadbolt type lock present on the bedroom doors. Staff present at tour stated the locks were used only to prevent patients from entering rooms. Staff verified that when locked one could not exit the room without use of a key to release the door.

2. Observation of B building , third floor, on 01/24/13 at 3:15 P.M. with Staff YY, revealed the presence of a locked behavioral unit. The unit had a capacity of 21 patient beds with a census of 17 patients. Observation of the patient bedroom doors revealed the presence of deadbolt type locks on the doors. Interview of Staff ZZ revealed the locks were used only when the patients were not permitted into the rooms. Staff YY and ZZ verified that when locked, anyone inside the rooms could not leave without use of a key.

Further interview of Staff YY verified that for behavioral units within the facility that utilized dead bolt type locks on patient bedroom doors, it was necessary to use a key when leaving the inside of the room.

3. On 01/24/13 tour of the same day surgery area was conducted with Staff YY. Observation of the patient rooms revealed the presence of dead bolt type locks. Interview of Staff YY revealed the locks were used to keep persons out of the rooms when the unit was not in use. Staff noted that if the rooms were locked, exit access from inside the room could occur by turning a thumb turn on the lock in addition to using the door handle.

Staff present verified there were 12 patient rooms with the thumb turn locks with a capacity of 23 patients.

Based on facility observation and staff interview and verification, the facility failed to ensure that illumination of means of egress, including exit discharge, was arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness. The facility had capacity for 203 beds with a census of 98 patients at the time of the survey.

Findings included;

On 01/23/13 between 9:15 A.M. and 10:10 A.M. tour of the second floor of the C building was initiated with Staff YY. Observation of an exit stairwell (Stair M1) revealed that exit discharge was inside a courtyard. Observation of the exit discharge revealed there was no illumination of the means of egress.

Travel to the courtyard exit discharge required travel across the snow covered courtyard to which lead to a grassy snow covered area approximately ten feet in length to another snow covered paved public way.

Interview of Staff YY verified there was no illumination of the exit discharge for Stair M1

Based on observation and interview, the facility failed to ensure the automatic sprinkler system was maintained in reliable operating condition, including the maintaining the cleanliness of each sprinkler head and prohibiting material stored less than 18 inches from the ceiling. This affected the sprinkler heads on the sixth, fourth and ground floor of the D building, on the fourth and first floor of the C building, in the surgical recovery area, in the decontamination room (LLB140), and in x-ray storage, which were dirty. This affected the sprinkler heads in the locker room on the first floor of the D building, the second floor of the A building, and in the general maintenance shop wherein material was found stored in a space less than 18 inches from the ceiling. This has the potential to affect all patients, visitors, and staff to the facility. The facility has a capacity for 203 beds and the census was 98 patients.

Findings include:

The sprinkler head of the soiled linen chute, located on the fourth four, was observed to be covered with a thick layer of dust.

On 01/23/13 at 10:20 A.M. observation was conducted of the first floor of building C with Staff YY. Sprinkler heads in the surgical recovery area corridor were observed to be covered with dusty residue.

Three sprinkler heads in a first floor corridor of building C ( T1312) were observed to be covered with a thick coating of dusty debris.

On 01/23/13 between 3:00 P.M. and 4:30 P.M. tour of the general maintenance shop was conducted with Staff YY. Storage shelves located in the middle of the room contained items stacked on the top shelves. The items were less than 18 inches from an automatic sprinkler head. In addition, observation of the sprinkler heads in the shop were noted to be covered with dusty debris.

On 01/24/13 at 10:45 A.M. tour of the decontamination room ( LLB140) revealed automatic sprinkler heads covered with a dusty debris. Staff YY present at the observation verified the findings.

On 01/24/13 observation of the x-ray storage room revealed automatic sprinkler heads covered with a dusty debris. Staff YY present at the observation verified the findings.






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A second tour of the sixth floor of the D building was conducted with Staff XX on 01/23/13 at 8:30 A.M. The tour revealed the floor to consist of two locked units for psychiatric care.

During the tour at 8:35 A.M. two dirty sprinkler head were observed in room 622E. This was confirmed by Staff XX during the tour.

On 01/23/13 at 11:10 A.M. a tour of the fourth floor of the D building was conducted with Staff XX. Observation of the sprinkler heads in the conference room (4181) revealed dirty sprinkler heads.

