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Based on observation and staff interview the facility failed to provide corridors that were resistant to the passage of smoke in accordance to NFPA 101 Section 19.3.6.2.2 as evidenced by the following item(s). This deficient practice could affect the patients in one of seven smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 11th, 2014 at 2:49 pm, it was observed that a hole, 6" in approximate size, was found in the wall behind the vending machine within the Administration waiting area. This corridor wall is not resistant to the passage of smoke in this condition.

This deficient practice was confirmed by observation and interview with Staff V (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide corridors openings that were resistant to the passage of smoke in accordance to NFPA 101 Section 19.3.6.3.1 as evidenced by the following item(s). This deficient practice could affect the patients in one of seven smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 11th, 2014 at 4:08 pm, it was observed that the paired doors into the corridor from the OB Suite are not equipped with an astragal at the meeting edge of these doors to resist the passage of smoke.

This deficient practice was confirmed by observation and interview with Staff V (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide and maintain the one-hour rated enclosures with 45-minute rated doors into hazardous areas per NFPA 101 [2000 Ed] Section 19.3.2.1 as evidenced by the following item(s). This deficient practice could affect the patients in one of seven smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 11th, 2014 at 3:45 pm, it was observed that the Pharmicists' office was greater than 100 square feet and being used for storage of a large quantity of combustibles. This space was not enclosed with one-hour walls and a 45-minute rated door with a closer. This former patient room was changed to an office function which now contains large amounts of combustibles making this space a hazardous room that should comply with new health care occupancy regulations.

2. On August 12th, 2014 at 8:09 am, it was observed within Film Storage, which is greater than 100 square feet, the following issues:
(a) Along the south wall, the gypsum wallboard did not extend to the floor deck above of the wall face within the soiled utility room and back corridor.
(b) The east, north and west walls have no tape and joint compound installed on the wall faces outside of this room. Both sides of a rated wall assembly shall have all taped joints covered with joint compound to meet the intended hourly rating.
(c) The west wall face, within Recovery, was not completely covered with gypsum wallboard along its entire length to the floor deck above.
(d) Within Film Storage, holes and penetrations and gaps at the top of the walls were not sealed with fire caulk to ensure a reliable one-hour fire rating.

3. On August 12th, 2014 at 9:23 am, it was observed within the Soiled Utility room of the OR suite that this space was not constructed to a one-hour fire barrier and had the following issues:
(a) The north, east and south walls are drywalled to the deck above yet no joints are taped and embedded in joint compound and screwheads were not covered with joint compound.
(b) The west wall of this one room was not drywalled to the deck above.
(c) The three doors into this room were not rated and the west and north door were not equipped with a door closer.

4. On August 12, 2014 at 8:40am, that the Soiled Utility room within the OB suite does not have the gypsum wallboard extending up to the floor deck above around the entire room. The room is not a enclosed with a one-hour fire barrier at present.

This deficient practice was confirmed by observation and interview with Staff V (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide corridors that were clear and unobstructed in accordance to NFPA 101 Section 19.2.3.3 as evidenced by the following item(s). This deficient practice could affect the patients in three of seven smoke compartments within the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 12th, 2014 at 10:01 am, it was observed that the corridor outside of the Maintenance office was being used for the storage of combustible items and a clear and unobstructed corridor was not being maintained.

This deficient practice was confirmed by observation and interview with Staff V (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide a sprinkler system that was installed in accordance to NFPA 13 - Installation of Sprinkler Systems [1999 Ed] as evidenced by the following item(s). This deficient practice could affect the patients in one of the seven smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 11th, 2014 at 2:35 pm, it was observed within the Administration suite, a closet has objects stored on shelves in two locations less than 18" below the ceiling that obstructed the discharge from the sprinkler head.

This deficient practice was confirmed by observation and interview with Staff V (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide a ventilation system that met code minimum standards as evidenced by the following item(s). This deficient practice could affect the patients in 4 of 7 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 11th, 2014 at 2:09 pm, it was observed that the corridor within the Med/Surg wing [First floor] of the hospital is being used as a return air plenum for the patient and ancillary rooms along this corridor. No ceiling height is available to install the ductwork to make this issue compliant with the codes.

