HospitalInspections.org

Based on Life Safety Plan review, observation, and staff interview the facility failed to maintain the 2 hour rated common wall between the existing building and the new tower. This has the potential to affect all patients and visitors to the facility. The facility census was 569.

Findings include:

1. Observation above the drop ceiling in the Southwest tower side through the double doors at the end of the ramp SE7180 on the 7th floor, completed on 10/1/15, revealed multiple penetrations varying in size and shape on the other side of the double doors in the 2 hour rated wall. These findings were confirmed by Staff BB at 2:10 PM.

2. Observation above the drop ceiling in Corridor vending area SE2122.1, located on the 2nd floor, completed on 10/02/15, revealed a 3/4 inch conduit penetrating the North 2 hour separation wall open on the end with white and orange data cables passing through. This finding was confirmed by Staff BB at 6:55 AM.

3. Observation above the drop ceiling in the Equipment Storage, room 1195 on the 1st floor, completed on 10/02/15, revealed a 1/2 inch hole behind red data cables. This finding was confirmed by Staff BB at 8:50 AM.

4. Observation in the Shell Space, 1197 on the 1st floor, completed on 10/02/15, revealed the wall was not sealed at the deck above in the Northwest corner. This finding was confirmed by Staff BB and CC at 9:20 AM.

Based on observation and interview, the facility failed to ensure self closers and latching hardware on doors that protected corridor openings closed and latched the doors. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

1. On 09/29/15 at 8:36 AM a tour of the sixth floor of the main hospital was conducted with Staff QQ, MM, and TT.

On 09/29/15 at 8:45 AM observation of the door protecting room A6436 from the corridor revealed it was on a magnetic release connected to the fire alarm system so that it would close when the alarm is activated. Further observation revealed two meal carts parked in front of the door that if the magnetic release was activated, the carts would prohibit the door from closing completely.

On 09/29/15 at 8:45 AM in an interview, Staff SS said, "That's where we store them" when they run out of space.

On 09/29/15 at 11:38 AM , observation of the door protecting the corridor from room m6407a revealed it had self closing, latching hardware. However, when tested, the door did not self close and latch.

On 09/29/15 at 11:38 AM, in an interview, Staff QQ confirmed the finding.

2. On 09/29/15 at 1:35 PM a tour was conducted of the fifth floor of the main building with Staff QQ, RR, and MM.

On 09/29/15 at 3:31 PM observation of the door protecting room 5610 from the corridor revealed it had self closing and latching hardware that did not close and latch the door.

On 09/29/15 at 3:31 PM in an interview, Staff QQ confirmed the finding.

3. On 09/30/15 at 10:06 AM a tour was conducted of the fourth floor of the main building with Staff QQ, RR, and MM.

On 09/30/15 at 11:04 AM observation of the door protecting data closet 4501b from the corridor revealed it had self closing and latching hardware that did not self close and latch.

On 09/30/15 at 11:04 AM in an interview, Staff QQ confirmed the finding.

4. On 09/30/15 at 4:27 PM a tour was conducted of the second floor of the main building with Staff QQ, RR, and MM.

On 09/30/15 at 4:48 PM observation of the laboratory revealed a pass-through opening onto the corridor for staff to give laboratory staff specimens. The observation revealed the corridor was protected from this opening by a fusible link, rated, drop down accordion door. However observation revealed a computer monitor was placed in an area under the accordion door preventing it from dropping all the way down and sealing off the opening.

On 09/30/15 at 4:48 PM in an interview, Staff QQ confirmed the finding.

5. On 10/01/15 at 3:06 PM a tour was taken of the third floor of the northwest wing with Staff QQ, RR, and MM.

On 10/01/15 at 4:17 PM observation of the door protecting room 3252 from the corridor revealed it had self closing and latching hardware that did not self close and latch.

On 10/01/15 at 4:17 PM in an interview, Staff QQ confirmed the finding.

6. On 10/02/15 at 10:19 AM a tour was taken of the first floor of the northwest wing with Staff QQ, RR, and MM.

On 10/02/15 at 10:59 AM observation of the door protecting room 1305 from the corridor revealed the arm to the self closing hardware was broke and the door wouldn't self close.

On 10/02/15 at 10:59 AM in an interview, Staff QQ confirmed the finding.

7. On 10/02/15 at 2:29 PM a tour was conducted of the fourth floor of the northeast wing with Staff QQ, RR, and MM.

On 10/02/15 at 2:35 PM observation of the door protecting a room, which is perpendicular to room m4486, from the corridor revealed it had self closing and latching hardware that did not self close and latch.

On 10/02/15 at 2:35 PM in an interview, Staff QQ confirmed the finding.

8. On 10/06/15 at 9:01 AM a tour was conducted of the sixth floor of the southwest development project building with Staff QQ, RR, and MM.

On 10/06/15 at 9:28 AM observation of the door protecting room sw6559 from the corridor revealed it had self closing and latching hardware that did not self close and latch.

On 10/06/15 at 9:28 AM in an interview, Staff QQ confirmed the finding.

Based on observation and interview, the facility failed to maintain the rated construction protecting its vertical openings, to maintain rating on doors to its vertical openings including dumb waiters, and to ensure doors in vertical openings were closed and latched. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

1. On 09/28/15 at 1:50 PM a tour was taken of the seventh floor of the main building with Staff QQ and MM.

a) On 09/28/15 at 1:50 PM a one inch opening was observed above the drop down ceiling in the two hour rated construction surrounding the shaft located to the right of the entrance to the reception area of the department of medicine. On 09/28/15 at 1:50 PM in an interview, Staff QQ confirmed the finding.

b) On 09/28/15 at 1:55 PM observation above the drop down ceiling of the two hour rated construction surrounding the shaft located to the left of the entrance to the reception area of the department of medicine revealed conduits traveling from the barrier to a junction box with a missing knock-out and a two inch by two inch square opening that revealed the shaft did not have enough layers of drywall to create two hours of protection. On 09/28/15 at 1:55 PM in an interview, Staff QQ confirmed the finding.

c) On 09/28/15 at 3:26 PM observation above the drop down ceiling of the east wall of the two hour rated barrier in equipment room sw7028, protecting an elevator shaft, revealed three one inch holes in the wall. On 09/28/15 at 3:36 PM in an interview, Staff QQ confirmed the finding.

2. On 09/28/15 at 3:31 PM and on 09/29/15 at 8:36 AM a tour was taken of the sixth floor of the main building with Staff QQ and MM.

a) On 09/28/15 at 4:01 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft near education room m6605 revealed an open half inch conduit holding two gray wires. On 09/28/15 at 4:01 PM in an interview, Staff QQ confirmed the finding.

b) On 09/28/15 at 4:08 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft near room of the two hour rated construction protecting a shaft near soiled utility room 6427 at the nursing station revealed wiring with a one inch annular space. On 09/28/15 at 4:08 PM in an interview, Staff QQ confirmed the finding.

c) On 09/28/15 at 4:40 PM the door to the two hour barrier protected shaft located at the nursing station and near the medication cart (not the automated medication dispensing system) was observed to be unrated. On 09/28/15 at 4:40 PM in an interview, Staff QQ confirmed the finding.

d) On 09/28/15 at 4:45 PM observation of the two hour rated construction protecting a shaft near room 6422 at the nursing station revealed a two inch annular space around the sprinkler line. On 09/28/15 at 4:45 PM in an interview, Staff QQ confirmed the finding.

e) On 09/29/15 at 8:43 AM observation of the door protecting the shaft located near rooms 6625 and 6623 revealed the door was unrated. On 09/29/15 at 8:43 AM in an interview, Staff QQ confirmed the finding.

f) On 09/29/15 at 8:45 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft near room 6624 revealed two one inch holes under an heating, ventilation and cooling duct. On 09/29/15 at 8:45 AM in an interview, Staff QQ confirmed the finding.

g) On 09/29/15 at 9:03 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft near room 6633 revealed an open six inch diameter pipe and six inch hole. On 09/29/15 at 9:03 AM in an interview, Staff QQ confirmed the finding.

h) On 09/29/15 at 9:12 AM observation above the drop down ceiling of the two hour rated construction protecting a chase next to stairwell sw, s-4, revealed, as seen from the corridor, an open one inch black pipe. On 09/29/15 at 9:12 AM in an interview, Staff QQ confirmed the finding.

i) On 09/29/15 at 9:58 AM observation of the access door in the two hour rated construction protecting a shaft in room 6418, a janitor closet, revealed it had latching hardware, however, was found to be open, unlatched, and unattended. On 09/29/15 at 9:58 AM in an interview, Staff QQ confirmed the finding.

j) On 09/29/15 at 10:12 AM observation above the drop down ceiling of the shaft across from the bank of service elevators and next to room 6401 revealed a one inch open conduit holding two gray wires. On 09/29/15 at 10:12 AM in an interview, Staff QQ confirmed the finding.

k) On 09/29/15 at 10:33 AM observation of the door to the linen chute in room 6415 (across from the nutrition room) revealed the door to be unrated. On 09/29/15 at 10:33 AM in an interview, Staff QQ confirmed the finding.

l) On 09/29/15 at 10:54 AM observation of the doors to the dumb waiters located in room 6403, six west, revealed the doors were unrated. On 09/29/15 at 10:54 AM in an interview, Staff QQ confirmed the finding.

m) On 09/29/15 at 11:06 AM observation of the doors to the dumb waiters located in room 6686 revealed the doors did not have a rating. On 09/29/15 at 11:06 AM in an interview, Staff QQ confirmed the finding.

n) On 09/29/15 at 11:51 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft near room 6637 revealed an open one inch conduit holding a yellow wire. On 09/29/15 at 11:51 AM in an interview, Staff QQ confirmed the finding.

o) On 09/29/15 at 12:03 PM observation above the drop down ceiling of the shaft opposite data closet 6690d at the nursing station revealed annular spaces around a copper pipe and around a stainless steel pipe. On 09/29/15 at 12:03 PM in an interview, Staff QQ confirmed the finding.

3. On 09/29/15 at 1:35 PM and on 09/30/15 at 8:15 AM a tour was conducted of the fifth floor of the main building with Staff QQ, RR, and MM.

a) On 09/29/15 at 1:35 PM observation of the two hour rated construction protecting a shaft behind the wall holding the television at the waiting area revealed an open electrical box. On 09/29/15 at 1:35 PM in an interview, Staff QQ confirmed the finding.

b) On 09/29/15 at 1:47 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft in the back of bathroom m5635 revealed an annular space around a conduit. On 09/29/15 at 1:47 PM in an interview, Staff QQ confirmed the finding.

c) On 09/29/15 at 1:50 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft toward the back of the bathroom next to bathroom m5636 revealed an annular space around a conduit.

d) On 09/29/15 at 3:42 PM observation of the dumb waiters in passage 5690a did not reveal a rating for their doors. On 09/29/15 at 3:42 PM in an interview, Staff QQ confirmed the finding.

e) On 09/29/15 at 3:49 PM observation of the access door in the two hour rated construction protecting the chase in room m5641 revealed the door had latches but was found open, unlatched, unrated, and unattended. On 09/29/15 at 3:49 PM in an interview, Staff QQ confirmed the finding.

f) On 09/29/15 at 3:51 PM observation of the fifth floor linen chute door revealed its rating to be unknown. On 09/29/15 at 3:51 PM in an interview, Staff QQ confirmed the finding.

g) On 09/29/15 at 4:22 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft at the nursing station and across from data closet 5625b, revealed one stainless steel pipe, one sprinkler line, and one fiber optic line with annular spaces around each. On 09/29/15 at 4:22 PM in an interview, Staff QQ confirmed the finding.

h) On 09/29/15 at 4:52 PM observation above the drop down ceiling of the two hour rated construction protecting the shaft between room 5568 and stair three revealed conduits traveling from the vertical opening to a junction box with a missing knock out from which two red wires traveled out. On 09/29/15 at 4:52 PM in an interview, Staff QQ confirmed the finding.

i) On 09/30/15 at 8:24 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft near rooms 5547 and 5549 revealed an opening between a sleeve and the fiber optic cable it was holding. On 09/30/15 at 8:24 AM in an interview, Staff QQ confirmed the finding.

4. On 09/30/15 at 8:34 AM and on 09/30/15 at 10:56 AM a tour was conducted of the fourth floor main building with Staff QQ, RR, and MM.

a) On 09/30/15 at 8:36 AM observation of the two hour rated construction protecting chase 4494c revealed an annular space around a fiber optic sleeve. On 09/30/15 at 8:36 AM in an interview, Staff QQ confirmed the finding.

b) On 09/30/15 at 8:38 AM observation of the doors to the dumb waiters in room m4516 did not reveal any rating for the doors. On 09/30/15 at 8:38 AM in an interview, Staff QQ confirmed the finding.

c) On 09/30/15 at 8:47 AM observation of the doors to the dumb waiters in room m4492a did not reveal any rating for the doors. On 09/30/15 at 8:47 AM in an interview, Staff QQ confirmed the finding.

d) On 09/30/15 at 8:49 AM observation of the door to the shaft in IT closet 4518 revealed the door did not have a rating. On 09/30/15 at 8:49 AM in an interview, Staff QQ confirmed the finding.

e) On 09/30/15 at 8:56 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft near room 4527 revealed conduits with open ends traveling through the construction. On 09/30/15 at 8:56 AM in an interview, Staff QQ confirmed the finding.

f) On 09/30/15 at 9:35 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft near the double doors near room 4410 revealed an open one inch conduit holding two gray wires. On 09/30/15 at 9:35 AM in an interview, Staff QQ confirmed the finding.

g) On 09/30/15 at 9:44 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft near room 4418 revealed an open one inch conduit holding a green wire. On 09/30/15 at 9:44 AM in an interview, Staff QQ confirmed the finding.

h) On 09/30/15 at 11:38 AM observation of the doors to the dumb waiters in room m4494e did not reveal any rating for the doors. On 09/30/15 at 11:38 AM in an interview, Staff QQ confirmed the finding.

i) On 09/30/15 at 11:55 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft near utility room 4450 and opposite data room 4445f revealed a four inch sleeve holding fiber optic snorkel tubing with space between it and the snorkel tubing. On 09/30/15 at 11:55 AM in an interview, Staff QQ confirmed the finding.

j) On 09/30/15 at 11:59 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft next to room 4448 revealed two one inch corrugated conduits with annular spaces, as seen from the hallway. On 09/30/15 at 11:59 AM in an interview, Staff QQ confirmed the finding.

k) On 09/30/15 at 1:08 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft near room 4468 revealed a conduit traveling from the barrier to a junction box that had red wires traveling from an open knock out. On 09/30/15 at 1:08 PM in an interview, Staff QQ confirmed the finding.

5. On 09/30/15 at 10:41 AM a tour was taken of the ground floor trash and linen chute room with Staff QQ, RR, and MM.

a) On 09/30/15 at 10:41 AM room mg441 was observed to contain the terminus of a chute. The chute door was observed to have latching hardware that did not latch the door when it was tested. On 09/30/15 at 10:41 AM in an interview, Staff QQ confirmed the finding.

b) On 09/30/15 at 10:48 AM room g103 was observed to contain the terminus of a chute. Observation to the door of the chute did not reveal any rating. On 09/30/15 at 10:48 AM in an interview, Staff QQ confirmed the finding.

6. On 09/30/15 at 1:35 PM a tour was conducted of the third floor of the main building with Staff QQ, RR, and MM.

a) On 09/30/15 at 1:50 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft across from elevator 5f revealed an open conduit holding red wires. On 09/30/15 at 1:50 PM in an interview, Staff QQ confirmed the finding.

b) On 09/30/15 at 2:02 PM observation of room 3423 revealed the room contained dumbwaiters. Observation of the doors to the dumbwaiters did not reveal any ratings for the doors. On 09/30/15 at 2:02 PM in an interview, Staff QQ confirmed the finding.

c) On 09/30/15 at 2:08 PM observation of galley room 3415 revealed the room contained dumbwaiters. Observation of the doors to the dumbwaiters did not reveal any ratings for the doors. On 09/30/15 at 2:08 PM in an interview, Staff QQ confirmed the finding.

d) On 09/30/15 at 2:16 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft by the fire extinguisher at the nursing station and across from data room 3407g revealed a penetration on top of yellow wiring traveling through the barrier. On 09/30/15 at 2:16 PM in an interview, Staff QQ confirmed the finding.

e) On 09/30/15 at 2:25 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft by soiled utility room m3404 revealed two smooth conduits with a180 degree annular space above them. On 09/30/15 at 2:25 PM in an interview, Staff QQ confirmed the finding.

f) On 09/30/15 at 3:14 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft west of conference room 3427 revealed a conduit holding a gray wire and having a 180 degree annular space. On 09/30/15 at 3:14 PM in an interview, Staff QQ confirmed the finding.

g) On 09/30/15 at 4:03 PM observation of the dumb waiters in room m3438 revealed the doors did not have a rating. On 09/30/15 at 4:03 PM in an interview, Staff QQ confirmed the finding.

h) On 09/30/15 at 4:14 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft by room 3322 revealed a half inch conduit open to air. On 09/30/15 at 4:14 PM in an interview, Staff QQ confirmed the finding.

7. On 09/30/15 at 4:27 PM and on 10/01/15 at 8:15 AM a tour was conducted of the second floor of the main building with Staff QQ, RR, and MM.

a) On 09/30/15 at 4:41 PM observation of room m2445 revealed the room had a shaft within with an access panel. Observation of the panel revealed it had latches but the door was observed to be unclosed, unlatched, and unattended. Observation within the shaft itself revealed nine yellow, "caution wet floor" signs were stored within. On 09/30/15 at 4:41 PM in an interview, Staff QQ confirmed the finding.

b) On 09/30/15 at 4:44 PM observation of the shaft across from room 2466 (histology) revealed the shaft had an access panel door that was unrated. On 09/30/15 at 4:44 PM in an interview, Staff QQ confirmed the finding.

c) On 09/30/15 at 5:03 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft next to room m2490 revealed an annular space around a tube system tube. On 09/30/15 at 5:03 PM in an interview, Staff QQ confirmed the finding.

d) On 09/30/15 at 5:06 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft by break room 2489 revealed an open copper-colored line. On 09/30/15 at 5:06 PM in an interview, Staff QQ confirmed the finding.

e) On 10/01/15 at 9:02 AM the shaft in room m2495c was observed to have an access door. The door was observed to have latched but was observed unclosed, unlatched, and unattended. Observation of the two hour rated construction protecting the shaft revealed a tourqouis snorkel tube to have an annular space. On 10/01/15 at 9:02 AM in an interview, Staff QQ confirmed the findings.

f) On 10/01/15 at 9:34 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft by bathroom 2381 revealed two black wires through a one inch penetration in the barrier. On 10/01/15 at 9:34 AM in an interview, Staff QQ confirmed the finding.

g) On 10/01/15 at 9:36 AM observation of the access door to the shaft opposite room m2223 revealed the door did not have a rating. On 10/01/15 at 9:36 AM in an interview, Staff QQ confirmed the finding.