During the tour, Staff XX confirmed the finding.

On 01/24/13 a tour was conducted of the operating room area on the first floor of the D building with Staff XX.

During the tour an observation of the men ' s locker room was made. Within 18 inches of the ceiling and on top of the lockers a pile of clothing was placed.

During the tour Staff XX confirmed the finding.

On 01/24/13 at 10:40 A.M. a tour was conducted of the ground floor of the D building with Staff XX. During the tour a dirty sprinkler head was observed in room 298, a biohazard room.

During the tour, Staff XX confirmed the finding.

On 01/25/13 at 10:05 A.M. supply room 2041 on the second floor of the A building was observed to have a cardboard box on top of a filing cabinet. The sprinkler pendant was observed to be within the box.

The observation was confirmed with Staff XX in an interview on 01/25/13 at 10:05 A.M.

Based on interview and observation, the facility failed to ensure each portable fire extinguisher was in compliance with NFPA 10, general requirement section (1-6.6). This involved one extinguisher on the sixth floor of the D building and one in the paint shop. The facility's capacity was 203 beds and the census was 98 patients.

Findings include:

On 01/23/13 between 3:00 P.M. and 4:30 P.M. observation of the paint shop was conducted with Staff YY. Observation of the fire extinguisher in the paint room revealed access to the extinguisher was blocked by boxes and buckets. Staff present on tour verified the materials affected easy accessibility of the fire extinguisher.


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On 01/22/13 at 2:42 a tour was conducted of the sixth floor of the D building with Staff XX. At 2:55 P.M. during the tour, a circular rack of patient charts was observed in front of fire extinguisher 047121A.

At 2:55 P.M. in an interview Staff AA, a nurse on the floor, stated the charts were always kept in the area in front of the fire extinguisher.

Based on observation and interview, the facility failed to ensure each patient care area was free of space heaters, and where used, used in accordance with manufacturer's directions. This has the potential to affect all patients, staff and visitors in the facility. The facility capacity was 203 beds and the census was 98 patients.
Findings include:
On 01/24/13 a tour was conducted of the operating room area on the first floor of the D building with Staff XX. Observation of the operating area revealed a space heater in the educator office (1252). This office shares the same smoke compartment as seven unsprinklered operating rooms.

During the tour, Staff XX confirmed the finding.

On 01/25/13 at 11:55 A.M. a tour was conducted with Staff XX of the Health Center of the ground floor. Within the health center a medical records room was observed. Within the room were two columns of medical records cases. Beside one case a space heater was observed to less than three feet from the medical records.

Observation of the heater revealed an instruction on it to not place it within three feet from anything that burns.

On 01/25/13 at 11:55 A.M. in an interview Staff XX confirmed the finding.

Based on observation and interview, the facility failed to ensure piped gases on the fourth floor of the A building complied with NFPA 99. This has the potential to affect an anesthetized patient in procedure room four. The census was 98 patients.
Findings include:
On 01/24/13 at 2:05 P.M. a tour was conducted of the fourth floor of the A building with Staff XX. During the tour a suite of four procedure rooms was observed on the northeast end of corridor 4038. Procedure room four was observed to be an anesthetizing location as evidenced by the presence of an anesthesia cart.

During the tour in an interview, Staff XX explained the physician wants to have general anesthesia available. He/she explained the area is a pain clinic and is used for the treatment of pain.

Observation revealed gas shut-off valves outside rooms three and four, but not outside room two.

During the tour in an interview, Staff XX explained room one was not used, but room two was used for conscious sedation. He/she also confirmed there wasn't a nearby shutoff valve for room two, but there was a shutoff valve further down the corridor for all four rooms.

(Consequently, if medical gases needed to be cut to room two, medical gas to all rooms, including the one equipped with general anesthesia, would have to be cut, perhaps when general anesthesia was in use.)

Based on observation and interview, the facility failed to ensure compliance with NFPA 70 in general, and NFPA 70 110 3(b) and 400-7(b) in particular. This has the potential to affect all patients, staff, and visitors who use the buildings. The capacity was 203 beds and the census was 98 patients.

