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Based on observations and interview, the facility has failed to maintain 2 of several smoke/fire barrier doors in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.7.5. This deficient practice could affect 40 of 406 patients as well as an undetermined number of staff, and visitors by allowing smoke to propagate from one smoke compartment to another.


Findings include:

On facility tour between 10:00 a.m. on 09/19/2016 and 4:00 p.m. on 09/21/2016, observation revealed that The following deficient conditions were found affecting the facility's smoke barrier doors:

1. The smoke barrier door H0024 did not positively latch into the door frame when tested.
2. Smoke barrier door W0700 in the Main Hospital West did not fully close and positively latch into the frame when tested.


This deficient condition was verified by Maintenance Staff.

Based on observation and staff interview, the facility failed to provide a means of egress in accordance with the following requirements of the NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 18.2.1. This deficient practice could affect 20 of 406 patients, as well as an undetermined number of staff, and visitors.

Findings include:

On facility tour between 10:00 a.m. on 09/19/2016 and 4:00 p.m. on 09/21/2016, Observation revealed that the secondary exit door out of the mechanical room located on the lower level of the Heart Hospital was blocked by a chair and a ladder.


This deficient condition was verified by Maintenance Staff.

Based on observations and an interview with staff, the facility has failed to ensure that emergency lighting has been tested and maintained in accordance with NFPA 110 Standard for Emergency and Standby Power Systems (99) section 3-1 and the NFPA 101 "The Life Safety Code" 2000 edition (LSC) sections 7.9.3, and 19.2.9.1. This deficient practice could affect 3 of 406 patients and an undetermined number of staff in the event of an emergency evacuation during a power outage.

Findings include:

On facility tour between 10:00 a.m. on 09/19/2016 and 4:00 p.m. on 09/21/2016, observations revealed the there are 3 operating rooms that are located in the Piper building that are not equipped with battery backup emergency lighting.


This deficient condition was verified by Maintenance Staff.

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of the NFPA 101 "The Life Safety Code" 2000 edition (LSC) Sections 18.3.4., and 9.6, as well as 1999 NFPA 72, Sections 7.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting 100 of 406 patients as well as an undetermined number of staff, and visitors to the facility.

Findings include:

On facility tour between 10:00 a.m. on 09/19/2016 and 4:00 p.m. on 09/21/2016, observation revealed that the fire alarm panel that is located in the lower level fire alarm room of the Heart Hospital was indicating that the system was in trouble and that the system was partially shut down.


This deficient condition was verified by Maintenance Staff.

Based on documentation review and staff interview, it was determined that the facility failed to maintain portable fire extinguishers in accordance with the NFPA 101 "The Life Safety Code" 2000 edition (LSC) sections 9.7.3.2, 19.3.5.6 and the NFPA 10 "Standard for Portable Fire Extinguishers" 1998 edition, section 1-6.6. This deficient practice could affect 10 of 42 residents, as well as an undetermined number of staff, and visitors.



Findings include:

On facility tour between 10:00 a.m. on 09/19/2016 and 4:00 p.m. on 09/21/2016, observation and staff interviews revealed that the following deficient conditions were found affecting the fire extinguishers located within the facility:

1. The fire extinguisher that is located on the second floor data room 216 of the Main Hospital East was on the floor and not mounted to the wall.

2. The fire extinguishers that were located in the kitchen were only rated for cooking grease fires and not for ordinary combustibles and electrical fires (no ABC fire extinguishers were found in the kitchen area)


This deficient condition was verified by Maintenance Staff.

Based on observations the facility failed to keep the means of egress continuous and free of all obstructions or impediments to full instant use in the case of fire or other emergency, in accordance with NFPA Life Safety Code 101 (2000 edition) Chapter 7, Section 7.1.10. These obstructions could interfere with the convenient and effective removal patients, as well as an undetermined number of staff and visitors in an emergency situation, and impede fire fighting operations during a fire emergency.


Findings include:

On facility tour between 10:00 a.m. on 09/19/2016 and 4:00 p.m. on 09/21/2016, during a fire drill that was conducted on 09/20/2016 in the Heart Hospital it was found that staff failed to maintain the corridors clear of obstructions to egress by not removing an empty patient bed and housekeeping carts from the 5th floor corridor.


This deficient condition was verified by Maintenance Staff.

Based on observations and staff interview, the facility has failed to store large trash and linen carts in properly protected rooms in accordance with the NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.7.5.5. This deficient practice could affect the safety of 20 of 406 patients and an undetermined number of staff if smoke or fire from one of these carts rendered the corridors untenable.

Findings include:

On facility tour between 10:00 a.m. on 09/19/2016 and 4:00 p.m. on 09/21/2016, it was found that the facility was storing a wheeled soiled linen bin that has a capacity that is greater than 32 gallons the corridor that is located in the surgical core of the Main Hospital East Building. and not in the required hazardous storage areas.


This deficient condition was verified by Maintenance Staff.