8. On 10/01/15 at 11:35 AM a tour was taken of the main kitchen with Staff QQ, RR, and MM.

a) On 10/01/15 at 11:35 AM observation of the doors to the dumb waiters on the clean side of the kitchen revealed they did not have a rating. On 10/01/15 at 11:35 AM in an interview, Staff QQ confirmed the finding.

9. On 10/01/15 at 1:25 PM a tour was taken of five west in the northwest wing with Staff QQ, RR, and MM.

a) On 10/01/15 at 1:25 PM the linen chute door was observed to be unrated. On 10/01/15 at 1:25 PM in an interview, Staff QQ confirmed the finding.

b) On 10/01/15 at 1:45 PM a tour was taken of the fourth floor of the northwest wing with Staff QQ, RR, and MM. On 10/01/15 at 2:26 PM observation of the two hour rated construction protecting a shaft in conference room one revealed three conduits with annular spaces and one with an open end holding a red wire. On 10/01/15 at 2:26 PM in an interview, Staff QQ confirmed the finding.

c. On 10/02/15 at 2:03 PM a tour was taken of the fifth floor of the northeast wing with Staff QQ, RR, and MM. On 10/02/15 at 2:12 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft by rooms 5582 and 5580 revealed an open conduit with a white tip. On 10/02/15 at 2:12 PM in an interview, Staff QQ confirmed the finding.


31007

10. During tour of the Southwest addition completed on 10/06/15 the following findings were noted.

a) Observation above the drop ceiling on the 7th floor in corridor SW7031 revealed a 6 inch water pipe penetrating the West wall of elevator shaft SW-F-1 with open annular space. This finding was confirmed by Staff CC at 1:20 PM.

b) Observation on the 7th floor in the Mechanical space 7570 revealed 3 1/2 inch by 2 inch hole at the deck in the north wall between the Mechanical space and the stairwell. This finding was confirmed by Staff CC at 9:45 AM.

d) Observation above the drop ceiling on the 7th floor in the Equipment storage area 7025 revealed multiple conduits with open space and non-rated yellow foam around the conduits penetrating the North wall to Stair #3. This finding was confirmed by Staff CC at 10:11 AM.

e) Observation above the drop ceiling on the 2nd floor in Office 2004 revealed the West Wall of Stair SE20W was not sealed at the deck above and a 1 inch blue conduit with blue data cables open on the end and with open annular space. These findings were confirmed by Staff BB at 10:34 AM.

f) Observation above the drop ceiling on the 2nd floor in the sterile corridor SW2137 revealed multiple penetrations in the West and South wall of the vertical shaft filled with a yellow non-rated foam. These findings were confirmed by Staff BB at 12:00 PM.

g) Observation above the drop ceiling on the 1st floor in the restroom 1148 revealed 1 inch and a 2 inch holes in the North 2 hour wall in room 1148, to the vertical shaft. These findings were confirmed by Staff BB at 2:20 PM.

Based on Life Safety Plan review, observation, and staff interview the facility failed to maintain the 2 hour construction around vertical openings. This has the potential to affect all patients and visitors in the facility. The facility census was 569.

Findings include:

During the tour of the Southeast Tower completed on 10/01/15 between the hours of 8:00 AM and 4:30 PM and on 10/02/15 between the hours of 6:55 AM and 1:30 PM the following findings were noted:

a) Observation of the elevator shafts T-01 and T-02 on the 11th floor revealed multiple penetrations varying in size above the elevator doors. These findings were confirmed by Staff BB at 8:50 AM.

b) Observation above the drop ceiling on the 9th floor in corridor SE9139 North wall to elevator shaft T-08 revealed a 3/4 inch red conduit with red data cables passing through, open on the end, and not sealed at the deck. These findings were confirmed by Staff BB at 9:30 AM.

c) Observation above the drop ceiling on the 7th floor in corridor SE7140's East wall revealed a 3/4 inch conduit with yellow and orange data cables passing through, at the deck, with an open annular space. This finding was confirmed by Staff BB at 2:00 PM.

d) Observation above the drop ceiling on the 6th floor in conference room SE6117 revealed a 3/4 inch blue conduit with blue data cables, open on the end, penetrating Stair-W's East wall. This finding was confirmed by Staff BB at 2:30 PM.

e) Observation in Stair-E on the 6th floor revealed a 3/4 inch copper pipe above the door with an open space. This finding was confirmed by Staff BB at 3:00 PM.

f) Observation above the drop ceiling on the 4th floor in conference room SE4117 revealed two 1/2 inch holes in the West wall of elevator shaft T-08 and not sealed around the steal beams in the East wall for Stair-W. These findings were confirmed by Staff BB at 3:40 PM.

g) Observation above the drop ceiling on the 2nd floor in corridor SE2090.1 above the double doors to Stair-C revealed a 1/2 inch by 1 1/2 inch hole with electrical wire passing through. This finding was confirmed by Staff BB at 7:20 AM.

h) Observation above the drop ceiling on the 2nd floor in Education Office 2028 revealed the 2 hour wall was not sealed at the deck above or the West and South walls. These findings were confirmed by Staff BB at 7:25 AM.

i) Observation above the drop ceiling on the 1st floor in the patient corridor across from room SE1204 revealed a 2 inch sprinkler pipe with an open space penetrating the South two hour wall of elevator shaft T-10. This finding was confirmed by Staff BB at 8:56 AM.

j) Observation above the drop ceiling on the 1st floor in corridor SE1110 revealed a 3/4 inch conduit with green data cables passing through above the exit access to door to stair-E. This finding was confirmed by Staff BB at 10:00 AM.

k) Observation above the drop ceiling in Soiled utility room SE1124 revealed two 3/4 inch conduits with open ends and open annular space in Stair-E South wall. This findings was confirmed by Staff BB at 10:00 AM.

l) Observation above the drop ceiling in corridor SEG140 across from elevator shaft T-06 revealed a 3/4 inch conduit open on the end in the North wall of the vertical shaft. This finding was confirmed by Staff BB at 11:00 AM.

Based on observation and interview, the facility failed to ensure access to exits were marked by approved, readily visible signs. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

1. On 09/29/15 at 8:36 AM a tour of the sixth floor of the main hospital was conducted with Staff QQ, MM, and TT. At 1:29 PM observation of the evacuation plan located at the nursing station on 6w/sw revealed the plan directed occupants to turn left at the nursing station and head toward the northwest wing building. An exit sign at the nursing station providing direction to this path of egress was not observed. On 09/29/15 at 1:29 PM in an interview, Staff QQ confirmed the finding.

2. On 10/01/15 at 1:45 PM a tour was taken of the fourth floor of the northwest wing with Staff QQ, RR, and MM. At 2:46 PM the therapy room nw4292 was observed from within the patient care area. The observation revealed on the corridor side of the room, there were five doors, two of which accessed the corridor. However, an exit sign showing the way out to the corridor was not obvious. On 10/01/15 at 2:46 PM in an interview, Staff QQ confirmed the finding.

Based on observation and interview, the facility failed to maintain the ratings of the protective construction in each of its smoke barriers. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

1. On 09/28/15 at 1:50 PM a tour was taken of the seventh floor of the main building with Staff QQ and MM.

a) Observation above the drop down ceiling of the two hour barrier along the south wall of office sw7026 revealed a half inch open conduit. On 09/28/15 at 3:15 PM in an interview, Staff QQ confirmed the finding.

b) On 09/28/15 at 3:21 PM observation of double doors sw7027b in a two hour rated barrier did not reveal a rating on either door. On 09/28/15 at 3:21 PM in an interview, Staff QQ confirmed the finding.

2. On 09/28/15 at 3:31 PM and on 09/29/15 at 8:36 AM a tour was taken of the sixth floor of the main building with Staff QQ and MM.

a) On 09/28/15 at 3:46 PM observation above the drop down ceiling near the door of and seen within the bed storage room revealed in a one hour smoke barrier a half inch by one inch opening located on top of a heating, ventilation and cooling line. On 09/28/15 at 3:46 PM in an interview, Staff QQ confirmed the finding.

b) On 09/29/15 at 10:50 AM observation above the drop down ceiling of the one hour smoke rated barrier in the bed storage room on six west and seen from within and to the right of the door, revealed two red and one gray wire in an open one inch hole. On 09/29/15 at 10:50 AM in an interview, Staff QQ confirmed the finding.

c) On 09/29/15 at 11:40 AM observation above the drop down ceiling over the double doors in the two hour rated barrier located at the six northwest connector revealed a two inch open sleeve. On 09/29/15 at 11:40 AM in an interview, Staff QQ confirmed the finding.

d) On 09/29/15 at 1:18 PM observation above the drop down ceiling of the one hour rated barrier over the double doors between the main building and the southwest development building revealed an open two inch conduit holding yellow/green optic fiber. On 09/29/15 at 1:18 PM, in an interview, Staff QQ confirmed the finding.

3. On 09/29/15 at 1:35 PM a tour was conducted of the fifth floor of the main building with Staff QQ, RR, and MM.

a) On 09/29/15 at 2:59 PM observation above the drop down ceiling of the one hour rated wall on the east side of the medical director's office revealed an open junction box with conduits traveling to the wall. On 09/29/15 at 2:59 PM in an interview, Staff QQ confirmed the finding.

4. On 09/29/15 at 8:34 AM a tour was conducted of the fourth floor main building with Staff QQ, RR, and MM.

a) On 09/29/15 at 8:37 AM observation above the drop down ceiling of the near the bank of service elevators revealed a broken snorkel tube which traveled through a one hour rated smoke barrier over double doors perpendicular to stair 3. On 09/29/15 at 8:37 AM in an interview, Staff QQ confirmed the finding.

b) On 09/29/15 at 8:59 AM observation of the one hour barrier over the double doors perpendicular to the physician dictation room and between the main and northwest building, revealed a fire alarm junction box with a missing knock out. On 09/29/15 at 8:59 AM in an interview, Staff QQ confirmed the finding.

c) On 09/29/15 at 9:14 AM observation of the one hour barrier by the television in the waiting area opposite the bank of public elevators revealed an open junction box. On 09/29/15 at 9:14 AM in an interview, Staff QQ confirmed the finding.

d) On 09/30/15 at 12:58 PM observation above the drop down ceiling of the one hour barrier over the double doors perpendicular room 4455 revealed a two inch hole. On 09/30/15 at 12:58 PM in an interview, Staff QQ confirmed the finding.

e) On 09/30/15 at 1:20 PM observation above the drop down ceiling of the one hour barrier in room 4443, by the window, revealed a one inch conduit with an annular space. On 09/30/15 at 1:20 PM in an interview, Staff QQ confirmed the finding.

f) On 09/30/15 at 1:30 PM observation above the drop down ceiling of the one hour rated barrier inside room 4444 revealed a half inch open conduit holding green wires. On 09/30/15 at 1:30 PM in an interview, Staff QQ confirmed the finding.

5. On 09/30/15 at 1:35 PM a tour was conducted of the third floor of the main building with Staff QQ, RR, and MM.
a) On 09/30/15 at 1:45 PM observation of the one hour barrier perpendicular to stair 3 and located in a locker room, revealed a small conduit with an annular space filled with unrated yellow foam. On 09/30/15 at 1:45 PM in an interview, Staff QQ confirmed the finding.

b) On 09/30/15 at 2:55 PM observation above the drop down ceiling of the one hour rated barrier between patient rooms 3342 and 3344 revealed a 180 degree annular space around medical gas lines. On 09/30/15 at 2:55 PM in an interview, Staff QQ confirmed the finding.

c) On 09/30/15 at 3:22 PM observation of the one hour smoke barrier above the double door perpendicular to the public elevator bank revealed a one inch penetration. On 09/30/15 at 3:22 PM in an interview, Staff QQ confirmed the finding.

d) On 09/30/15 at 3:27 PM observation above the drop down ceiling of the one hour barrier in the waiting area perpendicular to the public elevators revealed, by the television, an open one foot by one foot junction box that had been dry walled around. On 09/30/15 at 3:27 PM in an interview, Staff QQ confirmed the finding.

6. On 10/01/15 at 8:15 AM a tour was conducted of the second floor with Staff QQ, RR, and MM.

a) On 10/01/15 at 9:35 AM observation above the drop down ceiling of the one hour barrier in the east wall of room 2511 revealed one layer of drywall was missing at the heating, ventilation and cooling duct and at the ceiling arcs. On 10/01/15 at 9:35 AM in an interview, Staff QQ confirmed the finding.

b) On 10/01/15 at 9:40 AM observation above the drop down ceiling of the two hour rated barrier just west of alcove 2227a revealed a two inch by two inch square cut into the wall. On 10/01/15 at 9:40 AM in an interview, Staff QQ confirmed the finding.

c) On 10/01/15 at 10:00 AM observation above the drop down ceiling of the two hour barrier opposite the oxygen refill station revealed penetrations created by two corrugated conduits. On 10/01/15 at 10:00 AM in an interview, Staff QQ confirmed the finding.

d) On 10/01/15 at 10:54 AM observation above the drop down ceiling of the one hour rated barrier in the eye exam room in the opthomology services area revealed a one inch hole in the drywall. On 10/01/15 at 10:54 AM in an interview, Staff RR confirmed the finding.

7. On 10/01/15 at 11:04 AM a tour was taken of the first floor of the main building with Staff QQ, RR, and MM.

a) On 10/01/15 at 11:04 AM observation above the drop down ceiling of the two hour rated wall that separated the corridor from room 1636a and opposite the valley café, revealed an open one inch conduit holding a red wire. On 10/01/15 at 11:04 AM in an interview, Staff RR confirmed the finding.

b) On 10/01/15 at 11:08 AM observation above the drop down ceiling of the two hour barrier just west of the main entrance revealed a one foot by one foot square opening cut into the barrier. On 10/01/15 at 11:08 am in an interview, Staff RR confirmed the finding.

c) On 10/01/15 at 11:13 AM observation of the double doors perpendicular to the single door to the valley café and west of the main entrance, and located within a two hour barrier, revealed the doors had self closing and latching hardware that did not close and latch the doors. On 10/01/15 at 11:13 AM in an interview, Staff QQ confirmed the finding.

d) On 10/01/15 at 11:15 AM observation of the single door to the back-end of the valley café and opposite lounge 1353, and located within a two hour barrier, revealed the door did not have a rating. On 10/01/15 at 11:15 AM in an interview, Staff QQ confirmed the finding.

8. On 10/01/15 at 1:25 PM a tour was taken of five west in the northwest wing with Staff QQ, RR, and MM.

a) On 10/01/15 at 1:27 PM observation above the drop down ceiling of the two hour barrier over the doors perpendicular to room nw5226a revealed an open two inch conduit holding a yellow wire, and a turquoise snorkel tube open to air. On 10/01/15 at 1:27 PM in an interview, Staff QQ confirmed the finding.

9. On 10/01/15 at 1:45 PM a tour was taken of the fourth floor of the northwest wing with Staff QQ, RR, and MM.

a) On 10/01/15 at 2:22 PM a white snorkel tube was observed open in data closet 4234a and traveling through the one hour smoke barrier. On 10/01/15 at 2:22 PM in an interview, Staff QQ confirmed the finding.

10. On 10/01/15 at 3:06 PM a tour was taken of the third floor of the northwest wing with Staff QQ, RR, and MM.

a) On 10/01/15 at 3:33 PM observation above the drop down ceiling of the one hour barrier at soiled utility room 3214 revealed an annular space within the ductwork collar that measured one by four inches. On 10/01/15 at 3:33 PM in an interview, Staff QQ confirmed the finding.

b) On 10/01/15 at 3:55 PM observation above the drop down ceiling of the one hour barrier over the south door to room nw3280d revealed a half inch circular opening in the drywall, near a sticker that read, "all penetrations must be fire caulked." On 10/01/15 at 3:55 PM in an interview, Staff QQ confirmed the finding.

11. On 10/01/15 at 4:26 PM a tour was taken of the second floor of the northwest wing with Staff QQ, RR, and MM.

a) On 10/01/15 at 4:26 PM observation of one hour rated construction protecting room nw2292b revealed a six by six inch square cut into the drywall, 180 degrees from the door to the room. On 10/02/15 at 9:00 AM a tour was taken of the second floor of the northwest wing with Staff QQ, RR, and MM.

b) On 10/02/15 at 9:21 AM observation above the drop down ceiling of the one hour barrier perpendicular to room nw2297 revealed an open four inch sleeve holding multiple blue wires. On 10/02/15 at 9:21 AM in an interview, Staff QQ confirmed the finding.

12. On 10/02/15 at 10:19 AM a tour was taken of the first floor of the northwest wing with Staff QQ, RR, and MM.

a) On 10/02/15 at 10:38 AM observation above the drop down ceiling of the one hour barrier on the perimeter of dressing area nw1313 revealed at the west wall an open conduit with a white tip holding gray wires and an open corrugated conduit lying on top of a tile and traced back and through the barrier. On 10/02/15 at 10:38 AM in an interview, Staff QQ confirmed the finding.

b) On 10/02/15 at 11:02 AM observation of the one hour barrier in the southwest corner of room nw1331 revealed an annular space a drain line. On 10/02/15 at 11:02 AM in an interview, Staff QQ confirmed the finding.

c) On 10/02/15 at 11:05 AM observation above the drop down ceiling of the one hour rated barrier between rooms nw1328 and nw1327 revealed a six inch by six inch square cut into the drywall. On 10/02/15 at 11:05 AM in an interview, Staff QQ confirmed the finding.

13. On 10/06/15 at 8:35 AM a tour was conducted of the third floor of the northeast wing with Staff QQ, RR, and MM.

a) On 10/06/15 at 8:55 AM observation above the drop down ceiling of the two hour barrier over the double doors leading to corridor nw3287 revealed an open snorkel tube holding a gray wire. On 10/06/15 at 8:55 AM in an interview, Staff QQ confirmed the finding.

14. On 10/06/15 at 9:01 AM a tour was taken of the sixth floor of the southwest development project building with Staff QQ, RR, and MM.

a) On 10/06/15 at 9:12 AM observation above the drop down ceiling of the one hour barrier in the waiting area by elevator lobby F, and over the fire strobe revealed a one inch penetration in the drywall holding two white wires and one red wire. On 10/06/15 at 9:12 AM in an interview, Staff QQ confirmed the finding.

b) On 10/06/15 at 10:44 AM observation above the drop down ceiling of the two hour rated barrier over the door to room sw6588 revealed an open, four inch sleeve through the barrier. On 10/06/15 at 10:44 AM in an interview, Staff QQ confirmed the finding.