Findings:

On 01/25/13 at 10:26 A.M. a tour was conducted of the case management office (246A) of the second floor of the A building with Staff XX. Within the room a power strip with six outlets had three items plus an extension cord plugged into it. Into that extension cord another power strip was plugged.

On 01/25/13 at 10:26 A.M. in an interview, Staff XX confirmed the observation.

Based on interview observation, the facility failed to ensure each fire wall was free of penetration and each door in the fire wall had an observable rating. This affected the fire wall on the second floor of the C building, in the credit union, in the staff bathroom located between the B and C building, on the fourth, third, second, and first floors of the D building, and the first floor of the A building. This affected the fire doors on the fifth floor of the D building and the third floor of the A building. This has the potential to affect all patients, visitors and staff who use the buidling. The capacity was 203 beds and the census was 98 patients.

Findings include:

On 01/23/13 between 8:30 A.M. and 4:30 P.M. tour of the facility was conducted with Staff YY. Observation on the second floor of the C building, above the ceiling tiles of a two hour fire rated barrier near the orthopaedic physician office, revealed a penetration surrounding three white pipes and two ducts. The floor decking above was not sealed in the same area.

Observation of a two hour fire rated barrier located in a leased space, revealed a penetration approximately six inches in length surrounding three conduits. The penetration was noted above the ceiling at the work desk in the student area.

Observation of a two hour fire rated barrier above the ceiling tiles within the credit union revealed a penetration surrounding electrical conduit. Located in the safe room, above the ceiling tiles, a penetration was observed surrounding a water pipe between the block and the floor decking above.

Observation of a two hour fire rated barrier above the ceiling tiles on the third floor in the staff bathroom, located between the B and C building revealed a a large portion of the fire barrier wall was missing. Staff CC verified a large portion of the fire barrier was not in place as noted on the building fire safety plans.









21521


On 01/23/13 at 9:45 A.M. a tour of the 5th floor of the D building was conducted with Staff XX. The fifth floor was a sleeping patient area consisting of orthopedic and medical surgical telemetry patients. During the tour stairwell D1 ' s fire door did not have an observable rating.

During the tour of the 5th floor, Staff XX confirmed the finding.

On 01/23/13 at 11:10 A.M. a tour of the fourth floor of the D building was conducted with Staff XX. The tour revealed a firewall that separated Building C from Building D. Observation above the drop down ceiling above the double doors opposite waiting area 4194 revealed an opening created by a two inch conduit.

Observation above the drop down ceiling revealed the fire wall separating corridor 4153 from corridor 4233 was comprised of two five eighths inch drywalls.

Observation above the drop down ceiling perpendicular to stairwell C2 revealed the fire wall to have a two inch penetration.

During the tour of the fourth floor Staff XX confirmed the observations.

On 01/23/13 at 2:50 P.M. a tour was conducted of the third floor with Staff XX. Observation above the dropdown ceiling between the single fire door in elevator lobby 3096 leading to stair C2 and the double doors leading to corridor 3128 revealed a two inch conduit open to air.

Observation above the dropdown ceiling above the double doors in elevator lobby 3096 leading to corridor 3128 revealed a five by 12 inch square missing from the drywall.

On 01/23/13 at 3:21 P.M. a tour was conducted of the second floor of the D building with Staff XX. During the tour a one inch conduit above the drop down ceiling above the single door leading to stair C2 was revealed to have an annular space in the fire wall.

During the tour a two inch conduit above the drop down ceiling above the double doors was observed to be in a fire wall and open to air.

During the tour, Staff XX confirmed the findings.

On 01/23/13 at 4:05 P.M. a tour of the first floor of the D building was conducted with Staff XX. During the tour the fire wall was observed to run from the northeast to the southeast in a zigzag like pattern. Observation of the firewall between the surgery waiting area and elevator lobby 1300 revealed, above the dropdown ceiling, three metallic channels each six inches wide by one inch deep and all open to air.

During the tour of the first floor of the D building revealed a fire door to stairwell C2 without an observable rating.

During the tour of the first floor of the D building, Staff XX confirmed the findings.

A second tour of the first floor of the D building was conducted with Staff XX on 01/24/13 at 8:40 A.M. During the tour, above the drop down ceiling above the double doors in corridor 1233 and parallel with stairway C2, a fist sized hole around a conduit holding blue wire was observed.