Based on observations and interview, the facility has failed to maintain 2 of several smoke/fire barrier doors in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.7.5. This deficient practice could affect 40 of 406 patients as well as an undetermined number of staff, and visitors by allowing smoke to propagate from one smoke compartment to another.


Findings include:

On facility tour between 10:00 a.m. on 09/19/2016 and 4:00 p.m. on 09/21/2016, observation revealed that The following deficient conditions were found affecting the facility's smoke barrier doors:

1. The smoke barrier door H0024 did not positively latch into the door frame when tested.
2. Smoke barrier door W0700 in the Main Hospital West did not fully close and positively latch into the frame when tested.


This deficient condition was verified by Maintenance Staff.

Based on observation and staff interview, the facility failed to provide a means of egress in accordance with the following requirements of the NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 18.2.1. This deficient practice could affect 20 of 406 patients, as well as an undetermined number of staff, and visitors.

Findings include:

On facility tour between 10:00 a.m. on 09/19/2016 and 4:00 p.m. on 09/21/2016, Observation revealed that the secondary exit door out of the mechanical room located on the lower level of the Heart Hospital was blocked by a chair and a ladder.


This deficient condition was verified by Maintenance Staff.

Based on observations and an interview with staff, the facility has failed to ensure that emergency lighting has been tested and maintained in accordance with NFPA 110 Standard for Emergency and Standby Power Systems (99) section 3-1 and the NFPA 101 "The Life Safety Code" 2000 edition (LSC) sections 7.9.3, and 19.2.9.1. This deficient practice could affect 3 of 406 patients and an undetermined number of staff in the event of an emergency evacuation during a power outage.

Findings include:

On facility tour between 10:00 a.m. on 09/19/2016 and 4:00 p.m. on 09/21/2016, observations revealed the there are 3 operating rooms that are located in the Piper building that are not equipped with battery backup emergency lighting.


This deficient condition was verified by Maintenance Staff.

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of the NFPA 101 "The Life Safety Code" 2000 edition (LSC) Sections 18.3.4., and 9.6, as well as 1999 NFPA 72, Sections 7.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting 100 of 406 patients as well as an undetermined number of staff, and visitors to the facility.

Findings include:

On facility tour between 10:00 a.m. on 09/19/2016 and 4:00 p.m. on 09/21/2016, observation revealed that the fire alarm panel that is located in the lower level fire alarm room of the Heart Hospital was indicating that the system was in trouble and that the system was partially shut down.


This deficient condition was verified by Maintenance Staff.

Based on documentation review and staff interview, it was determined that the facility failed to maintain portable fire extinguishers in accordance with the NFPA 101 "The Life Safety Code" 2000 edition (LSC) sections 9.7.3.2, 19.3.5.6 and the NFPA 10 "Standard for Portable Fire Extinguishers" 1998 edition, section 1-6.6. This deficient practice could affect 10 of 42 residents, as well as an undetermined number of staff, and visitors.



Findings include:

On facility tour between 10:00 a.m. on 09/19/2016 and 4:00 p.m. on 09/21/2016, observation and staff interviews revealed that the following deficient conditions were found affecting the fire extinguishers located within the facility:

1. The fire extinguisher that is located on the second floor data room 216 of the Main Hospital East was on the floor and not mounted to the wall.

2. The fire extinguishers that were located in the kitchen were only rated for cooking grease fires and not for ordinary combustibles and electrical fires (no ABC fire extinguishers were found in the kitchen area)


This deficient condition was verified by Maintenance Staff.

Based on observations the facility failed to keep the means of egress continuous and free of all obstructions or impediments to full instant use in the case of fire or other emergency, in accordance with NFPA Life Safety Code 101 (2000 edition) Chapter 7, Section 7.1.10. These obstructions could interfere with the convenient and effective removal patients, as well as an undetermined number of staff and visitors in an emergency situation, and impede fire fighting operations during a fire emergency.


Findings include:

On facility tour between 10:00 a.m. on 09/19/2016 and 4:00 p.m. on 09/21/2016, during a fire drill that was conducted on 09/20/2016 in the Heart Hospital it was found that staff failed to maintain the corridors clear of obstructions to egress by not removing an empty patient bed and housekeeping carts from the 5th floor corridor.


This deficient condition was verified by Maintenance Staff.

Based on observations and staff interview, the facility has failed to store large trash and linen carts in properly protected rooms in accordance with the NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.7.5.5. This deficient practice could affect the safety of 20 of 406 patients and an undetermined number of staff if smoke or fire from one of these carts rendered the corridors untenable.

Findings include:

On facility tour between 10:00 a.m. on 09/19/2016 and 4:00 p.m. on 09/21/2016, it was found that the facility was storing a wheeled soiled linen bin that has a capacity that is greater than 32 gallons the corridor that is located in the surgical core of the Main Hospital East Building. and not in the required hazardous storage areas.


This deficient condition was verified by Maintenance Staff.