15. On 10/06/15 at 10:56 AM a tour was taken of the fourth floor of the southwest development building with Staff QQ, RR, and MM.

a) On 10/06/15 at 11:18 AM observation above the drop down ceiling of the one hour barrier on the perimeter of soiled utility room sw4564 revealed at the south wall in the dry wall an open one inch hole holding a green wire. On 10/06/15 at 11:18 AM in an interview, Staff QQ confirmed the finding.



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16. During tour of the Southwest addition completed on 10/06/15 the following findings were noted.

a) Observation above the drop ceiling on the 6th floor in corridor SW7570 revealed 1 inch by 2 inch hole at the deck in the East smoke barrier wall of the corridor outside group room SW7568. This finding was confirmed by Staff BB at 9:40 AM.

b) Observation above the drop ceiling on the 6th floor in the equipment room 7025 revealed seams not sealed and not sealed at the deck above in the Southeast corner smoke barrier wall. These findings were confirmed by Staff BB at 10:11 AM.

c) Observation above the drop ceiling on the 2nd floor above the double doors leading from the elevator lobby SW2000A revealed the smoke barrier wall not sealed at the deck above and a 3/4 inch conduit open on the end. These findings were confirmed by Staff BB at 10:25 AM.

d) Observation above the drop ceiling on the 2nd floor in corridor SW2000 revealed a 12 inch space covered with clear plastic running the entire length of the East corridor smoke barrier wall. This finding was verified by Staff BB and Staff CC at 10:34 AM.

e) Observation above the drop ceiling on the 2nd floor over the double doors between corridors SW2003 and SW2004B revealed a 3 inch conduit open on the end with data cables on both sides of the double doors in the smoke barrier. This finding was confirmed by Staff BB and Staff CC at 10:42 AM.

f) Observation above the drop ceiling on the 2nd floor in corridor SW2060 above the double doors on the Pre-operative side revealed 2 inch conduit with green data cables open on the end. This finding was confirmed by Staff BB at 10:50 AM.

g) Observation above the drop ceiling on the 2nd floor in corridor SW2087 above the single south door on the Pre-operative side revealed a penetration with green data cables with open annular space. This finding was confirmed by Staff CC at 10:55 AM.

h) Observation above the drop ceiling on the 2nd floor in the sterile corridor SW2146 revealed multiple penetrations and holes varying in size and shape in the smoke wall above the Control room 2122 to OR #5. These findings were confirmed by Staff CC at 11:45 AM.

i) Observation above the drop ceiling on the 1st floor in the physician dictation area SW1236 between exam bays 42 and 44 revealed 1 1/2 inch hole above the door. This finding was confirmed by Staff CC at 1:45 PM

j) Observation above the drop ceiling on the 1st floor above the double doors in corridor SW1189 by the door to the Soiled Utility room 1275 revealed three 3/4 inch holes. These findings were confirmed by Staff BB at 1:50 PM.

k) Observation above the drop ceiling on the 1st floor above the double doors where corridors SW1189 and SW1247 meet revealed a 2 inch hole with a 1/2 inch conduit penetrating the smoke barrier. This finding was confirmed by Staff BB at 1:57 PM.

l) Observation above the drop ceiling on the 1st floor in corridor SW1189 revealed 1/2 inch green conduit with open annular space in the wall between the corridor and the Soiled Utility Room 1275. This finding was confirmed by Staff BB at 2:00 PM.

m) Observation above the drop ceiling on the 1st floor in the restroom 1148 revealed multiple penetrations of the South restroom smoke barrier rated wall above the door. These findings were confirmed by Staff BB at 2:20 PM.

n) Observation above the drop ceiling on both sides of the double doors between corridors SW1061 and SW1024 revealed a large rectangular hole with multiple data cable not sealed with a fire rated material on both sides of double doors. These findings were confirmed by Staff CC at 2:30 PM.



o) During the tour of the facility on 10/01/15 at 11:40 AM above the drop ceiling from inside the Staff lounge on the first floor west wing B1246 was found three penetrations through the two hour fire wall. One, two inch diameter hole with nothing passing through, and two, one inch holes just to the left of the entrance doorway. This was confirmed by Staff VV and WW at the time of discovery.
p) Additionally, at 11:55 AM on 10/01/15 from the corridor side above the doorway leading to the receptionist desk B1200A a penetration through the two hour wall was found one inch hole with nothing passing through. This was confirmed by Staff VV and WW at the time of discovery.
q) During the tour of the second floor west wing above the drop ceiling and over the doorway B2270A was found a four inch square metal box with a black and red wire passing through and a white wire passing outside the box. The cover was not attached covering the box. This was confirmed by Staff VV and WW at the time of discovery.
r) At 2:16 PM on 10/01/15 on the corridor side of the two hour fire wall outside the physician lounge just left of the entrance doorway was found a four inch square metal box with wire passing through the box that did not have a cover closing the box. This was confirmed by Staff VV and WW at the time of discovery.
s) At 2:30 PM on 10/01/15 to the left of the doorway at B2091 above the drop ceiling was found a four inch square metal box with a single white wire inside with the cover missing. This was confirmed by Staff VV and WW at the time of discovery.

Based on Life Safety Plan review, observation, and staff interview the facility failed to maintain the integrity of the fire rated smoke walls. This has the potential to affect all patients and visitors in the facility. The facility census was 569.

Findings include:

During the tour of the Southeast Tower completed on 10/02/15 between the hours of 6:55 AM and 1:30 PM and the following findings were noted.

a) Observation above the drop ceiling on the 2nd floor where Corridor SE2040 and corridor SE2201 meet revealed a 3/4 inch conduit open on the end in the East side of the double doors and a large open area at the left corner on the West side of the double doors. These findings were confirmed by Staff BB and Staff CC at 7:55 AM.

b) Observation above the drop ceiling on the 2nd floor above the double doors in corridor SE2190 revealed a 2 foot duct with open space on both sides of the double doors. These findings were confirmed by Staff BB and Staff CC at 8:00 AM.

c) Observation above the drop ceiling on the 1st floor in corridor SE1115 revealed two 1 inch holes above the double doors to the Heart Lobby area SE1147. This finding was confirmed by Staff CC at 10:00 AM.

d) Observation above the drop ceiling on the 1st floor in room 1164 revealed a 3/4 inch conduit with blue data cables penetrating the West wall open on the end. This finding was confirmed by Staff BB at 10:03 AM.

e) Observation above the drop ceiling on the 1st floor in heart registration room 1165 revealed a 1/2 inch hole with yellow data cables above the door in the West wall above the door leading to the waiting area SE1169. This finding was confirmed by Staff CC at 10:07 AM.

Based on observation and interview, the facility failed to ensure that doors in barriers with self closing and latching hardware closed and latched the doors, that the doors were rated, and that double doors closed such that one did not keep the other from closing. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

1. On 09/29/15 at 1:35 PM a tour was conducted of the fifth floor of the main building with Staff QQ, RR, and MM.

a) On 09/29/15 at 3:35 PM observation of the corridor door in the one hour rated barrier in room 5594, revealed the door had self closing and latching hardware that did not self close and latch. On 09/29/15 at 3:35 PM in an interview, Staff QQ confirmed the finding.

2. On 10/01/15 at 8:15 AM a tour was conducted of the second floor with Staff QQ, RR, and MM.

a) On 10/01/15 at 9:29 AM observation of the one hour barrier along the double door to room m2222 revealed when the two doors closed, there wasn't a functioning coordinator to ensure they closed in such a way one door didn't prevent the other from closing. On 10/01/15 at 9:29 am in an interview, Staff QQ confirmed the finding.

b) On 10/01/15 at 9:38 AM observation of the one hour barrier along the double door to room m2224 revealed when the two doors closed, there wasn't a functioning coordinator to ensure they closed in such a way one door didn't prevent the other from closing. On 10/01/15 at 9:38 AM in an interview, Staff QQ confirmed the finding.

c) On 10/01/15 at 10:00 AM observation of the door at room m2201 and in the one hour rated barrier revealed it had a self closer with latching hardware that did not close and latch the door. On 10/01/15 at 10:00 AM in an interview, Staff QQ confirmed the finding.

3. On 10/01/15 at 11:04 AM a tour was taken of the first floor of the main building with Staff QQ, RR, and MM.

a) On 10/01/15 at 11:11 AM observation of the single door to the valley café and west of the main entrance, revealed it was located within a two hour barrier, but was not rated. On 10/01/15 at 11:11 AM in an interview, Staff QQ confirmed the finding.

4. On 10/01/15 at 1:45 PM a tour was taken of the fourth floor of the northwest wing with Staff QQ, RR, and MM.

a) On 10/01/15 at 2:15 PM the door to the educator room was observed to be in a one hour barrier and with a self closer and latching hardware that did not close and latch the door. On 10/01/15 at 2:15 PM in an interview, Staff QQ confirmed the finding.

b) On 10/01/15 at 2:36 PM observation of the door in the one hour rated barrier perpendicular to office 4269 did not reveal a rating. On 10/01/15 at 2:36 PM in an interview, Staff QQ confirmed the finding.

5. On 10/02/15 at 10:19 AM a tour was taken of the first floor of the northwest wing with Staff QQ, RR, and MM.

a) On 10/02/15 at 10:20 AM observation of the double doors to family waiting area nw1356 and in the one hour barrier revealed when the two doors closed, there wasn't a functioning coordinator to ensure they closed in such a way one door didn't prevent the other from closing. On 10/02/15 at 10:20 AM in an interview, Staff QQ confirmed the finding.

b) On 10/02/15 at 10:35 AM the door protecting room nw1317 from the corridor and located in a one hour smoke barrier revealed it had self closing and latching hardware that did not self close and latch. On 10/02/15 at 10:35 AM in an interview, Staff QQ confirmed the finding.

c) On 10/02/15 at 10:52 AM observation of the double doors in the two hour barrier in room m1426 revealed when the two doors closed, there wasn't a functioning coordinator to ensure they closed in such a way one door didn't prevent the other from closing. On 10/02/15 at 10:52 AM in an interview, Staff QQ confirmed the finding.

d) On 10/02/15 at 11:30 AM observation of the double doors in the one hour barrier in trash room 1379 revealed when the two doors closed, there wasn't a functioning coordinator to ensure they closed in such a way one door didn't prevent the other from closing. On 10/02/15 at 11:30 AM in an interview, Staff QQ confirmed the finding.

e) On 10/02/15 at 12:03 PM observation of the double doors in the two hour rated barrier between the power room and the chute room revealed when the two doors closed, there wasn't a functioning coordinator to ensure they closed in such a way one door didn't prevent the other from closing. On 10/02/15 at 12:03 PM in an interview, Staff QQ confirmed the finding.

f) On 10/02/15 at 1:28 PM observation of the door to the comprehensive outpatient rehabilitation program waiting area and in a two hour barrier revealed the door had a rating of 20 minutes. On 10/02/15 at 1:28 PM in an interview, Staff QQ confirmed the finding.

6. On 10/06/15 at 8:35 AM a tour was conducted of the third floor of the northeast wing with Staff QQ, RR, and MM.

a) On 10/06/15 at 8:50 AM observation of the door to clean equipment room m3467c revealed it to be in a one hour barrier and unrated. On 10/06/15 at 8:50 AM in an interview, Staff QQ confirmed the finding.

7. On 10/06/15 at 9:01 AM a tour was taken of the sixth floor of the southwest development project building with Staff QQ, RR, and MM.

a) On 10/06/15 at 10:03 AM observation of the door protecting the oxygen refill room (sw6579a) revealed it had self closing and latching hardware that did not self close and latch. On 10/06/15 at 10:03 AM in an interview, Staff QQ confirmed the finding.

b) On 10/06/15 at 10:07 AM observation of the door in the one hour rated construction in the clean utility room (sw6606) revealed it was unrated. On 10/06/15 at 10:07 AM in an interview, Staff QQ confirmed the finding.

c) On 10/06/15 at 10:27 AM observation of the double doors to bed parking room 6594 and in a one hour barrier revealed when the two doors closed, there wasn't a functioning coordinator to ensure they closed in such a way one door didn't prevent the other from closing.



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8. Observation of the double smoke doors on the 2nd floor of the Southwest addition in the Elevator lobby area revealed the door on the Left did not close to a latching position when tested two times. This finding was confirmed by Staff BB and Staff CC at 10:30 AM.

Based on observation and interview, the facility failed to ensure each of its sprinklered, hazardous areas were able to resist the passage of smoke. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

On 09/30/15 at 10:41 AM a tour was taken of the ground floor trash and linen chute rooms with Staff QQ, RR, and MM. At 10:53 AM observation of the double doors enclosing the linen supply room revealed a quarter inch gap between the doors at the latch. On 09/30/15 at 10:53 AM in an interview, Staff QQ confirmed the finding.

Based on review of Life Safety Plans, observation, and staff confirmation the facility failed to ensure the walls were constructed of at least a 1 hour protection rating around hazardous areas, and doors in hazardous areas closed to a latching position. This has the potential to affect all patients and visitors in the facility.

Findings include:

1. Tour of the "Bed Tower" was conducted on 09/29/15 between the hours of 8:00 AM and 4:30 PM. Observation above the drop ceiling in the Clean Utility room on the 2nd floor revealed a half inch hole above the entry door. This finding was confirmed by Staff AA at 2:30 PM.

2. Tour of the "DT Building" was conducted on 09/30/15 between the hours of 7:45 AM and 12:00 PM. Observation in Data room 2214A in the OR sterile area revealed a 3 1/2 X 2 inch hole approximately 4 1/2 feet off of the ground in the 1 hour south wall between the Data room and equipment storage 2410. This finding was confirmed by Staff AA at 8:30 AM.

3. Observation of the door to the Supply room 273 from the sterile corridor C28 was tested and revealed the door did not close due to hitting the door frame, the bottom hinge appeared to be bent. This finding was confirmed by Staff AA at 8:40 AM.

4. Observation above the drop ceiling in Equipment room 2414 located between the OR's revealed multiple penetrations and holes varying in size and shape in the North wall and a 6 inch conduit with open end on the South wall. These findings were confirmed by Staff AA at 8:40 AM.

5. Observation above the drop ceiling in Sterile supply 2087 revealed a 3/4 inch conduit with 2 data cables passing through open on the end in the West wall of the room. This finding was confirmed by Staff AA at 8:47 AM.

6. Observation above the drop ceiling in the ATA work area 1731A revealed a 2 inch sprinkler pipe penetrating the 1 hour West and South Walls with an nonrated white material sealing the penetrations. These findings were confirmed by Staff AA at 9:55 AM.

7. Observation above the drop ceiling in Supply Room 1844 revealed multiple penetrations and holes varying in size and shape on all 4 walls. These findings were confirmed by Staff AA at 10:15 AM.

Based on review of Life Safety Plans, observation, and staff confirmation the facility failed to ensure the walls were constructed of at least a 1 hour protection rating around hazardous areas. This has the potential to affect all patients and visitors in the facility. The facility census was 569.

Findings include:

During the tour of the Southeast Tower completed on 10/01/15 between the hours of 8:00 AM and 4:30 PM and 10/02/15 between the hours of 6:50 AM and 1:30 PM the following findings were noted:

a) Observation above the drop ceiling on the 9th floor in corridor SE9060 above the door to equipment room 9114 revealed multiple penetrations varying in size and shape. These findings were confirmed by Staff BB at 9:45 AM.

b) Observation above the drop ceiling on the 9th floor in Equipment room 9114 revealed 3/4 inch flex conduits open on the end and a 3/4 inch flex conduit with a 6 inch by 6 inch open space in the column by the door. These finding were confirmed by Staff BB at 9:50 AM.

c) Observation above the drop ceiling on the 9th floor in Equipment room 9137 revealed penetrations unsealed behind the steel column. These findings were confirmed by Staff BB at 10:02 AM.

d) Observation above the drop ceiling on the 9th floor in Corridor SE9110 revealed multiple penetrations varying in size and shape above the door to Clean Utility Room 9136. These findings were confirmed by Staff BB at 10:05 AM.

e) Observation above the drop ceiling on the 9th floor in Clean Utility Room 9136 revealed a 3/4 inch conduit open on the end with a white cable passing through and a 1/4 inch gap above the HVAC duct above the door to the Corridor. These findings were confirmed by Staff BB at 10:07 AM.

f) Observation above the drop ceiling on the 9th floor in Family Waiting area SE9132 revealed a 3/4 inch conduit with blue data cable open on the end penetrating the West wall for electrical room 9134. This finding was confirmed by Staff BB at 10:12 AM.

g) Observation above the drop ceiling on the 8th floor in corridor SE8060 above the door to equipment room 8114 revealed multiple penetrations varying in size and shape. These findings were confirmed by Staff BB at 10:46 AM.

h) Observation above the drop ceiling on the 8th floor in Equipment room 8114 revealed a 3/4 inch flex conduit open on the end and a 6 inch by 6 inch opening around the conduit to the right of the door to the corridor. These findings were confirmed by Staff BB at 10:50 AM.

i) Observation above the drop ceiling on the 8th floor in corridor SE8110 revealed multiple penetrations varying in size and shape above the door to Clean Utility room 8136. These findings were confirmed by Staff BB at 11:00 AM.

j) Observation above the drop ceiling on the 8th floor in equipment room 8137 revealed a 3/4 inch conduit with red data cables passing through open on the end penetrating the round wall above the door. This finding was confirmed by Staff BB at 11:02 AM.

k) Observation in electrical room 7134 on the 7th floor revealed a 3/4 inch conduit open on the end penetrating the South 1 hour wall. This finding was confirmed by Staff BB at 1:13 PM.

l) Observation above the drop ceiling on the 7th floor in corridor SE7000 revealed multiple penetrations above the door to Clean Utility Room 7136. These findings were confirmed by Staff BB at 1:18 PM.

m) Observation above the drop ceiling on the 7th floor in Clean Utility Room 7136 revealed two 3/4 inch flex conduits with data cables open on the ends above the door to the corridor. These findings were confirmed by Staff BB at 1:20 PM.

n) Observation above the drop ceiling on the 7th floor in Equipment Supply Room 7137 revealed a 16 inch hole with 8 inch insulated HVAC duct passing through behind a column in the rounded wall. This finding was confirmed by Staff BB at 1:23 PM.

o) Observation above the drop ceiling on the 7th floor in Equipment Room 7114 revealed a 6 inch hole with 3/4 inch flex conduit passing through and the 3/4 inch flex conduit open on the end. These findings were confirmed by Staff BB at 1:30 PM.

p) Observation above the drop ceiling on the 7th floor in corridor SE7060 revealed multiple penetrations varying in size and shape above the door to Equipment Room 7114. These findings were confirmed by Staff BB at 1:38 PM.

q) Observation above the drop ceiling on the 7th floor in Soiled Utility room 7125 revealed a 4X4 and 5X5 junction box covers inset into the South wall with an open space around both. These findings were confirmed by Staff BB at 1:50 PM.