During the tour of the first floor of the D building, Staff XX confirmed the findings.

On 01/24/13 at 3:17 P.M. a tour was conducted of the third floor of the A building with Staff XX. During the tour the fire doors to stairway A4 and A1 was observed without an observable rating.

During the tour, Staff XX confirmed the finding.

On 01/25/13 at 10:00 A.M. a tour was conducted of the first floor with Staff XX. Observation of the firewall above the drop down ceiling near stairwell A1 revealed three three inch electrical conduits open to air.

During the tour, in an interview Staff XX confirmed the finding.

Based on interview and observation, the facility failed to ensure each waiting area was protected by a smoke detection system or had direct supervision by the staff. This affected waiting area 4194 in the D building and 324A in the A building. This has the potential to affect all patients, staff, and visitors who use the A and D buildings. The capacity was 203 beds and the facility census was 98.
Findings include:
On 01/23/13 at 11:10 A.M. a tour was conducted of the fourth floor of the D building with Staff XX. During the tour waiting area 4194 was observed to have neither smoke detection nor sprinkler protection. It was also observed to be without any human supervision.

During the tour Staff XX confirmed the observation in an interview.

On 01/24/13 at 3:17 P.M. a tour was conducted of the third floor of the A building. Observation of waiting area 324A revealed the door propped open to the corridor and no one was in attendance to view the room. The room was observed without sprinklers and smoke detectors.

On 01/24/13 at 3:20 P.M. Staff BB stated the door was left open so that patients could come and sit early in the morning, before staff arrived.

Based on facility tour and staff interview and verification, the facility failed to ensure that doors in sprinklered buildings were only required to resist the passage of smoke. There was no impediment to the closing of the doors. Doors were to be provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 were permitted but not provided. The facility had capacity for 203 beds with a census of 98 patients at the time of the survey.

Findings included;

On 01/24/13 tour of the laboratory area located on the ground floor was conducted with Staff YY. Observation of the outpatient lab area revealed the presence of Dutch doors. The Dutch doors were located within a one hour fire rated smoke/fire barrier corridor wall. The outpatient lab and the corridor were provided with automatic sprinkler protection.

Observation of the wood Dutch doors revealed there was no closing device on either the top or bottom portions of the door. There was no astragal noted at the door separation. Staff present in the area stated the bottom portion of the Dutch door was typically kept closed and was used for patients to check in at the lab prior to going to the waiting area.

Staff present on tour verified there was no closing devices on the upper or lower halves of the Dutch door.

Based on observation and interview, the facility failed to ensure each access to an exit on the sixth, second, and ground floor of the D building were marked by approved, readily visible exit signs. This has the potential to affect all patients, staff, and visitors of the facility. The capacity was 203 beds, and the census was 98 patients.

Findings include:

A second tour of the sixth floor of the D building was conducted with Staff XX on 01/23/13 at 8:30 A.M. The tour revealed the floor to consist of two locked units for psychiatric care.

During the tour, a path of egress defined by the evacuation plan posted at stairwell D2, revealed a path of egress from the stairwell traveling northeast along the corridor past the double doors bridging rooms 609 and 622E, then turning right at the patient lounge.

Observation of the exit sign before approaching the double doors, however, revealed a chevron directing occupants into room 609.

During the tour of 01/23/13 at 8:30 A.M., Staff XX confirmed the observation.

During the tour, a path of egress defined by the evacuation plan posted at the northeast corner of the floor revealed a path of egress going down the corridor and turning left at the patient lounge. However, observation of the exit sign prior to the double doors bridging rooms 609 and 622E did not reveal an chevron pointing to the left to direct occupants to go left at the patient lounge.

During the tour of 01/23/13 at 8:30 A.M., Staff XX confirmed the observation.

On 01/23/13 at 3:21 P.M. a tour was conducted of the second floor of the D building with Staff XX. Within the tour of the floor a physical therapy suite was observed. From the most eastern portion of the room, an exit sign along the path of egress was not observed.

During the tour Staff XX confirmed the finding.

On 01/24/13 at 10:40 A.M. a tour was conducted of the ground floor of the D building with Staff XX. During the tour, corridor 327 was observed to be on a path of egress. However, observation from the most northeast portion of the corridor down to the southwest portion did not reveal an exit sign above the door between rooms 334 and 335.