2. On August 11th, 2014 at 2:13 pm, it was observed that the East and West wing [First floor] of the hospital patient rooms do not have any air changes provided from the ventilation system. No supply air is being provided to these rooms as well. No ceiling height is available to install new ductwork to alleviate this code violation.

3. On August 11th, 2014 at 2:43 pm, it was observed that an existing Patient room was converted to a Procedure room for colonoscopy exams. The toilet room function was switched to the decontamination/sterilizing space for the 'scopes' used in this procedure. The cleaned scopes are hung in a closet, not completely enclosed, that is open to the procedure room for drying. Air within the closet is allowed to mix with the air of the procedure room. The former toilet room had the door removed when the space changed functions; this allows the air within a 'dirty area' to mix freely with air within the procedure room. The existing ventilation had no changes made to the existing system when either space [patient room and toilet] changed the functions to a procedure room and decontamination/sterilizing space.

4. On August 12th, 2014 at 9:08 am, it was observed that both Operating rooms were observed to not have sufficient positive air movement from these spaces to their surroundings. The east OR had no positive pressure in relationship to the hall and the west OR had a negligible positive pressure to the hall.

This deficient practice was confirmed by observation and interview with Staff V (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide smoke barriers that were resistant to the passage of smoke in accordance to NFPA 101 Section 8.3.6 as evidenced by the following item(s). This deficient practice could affect the patients in two of seven smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 12th, 2014 at 10:47 am, it was observed that the ceiling within the ICU hand a 3" round penetration that was not sealed to resist the passage of smoke. This could affect the integrity of the smoke compartment between the first floor and second floor of this building.

This deficient practice was confirmed by observation and interview with Staff V (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide components within the means of egress to code minimum standards as evidenced by the following item(s). This deficient practice could affect the patients in 3 of 7 smoke compartments, as well as an undetermined number of visitors.

Findings include:
1. On August 11th, 2014 at 2:31 pm, it was observed during a tour of the facility that the required means of egress from the northeast door of Stair #3 had an elevation difference between two sections of the sidewalk that was measured at 2" of vertical rise. This does not meet Section 19.2.1 General and Section 7-1.6.2 of Chapter 7 Means of Egress.

This deficient practice was confirmed by observation and interview with Staff V (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide corridors that were resistant to the passage of smoke in accordance to NFPA 101 Section 19.3.6.2.2 as evidenced by the following item(s). This deficient practice could affect the patients in one of seven smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 11th, 2014 at 2:49 pm, it was observed that a hole, 6" in approximate size, was found in the wall behind the vending machine within the Administration waiting area. This corridor wall is not resistant to the passage of smoke in this condition.

This deficient practice was confirmed by observation and interview with Staff V (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide corridors openings that were resistant to the passage of smoke in accordance to NFPA 101 Section 19.3.6.3.1 as evidenced by the following item(s). This deficient practice could affect the patients in one of seven smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 11th, 2014 at 4:08 pm, it was observed that the paired doors into the corridor from the OB Suite are not equipped with an astragal at the meeting edge of these doors to resist the passage of smoke.

This deficient practice was confirmed by observation and interview with Staff V (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide and maintain the one-hour rated enclosures with 45-minute rated doors into hazardous areas per NFPA 101 [2000 Ed] Section 19.3.2.1 as evidenced by the following item(s). This deficient practice could affect the patients in one of seven smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 11th, 2014 at 3:45 pm, it was observed that the Pharmicists' office was greater than 100 square feet and being used for storage of a large quantity of combustibles. This space was not enclosed with one-hour walls and a 45-minute rated door with a closer. This former patient room was changed to an office function which now contains large amounts of combustibles making this space a hazardous room that should comply with new health care occupancy regulations.

2. On August 12th, 2014 at 8:09 am, it was observed within Film Storage, which is greater than 100 square feet, the following issues:
(a) Along the south wall, the gypsum wallboard did not extend to the floor deck above of the wall face within the soiled utility room and back corridor.
(b) The east, north and west walls have no tape and joint compound installed on the wall faces outside of this room. Both sides of a rated wall assembly shall have all taped joints covered with joint compound to meet the intended hourly rating.
(c) The west wall face, within Recovery, was not completely covered with gypsum wallboard along its entire length to the floor deck above.
(d) Within Film Storage, holes and penetrations and gaps at the top of the walls were not sealed with fire caulk to ensure a reliable one-hour fire rating.