r) Observation above the drop ceiling on the 6th floor in corridor SE6130 revealed a 6 inch HVAC duct in a 10 inch hole penetrating the 1 hour wall to Oxygen fill station room 6108. This finding was confirmed by Staff BB at 2:25 PM.

s) Observation above the drop ceiling on the 6th floor in Soiled Utility room 6125 revealed a 5X5 junction box cover inset into the South wall with open space around. This finding was confirmed by Staff BB at 2:42 PM.

t) Observation above the drop ceiling on the 6th floor in corridor SE6060 revealed multiple penetrations varying in size and shape above the door to Equipment Room 6114. These findings were confirmed by Staff BB at 2:47 PM.

u) Observation above the drop ceiling on the 6th floor in Equipment Room 6137 revealed a 8 inch by 24 inch open space with multiple conduits passing through behind the steel column. This finding was confirmed by Staff BB at 2:52 PM.

v) Observation above the drop ceiling on the 6th floor in corridor SE6000 revealed a 3 inch sprinkler pipe penetrating the 1 hour wall above the door to the Clean Utility Room 6136 with open annular space. This finding was confirmed by Staff BB at 3:07 PM.

w) Observation above the drop ceiling on the 6th floor in the Clean Utility Room 6136 revealed multiple penetrations and holes varying in size and shape. These findings were confirmed by Staff BB at 3:09 PM.

x) Observation above the drop ceiling in the 6th floor family waiting area SE6132 revealed a 2 inch by 1 inch hole in the East 1 hour wall of Electrical Room 6134 at the deck. This finding was confirmed by Staff BB at 3:12 PM.

y) Observation above the drop ceiling on the 4th floor in corridor SE4130 above Oxygen fill station room 4108 door revealed a 6 inch HVAC duct penetrating the 1 hour wall with open space around the duct. This finding was confirmed by Staff BB at 3:32 PM.

z) Observation above the drop ceiling on the 4th floor in the Soiled Utility Room 4125 revealed a 6 inch by 1 inch space above the sink area. This finding was confirmed by Staff BB at 3:40 PM.

aa) Observation above the drop ceiling on the 4th floor in Equipment room 4114 revealed a 6 inch hole with a 3/4 inch flex conduit open on the end passing through. This finding was confirmed by Staff BB at 3:45 PM.

bb) Observation above the drop ceiling on the 4th floor in the Equipment room 4137 revealed a 2 inch by 10 inch gap between the gypsum board and the steal column and the wall around the column was not capped. These finding were confirmed by Staff BB at 3:55 PM.

cc) Observation above the drop ceiling on the 4th floor in corridor SE4000 revealed a 8 inch round HVAC duct passing through a square hole penetrating the 1 hour round wall to the Clean Utility Room 4136. This finding was confirmed by Staff BB at 4:00 PM.

dd) Observation above the drop ceiling on the 4th floor in the Clean Utility Room 4136 revealed multiple penetrations and holes varying in size and shape above the door to the corridor. These findings were confirmed by Staff BB at 4:02 PM.

ee) Observation above the drop ceiling in 4th floor family waiting 4132 revealed two 3/4 inch conduits with blue and green data cables penetrating the West wall of Electrical room 4125 open on the ends. These findings were confirmed by Staff BB at 4:10 PM.

ff) Observation above the drop ceiling on the 2nd floor in corridor SE2080 revealed a 6 inch HVAC duct penetrating the West 1 hour rated wall for the Soiled Utility room 2127 with open annular space. This finding was confirmed by Staff BB at 7:00 AM.

gg) Observation above the drop ceiling on the 2nd floor in Soiled Utility room 2127 revealed a 6 inch HVAC duct penetrating the West and north walls with open annular space. These findings were confirmed by Staff BB at 7:02 AM.

hh) Observation above the drop ceiling on the 2nd floor in corridor SE2090.3 revealed a 3/4 inch conduit with 3 green data cables penetrating the South Soiled Utility Room 2127 wall open on the end.

ii) Observation above the drop ceiling on the 2nd floor in Equipment Room 2022 revealed a 3/4 inch conduit open on the end penetrating the West wall. This finding was confirmed by Staff BB at 7:10 AM.

jj) Observation above the drop ceiling on the 1st floor in Soiled Utility Room 1124 revealed a 3/4 inch conduit open on the end in the South 1 hour rated wall. This finding was confirmed by Staff BB at 10:00 AM.

kk) Observation above the drop ceiling on the 1st floor in Clean Utility/medication room 1146 revealed multiple penetrations varying in size and shape in the East and South wall. These findings were confirmed by Staff BB at 10:07 AM.

Based on observation and interview, the facility failed to ensure the stairways used as exit components had doors that closed, latched and were rated to the rating of the construction protecting the stairway. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

1. On 09/29/15 at 8:36 AM a tour of the sixth floor of the main hospital was conducted with Staff QQ, MM, and TT.

a) On 09/29/15 at 1:04 PM observation of the door to the west exit stair (S1) revealed its rating was unknown. On 09/29/15 at 1:04 PM in an interview, Staff QQ confirmed the finding.

2. On 09/29/15 at 1:35 PM a tour was conducted of the fifth floor of the main building with Staff QQ, RR, and MM.

a) On 09/29/15 at 2:56 PM observation of the door protecting exit stairwell five revealed it had self closing and latching hardware that did not self close and latch the door when tested. On 09/29/15 at 2:56 PM in an interview, Staff QQ confirmed the finding.

3. On 10/01/15 at 1:05 PM observation of the door at the very top of the apple street stair (stair s-2) to the mechanical space at the top of the northwest wing revealed it was open and the self closing mechanism was broke. On 10/01/15 at 1:05 PM in an interview, Staff QQ confirmed the finding.

4. On 10/01/15 at 3:06 PM a tour was taken of the third floor of the northwest wing with Staff QQ, RR, and MM.

a) On 10/01/15 at 3:40 PM observation of the door in the two hour rated construction around stair one revealed the self closing and latching hardware did not close and latch the door. On 10/01/15 at 3:40 PM in an interview, Staff QQ confirmed the finding.

5. On 10/02/15 at 2:29 PM a tour was conducted of the fourth floor of the northeast wing with Staff QQ, RR, and MM.

a) On 10/02/15 at 2:37 PM observation of the door on the exit stairway perpendicular room m4491 revealed the door was unrated. On 10/02/15 at 2:37 PM in an interview, Staff QQ confirmed the finding.

Based on facility documentation review, staff interview, and Life Safety Plan review the facility failed to maintain a clear width of at least 8 feet in exit access corridors. This has the potential to affect all patients and visitors in the facility. The facility census was 32.

Findings include:

Review of the document from RTM Consultants, INC to request a traditional equivalency completed on 09/30/15 revealed the clear width of corridor C28 was 6 feet 9 inches in clear with; and in corridors C21 and C214 the clear width was 7 feet 5 inches due to column enclosures.

Review of the Life Safety Plan completed on 09/30/15 revealed 3 column enclosures in corridor C21, 3 column enclosures in corridor C21, and 1 column enclosure in C214 all of which decrease the width of the corridor.

Interview with Staff AA completed on 09/30/15 revealed these areas were part of the facility when it was considered a free standing ED which was under chapter 20 new ambulatory health care and was built to meet the code for that construction type. Additional structures were added changing it to chapter 18 new healthcare. This was the reason for the corridors not being of clear width where the column enclosures are located.

Based on documentation review and staff interview the facility failed to hold fire drills on third shift at varying times. This has the potential to affect all patients and visitors in the facility. The facility census was 32.

Findings include:

Review of the Summary for fire drills completed on 09/30/15 revealed the third shift fire drill times which include: fire drill dated 03/09/15 was completed at 11:02 PM, fire drill dated 03/17/15 was completed at 11:20 PM, fire drill dated 06/10/15 was completed at 11:33 PM, fire drill dated 08/12/15 was completed at 11:14 PM, and the fire drill completed on 09/04/15 was completed at 11:01 PM. All were completed within a 32 minute window. These findings were confirmed by Staff AA on 09/30/15.

Based on observation and interview, the facility failed to ensure each of its smoke detectors were unobstructed and tested yearly. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

1. On 09/29/15 at 8:34 AM a tour was conducted of the fourth floor main building with Staff QQ, RR, and MM. At 9:07 AM two smoke detectors by the public elevator and one in the adjacent waiting area were observed to have plastic covers over them. No work was observed being performed in the area. On 09/29/15 at 9:07 AM in an interview, Staff QQ confirmed the finding.

2. On 10/06/15 a review of the facility's fire alarm system documentation revealed two smoke detectors were untested for 2014 and 2015. In the pass, test date, init., columns "no key access" was written.

On 10/06/15 at 3:30 PM in an interview, Staff QQ and UU explained the smoke detectors had gone untested for the past two years because the staff testing them do not have access to the rooms in question.

Based on documentation review and staff interview the facility failed to document the time the alarm was activated and the time the monitoring company received an alarm signal as in accordance with National Fire Protection Association 72. This has the potential to affect all patients and visitors in the facility. The facility's census was 32.

Findings include:

Review of the Fire Alarm testing documentation completed on 09/30/15 revealed no documentation of the time the alarm was activated and the time the monitoring company received the signal. A request was made for documentation of this action on 09/30/15 and none was provided by exit from the hospital on 10/06/15. Interview with Staff AA completed on 09/30/15 revealed the signal goes directly to the local fire department but was unable to show the time on the documentation.

Based on document review and staff interview it was determined that the facility failed to perform the required sensitivity test for smoke detectors at least Bi-annually. This has the potential to affect all patients and visitors within the facility.

Findings include:

During the document review on 09/30/15 it was found that the facility had the fire alarm system checked but failed to provide documentation that the smoke detectors sensitivity testing was done at the time of inspection. During an interview with Staff AA on 09/30/15 at 9:00 AM it was determined that the test had not been done or documented.

Based on document review and staff interview it was determined that the facility failed to perform the required sensitivity test for smoke detectors at least Bi-annually. This has a potential to affect all patients and visitors within the facility.

Findings include:

During document review on 09/29/15 it was found that the facility had the fire alarm system checked but failed to provide the documentation that the smoke detectors sensitivity testing was done at the time of the inspection. During an interview with Staff AA on 09/29/15 at 4:30 PM it was determined that the test had not been done or documented.

Based on document review and staff interview it was determined that the facility failed to perform the required sensitivity test for smoke detectors at least Bi-annually. This has the potential to affect all patients and visitors within the facility.

Findings include:

During document review on 09/29/15 it was found that the facility had the fire alarm system checked but failed to provide documentation that the smoke detectors sensitivity testing was done at the time of inspection. During an interview with Staff AA on 09/29/15 at 11:30 AM it was determined that the test had not been done or documented.

Based on observation and interview, the facility failed to ensure the sprinklers in its system were clean and items were at or greater than 18 inches beneath the sprinklers. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

1. On 09/29/15 at 8:36 AM the tour of the sixth floor of the main hospital was conducted with Staff QQ, MM, and TT. On 09/29/15 at 9:50 AM observation of supplies in the fully sprinklered galley revealed they were stacked to less than 12 inches from the ceiling. On 09/29/15 at 9:50 AM in an interview, Staff QQ confirmed the finding.

2. On 09/29/15 at 1:35 PM a tour was conducted of the fifth floor of the main building with Staff QQ, RR, and MM. On 09/29/15 at 3:58 PM observation of the sprinkler heads in the pharmacy student work area revealed them to be covered in dust such that the color of the bulb fluid was difficult to see. On 09/29/15 at 3:58 PM in an interview, Staff QQ confirmed the finding.

3. On 09/29/15 at 8:34 AM and on 09/30/15 at 10:56 AM a tour was conducted of the fourth floor main building with Staff QQ, RR, and MM.

a) On 09/29/15 at 8:44 AM observation of the sprinkler heads in room 4517 revealed two were missing escutcheon plates. On 09/29/15 at 8:44 AM in an interview, Staff QQ confirmed the finding.

b) On 09/30/15 at 1:05 PM the sprinkler heads in rooms 4464, 4466, and 4467 were observed to be covered in gossamer-like dust. On 09/30/15 at 1:05 PM in an interview, Staff QQ confirmed the finding.

c) On 09/29/15 at 9:37 AM the sprinkler head in room 4410 was observed to be covered in gossamer-like dust. On 09/29/15 at 9:37 AM in an interview, Staff QQ confirmed the finding.

4. On 09/30/15 at 1:35 PM a tour was conducted of the third floor of the main building with Staff QQ, RR, and MM.

a) On 09/30/15 at 2:29 PM a sprinkler head in room 3341 was observed to be covered in gossamer-like dust. On 09/30/15 at 2:29 PM in an interview, Staff QQ confirmed the finding.

b) On 09/30/15 at 4:16 PM observation of the sprinkler head in room 3324 revealed it to be covered in gossamer-like dust. On 09/30/15 at 4:16 PM in an interview, Staff QQ confirmed the finding.

c) On 09/30/15 at 4:22 PM observation of the sprinkler head in room 3334 revealed it to be covered in gossamer-like dust. On 09/30/15 at 4:22 PM in an interview, Staff QQ confirmed the finding.

5. On 10/01/15 at 8:15 AM a tour was conducted of the second floor with Staff QQ, RR, and MM. At 10:30 AM observation of the sprinkler head in room 2244 revealed it to be covered in gossamer-like dust. On 10/01/15 at 10:30 AM in an interview, Staff RR confirmed the finding.

6. On 10/06/15 at 8:35 AM a tour was conducted of the third floor of the northeast wing with Staff QQ, RR, and MM. At 8:45 AM observation of the sprinkler head in chute room 3467a revealed the bulb was covered in dust. On 10/06/15 at 8:45 AM in an interview, Staff QQ confirmed the finding.

7. On 10/06/15 at 9:01 AM a tour was taken of the sixth floor of the southwest development project building with Staff QQ, RR, and MM. At 10:41 AM observation of the lockers in locker room sw6595 revealed a row of lockers ran through the middle of the room and were 14 inches from the ceiling. The room was fully sprinklered. On 10/06/15 at 10:41 AM in an interview, Staff QQ confirmed the finding.

Based on observation, interview, and record review, the facility failed to maintain a water supply which provided continuous and adequate pressure to its sprinkler system. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

On 10/06/15 at 8:45 AM observation of a sprinkler system riser by chute room 3467a revealed a hydraulic nameplate that called for a residual pressure of 129.128.

On 10/06/15 a review of the facility's sprinkler system documentation was completed. The review of the main drain test for sprinkler system riser by chute room 3467 revealed the residual pressure was 100 psi, 29.128 psi less than called for by the nameplate.

On 10/06/15 at 3:45 PM Staff QQ and TT confirmed the documentation.

Based on observation and interview, the facility failed to deploy a class k fire extinguisher in accordance with NFPA 10 to the kitchen in its physician lounge. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

On 10/01/15 at 11:46 AM a tour was taken of the kitchen in the physician's lounge with Staff QQ, RR, and MM. At 11:46 AM a type k fire extinguisher was not observed near the cooking appliances that used combustible cooking substances.

On 10/01/15 at 11:46 AM in an interview, Staff QQ confirmed the finding.

Based on interview and record review, the facility failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

On 09/29/15 at 1:31 PM a tour was taken of the fifth floor with Staff QQ, RR, and MM. At 2:30 PM Staff QQ explained the unit on the east wing, because of the patients' compromised immune systems due to disease (the unit is used for bone marrow transplant patients), it has its own dedicated air handling system. Staff QQ also explained, unlike the bone marrow unit which is fully ducted, the nursing units with sleeping patients on the third, fourth, fifth and sixth floors had return air shafts (vertical openings) built between every two patient rooms.

Observation throughout the survey of these areas in the main building from 09/28/15 to 10/01/15 with Staff QQ, RR, and MM. revealed the air returned through a grill in the bathrooms of the patient rooms. Observation of these grills revealed they were in two hour protected construction and had a drop-down door on a fusible link.

On 10/06/15 at 3:40 PM Staff TT said he/she was unable to find any documentation for testing of the dampers on the air handler servicing the patients in the bone marrow unit. He/she did present documentation showing dampers operated by fusible link were tested 07/21/08 to 08/01/08, greater than six years ago. The documentation also showed fifteen percent were inaccessible. He/she was unable to say how the ones that were inaccessible were managed: i.e., eventually accessed, decommissioned, or completely removed.

Based on observation and interview, the facility failed to ensure its trash chutes discharged into a trash collection room protected in accordance with National Fire Protection Association 101, 8.4. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

On 10/01/15 at 11:33 AM observation of the door in the two hour construction protecting chute room mg436c revealed it did not have a rating. On 10/01/15 at 11:33 AM in an interview, Staff QQ confirmed the finding.

Based on observation, plan review, and staff interview it was determined that the facility failed to provide a separation from other occupants with a wall of at least a one hour fire resistance rating and failed to maintain the smoke barrier on a serviceable condition. This had the potential to affect all patients and visitors within the facility.
Findings include:
1. In review of the floor plans it was determined that the facility failed to be separated from tenants by a fire barrier with at least a one hour fire resistance rating. During the tour of the facility on 09/28/15 the finding was confirmed, and Staff AA during an interview also confirmed that a separation was not in place.

2. During the tour of the facility on 09/28/15 at 2:12 PM it was found that above the drop ceiling above the doorway to the emergency room, adjacent to the conference room, two pieces of ½ inch flexible conduit had wires passing through them that were not sealed at the opening. At the western double door entrance to the emergency room above the drop ceiling was found an area to the left over the delivery and storage room an approximately eight foot by three foot area not covered by dry wall. Additionally, there were two one inch holes right above the doorway with wires passing thru, were not sealed around the wires and two pieces of flexible conduit with wires passing through were not sealed at the openings. Plus, one ½ inch bear copper wire passing through a one inch hole in the dry wall was not sealed around the wire.

Based on observation and interview, the facility failed to ensure power strips were used in accordance with National Fire Protection Association 70, 1999 edition. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

1. On 09/30/15 at 1:35 PM a tour was conducted of the third floor of the main building with Staff QQ, RR, and MM. At 2:00 PM observation within office 3417 revealed one power strip with two receptacles in use, plugged into another power strip that had a microwave plugged into it, which then plugged into the wall. On 09/30/15 at 2:00 PM in an interview, Staff QQ confirmed the finding.

2. On 10/01/15 at 8:15 AM a tour was conducted of the second floor with Staff QQ, RR, and MM. At 8:52 AM observation in call room six revealed a power strip with two receptacles in use plugged into an extension cord. The extension cord receptacle was observed not to have a hole for the ground plug, and the ground plug to the power strip was observed to be wedged underneath the receptacle. On 10/01/15 at 8:52 AM in an interview, Staff QQ confirmed the finding.