During the tour Staff XX confirmed the finding.

Based on observation and interview, the facility failed to ensure each smoke barrier was free of penetrations. This affected the smoke wall in the cafeteria, the sixth and fifth floor of the D building, the fourth floor of the C building, and the ground floor of the heart center. This has the potential to affect all visitors, staff, and patients who use the facility. The capacity was 203 beds and the census was 98 patients.
Findings include:

On 01/22/13 at 2:30 P.M. tour of building C , fourth floor was conducted with Staff YY. Observation of the one hour fire rated smoke barriers revealed a penetration approximately one inch in diameter located above the fire rated door next to the restroom. Staff present on tour filled the penetration with fire rated caulking material.

On 01/23/13 between 11:50 A.M. and 4:30 P.M., observation above the ceiling tiles of a one hour fire rated fire barrier was conducted with Staff YY. A penetration was noted in the one hour fire/smoke barrier located at the continuous care room 5-8. The penetration surrounded a duct and a conduit.

Observation above the ceiling tiles of the one hour fire rated barrier located in the cafeteria revealed a large penetration in the floor decking. The open area in the floor decking was estimated by the staff to be approximately one square foot. Wood, wire and lathe could be seen through the open area.

On 01/24/13 tour of the one hour fire rated barrier located on the ground floor near the heart center was conducted with Staff YY. Observation at the "Mountain Landscape" picture, above the ceiling tiles, revealed a penetration through two sheets of gypsum boards. Steel studs were exposed in the one hour fire rated barrier. Staff CC, a contractor , was present and verified the observation did not meet the construction requirement for a one hour fire rated barrier.






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On 01/22/13 at 2:42 P.M. a tour was conducted of the sixth floor of the D building with Staff XX. The tour revealed the floor to consist of two locked units for psychiatric care. Review of the schematic for the sixth floor of the D building, and observation during tour, revealed the unit to be divided into two smoke compartments by a smoke barrier running from the northwest to the southeast, beginning at room 609 and finishing at the nurses lounge.

At 3:45 P.M. observation above the drop-down ceiling of the wall dividing room 609 from 610 revealed it to be pierced by part of a smoke damper.

Observation above the drop-down ceiling over the double doors that bridged room 609 with 622E revealed it to be pierced with a two inch conduit which ran grey wires around which was an annular space. The corrugations of the corrugated ceiling were also observed to be without fire stopping material.

In an interview during the tour of 01/22/13 at 2:42 P.M., Staff XX confirmed the findings.

On 01/23/13 at 9:45 A.M. a tour of the 5th floor of the D building was conducted with Staff XX. The fifth floor was a sleeping patient area consisting of orthopedic and medical surgical telemetry patients. The floor was bisected by a smoke wall running from the northwest to the southeast. Observation of the doors to the conference room (room 5039) and to the family waiting (room 5040) did not reveal a rating.

In an interview during the tour of 01/23/13 at 9:45 A.M., Staff XX confirmed the findings.

Observation of the smoke wall as it divided the staff lockers room (5041) and conference room (5039), revealed a finger sized penetration.

Based on facility tour and staff interview and verification, the facility failed to ensure that one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected a hazardous area. The facility had capacity for 203 beds with a census of 98 patients at the time of the survey.

Findings include:

1. On 01/23/13 at 10:40 A.M. tour with Staff YY was conducted of the psychiatric occupational therapy corridor. Observation of the area revealed the presence of a mechanical room. Observation inside the locked mechanical room revealed a narrow room about ten feet in length. Contents of the room included a large air conditioning (AC) unit. Observation of the mechanical room also revealed a large penetration in the wall surrounding the AC unit.

Staff YY opened the room located in the corridor next to the mechanical room to reveal an occupational therapy office. Immediately inside the room, to the left, was the large AC unit. There was no wall surrounding the unit which allowed the AC unit be open and exposed in the office. Staff YY verified the AC unit was functional and provided cooling to the entire corridor and the offices in the area.

Staff CC, a contractor, was summoned to the room and verified the office was once part of a mechanical room which housed the AC unit. The mechanical room was renovated by expansion and made into an office. Staff YY and CC verified no wall was constructed to separate the office from the mechanical room.