3. On August 12th, 2014 at 9:23 am, it was observed within the Soiled Utility room of the OR suite that this space was not constructed to a one-hour fire barrier and had the following issues:
(a) The north, east and south walls are drywalled to the deck above yet no joints are taped and embedded in joint compound and screwheads were not covered with joint compound.
(b) The west wall of this one room was not drywalled to the deck above.
(c) The three doors into this room were not rated and the west and north door were not equipped with a door closer.

4. On August 12, 2014 at 8:40am, that the Soiled Utility room within the OB suite does not have the gypsum wallboard extending up to the floor deck above around the entire room. The room is not a enclosed with a one-hour fire barrier at present.

This deficient practice was confirmed by observation and interview with Staff V (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide corridors that were clear and unobstructed in accordance to NFPA 101 Section 19.2.3.3 as evidenced by the following item(s). This deficient practice could affect the patients in three of seven smoke compartments within the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 12th, 2014 at 10:01 am, it was observed that the corridor outside of the Maintenance office was being used for the storage of combustible items and a clear and unobstructed corridor was not being maintained.

This deficient practice was confirmed by observation and interview with Staff V (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide a sprinkler system that was installed in accordance to NFPA 13 - Installation of Sprinkler Systems [1999 Ed] as evidenced by the following item(s). This deficient practice could affect the patients in one of the seven smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 11th, 2014 at 2:35 pm, it was observed within the Administration suite, a closet has objects stored on shelves in two locations less than 18" below the ceiling that obstructed the discharge from the sprinkler head.

This deficient practice was confirmed by observation and interview with Staff V (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide a ventilation system that met code minimum standards as evidenced by the following item(s). This deficient practice could affect the patients in 4 of 7 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 11th, 2014 at 2:09 pm, it was observed that the corridor within the Med/Surg wing [First floor] of the hospital is being used as a return air plenum for the patient and ancillary rooms along this corridor. No ceiling height is available to install the ductwork to make this issue compliant with the codes.

2. On August 11th, 2014 at 2:13 pm, it was observed that the East and West wing [First floor] of the hospital patient rooms do not have any air changes provided from the ventilation system. No supply air is being provided to these rooms as well. No ceiling height is available to install new ductwork to alleviate this code violation.

3. On August 11th, 2014 at 2:43 pm, it was observed that an existing Patient room was converted to a Procedure room for colonoscopy exams. The toilet room function was switched to the decontamination/sterilizing space for the 'scopes' used in this procedure. The cleaned scopes are hung in a closet, not completely enclosed, that is open to the procedure room for drying. Air within the closet is allowed to mix with the air of the procedure room. The former toilet room had the door removed when the space changed functions; this allows the air within a 'dirty area' to mix freely with air within the procedure room. The existing ventilation had no changes made to the existing system when either space [patient room and toilet] changed the functions to a procedure room and decontamination/sterilizing space.

4. On August 12th, 2014 at 9:08 am, it was observed that both Operating rooms were observed to not have sufficient positive air movement from these spaces to their surroundings. The east OR had no positive pressure in relationship to the hall and the west OR had a negligible positive pressure to the hall.

This deficient practice was confirmed by observation and interview with Staff V (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide smoke barriers that were resistant to the passage of smoke in accordance to NFPA 101 Section 8.3.6 as evidenced by the following item(s). This deficient practice could affect the patients in two of seven smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 12th, 2014 at 10:47 am, it was observed that the ceiling within the ICU hand a 3" round penetration that was not sealed to resist the passage of smoke. This could affect the integrity of the smoke compartment between the first floor and second floor of this building.

This deficient practice was confirmed by observation and interview with Staff V (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide components within the means of egress to code minimum standards as evidenced by the following item(s). This deficient practice could affect the patients in 3 of 7 smoke compartments, as well as an undetermined number of visitors.

Findings include:
1. On August 11th, 2014 at 2:31 pm, it was observed during a tour of the facility that the required means of egress from the northeast door of Stair #3 had an elevation difference between two sections of the sidewalk that was measured at 2" of vertical rise. This does not meet Section 19.2.1 General and Section 7-1.6.2 of Chapter 7 Means of Egress.

This deficient practice was confirmed by observation and interview with Staff V (Facilities Director) at the time of discovery.