Based on Life Safety Plan review, observation, and staff interview the facility failed to maintain the 2 hour rated common wall between the existing building and the new tower. This has the potential to affect all patients and visitors to the facility. The facility census was 569.

Findings include:

1. Observation above the drop ceiling in the Southwest tower side through the double doors at the end of the ramp SE7180 on the 7th floor, completed on 10/1/15, revealed multiple penetrations varying in size and shape on the other side of the double doors in the 2 hour rated wall. These findings were confirmed by Staff BB at 2:10 PM.

2. Observation above the drop ceiling in Corridor vending area SE2122.1, located on the 2nd floor, completed on 10/02/15, revealed a 3/4 inch conduit penetrating the North 2 hour separation wall open on the end with white and orange data cables passing through. This finding was confirmed by Staff BB at 6:55 AM.

3. Observation above the drop ceiling in the Equipment Storage, room 1195 on the 1st floor, completed on 10/02/15, revealed a 1/2 inch hole behind red data cables. This finding was confirmed by Staff BB at 8:50 AM.

4. Observation in the Shell Space, 1197 on the 1st floor, completed on 10/02/15, revealed the wall was not sealed at the deck above in the Northwest corner. This finding was confirmed by Staff BB and CC at 9:20 AM.

Based on observation and interview, the facility failed to ensure self closers and latching hardware on doors that protected corridor openings closed and latched the doors. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

1. On 09/29/15 at 8:36 AM a tour of the sixth floor of the main hospital was conducted with Staff QQ, MM, and TT.

On 09/29/15 at 8:45 AM observation of the door protecting room A6436 from the corridor revealed it was on a magnetic release connected to the fire alarm system so that it would close when the alarm is activated. Further observation revealed two meal carts parked in front of the door that if the magnetic release was activated, the carts would prohibit the door from closing completely.

On 09/29/15 at 8:45 AM in an interview, Staff SS said, "That's where we store them" when they run out of space.

On 09/29/15 at 11:38 AM , observation of the door protecting the corridor from room m6407a revealed it had self closing, latching hardware. However, when tested, the door did not self close and latch.

On 09/29/15 at 11:38 AM, in an interview, Staff QQ confirmed the finding.

2. On 09/29/15 at 1:35 PM a tour was conducted of the fifth floor of the main building with Staff QQ, RR, and MM.

On 09/29/15 at 3:31 PM observation of the door protecting room 5610 from the corridor revealed it had self closing and latching hardware that did not close and latch the door.

On 09/29/15 at 3:31 PM in an interview, Staff QQ confirmed the finding.

3. On 09/30/15 at 10:06 AM a tour was conducted of the fourth floor of the main building with Staff QQ, RR, and MM.

On 09/30/15 at 11:04 AM observation of the door protecting data closet 4501b from the corridor revealed it had self closing and latching hardware that did not self close and latch.

On 09/30/15 at 11:04 AM in an interview, Staff QQ confirmed the finding.

4. On 09/30/15 at 4:27 PM a tour was conducted of the second floor of the main building with Staff QQ, RR, and MM.

On 09/30/15 at 4:48 PM observation of the laboratory revealed a pass-through opening onto the corridor for staff to give laboratory staff specimens. The observation revealed the corridor was protected from this opening by a fusible link, rated, drop down accordion door. However observation revealed a computer monitor was placed in an area under the accordion door preventing it from dropping all the way down and sealing off the opening.

On 09/30/15 at 4:48 PM in an interview, Staff QQ confirmed the finding.

5. On 10/01/15 at 3:06 PM a tour was taken of the third floor of the northwest wing with Staff QQ, RR, and MM.

On 10/01/15 at 4:17 PM observation of the door protecting room 3252 from the corridor revealed it had self closing and latching hardware that did not self close and latch.

On 10/01/15 at 4:17 PM in an interview, Staff QQ confirmed the finding.

6. On 10/02/15 at 10:19 AM a tour was taken of the first floor of the northwest wing with Staff QQ, RR, and MM.

On 10/02/15 at 10:59 AM observation of the door protecting room 1305 from the corridor revealed the arm to the self closing hardware was broke and the door wouldn't self close.

On 10/02/15 at 10:59 AM in an interview, Staff QQ confirmed the finding.

7. On 10/02/15 at 2:29 PM a tour was conducted of the fourth floor of the northeast wing with Staff QQ, RR, and MM.

On 10/02/15 at 2:35 PM observation of the door protecting a room, which is perpendicular to room m4486, from the corridor revealed it had self closing and latching hardware that did not self close and latch.

On 10/02/15 at 2:35 PM in an interview, Staff QQ confirmed the finding.

8. On 10/06/15 at 9:01 AM a tour was conducted of the sixth floor of the southwest development project building with Staff QQ, RR, and MM.

On 10/06/15 at 9:28 AM observation of the door protecting room sw6559 from the corridor revealed it had self closing and latching hardware that did not self close and latch.

On 10/06/15 at 9:28 AM in an interview, Staff QQ confirmed the finding.

Based on observation and interview, the facility failed to maintain the rated construction protecting its vertical openings, to maintain rating on doors to its vertical openings including dumb waiters, and to ensure doors in vertical openings were closed and latched. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

1. On 09/28/15 at 1:50 PM a tour was taken of the seventh floor of the main building with Staff QQ and MM.

a) On 09/28/15 at 1:50 PM a one inch opening was observed above the drop down ceiling in the two hour rated construction surrounding the shaft located to the right of the entrance to the reception area of the department of medicine. On 09/28/15 at 1:50 PM in an interview, Staff QQ confirmed the finding.

b) On 09/28/15 at 1:55 PM observation above the drop down ceiling of the two hour rated construction surrounding the shaft located to the left of the entrance to the reception area of the department of medicine revealed conduits traveling from the barrier to a junction box with a missing knock-out and a two inch by two inch square opening that revealed the shaft did not have enough layers of drywall to create two hours of protection. On 09/28/15 at 1:55 PM in an interview, Staff QQ confirmed the finding.

c) On 09/28/15 at 3:26 PM observation above the drop down ceiling of the east wall of the two hour rated barrier in equipment room sw7028, protecting an elevator shaft, revealed three one inch holes in the wall. On 09/28/15 at 3:36 PM in an interview, Staff QQ confirmed the finding.

2. On 09/28/15 at 3:31 PM and on 09/29/15 at 8:36 AM a tour was taken of the sixth floor of the main building with Staff QQ and MM.

a) On 09/28/15 at 4:01 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft near education room m6605 revealed an open half inch conduit holding two gray wires. On 09/28/15 at 4:01 PM in an interview, Staff QQ confirmed the finding.

b) On 09/28/15 at 4:08 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft near room of the two hour rated construction protecting a shaft near soiled utility room 6427 at the nursing station revealed wiring with a one inch annular space. On 09/28/15 at 4:08 PM in an interview, Staff QQ confirmed the finding.

c) On 09/28/15 at 4:40 PM the door to the two hour barrier protected shaft located at the nursing station and near the medication cart (not the automated medication dispensing system) was observed to be unrated. On 09/28/15 at 4:40 PM in an interview, Staff QQ confirmed the finding.

d) On 09/28/15 at 4:45 PM observation of the two hour rated construction protecting a shaft near room 6422 at the nursing station revealed a two inch annular space around the sprinkler line. On 09/28/15 at 4:45 PM in an interview, Staff QQ confirmed the finding.

e) On 09/29/15 at 8:43 AM observation of the door protecting the shaft located near rooms 6625 and 6623 revealed the door was unrated. On 09/29/15 at 8:43 AM in an interview, Staff QQ confirmed the finding.

f) On 09/29/15 at 8:45 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft near room 6624 revealed two one inch holes under an heating, ventilation and cooling duct. On 09/29/15 at 8:45 AM in an interview, Staff QQ confirmed the finding.

g) On 09/29/15 at 9:03 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft near room 6633 revealed an open six inch diameter pipe and six inch hole. On 09/29/15 at 9:03 AM in an interview, Staff QQ confirmed the finding.

h) On 09/29/15 at 9:12 AM observation above the drop down ceiling of the two hour rated construction protecting a chase next to stairwell sw, s-4, revealed, as seen from the corridor, an open one inch black pipe. On 09/29/15 at 9:12 AM in an interview, Staff QQ confirmed the finding.

i) On 09/29/15 at 9:58 AM observation of the access door in the two hour rated construction protecting a shaft in room 6418, a janitor closet, revealed it had latching hardware, however, was found to be open, unlatched, and unattended. On 09/29/15 at 9:58 AM in an interview, Staff QQ confirmed the finding.

j) On 09/29/15 at 10:12 AM observation above the drop down ceiling of the shaft across from the bank of service elevators and next to room 6401 revealed a one inch open conduit holding two gray wires. On 09/29/15 at 10:12 AM in an interview, Staff QQ confirmed the finding.

k) On 09/29/15 at 10:33 AM observation of the door to the linen chute in room 6415 (across from the nutrition room) revealed the door to be unrated. On 09/29/15 at 10:33 AM in an interview, Staff QQ confirmed the finding.

l) On 09/29/15 at 10:54 AM observation of the doors to the dumb waiters located in room 6403, six west, revealed the doors were unrated. On 09/29/15 at 10:54 AM in an interview, Staff QQ confirmed the finding.

m) On 09/29/15 at 11:06 AM observation of the doors to the dumb waiters located in room 6686 revealed the doors did not have a rating. On 09/29/15 at 11:06 AM in an interview, Staff QQ confirmed the finding.

n) On 09/29/15 at 11:51 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft near room 6637 revealed an open one inch conduit holding a yellow wire. On 09/29/15 at 11:51 AM in an interview, Staff QQ confirmed the finding.

o) On 09/29/15 at 12:03 PM observation above the drop down ceiling of the shaft opposite data closet 6690d at the nursing station revealed annular spaces around a copper pipe and around a stainless steel pipe. On 09/29/15 at 12:03 PM in an interview, Staff QQ confirmed the finding.

3. On 09/29/15 at 1:35 PM and on 09/30/15 at 8:15 AM a tour was conducted of the fifth floor of the main building with Staff QQ, RR, and MM.

a) On 09/29/15 at 1:35 PM observation of the two hour rated construction protecting a shaft behind the wall holding the television at the waiting area revealed an open electrical box. On 09/29/15 at 1:35 PM in an interview, Staff QQ confirmed the finding.

b) On 09/29/15 at 1:47 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft in the back of bathroom m5635 revealed an annular space around a conduit. On 09/29/15 at 1:47 PM in an interview, Staff QQ confirmed the finding.

c) On 09/29/15 at 1:50 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft toward the back of the bathroom next to bathroom m5636 revealed an annular space around a conduit.

d) On 09/29/15 at 3:42 PM observation of the dumb waiters in passage 5690a did not reveal a rating for their doors. On 09/29/15 at 3:42 PM in an interview, Staff QQ confirmed the finding.

e) On 09/29/15 at 3:49 PM observation of the access door in the two hour rated construction protecting the chase in room m5641 revealed the door had latches but was found open, unlatched, unrated, and unattended. On 09/29/15 at 3:49 PM in an interview, Staff QQ confirmed the finding.

f) On 09/29/15 at 3:51 PM observation of the fifth floor linen chute door revealed its rating to be unknown. On 09/29/15 at 3:51 PM in an interview, Staff QQ confirmed the finding.

g) On 09/29/15 at 4:22 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft at the nursing station and across from data closet 5625b, revealed one stainless steel pipe, one sprinkler line, and one fiber optic line with annular spaces around each. On 09/29/15 at 4:22 PM in an interview, Staff QQ confirmed the finding.

h) On 09/29/15 at 4:52 PM observation above the drop down ceiling of the two hour rated construction protecting the shaft between room 5568 and stair three revealed conduits traveling from the vertical opening to a junction box with a missing knock out from which two red wires traveled out. On 09/29/15 at 4:52 PM in an interview, Staff QQ confirmed the finding.

i) On 09/30/15 at 8:24 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft near rooms 5547 and 5549 revealed an opening between a sleeve and the fiber optic cable it was holding. On 09/30/15 at 8:24 AM in an interview, Staff QQ confirmed the finding.

4. On 09/30/15 at 8:34 AM and on 09/30/15 at 10:56 AM a tour was conducted of the fourth floor main building with Staff QQ, RR, and MM.

a) On 09/30/15 at 8:36 AM observation of the two hour rated construction protecting chase 4494c revealed an annular space around a fiber optic sleeve. On 09/30/15 at 8:36 AM in an interview, Staff QQ confirmed the finding.

b) On 09/30/15 at 8:38 AM observation of the doors to the dumb waiters in room m4516 did not reveal any rating for the doors. On 09/30/15 at 8:38 AM in an interview, Staff QQ confirmed the finding.

c) On 09/30/15 at 8:47 AM observation of the doors to the dumb waiters in room m4492a did not reveal any rating for the doors. On 09/30/15 at 8:47 AM in an interview, Staff QQ confirmed the finding.

d) On 09/30/15 at 8:49 AM observation of the door to the shaft in IT closet 4518 revealed the door did not have a rating. On 09/30/15 at 8:49 AM in an interview, Staff QQ confirmed the finding.

e) On 09/30/15 at 8:56 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft near room 4527 revealed conduits with open ends traveling through the construction. On 09/30/15 at 8:56 AM in an interview, Staff QQ confirmed the finding.

f) On 09/30/15 at 9:35 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft near the double doors near room 4410 revealed an open one inch conduit holding two gray wires. On 09/30/15 at 9:35 AM in an interview, Staff QQ confirmed the finding.

g) On 09/30/15 at 9:44 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft near room 4418 revealed an open one inch conduit holding a green wire. On 09/30/15 at 9:44 AM in an interview, Staff QQ confirmed the finding.

h) On 09/30/15 at 11:38 AM observation of the doors to the dumb waiters in room m4494e did not reveal any rating for the doors. On 09/30/15 at 11:38 AM in an interview, Staff QQ confirmed the finding.

i) On 09/30/15 at 11:55 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft near utility room 4450 and opposite data room 4445f revealed a four inch sleeve holding fiber optic snorkel tubing with space between it and the snorkel tubing. On 09/30/15 at 11:55 AM in an interview, Staff QQ confirmed the finding.

j) On 09/30/15 at 11:59 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft next to room 4448 revealed two one inch corrugated conduits with annular spaces, as seen from the hallway. On 09/30/15 at 11:59 AM in an interview, Staff QQ confirmed the finding.

k) On 09/30/15 at 1:08 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft near room 4468 revealed a conduit traveling from the barrier to a junction box that had red wires traveling from an open knock out. On 09/30/15 at 1:08 PM in an interview, Staff QQ confirmed the finding.

5. On 09/30/15 at 10:41 AM a tour was taken of the ground floor trash and linen chute room with Staff QQ, RR, and MM.

a) On 09/30/15 at 10:41 AM room mg441 was observed to contain the terminus of a chute. The chute door was observed to have latching hardware that did not latch the door when it was tested. On 09/30/15 at 10:41 AM in an interview, Staff QQ confirmed the finding.

b) On 09/30/15 at 10:48 AM room g103 was observed to contain the terminus of a chute. Observation to the door of the chute did not reveal any rating. On 09/30/15 at 10:48 AM in an interview, Staff QQ confirmed the finding.

6. On 09/30/15 at 1:35 PM a tour was conducted of the third floor of the main building with Staff QQ, RR, and MM.

a) On 09/30/15 at 1:50 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft across from elevator 5f revealed an open conduit holding red wires. On 09/30/15 at 1:50 PM in an interview, Staff QQ confirmed the finding.

b) On 09/30/15 at 2:02 PM observation of room 3423 revealed the room contained dumbwaiters. Observation of the doors to the dumbwaiters did not reveal any ratings for the doors. On 09/30/15 at 2:02 PM in an interview, Staff QQ confirmed the finding.

c) On 09/30/15 at 2:08 PM observation of galley room 3415 revealed the room contained dumbwaiters. Observation of the doors to the dumbwaiters did not reveal any ratings for the doors. On 09/30/15 at 2:08 PM in an interview, Staff QQ confirmed the finding.

d) On 09/30/15 at 2:16 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft by the fire extinguisher at the nursing station and across from data room 3407g revealed a penetration on top of yellow wiring traveling through the barrier. On 09/30/15 at 2:16 PM in an interview, Staff QQ confirmed the finding.

e) On 09/30/15 at 2:25 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft by soiled utility room m3404 revealed two smooth conduits with a180 degree annular space above them. On 09/30/15 at 2:25 PM in an interview, Staff QQ confirmed the finding.

f) On 09/30/15 at 3:14 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft west of conference room 3427 revealed a conduit holding a gray wire and having a 180 degree annular space. On 09/30/15 at 3:14 PM in an interview, Staff QQ confirmed the finding.

g) On 09/30/15 at 4:03 PM observation of the dumb waiters in room m3438 revealed the doors did not have a rating. On 09/30/15 at 4:03 PM in an interview, Staff QQ confirmed the finding.

h) On 09/30/15 at 4:14 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft by room 3322 revealed a half inch conduit open to air. On 09/30/15 at 4:14 PM in an interview, Staff QQ confirmed the finding.

7. On 09/30/15 at 4:27 PM and on 10/01/15 at 8:15 AM a tour was conducted of the second floor of the main building with Staff QQ, RR, and MM.

a) On 09/30/15 at 4:41 PM observation of room m2445 revealed the room had a shaft within with an access panel. Observation of the panel revealed it had latches but the door was observed to be unclosed, unlatched, and unattended. Observation within the shaft itself revealed nine yellow, "caution wet floor" signs were stored within. On 09/30/15 at 4:41 PM in an interview, Staff QQ confirmed the finding.

b) On 09/30/15 at 4:44 PM observation of the shaft across from room 2466 (histology) revealed the shaft had an access panel door that was unrated. On 09/30/15 at 4:44 PM in an interview, Staff QQ confirmed the finding.

c) On 09/30/15 at 5:03 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft next to room m2490 revealed an annular space around a tube system tube. On 09/30/15 at 5:03 PM in an interview, Staff QQ confirmed the finding.

d) On 09/30/15 at 5:06 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft by break room 2489 revealed an open copper-colored line. On 09/30/15 at 5:06 PM in an interview, Staff QQ confirmed the finding.

e) On 10/01/15 at 9:02 AM the shaft in room m2495c was observed to have an access door. The door was observed to have latched but was observed unclosed, unlatched, and unattended. Observation of the two hour rated construction protecting the shaft revealed a tourqouis snorkel tube to have an annular space. On 10/01/15 at 9:02 AM in an interview, Staff QQ confirmed the findings.

f) On 10/01/15 at 9:34 AM observation above the drop down ceiling of the two hour rated construction protecting a shaft by bathroom 2381 revealed two black wires through a one inch penetration in the barrier. On 10/01/15 at 9:34 AM in an interview, Staff QQ confirmed the finding.

g) On 10/01/15 at 9:36 AM observation of the access door to the shaft opposite room m2223 revealed the door did not have a rating. On 10/01/15 at 9:36 AM in an interview, Staff QQ confirmed the finding.