2. On 01/23/13 observation of the first floor, building C, revealed a leased room used by the tenant to store files. The file room contained a significant number of cardboard boxes. The file storage room had no automatic sprinkler system. There was no door to secure the room.

3. On 01/24/13 tour of the basement area was conducted with Staff YY. Observation of a physician office, Suite LL100, revealed a storage area, TB190. The storage area contained various combustible items which included boxes. The storage area had no automatic sprinkler system. Observation above the ceiling tiles revealed there was no one hour fire rated construction as evidenced by large sections of wall missing. The door to the storage area was a wooden door with no noted fire rating and no closing device.

Staff YY present at the observation, verified the findings.

Based on facility observation and staff interview and verification, the facility failed to ensure that exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1 and 19.2 This affected the exits on the locked behavioral units, including the sixth floor of the D building. The facility had capacity for 203 beds with a census of 98 patients at the time of the survey.

Findings include:

On 01/23/13 between 9:15 A.M. and 10:10 A.M. tour of the second floor of the C building was initiated with Staff YY. Observation of an exit stairwell (Stair M1) revealed that exit discharge was inside a courtyard. The courtyard was snow covered and the path to the courtyard exit was snow covered. At the courtyard exit discharge observation revealed a grassy snow covered area approximately ten feet in length to another snow covered paved public way.

Interview of Staff YY verified the courtyard did not have a cleared pathway to the courtyard discharge opening. Staff YY further verified the exit discharge from the courtyard was an uneven grassy area under the snow.

Tour of the locked behavioral units located throughout the facility on 01/22 through 01/25/13 with Staff XX, and YY revealed that five of six units had two sets of locked doors at the entrance/exits of the units. The sets of doors were noted to have magnetic locks which prevented the doors from opening. Staff present at tour revealed that a swipe card or a key was required to override the magnetic locks and disengage the doors to enter or leave the units.

Staff XX and YY were interviewed regarding the release of the doors in the event of a fire alarm. Both staff revealed that if a pull station or an alarm was activated in that area then the doors would release. If the alarm was activated on another floor or in another area of the facility then the doors would not release without use of a key or swipe card.

On 01/25/13 at 10:30 A.M. review of facility fire alarm documentation with Staff YY revealed an alarm was pulled for a fire drill in July 2012 at 2:20 P.M.. Documentation of the fire drill revealed the magnetic locks released for doors to the secured behavioral unit located on D building, sixth floor. There was no additional information regarding the disengagement of the other doors for other secured units in the facility.



21521

A second tour of the sixth floor of the D building was conducted with Staff XX on 01/23/13 at 8:30 A.M. The tour revealed the floor to consist of two locked units for psychiatric care.

During the tour, a path of egress defined by the evacuation plan posted at the northeast corner of the floor revealed a path of egress going down the corridor through locked doors and turning left at the patient lounge. The path then proceeded to a second locked door at the stairway.

On 01/25/13 at 3:00 P.M. in an interview Staff XX stated if an alarm local to the 6th floor is sounded, all locked door will release. However, he/she stated if a central alarm is sounded, or an alarm is sounded on another floor, the locked doors would each need to be keyed open.

On 01/25/13 at 9:30 A.M. a tour was conducted of the second floor of the A building with Staff XX. During the tour the path of egress as defined by the evacuation plan posted near stairwell A4 revealed the path took occupants through a psychiatric area that included two delayed egress doors.

During the tour, Staff XX confirmed the finding.

Based on facility observation ands staff interview and verification, the facility failed to ensure that patient room doors were arranged so that the patients could open the door from inside without using a key. The facility had capacity for 203 beds with a census of 98 patients at the time of the survey. At least two of five locked patient care units were affected. One patient surgical area was affected.

Findings include:

1. On 01/22/13 between 2:30 P.M. and 4:30 P.M. tour of the facility was conducted with Staff YY. Observation of building C, fourth floor, revealed a locked behavioral health unit. The unit was noted to have a capacity of ten patient beds with a census of six patients.

Observation of the patient bedrooms revealed a deadbolt type lock present on the bedroom doors. Staff present at tour stated the locks were used only to prevent patients from entering rooms. Staff verified that when locked one could not exit the room without use of a key to release the door.