8. On 10/01/15 at 11:35 AM a tour was taken of the main kitchen with Staff QQ, RR, and MM.

a) On 10/01/15 at 11:35 AM observation of the doors to the dumb waiters on the clean side of the kitchen revealed they did not have a rating. On 10/01/15 at 11:35 AM in an interview, Staff QQ confirmed the finding.

9. On 10/01/15 at 1:25 PM a tour was taken of five west in the northwest wing with Staff QQ, RR, and MM.

a) On 10/01/15 at 1:25 PM the linen chute door was observed to be unrated. On 10/01/15 at 1:25 PM in an interview, Staff QQ confirmed the finding.

b) On 10/01/15 at 1:45 PM a tour was taken of the fourth floor of the northwest wing with Staff QQ, RR, and MM. On 10/01/15 at 2:26 PM observation of the two hour rated construction protecting a shaft in conference room one revealed three conduits with annular spaces and one with an open end holding a red wire. On 10/01/15 at 2:26 PM in an interview, Staff QQ confirmed the finding.

c. On 10/02/15 at 2:03 PM a tour was taken of the fifth floor of the northeast wing with Staff QQ, RR, and MM. On 10/02/15 at 2:12 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft by rooms 5582 and 5580 revealed an open conduit with a white tip. On 10/02/15 at 2:12 PM in an interview, Staff QQ confirmed the finding.


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10. During tour of the Southwest addition completed on 10/06/15 the following findings were noted.

a) Observation above the drop ceiling on the 7th floor in corridor SW7031 revealed a 6 inch water pipe penetrating the West wall of elevator shaft SW-F-1 with open annular space. This finding was confirmed by Staff CC at 1:20 PM.

b) Observation on the 7th floor in the Mechanical space 7570 revealed 3 1/2 inch by 2 inch hole at the deck in the north wall between the Mechanical space and the stairwell. This finding was confirmed by Staff CC at 9:45 AM.

d) Observation above the drop ceiling on the 7th floor in the Equipment storage area 7025 revealed multiple conduits with open space and non-rated yellow foam around the conduits penetrating the North wall to Stair #3. This finding was confirmed by Staff CC at 10:11 AM.

e) Observation above the drop ceiling on the 2nd floor in Office 2004 revealed the West Wall of Stair SE20W was not sealed at the deck above and a 1 inch blue conduit with blue data cables open on the end and with open annular space. These findings were confirmed by Staff BB at 10:34 AM.

f) Observation above the drop ceiling on the 2nd floor in the sterile corridor SW2137 revealed multiple penetrations in the West and South wall of the vertical shaft filled with a yellow non-rated foam. These findings were confirmed by Staff BB at 12:00 PM.

g) Observation above the drop ceiling on the 1st floor in the restroom 1148 revealed 1 inch and a 2 inch holes in the North 2 hour wall in room 1148, to the vertical shaft. These findings were confirmed by Staff BB at 2:20 PM.

Based on Life Safety Plan review, observation, and staff interview the facility failed to maintain the 2 hour construction around vertical openings. This has the potential to affect all patients and visitors in the facility. The facility census was 569.

Findings include:

During the tour of the Southeast Tower completed on 10/01/15 between the hours of 8:00 AM and 4:30 PM and on 10/02/15 between the hours of 6:55 AM and 1:30 PM the following findings were noted:

a) Observation of the elevator shafts T-01 and T-02 on the 11th floor revealed multiple penetrations varying in size above the elevator doors. These findings were confirmed by Staff BB at 8:50 AM.

b) Observation above the drop ceiling on the 9th floor in corridor SE9139 North wall to elevator shaft T-08 revealed a 3/4 inch red conduit with red data cables passing through, open on the end, and not sealed at the deck. These findings were confirmed by Staff BB at 9:30 AM.

c) Observation above the drop ceiling on the 7th floor in corridor SE7140's East wall revealed a 3/4 inch conduit with yellow and orange data cables passing through, at the deck, with an open annular space. This finding was confirmed by Staff BB at 2:00 PM.

d) Observation above the drop ceiling on the 6th floor in conference room SE6117 revealed a 3/4 inch blue conduit with blue data cables, open on the end, penetrating Stair-W's East wall. This finding was confirmed by Staff BB at 2:30 PM.

e) Observation in Stair-E on the 6th floor revealed a 3/4 inch copper pipe above the door with an open space. This finding was confirmed by Staff BB at 3:00 PM.

f) Observation above the drop ceiling on the 4th floor in conference room SE4117 revealed two 1/2 inch holes in the West wall of elevator shaft T-08 and not sealed around the steal beams in the East wall for Stair-W. These findings were confirmed by Staff BB at 3:40 PM.

g) Observation above the drop ceiling on the 2nd floor in corridor SE2090.1 above the double doors to Stair-C revealed a 1/2 inch by 1 1/2 inch hole with electrical wire passing through. This finding was confirmed by Staff BB at 7:20 AM.

h) Observation above the drop ceiling on the 2nd floor in Education Office 2028 revealed the 2 hour wall was not sealed at the deck above or the West and South walls. These findings were confirmed by Staff BB at 7:25 AM.

i) Observation above the drop ceiling on the 1st floor in the patient corridor across from room SE1204 revealed a 2 inch sprinkler pipe with an open space penetrating the South two hour wall of elevator shaft T-10. This finding was confirmed by Staff BB at 8:56 AM.

j) Observation above the drop ceiling on the 1st floor in corridor SE1110 revealed a 3/4 inch conduit with green data cables passing through above the exit access to door to stair-E. This finding was confirmed by Staff BB at 10:00 AM.

k) Observation above the drop ceiling in Soiled utility room SE1124 revealed two 3/4 inch conduits with open ends and open annular space in Stair-E South wall. This findings was confirmed by Staff BB at 10:00 AM.

l) Observation above the drop ceiling in corridor SEG140 across from elevator shaft T-06 revealed a 3/4 inch conduit open on the end in the North wall of the vertical shaft. This finding was confirmed by Staff BB at 11:00 AM.

Based on observation and interview, the facility failed to ensure access to exits were marked by approved, readily visible signs. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

1. On 09/29/15 at 8:36 AM a tour of the sixth floor of the main hospital was conducted with Staff QQ, MM, and TT. At 1:29 PM observation of the evacuation plan located at the nursing station on 6w/sw revealed the plan directed occupants to turn left at the nursing station and head toward the northwest wing building. An exit sign at the nursing station providing direction to this path of egress was not observed. On 09/29/15 at 1:29 PM in an interview, Staff QQ confirmed the finding.

2. On 10/01/15 at 1:45 PM a tour was taken of the fourth floor of the northwest wing with Staff QQ, RR, and MM. At 2:46 PM the therapy room nw4292 was observed from within the patient care area. The observation revealed on the corridor side of the room, there were five doors, two of which accessed the corridor. However, an exit sign showing the way out to the corridor was not obvious. On 10/01/15 at 2:46 PM in an interview, Staff QQ confirmed the finding.

Based on observation and interview, the facility failed to maintain the ratings of the protective construction in each of its smoke barriers. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

1. On 09/28/15 at 1:50 PM a tour was taken of the seventh floor of the main building with Staff QQ and MM.

a) Observation above the drop down ceiling of the two hour barrier along the south wall of office sw7026 revealed a half inch open conduit. On 09/28/15 at 3:15 PM in an interview, Staff QQ confirmed the finding.

b) On 09/28/15 at 3:21 PM observation of double doors sw7027b in a two hour rated barrier did not reveal a rating on either door. On 09/28/15 at 3:21 PM in an interview, Staff QQ confirmed the finding.

2. On 09/28/15 at 3:31 PM and on 09/29/15 at 8:36 AM a tour was taken of the sixth floor of the main building with Staff QQ and MM.

a) On 09/28/15 at 3:46 PM observation above the drop down ceiling near the door of and seen within the bed storage room revealed in a one hour smoke barrier a half inch by one inch opening located on top of a heating, ventilation and cooling line. On 09/28/15 at 3:46 PM in an interview, Staff QQ confirmed the finding.

b) On 09/29/15 at 10:50 AM observation above the drop down ceiling of the one hour smoke rated barrier in the bed storage room on six west and seen from within and to the right of the door, revealed two red and one gray wire in an open one inch hole. On 09/29/15 at 10:50 AM in an interview, Staff QQ confirmed the finding.

c) On 09/29/15 at 11:40 AM observation above the drop down ceiling over the double doors in the two hour rated barrier located at the six northwest connector revealed a two inch open sleeve. On 09/29/15 at 11:40 AM in an interview, Staff QQ confirmed the finding.

d) On 09/29/15 at 1:18 PM observation above the drop down ceiling of the one hour rated barrier over the double doors between the main building and the southwest development building revealed an open two inch conduit holding yellow/green optic fiber. On 09/29/15 at 1:18 PM, in an interview, Staff QQ confirmed the finding.

3. On 09/29/15 at 1:35 PM a tour was conducted of the fifth floor of the main building with Staff QQ, RR, and MM.

a) On 09/29/15 at 2:59 PM observation above the drop down ceiling of the one hour rated wall on the east side of the medical director's office revealed an open junction box with conduits traveling to the wall. On 09/29/15 at 2:59 PM in an interview, Staff QQ confirmed the finding.

4. On 09/29/15 at 8:34 AM a tour was conducted of the fourth floor main building with Staff QQ, RR, and MM.

a) On 09/29/15 at 8:37 AM observation above the drop down ceiling of the near the bank of service elevators revealed a broken snorkel tube which traveled through a one hour rated smoke barrier over double doors perpendicular to stair 3. On 09/29/15 at 8:37 AM in an interview, Staff QQ confirmed the finding.

b) On 09/29/15 at 8:59 AM observation of the one hour barrier over the double doors perpendicular to the physician dictation room and between the main and northwest building, revealed a fire alarm junction box with a missing knock out. On 09/29/15 at 8:59 AM in an interview, Staff QQ confirmed the finding.

c) On 09/29/15 at 9:14 AM observation of the one hour barrier by the television in the waiting area opposite the bank of public elevators revealed an open junction box. On 09/29/15 at 9:14 AM in an interview, Staff QQ confirmed the finding.

d) On 09/30/15 at 12:58 PM observation above the drop down ceiling of the one hour barrier over the double doors perpendicular room 4455 revealed a two inch hole. On 09/30/15 at 12:58 PM in an interview, Staff QQ confirmed the finding.

e) On 09/30/15 at 1:20 PM observation above the drop down ceiling of the one hour barrier in room 4443, by the window, revealed a one inch conduit with an annular space. On 09/30/15 at 1:20 PM in an interview, Staff QQ confirmed the finding.

f) On 09/30/15 at 1:30 PM observation above the drop down ceiling of the one hour rated barrier inside room 4444 revealed a half inch open conduit holding green wires. On 09/30/15 at 1:30 PM in an interview, Staff QQ confirmed the finding.

5. On 09/30/15 at 1:35 PM a tour was conducted of the third floor of the main building with Staff QQ, RR, and MM.
a) On 09/30/15 at 1:45 PM observation of the one hour barrier perpendicular to stair 3 and located in a locker room, revealed a small conduit with an annular space filled with unrated yellow foam. On 09/30/15 at 1:45 PM in an interview, Staff QQ confirmed the finding.

b) On 09/30/15 at 2:55 PM observation above the drop down ceiling of the one hour rated barrier between patient rooms 3342 and 3344 revealed a 180 degree annular space around medical gas lines. On 09/30/15 at 2:55 PM in an interview, Staff QQ confirmed the finding.

c) On 09/30/15 at 3:22 PM observation of the one hour smoke barrier above the double door perpendicular to the public elevator bank revealed a one inch penetration. On 09/30/15 at 3:22 PM in an interview, Staff QQ confirmed the finding.

d) On 09/30/15 at 3:27 PM observation above the drop down ceiling of the one hour barrier in the waiting area perpendicular to the public elevators revealed, by the television, an open one foot by one foot junction box that had been dry walled around. On 09/30/15 at 3:27 PM in an interview, Staff QQ confirmed the finding.

6. On 10/01/15 at 8:15 AM a tour was conducted of the second floor with Staff QQ, RR, and MM.

a) On 10/01/15 at 9:35 AM observation above the drop down ceiling of the one hour barrier in the east wall of room 2511 revealed one layer of drywall was missing at the heating, ventilation and cooling duct and at the ceiling arcs. On 10/01/15 at 9:35 AM in an interview, Staff QQ confirmed the finding.

b) On 10/01/15 at 9:40 AM observation above the drop down ceiling of the two hour rated barrier just west of alcove 2227a revealed a two inch by two inch square cut into the wall. On 10/01/15 at 9:40 AM in an interview, Staff QQ confirmed the finding.

c) On 10/01/15 at 10:00 AM observation above the drop down ceiling of the two hour barrier opposite the oxygen refill station revealed penetrations created by two corrugated conduits. On 10/01/15 at 10:00 AM in an interview, Staff QQ confirmed the finding.

d) On 10/01/15 at 10:54 AM observation above the drop down ceiling of the one hour rated barrier in the eye exam room in the opthomology services area revealed a one inch hole in the drywall. On 10/01/15 at 10:54 AM in an interview, Staff RR confirmed the finding.

7. On 10/01/15 at 11:04 AM a tour was taken of the first floor of the main building with Staff QQ, RR, and MM.

a) On 10/01/15 at 11:04 AM observation above the drop down ceiling of the two hour rated wall that separated the corridor from room 1636a and opposite the valley café, revealed an open one inch conduit holding a red wire. On 10/01/15 at 11:04 AM in an interview, Staff RR confirmed the finding.

b) On 10/01/15 at 11:08 AM observation above the drop down ceiling of the two hour barrier just west of the main entrance revealed a one foot by one foot square opening cut into the barrier. On 10/01/15 at 11:08 am in an interview, Staff RR confirmed the finding.

c) On 10/01/15 at 11:13 AM observation of the double doors perpendicular to the single door to the valley café and west of the main entrance, and located within a two hour barrier, revealed the doors had self closing and latching hardware that did not close and latch the doors. On 10/01/15 at 11:13 AM in an interview, Staff QQ confirmed the finding.

d) On 10/01/15 at 11:15 AM observation of the single door to the back-end of the valley café and opposite lounge 1353, and located within a two hour barrier, revealed the door did not have a rating. On 10/01/15 at 11:15 AM in an interview, Staff QQ confirmed the finding.

8. On 10/01/15 at 1:25 PM a tour was taken of five west in the northwest wing with Staff QQ, RR, and MM.

a) On 10/01/15 at 1:27 PM observation above the drop down ceiling of the two hour barrier over the doors perpendicular to room nw5226a revealed an open two inch conduit holding a yellow wire, and a turquoise snorkel tube open to air. On 10/01/15 at 1:27 PM in an interview, Staff QQ confirmed the finding.

9. On 10/01/15 at 1:45 PM a tour was taken of the fourth floor of the northwest wing with Staff QQ, RR, and MM.

a) On 10/01/15 at 2:22 PM a white snorkel tube was observed open in data closet 4234a and traveling through the one hour smoke barrier. On 10/01/15 at 2:22 PM in an interview, Staff QQ confirmed the finding.

10. On 10/01/15 at 3:06 PM a tour was taken of the third floor of the northwest wing with Staff QQ, RR, and MM.

a) On 10/01/15 at 3:33 PM observation above the drop down ceiling of the one hour barrier at soiled utility room 3214 revealed an annular space within the ductwork collar that measured one by four inches. On 10/01/15 at 3:33 PM in an interview, Staff QQ confirmed the finding.

b) On 10/01/15 at 3:55 PM observation above the drop down ceiling of the one hour barrier over the south door to room nw3280d revealed a half inch circular opening in the drywall, near a sticker that read, "all penetrations must be fire caulked." On 10/01/15 at 3:55 PM in an interview, Staff QQ confirmed the finding.

11. On 10/01/15 at 4:26 PM a tour was taken of the second floor of the northwest wing with Staff QQ, RR, and MM.

a) On 10/01/15 at 4:26 PM observation of one hour rated construction protecting room nw2292b revealed a six by six inch square cut into the drywall, 180 degrees from the door to the room. On 10/02/15 at 9:00 AM a tour was taken of the second floor of the northwest wing with Staff QQ, RR, and MM.

b) On 10/02/15 at 9:21 AM observation above the drop down ceiling of the one hour barrier perpendicular to room nw2297 revealed an open four inch sleeve holding multiple blue wires. On 10/02/15 at 9:21 AM in an interview, Staff QQ confirmed the finding.

12. On 10/02/15 at 10:19 AM a tour was taken of the first floor of the northwest wing with Staff QQ, RR, and MM.

a) On 10/02/15 at 10:38 AM observation above the drop down ceiling of the one hour barrier on the perimeter of dressing area nw1313 revealed at the west wall an open conduit with a white tip holding gray wires and an open corrugated conduit lying on top of a tile and traced back and through the barrier. On 10/02/15 at 10:38 AM in an interview, Staff QQ confirmed the finding.

b) On 10/02/15 at 11:02 AM observation of the one hour barrier in the southwest corner of room nw1331 revealed an annular space a drain line. On 10/02/15 at 11:02 AM in an interview, Staff QQ confirmed the finding.

c) On 10/02/15 at 11:05 AM observation above the drop down ceiling of the one hour rated barrier between rooms nw1328 and nw1327 revealed a six inch by six inch square cut into the drywall. On 10/02/15 at 11:05 AM in an interview, Staff QQ confirmed the finding.

13. On 10/06/15 at 8:35 AM a tour was conducted of the third floor of the northeast wing with Staff QQ, RR, and MM.

a) On 10/06/15 at 8:55 AM observation above the drop down ceiling of the two hour barrier over the double doors leading to corridor nw3287 revealed an open snorkel tube holding a gray wire. On 10/06/15 at 8:55 AM in an interview, Staff QQ confirmed the finding.

14. On 10/06/15 at 9:01 AM a tour was taken of the sixth floor of the southwest development project building with Staff QQ, RR, and MM.

a) On 10/06/15 at 9:12 AM observation above the drop down ceiling of the one hour barrier in the waiting area by elevator lobby F, and over the fire strobe revealed a one inch penetration in the drywall holding two white wires and one red wire. On 10/06/15 at 9:12 AM in an interview, Staff QQ confirmed the finding.

b) On 10/06/15 at 10:44 AM observation above the drop down ceiling of the two hour rated barrier over the door to room sw6588 revealed an open, four inch sleeve through the barrier. On 10/06/15 at 10:44 AM in an interview, Staff QQ confirmed the finding.