2. Observation of B building , third floor, on 01/24/13 at 3:15 P.M. with Staff YY, revealed the presence of a locked behavioral unit. The unit had a capacity of 21 patient beds with a census of 17 patients. Observation of the patient bedroom doors revealed the presence of deadbolt type locks on the doors. Interview of Staff ZZ revealed the locks were used only when the patients were not permitted into the rooms. Staff YY and ZZ verified that when locked, anyone inside the rooms could not leave without use of a key.

Further interview of Staff YY verified that for behavioral units within the facility that utilized dead bolt type locks on patient bedroom doors, it was necessary to use a key when leaving the inside of the room.

3. On 01/24/13 tour of the same day surgery area was conducted with Staff YY. Observation of the patient rooms revealed the presence of dead bolt type locks. Interview of Staff YY revealed the locks were used to keep persons out of the rooms when the unit was not in use. Staff noted that if the rooms were locked, exit access from inside the room could occur by turning a thumb turn on the lock in addition to using the door handle.

Staff present verified there were 12 patient rooms with the thumb turn locks with a capacity of 23 patients.

Based on facility observation and staff interview and verification, the facility failed to ensure that illumination of means of egress, including exit discharge, was arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness. The facility had capacity for 203 beds with a census of 98 patients at the time of the survey.

Findings included;

On 01/23/13 between 9:15 A.M. and 10:10 A.M. tour of the second floor of the C building was initiated with Staff YY. Observation of an exit stairwell (Stair M1) revealed that exit discharge was inside a courtyard. Observation of the exit discharge revealed there was no illumination of the means of egress.

Travel to the courtyard exit discharge required travel across the snow covered courtyard to which lead to a grassy snow covered area approximately ten feet in length to another snow covered paved public way.

Interview of Staff YY verified there was no illumination of the exit discharge for Stair M1

Based on observation and interview, the facility failed to ensure the automatic sprinkler system was maintained in reliable operating condition, including the maintaining the cleanliness of each sprinkler head and prohibiting material stored less than 18 inches from the ceiling. This affected the sprinkler heads on the sixth, fourth and ground floor of the D building, on the fourth and first floor of the C building, in the surgical recovery area, in the decontamination room (LLB140), and in x-ray storage, which were dirty. This affected the sprinkler heads in the locker room on the first floor of the D building, the second floor of the A building, and in the general maintenance shop wherein material was found stored in a space less than 18 inches from the ceiling. This has the potential to affect all patients, visitors, and staff to the facility. The facility has a capacity for 203 beds and the census was 98 patients.

Findings include:

The sprinkler head of the soiled linen chute, located on the fourth four, was observed to be covered with a thick layer of dust.

On 01/23/13 at 10:20 A.M. observation was conducted of the first floor of building C with Staff YY. Sprinkler heads in the surgical recovery area corridor were observed to be covered with dusty residue.

Three sprinkler heads in a first floor corridor of building C ( T1312) were observed to be covered with a thick coating of dusty debris.

On 01/23/13 between 3:00 P.M. and 4:30 P.M. tour of the general maintenance shop was conducted with Staff YY. Storage shelves located in the middle of the room contained items stacked on the top shelves. The items were less than 18 inches from an automatic sprinkler head. In addition, observation of the sprinkler heads in the shop were noted to be covered with dusty debris.

On 01/24/13 at 10:45 A.M. tour of the decontamination room ( LLB140) revealed automatic sprinkler heads covered with a dusty debris. Staff YY present at the observation verified the findings.

On 01/24/13 observation of the x-ray storage room revealed automatic sprinkler heads covered with a dusty debris. Staff YY present at the observation verified the findings.






21521


A second tour of the sixth floor of the D building was conducted with Staff XX on 01/23/13 at 8:30 A.M. The tour revealed the floor to consist of two locked units for psychiatric care.

During the tour at 8:35 A.M. two dirty sprinkler head were observed in room 622E. This was confirmed by Staff XX during the tour.

On 01/23/13 at 11:10 A.M. a tour of the fourth floor of the D building was conducted with Staff XX. Observation of the sprinkler heads in the conference room (4181) revealed dirty sprinkler heads.

During the tour, Staff XX confirmed the finding.

On 01/24/13 a tour was conducted of the operating room area on the first floor of the D building with Staff XX.

During the tour an observation of the men ' s locker room was made. Within 18 inches of the ceiling and on top of the lockers a pile of clothing was placed.

During the tour Staff XX confirmed the finding.

On 01/24/13 at 10:40 A.M. a tour was conducted of the ground floor of the D building with Staff XX. During the tour a dirty sprinkler head was observed in room 298, a biohazard room.

During the tour, Staff XX confirmed the finding.

On 01/25/13 at 10:05 A.M. supply room 2041 on the second floor of the A building was observed to have a cardboard box on top of a filing cabinet. The sprinkler pendant was observed to be within the box.

The observation was confirmed with Staff XX in an interview on 01/25/13 at 10:05 A.M.

Based on interview and observation, the facility failed to ensure each portable fire extinguisher was in compliance with NFPA 10, general requirement section (1-6.6). This involved one extinguisher on the sixth floor of the D building and one in the paint shop. The facility's capacity was 203 beds and the census was 98 patients.

Findings include:

On 01/23/13 between 3:00 P.M. and 4:30 P.M. observation of the paint shop was conducted with Staff YY. Observation of the fire extinguisher in the paint room revealed access to the extinguisher was blocked by boxes and buckets. Staff present on tour verified the materials affected easy accessibility of the fire extinguisher.


21521


On 01/22/13 at 2:42 a tour was conducted of the sixth floor of the D building with Staff XX. At 2:55 P.M. during the tour, a circular rack of patient charts was observed in front of fire extinguisher 047121A.

At 2:55 P.M. in an interview Staff AA, a nurse on the floor, stated the charts were always kept in the area in front of the fire extinguisher.

Based on observation and interview, the facility failed to ensure each patient care area was free of space heaters, and where used, used in accordance with manufacturer's directions. This has the potential to affect all patients, staff and visitors in the facility. The facility capacity was 203 beds and the census was 98 patients.
Findings include:
On 01/24/13 a tour was conducted of the operating room area on the first floor of the D building with Staff XX. Observation of the operating area revealed a space heater in the educator office (1252). This office shares the same smoke compartment as seven unsprinklered operating rooms.

During the tour, Staff XX confirmed the finding.

On 01/25/13 at 11:55 A.M. a tour was conducted with Staff XX of the Health Center of the ground floor. Within the health center a medical records room was observed. Within the room were two columns of medical records cases. Beside one case a space heater was observed to less than three feet from the medical records.

Observation of the heater revealed an instruction on it to not place it within three feet from anything that burns.

On 01/25/13 at 11:55 A.M. in an interview Staff XX confirmed the finding.

Based on observation and interview, the facility failed to ensure piped gases on the fourth floor of the A building complied with NFPA 99. This has the potential to affect an anesthetized patient in procedure room four. The census was 98 patients.
Findings include:
On 01/24/13 at 2:05 P.M. a tour was conducted of the fourth floor of the A building with Staff XX. During the tour a suite of four procedure rooms was observed on the northeast end of corridor 4038. Procedure room four was observed to be an anesthetizing location as evidenced by the presence of an anesthesia cart.

During the tour in an interview, Staff XX explained the physician wants to have general anesthesia available. He/she explained the area is a pain clinic and is used for the treatment of pain.

Observation revealed gas shut-off valves outside rooms three and four, but not outside room two.

During the tour in an interview, Staff XX explained room one was not used, but room two was used for conscious sedation. He/she also confirmed there wasn't a nearby shutoff valve for room two, but there was a shutoff valve further down the corridor for all four rooms.

(Consequently, if medical gases needed to be cut to room two, medical gas to all rooms, including the one equipped with general anesthesia, would have to be cut, perhaps when general anesthesia was in use.)

Based on observation and interview, the facility failed to ensure compliance with NFPA 70 in general, and NFPA 70 110 3(b) and 400-7(b) in particular. This has the potential to affect all patients, staff, and visitors who use the buildings. The capacity was 203 beds and the census was 98 patients.

Findings:

On 01/25/13 at 10:26 A.M. a tour was conducted of the case management office (246A) of the second floor of the A building with Staff XX. Within the room a power strip with six outlets had three items plus an extension cord plugged into it. Into that extension cord another power strip was plugged.

On 01/25/13 at 10:26 A.M. in an interview, Staff XX confirmed the observation.