15. On 10/06/15 at 10:56 AM a tour was taken of the fourth floor of the southwest development building with Staff QQ, RR, and MM.

a) On 10/06/15 at 11:18 AM observation above the drop down ceiling of the one hour barrier on the perimeter of soiled utility room sw4564 revealed at the south wall in the dry wall an open one inch hole holding a green wire. On 10/06/15 at 11:18 AM in an interview, Staff QQ confirmed the finding.



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16. During tour of the Southwest addition completed on 10/06/15 the following findings were noted.

a) Observation above the drop ceiling on the 6th floor in corridor SW7570 revealed 1 inch by 2 inch hole at the deck in the East smoke barrier wall of the corridor outside group room SW7568. This finding was confirmed by Staff BB at 9:40 AM.

b) Observation above the drop ceiling on the 6th floor in the equipment room 7025 revealed seams not sealed and not sealed at the deck above in the Southeast corner smoke barrier wall. These findings were confirmed by Staff BB at 10:11 AM.

c) Observation above the drop ceiling on the 2nd floor above the double doors leading from the elevator lobby SW2000A revealed the smoke barrier wall not sealed at the deck above and a 3/4 inch conduit open on the end. These findings were confirmed by Staff BB at 10:25 AM.

d) Observation above the drop ceiling on the 2nd floor in corridor SW2000 revealed a 12 inch space covered with clear plastic running the entire length of the East corridor smoke barrier wall. This finding was verified by Staff BB and Staff CC at 10:34 AM.

e) Observation above the drop ceiling on the 2nd floor over the double doors between corridors SW2003 and SW2004B revealed a 3 inch conduit open on the end with data cables on both sides of the double doors in the smoke barrier. This finding was confirmed by Staff BB and Staff CC at 10:42 AM.

f) Observation above the drop ceiling on the 2nd floor in corridor SW2060 above the double doors on the Pre-operative side revealed 2 inch conduit with green data cables open on the end. This finding was confirmed by Staff BB at 10:50 AM.

g) Observation above the drop ceiling on the 2nd floor in corridor SW2087 above the single south door on the Pre-operative side revealed a penetration with green data cables with open annular space. This finding was confirmed by Staff CC at 10:55 AM.

h) Observation above the drop ceiling on the 2nd floor in the sterile corridor SW2146 revealed multiple penetrations and holes varying in size and shape in the smoke wall above the Control room 2122 to OR #5. These findings were confirmed by Staff CC at 11:45 AM.

i) Observation above the drop ceiling on the 1st floor in the physician dictation area SW1236 between exam bays 42 and 44 revealed 1 1/2 inch hole above the door. This finding was confirmed by Staff CC at 1:45 PM

j) Observation above the drop ceiling on the 1st floor above the double doors in corridor SW1189 by the door to the Soiled Utility room 1275 revealed three 3/4 inch holes. These findings were confirmed by Staff BB at 1:50 PM.

k) Observation above the drop ceiling on the 1st floor above the double doors where corridors SW1189 and SW1247 meet revealed a 2 inch hole with a 1/2 inch conduit penetrating the smoke barrier. This finding was confirmed by Staff BB at 1:57 PM.

l) Observation above the drop ceiling on the 1st floor in corridor SW1189 revealed 1/2 inch green conduit with open annular space in the wall between the corridor and the Soiled Utility Room 1275. This finding was confirmed by Staff BB at 2:00 PM.

m) Observation above the drop ceiling on the 1st floor in the restroom 1148 revealed multiple penetrations of the South restroom smoke barrier rated wall above the door. These findings were confirmed by Staff BB at 2:20 PM.

n) Observation above the drop ceiling on both sides of the double doors between corridors SW1061 and SW1024 revealed a large rectangular hole with multiple data cable not sealed with a fire rated material on both sides of double doors. These findings were confirmed by Staff CC at 2:30 PM.



o) During the tour of the facility on 10/01/15 at 11:40 AM above the drop ceiling from inside the Staff lounge on the first floor west wing B1246 was found three penetrations through the two hour fire wall. One, two inch diameter hole with nothing passing through, and two, one inch holes just to the left of the entrance doorway. This was confirmed by Staff VV and WW at the time of discovery.
p) Additionally, at 11:55 AM on 10/01/15 from the corridor side above the doorway leading to the receptionist desk B1200A a penetration through the two hour wall was found one inch hole with nothing passing through. This was confirmed by Staff VV and WW at the time of discovery.
q) During the tour of the second floor west wing above the drop ceiling and over the doorway B2270A was found a four inch square metal box with a black and red wire passing through and a white wire passing outside the box. The cover was not attached covering the box. This was confirmed by Staff VV and WW at the time of discovery.
r) At 2:16 PM on 10/01/15 on the corridor side of the two hour fire wall outside the physician lounge just left of the entrance doorway was found a four inch square metal box with wire passing through the box that did not have a cover closing the box. This was confirmed by Staff VV and WW at the time of discovery.
s) At 2:30 PM on 10/01/15 to the left of the doorway at B2091 above the drop ceiling was found a four inch square metal box with a single white wire inside with the cover missing. This was confirmed by Staff VV and WW at the time of discovery.

Based on Life Safety Plan review, observation, and staff interview the facility failed to maintain the integrity of the fire rated smoke walls. This has the potential to affect all patients and visitors in the facility. The facility census was 569.

Findings include:

During the tour of the Southeast Tower completed on 10/02/15 between the hours of 6:55 AM and 1:30 PM and the following findings were noted.

a) Observation above the drop ceiling on the 2nd floor where Corridor SE2040 and corridor SE2201 meet revealed a 3/4 inch conduit open on the end in the East side of the double doors and a large open area at the left corner on the West side of the double doors. These findings were confirmed by Staff BB and Staff CC at 7:55 AM.

b) Observation above the drop ceiling on the 2nd floor above the double doors in corridor SE2190 revealed a 2 foot duct with open space on both sides of the double doors. These findings were confirmed by Staff BB and Staff CC at 8:00 AM.

c) Observation above the drop ceiling on the 1st floor in corridor SE1115 revealed two 1 inch holes above the double doors to the Heart Lobby area SE1147. This finding was confirmed by Staff CC at 10:00 AM.

d) Observation above the drop ceiling on the 1st floor in room 1164 revealed a 3/4 inch conduit with blue data cables penetrating the West wall open on the end. This finding was confirmed by Staff BB at 10:03 AM.

e) Observation above the drop ceiling on the 1st floor in heart registration room 1165 revealed a 1/2 inch hole with yellow data cables above the door in the West wall above the door leading to the waiting area SE1169. This finding was confirmed by Staff CC at 10:07 AM.

Based on observation and interview, the facility failed to ensure that doors in barriers with self closing and latching hardware closed and latched the doors, that the doors were rated, and that double doors closed such that one did not keep the other from closing. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

1. On 09/29/15 at 1:35 PM a tour was conducted of the fifth floor of the main building with Staff QQ, RR, and MM.

a) On 09/29/15 at 3:35 PM observation of the corridor door in the one hour rated barrier in room 5594, revealed the door had self closing and latching hardware that did not self close and latch. On 09/29/15 at 3:35 PM in an interview, Staff QQ confirmed the finding.

2. On 10/01/15 at 8:15 AM a tour was conducted of the second floor with Staff QQ, RR, and MM.

a) On 10/01/15 at 9:29 AM observation of the one hour barrier along the double door to room m2222 revealed when the two doors closed, there wasn't a functioning coordinator to ensure they closed in such a way one door didn't prevent the other from closing. On 10/01/15 at 9:29 am in an interview, Staff QQ confirmed the finding.

b) On 10/01/15 at 9:38 AM observation of the one hour barrier along the double door to room m2224 revealed when the two doors closed, there wasn't a functioning coordinator to ensure they closed in such a way one door didn't prevent the other from closing. On 10/01/15 at 9:38 AM in an interview, Staff QQ confirmed the finding.

c) On 10/01/15 at 10:00 AM observation of the door at room m2201 and in the one hour rated barrier revealed it had a self closer with latching hardware that did not close and latch the door. On 10/01/15 at 10:00 AM in an interview, Staff QQ confirmed the finding.

3. On 10/01/15 at 11:04 AM a tour was taken of the first floor of the main building with Staff QQ, RR, and MM.

a) On 10/01/15 at 11:11 AM observation of the single door to the valley café and west of the main entrance, revealed it was located within a two hour barrier, but was not rated. On 10/01/15 at 11:11 AM in an interview, Staff QQ confirmed the finding.

4. On 10/01/15 at 1:45 PM a tour was taken of the fourth floor of the northwest wing with Staff QQ, RR, and MM.

a) On 10/01/15 at 2:15 PM the door to the educator room was observed to be in a one hour barrier and with a self closer and latching hardware that did not close and latch the door. On 10/01/15 at 2:15 PM in an interview, Staff QQ confirmed the finding.

b) On 10/01/15 at 2:36 PM observation of the door in the one hour rated barrier perpendicular to office 4269 did not reveal a rating. On 10/01/15 at 2:36 PM in an interview, Staff QQ confirmed the finding.

5. On 10/02/15 at 10:19 AM a tour was taken of the first floor of the northwest wing with Staff QQ, RR, and MM.

a) On 10/02/15 at 10:20 AM observation of the double doors to family waiting area nw1356 and in the one hour barrier revealed when the two doors closed, there wasn't a functioning coordinator to ensure they closed in such a way one door didn't prevent the other from closing. On 10/02/15 at 10:20 AM in an interview, Staff QQ confirmed the finding.

b) On 10/02/15 at 10:35 AM the door protecting room nw1317 from the corridor and located in a one hour smoke barrier revealed it had self closing and latching hardware that did not self close and latch. On 10/02/15 at 10:35 AM in an interview, Staff QQ confirmed the finding.

c) On 10/02/15 at 10:52 AM observation of the double doors in the two hour barrier in room m1426 revealed when the two doors closed, there wasn't a functioning coordinator to ensure they closed in such a way one door didn't prevent the other from closing. On 10/02/15 at 10:52 AM in an interview, Staff QQ confirmed the finding.

d) On 10/02/15 at 11:30 AM observation of the double doors in the one hour barrier in trash room 1379 revealed when the two doors closed, there wasn't a functioning coordinator to ensure they closed in such a way one door didn't prevent the other from closing. On 10/02/15 at 11:30 AM in an interview, Staff QQ confirmed the finding.

e) On 10/02/15 at 12:03 PM observation of the double doors in the two hour rated barrier between the power room and the chute room revealed when the two doors closed, there wasn't a functioning coordinator to ensure they closed in such a way one door didn't prevent the other from closing. On 10/02/15 at 12:03 PM in an interview, Staff QQ confirmed the finding.

f) On 10/02/15 at 1:28 PM observation of the door to the comprehensive outpatient rehabilitation program waiting area and in a two hour barrier revealed the door had a rating of 20 minutes. On 10/02/15 at 1:28 PM in an interview, Staff QQ confirmed the finding.

6. On 10/06/15 at 8:35 AM a tour was conducted of the third floor of the northeast wing with Staff QQ, RR, and MM.

a) On 10/06/15 at 8:50 AM observation of the door to clean equipment room m3467c revealed it to be in a one hour barrier and unrated. On 10/06/15 at 8:50 AM in an interview, Staff QQ confirmed the finding.

7. On 10/06/15 at 9:01 AM a tour was taken of the sixth floor of the southwest development project building with Staff QQ, RR, and MM.

a) On 10/06/15 at 10:03 AM observation of the door protecting the oxygen refill room (sw6579a) revealed it had self closing and latching hardware that did not self close and latch. On 10/06/15 at 10:03 AM in an interview, Staff QQ confirmed the finding.

b) On 10/06/15 at 10:07 AM observation of the door in the one hour rated construction in the clean utility room (sw6606) revealed it was unrated. On 10/06/15 at 10:07 AM in an interview, Staff QQ confirmed the finding.

c) On 10/06/15 at 10:27 AM observation of the double doors to bed parking room 6594 and in a one hour barrier revealed when the two doors closed, there wasn't a functioning coordinator to ensure they closed in such a way one door didn't prevent the other from closing.



31007

8. Observation of the double smoke doors on the 2nd floor of the Southwest addition in the Elevator lobby area revealed the door on the Left did not close to a latching position when tested two times. This finding was confirmed by Staff BB and Staff CC at 10:30 AM.

Based on observation and interview, the facility failed to ensure each of its sprinklered, hazardous areas were able to resist the passage of smoke. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

On 09/30/15 at 10:41 AM a tour was taken of the ground floor trash and linen chute rooms with Staff QQ, RR, and MM. At 10:53 AM observation of the double doors enclosing the linen supply room revealed a quarter inch gap between the doors at the latch. On 09/30/15 at 10:53 AM in an interview, Staff QQ confirmed the finding.

Based on review of Life Safety Plans, observation, and staff confirmation the facility failed to ensure the walls were constructed of at least a 1 hour protection rating around hazardous areas, and doors in hazardous areas closed to a latching position. This has the potential to affect all patients and visitors in the facility.

Findings include:

1. Tour of the "Bed Tower" was conducted on 09/29/15 between the hours of 8:00 AM and 4:30 PM. Observation above the drop ceiling in the Clean Utility room on the 2nd floor revealed a half inch hole above the entry door. This finding was confirmed by Staff AA at 2:30 PM.

2. Tour of the "DT Building" was conducted on 09/30/15 between the hours of 7:45 AM and 12:00 PM. Observation in Data room 2214A in the OR sterile area revealed a 3 1/2 X 2 inch hole approximately 4 1/2 feet off of the ground in the 1 hour south wall between the Data room and equipment storage 2410. This finding was confirmed by Staff AA at 8:30 AM.

3. Observation of the door to the Supply room 273 from the sterile corridor C28 was tested and revealed the door did not close due to hitting the door frame, the bottom hinge appeared to be bent. This finding was confirmed by Staff AA at 8:40 AM.

4. Observation above the drop ceiling in Equipment room 2414 located between the OR's revealed multiple penetrations and holes varying in size and shape in the North wall and a 6 inch conduit with open end on the South wall. These findings were confirmed by Staff AA at 8:40 AM.

5. Observation above the drop ceiling in Sterile supply 2087 revealed a 3/4 inch conduit with 2 data cables passing through open on the end in the West wall of the room. This finding was confirmed by Staff AA at 8:47 AM.

6. Observation above the drop ceiling in the ATA work area 1731A revealed a 2 inch sprinkler pipe penetrating the 1 hour West and South Walls with an nonrated white material sealing the penetrations. These findings were confirmed by Staff AA at 9:55 AM.

7. Observation above the drop ceiling in Supply Room 1844 revealed multiple penetrations and holes varying in size and shape on all 4 walls. These findings were confirmed by Staff AA at 10:15 AM.

Based on review of Life Safety Plans, observation, and staff confirmation the facility failed to ensure the walls were constructed of at least a 1 hour protection rating around hazardous areas. This has the potential to affect all patients and visitors in the facility. The facility census was 569.

Findings include:

During the tour of the Southeast Tower completed on 10/01/15 between the hours of 8:00 AM and 4:30 PM and 10/02/15 between the hours of 6:50 AM and 1:30 PM the following findings were noted:

a) Observation above the drop ceiling on the 9th floor in corridor SE9060 above the door to equipment room 9114 revealed multiple penetrations varying in size and shape. These findings were confirmed by Staff BB at 9:45 AM.

b) Observation above the drop ceiling on the 9th floor in Equipment room 9114 revealed 3/4 inch flex conduits open on the end and a 3/4 inch flex conduit with a 6 inch by 6 inch open space in the column by the door. These finding were confirmed by Staff BB at 9:50 AM.

c) Observation above the drop ceiling on the 9th floor in Equipment room 9137 revealed penetrations unsealed behind the steel column. These findings were confirmed by Staff BB at 10:02 AM.

d) Observation above the drop ceiling on the 9th floor in Corridor SE9110 revealed multiple penetrations varying in size and shape above the door to Clean Utility Room 9136. These findings were confirmed by Staff BB at 10:05 AM.

e) Observation above the drop ceiling on the 9th floor in Clean Utility Room 9136 revealed a 3/4 inch conduit open on the end with a white cable passing through and a 1/4 inch gap above the HVAC duct above the door to the Corridor. These findings were confirmed by Staff BB at 10:07 AM.

f) Observation above the drop ceiling on the 9th floor in Family Waiting area SE9132 revealed a 3/4 inch conduit with blue data cable open on the end penetrating the West wall for electrical room 9134. This finding was confirmed by Staff BB at 10:12 AM.

g) Observation above the drop ceiling on the 8th floor in corridor SE8060 above the door to equipment room 8114 revealed multiple penetrations varying in size and shape. These findings were confirmed by Staff BB at 10:46 AM.

h) Observation above the drop ceiling on the 8th floor in Equipment room 8114 revealed a 3/4 inch flex conduit open on the end and a 6 inch by 6 inch opening around the conduit to the right of the door to the corridor. These findings were confirmed by Staff BB at 10:50 AM.

i) Observation above the drop ceiling on the 8th floor in corridor SE8110 revealed multiple penetrations varying in size and shape above the door to Clean Utility room 8136. These findings were confirmed by Staff BB at 11:00 AM.

j) Observation above the drop ceiling on the 8th floor in equipment room 8137 revealed a 3/4 inch conduit with red data cables passing through open on the end penetrating the round wall above the door. This finding was confirmed by Staff BB at 11:02 AM.

k) Observation in electrical room 7134 on the 7th floor revealed a 3/4 inch conduit open on the end penetrating the South 1 hour wall. This finding was confirmed by Staff BB at 1:13 PM.

l) Observation above the drop ceiling on the 7th floor in corridor SE7000 revealed multiple penetrations above the door to Clean Utility Room 7136. These findings were confirmed by Staff BB at 1:18 PM.

m) Observation above the drop ceiling on the 7th floor in Clean Utility Room 7136 revealed two 3/4 inch flex conduits with data cables open on the ends above the door to the corridor. These findings were confirmed by Staff BB at 1:20 PM.

n) Observation above the drop ceiling on the 7th floor in Equipment Supply Room 7137 revealed a 16 inch hole with 8 inch insulated HVAC duct passing through behind a column in the rounded wall. This finding was confirmed by Staff BB at 1:23 PM.

o) Observation above the drop ceiling on the 7th floor in Equipment Room 7114 revealed a 6 inch hole with 3/4 inch flex conduit passing through and the 3/4 inch flex conduit open on the end. These findings were confirmed by Staff BB at 1:30 PM.

p) Observation above the drop ceiling on the 7th floor in corridor SE7060 revealed multiple penetrations varying in size and shape above the door to Equipment Room 7114. These findings were confirmed by Staff BB at 1:38 PM.

q) Observation above the drop ceiling on the 7th floor in Soiled Utility room 7125 revealed a 4X4 and 5X5 junction box covers inset into the South wall with an open space around both. These findings were confirmed by Staff BB at 1:50 PM.

r) Observation above the drop ceiling on the 6th floor in corridor SE6130 revealed a 6 inch HVAC duct in a 10 inch hole penetrating the 1 hour wall to Oxygen fill station room 6108. This finding was confirmed by Staff BB at 2:25 PM.

s) Observation above the drop ceiling on the 6th floor in Soiled Utility room 6125 revealed a 5X5 junction box cover inset into the South wall with open space around. This finding was confirmed by Staff BB at 2:42 PM.

t) Observation above the drop ceiling on the 6th floor in corridor SE6060 revealed multiple penetrations varying in size and shape above the door to Equipment Room 6114. These findings were confirmed by Staff BB at 2:47 PM.

u) Observation above the drop ceiling on the 6th floor in Equipment Room 6137 revealed a 8 inch by 24 inch open space with multiple conduits passing through behind the steel column. This finding was confirmed by Staff BB at 2:52 PM.

v) Observation above the drop ceiling on the 6th floor in corridor SE6000 revealed a 3 inch sprinkler pipe penetrating the 1 hour wall above the door to the Clean Utility Room 6136 with open annular space. This finding was confirmed by Staff BB at 3:07 PM.

w) Observation above the drop ceiling on the 6th floor in the Clean Utility Room 6136 revealed multiple penetrations and holes varying in size and shape. These findings were confirmed by Staff BB at 3:09 PM.

x) Observation above the drop ceiling in the 6th floor family waiting area SE6132 revealed a 2 inch by 1 inch hole in the East 1 hour wall of Electrical Room 6134 at the deck. This finding was confirmed by Staff BB at 3:12 PM.

y) Observation above the drop ceiling on the 4th floor in corridor SE4130 above Oxygen fill station room 4108 door revealed a 6 inch HVAC duct penetrating the 1 hour wall with open space around the duct. This finding was confirmed by Staff BB at 3:32 PM.

z) Observation above the drop ceiling on the 4th floor in the Soiled Utility Room 4125 revealed a 6 inch by 1 inch space above the sink area. This finding was confirmed by Staff BB at 3:40 PM.

aa) Observation above the drop ceiling on the 4th floor in Equipment room 4114 revealed a 6 inch hole with a 3/4 inch flex conduit open on the end passing through. This finding was confirmed by Staff BB at 3:45 PM.

bb) Observation above the drop ceiling on the 4th floor in the Equipment room 4137 revealed a 2 inch by 10 inch gap between the gypsum board and the steal column and the wall around the column was not capped. These finding were confirmed by Staff BB at 3:55 PM.

cc) Observation above the drop ceiling on the 4th floor in corridor SE4000 revealed a 8 inch round HVAC duct passing through a square hole penetrating the 1 hour round wall to the Clean Utility Room 4136. This finding was confirmed by Staff BB at 4:00 PM.

dd) Observation above the drop ceiling on the 4th floor in the Clean Utility Room 4136 revealed multiple penetrations and holes varying in size and shape above the door to the corridor. These findings were confirmed by Staff BB at 4:02 PM.

ee) Observation above the drop ceiling in 4th floor family waiting 4132 revealed two 3/4 inch conduits with blue and green data cables penetrating the West wall of Electrical room 4125 open on the ends. These findings were confirmed by Staff BB at 4:10 PM.

ff) Observation above the drop ceiling on the 2nd floor in corridor SE2080 revealed a 6 inch HVAC duct penetrating the West 1 hour rated wall for the Soiled Utility room 2127 with open annular space. This finding was confirmed by Staff BB at 7:00 AM.

gg) Observation above the drop ceiling on the 2nd floor in Soiled Utility room 2127 revealed a 6 inch HVAC duct penetrating the West and north walls with open annular space. These findings were confirmed by Staff BB at 7:02 AM.

hh) Observation above the drop ceiling on the 2nd floor in corridor SE2090.3 revealed a 3/4 inch conduit with 3 green data cables penetrating the South Soiled Utility Room 2127 wall open on the end.

ii) Observation above the drop ceiling on the 2nd floor in Equipment Room 2022 revealed a 3/4 inch conduit open on the end penetrating the West wall. This finding was confirmed by Staff BB at 7:10 AM.

jj) Observation above the drop ceiling on the 1st floor in Soiled Utility Room 1124 revealed a 3/4 inch conduit open on the end in the South 1 hour rated wall. This finding was confirmed by Staff BB at 10:00 AM.

kk) Observation above the drop ceiling on the 1st floor in Clean Utility/medication room 1146 revealed multiple penetrations varying in size and shape in the East and South wall. These findings were confirmed by Staff BB at 10:07 AM.

Based on observation and interview, the facility failed to ensure the stairways used as exit components had doors that closed, latched and were rated to the rating of the construction protecting the stairway. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

1. On 09/29/15 at 8:36 AM a tour of the sixth floor of the main hospital was conducted with Staff QQ, MM, and TT.

a) On 09/29/15 at 1:04 PM observation of the door to the west exit stair (S1) revealed its rating was unknown. On 09/29/15 at 1:04 PM in an interview, Staff QQ confirmed the finding.

2. On 09/29/15 at 1:35 PM a tour was conducted of the fifth floor of the main building with Staff QQ, RR, and MM.

a) On 09/29/15 at 2:56 PM observation of the door protecting exit stairwell five revealed it had self closing and latching hardware that did not self close and latch the door when tested. On 09/29/15 at 2:56 PM in an interview, Staff QQ confirmed the finding.

3. On 10/01/15 at 1:05 PM observation of the door at the very top of the apple street stair (stair s-2) to the mechanical space at the top of the northwest wing revealed it was open and the self closing mechanism was broke. On 10/01/15 at 1:05 PM in an interview, Staff QQ confirmed the finding.

4. On 10/01/15 at 3:06 PM a tour was taken of the third floor of the northwest wing with Staff QQ, RR, and MM.

a) On 10/01/15 at 3:40 PM observation of the door in the two hour rated construction around stair one revealed the self closing and latching hardware did not close and latch the door. On 10/01/15 at 3:40 PM in an interview, Staff QQ confirmed the finding.

5. On 10/02/15 at 2:29 PM a tour was conducted of the fourth floor of the northeast wing with Staff QQ, RR, and MM.

a) On 10/02/15 at 2:37 PM observation of the door on the exit stairway perpendicular room m4491 revealed the door was unrated. On 10/02/15 at 2:37 PM in an interview, Staff QQ confirmed the finding.

Based on facility documentation review, staff interview, and Life Safety Plan review the facility failed to maintain a clear width of at least 8 feet in exit access corridors. This has the potential to affect all patients and visitors in the facility. The facility census was 32.

Findings include:

Review of the document from RTM Consultants, INC to request a traditional equivalency completed on 09/30/15 revealed the clear width of corridor C28 was 6 feet 9 inches in clear with; and in corridors C21 and C214 the clear width was 7 feet 5 inches due to column enclosures.

Review of the Life Safety Plan completed on 09/30/15 revealed 3 column enclosures in corridor C21, 3 column enclosures in corridor C21, and 1 column enclosure in C214 all of which decrease the width of the corridor.

Interview with Staff AA completed on 09/30/15 revealed these areas were part of the facility when it was considered a free standing ED which was under chapter 20 new ambulatory health care and was built to meet the code for that construction type. Additional structures were added changing it to chapter 18 new healthcare. This was the reason for the corridors not being of clear width where the column enclosures are located.

Based on documentation review and staff interview the facility failed to hold fire drills on third shift at varying times. This has the potential to affect all patients and visitors in the facility. The facility census was 32.

Findings include:

Review of the Summary for fire drills completed on 09/30/15 revealed the third shift fire drill times which include: fire drill dated 03/09/15 was completed at 11:02 PM, fire drill dated 03/17/15 was completed at 11:20 PM, fire drill dated 06/10/15 was completed at 11:33 PM, fire drill dated 08/12/15 was completed at 11:14 PM, and the fire drill completed on 09/04/15 was completed at 11:01 PM. All were completed within a 32 minute window. These findings were confirmed by Staff AA on 09/30/15.

Based on observation and interview, the facility failed to ensure each of its smoke detectors were unobstructed and tested yearly. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

1. On 09/29/15 at 8:34 AM a tour was conducted of the fourth floor main building with Staff QQ, RR, and MM. At 9:07 AM two smoke detectors by the public elevator and one in the adjacent waiting area were observed to have plastic covers over them. No work was observed being performed in the area. On 09/29/15 at 9:07 AM in an interview, Staff QQ confirmed the finding.

2. On 10/06/15 a review of the facility's fire alarm system documentation revealed two smoke detectors were untested for 2014 and 2015. In the pass, test date, init., columns "no key access" was written.

On 10/06/15 at 3:30 PM in an interview, Staff QQ and UU explained the smoke detectors had gone untested for the past two years because the staff testing them do not have access to the rooms in question.

Based on documentation review and staff interview the facility failed to document the time the alarm was activated and the time the monitoring company received an alarm signal as in accordance with National Fire Protection Association 72. This has the potential to affect all patients and visitors in the facility. The facility's census was 32.

Findings include:

Review of the Fire Alarm testing documentation completed on 09/30/15 revealed no documentation of the time the alarm was activated and the time the monitoring company received the signal. A request was made for documentation of this action on 09/30/15 and none was provided by exit from the hospital on 10/06/15. Interview with Staff AA completed on 09/30/15 revealed the signal goes directly to the local fire department but was unable to show the time on the documentation.

Based on document review and staff interview it was determined that the facility failed to perform the required sensitivity test for smoke detectors at least Bi-annually. This has the potential to affect all patients and visitors within the facility.

Findings include:

During the document review on 09/30/15 it was found that the facility had the fire alarm system checked but failed to provide documentation that the smoke detectors sensitivity testing was done at the time of inspection. During an interview with Staff AA on 09/30/15 at 9:00 AM it was determined that the test had not been done or documented.

Based on document review and staff interview it was determined that the facility failed to perform the required sensitivity test for smoke detectors at least Bi-annually. This has a potential to affect all patients and visitors within the facility.

Findings include:

During document review on 09/29/15 it was found that the facility had the fire alarm system checked but failed to provide the documentation that the smoke detectors sensitivity testing was done at the time of the inspection. During an interview with Staff AA on 09/29/15 at 4:30 PM it was determined that the test had not been done or documented.

Based on document review and staff interview it was determined that the facility failed to perform the required sensitivity test for smoke detectors at least Bi-annually. This has the potential to affect all patients and visitors within the facility.

Findings include:

During document review on 09/29/15 it was found that the facility had the fire alarm system checked but failed to provide documentation that the smoke detectors sensitivity testing was done at the time of inspection. During an interview with Staff AA on 09/29/15 at 11:30 AM it was determined that the test had not been done or documented.

Based on observation and interview, the facility failed to ensure the sprinklers in its system were clean and items were at or greater than 18 inches beneath the sprinklers. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

1. On 09/29/15 at 8:36 AM the tour of the sixth floor of the main hospital was conducted with Staff QQ, MM, and TT. On 09/29/15 at 9:50 AM observation of supplies in the fully sprinklered galley revealed they were stacked to less than 12 inches from the ceiling. On 09/29/15 at 9:50 AM in an interview, Staff QQ confirmed the finding.

2. On 09/29/15 at 1:35 PM a tour was conducted of the fifth floor of the main building with Staff QQ, RR, and MM. On 09/29/15 at 3:58 PM observation of the sprinkler heads in the pharmacy student work area revealed them to be covered in dust such that the color of the bulb fluid was difficult to see. On 09/29/15 at 3:58 PM in an interview, Staff QQ confirmed the finding.

3. On 09/29/15 at 8:34 AM and on 09/30/15 at 10:56 AM a tour was conducted of the fourth floor main building with Staff QQ, RR, and MM.

a) On 09/29/15 at 8:44 AM observation of the sprinkler heads in room 4517 revealed two were missing escutcheon plates. On 09/29/15 at 8:44 AM in an interview, Staff QQ confirmed the finding.

b) On 09/30/15 at 1:05 PM the sprinkler heads in rooms 4464, 4466, and 4467 were observed to be covered in gossamer-like dust. On 09/30/15 at 1:05 PM in an interview, Staff QQ confirmed the finding.

c) On 09/29/15 at 9:37 AM the sprinkler head in room 4410 was observed to be covered in gossamer-like dust. On 09/29/15 at 9:37 AM in an interview, Staff QQ confirmed the finding.

4. On 09/30/15 at 1:35 PM a tour was conducted of the third floor of the main building with Staff QQ, RR, and MM.

a) On 09/30/15 at 2:29 PM a sprinkler head in room 3341 was observed to be covered in gossamer-like dust. On 09/30/15 at 2:29 PM in an interview, Staff QQ confirmed the finding.

b) On 09/30/15 at 4:16 PM observation of the sprinkler head in room 3324 revealed it to be covered in gossamer-like dust. On 09/30/15 at 4:16 PM in an interview, Staff QQ confirmed the finding.

c) On 09/30/15 at 4:22 PM observation of the sprinkler head in room 3334 revealed it to be covered in gossamer-like dust. On 09/30/15 at 4:22 PM in an interview, Staff QQ confirmed the finding.

5. On 10/01/15 at 8:15 AM a tour was conducted of the second floor with Staff QQ, RR, and MM. At 10:30 AM observation of the sprinkler head in room 2244 revealed it to be covered in gossamer-like dust. On 10/01/15 at 10:30 AM in an interview, Staff RR confirmed the finding.

6. On 10/06/15 at 8:35 AM a tour was conducted of the third floor of the northeast wing with Staff QQ, RR, and MM. At 8:45 AM observation of the sprinkler head in chute room 3467a revealed the bulb was covered in dust. On 10/06/15 at 8:45 AM in an interview, Staff QQ confirmed the finding.

7. On 10/06/15 at 9:01 AM a tour was taken of the sixth floor of the southwest development project building with Staff QQ, RR, and MM. At 10:41 AM observation of the lockers in locker room sw6595 revealed a row of lockers ran through the middle of the room and were 14 inches from the ceiling. The room was fully sprinklered. On 10/06/15 at 10:41 AM in an interview, Staff QQ confirmed the finding.

Based on observation, interview, and record review, the facility failed to maintain a water supply which provided continuous and adequate pressure to its sprinkler system. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

On 10/06/15 at 8:45 AM observation of a sprinkler system riser by chute room 3467a revealed a hydraulic nameplate that called for a residual pressure of 129.128.

On 10/06/15 a review of the facility's sprinkler system documentation was completed. The review of the main drain test for sprinkler system riser by chute room 3467 revealed the residual pressure was 100 psi, 29.128 psi less than called for by the nameplate.

On 10/06/15 at 3:45 PM Staff QQ and TT confirmed the documentation.

Based on observation and interview, the facility failed to deploy a class k fire extinguisher in accordance with NFPA 10 to the kitchen in its physician lounge. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

On 10/01/15 at 11:46 AM a tour was taken of the kitchen in the physician's lounge with Staff QQ, RR, and MM. At 11:46 AM a type k fire extinguisher was not observed near the cooking appliances that used combustible cooking substances.

On 10/01/15 at 11:46 AM in an interview, Staff QQ confirmed the finding.

Based on interview and record review, the facility failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

On 09/29/15 at 1:31 PM a tour was taken of the fifth floor with Staff QQ, RR, and MM. At 2:30 PM Staff QQ explained the unit on the east wing, because of the patients' compromised immune systems due to disease (the unit is used for bone marrow transplant patients), it has its own dedicated air handling system. Staff QQ also explained, unlike the bone marrow unit which is fully ducted, the nursing units with sleeping patients on the third, fourth, fifth and sixth floors had return air shafts (vertical openings) built between every two patient rooms.

Observation throughout the survey of these areas in the main building from 09/28/15 to 10/01/15 with Staff QQ, RR, and MM. revealed the air returned through a grill in the bathrooms of the patient rooms. Observation of these grills revealed they were in two hour protected construction and had a drop-down door on a fusible link.

On 10/06/15 at 3:40 PM Staff TT said he/she was unable to find any documentation for testing of the dampers on the air handler servicing the patients in the bone marrow unit. He/she did present documentation showing dampers operated by fusible link were tested 07/21/08 to 08/01/08, greater than six years ago. The documentation also showed fifteen percent were inaccessible. He/she was unable to say how the ones that were inaccessible were managed: i.e., eventually accessed, decommissioned, or completely removed.

Based on observation and interview, the facility failed to ensure its trash chutes discharged into a trash collection room protected in accordance with National Fire Protection Association 101, 8.4. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

On 10/01/15 at 11:33 AM observation of the door in the two hour construction protecting chute room mg436c revealed it did not have a rating. On 10/01/15 at 11:33 AM in an interview, Staff QQ confirmed the finding.

Based on observation, plan review, and staff interview it was determined that the facility failed to provide a separation from other occupants with a wall of at least a one hour fire resistance rating and failed to maintain the smoke barrier on a serviceable condition. This had the potential to affect all patients and visitors within the facility.
Findings include:
1. In review of the floor plans it was determined that the facility failed to be separated from tenants by a fire barrier with at least a one hour fire resistance rating. During the tour of the facility on 09/28/15 the finding was confirmed, and Staff AA during an interview also confirmed that a separation was not in place.

2. During the tour of the facility on 09/28/15 at 2:12 PM it was found that above the drop ceiling above the doorway to the emergency room, adjacent to the conference room, two pieces of ½ inch flexible conduit had wires passing through them that were not sealed at the opening. At the western double door entrance to the emergency room above the drop ceiling was found an area to the left over the delivery and storage room an approximately eight foot by three foot area not covered by dry wall. Additionally, there were two one inch holes right above the doorway with wires passing thru, were not sealed around the wires and two pieces of flexible conduit with wires passing through were not sealed at the openings. Plus, one ½ inch bear copper wire passing through a one inch hole in the dry wall was not sealed around the wire.

Based on observation and interview, the facility failed to ensure power strips were used in accordance with National Fire Protection Association 70, 1999 edition. This has the potential to affect all patients and visitors to the facility. The facility had a census of 569 patients.

Findings include:

1. On 09/30/15 at 1:35 PM a tour was conducted of the third floor of the main building with Staff QQ, RR, and MM. At 2:00 PM observation within office 3417 revealed one power strip with two receptacles in use, plugged into another power strip that had a microwave plugged into it, which then plugged into the wall. On 09/30/15 at 2:00 PM in an interview, Staff QQ confirmed the finding.

2. On 10/01/15 at 8:15 AM a tour was conducted of the second floor with Staff QQ, RR, and MM. At 8:52 AM observation in call room six revealed a power strip with two receptacles in use plugged into an extension cord. The extension cord receptacle was observed not to have a hole for the ground plug, and the ground plug to the power strip was observed to be wedged underneath the receptacle. On 10/01/15 at 8:52 AM in an interview, Staff QQ confirmed the finding.