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Based on visual verification of the facility's two hour fire separation and staff verification it was determined this facility failed to ensure the common wall separating the nonconforming buildings was constructed with at least a two hour fire resistance rating. This had the potential to affect all those utilizing this area of the facility. The facility's census at the start of the survey was 156.

Findings include:

Tour of the facility took place on 08/11/10 through 08/14/10 with Staff members 1, 2, 3 and 4. During tour of the common wall in the corridor near the vending machines which separates the Prospect building from the cardiac building, observation was made above the double doors and ceiling tile, of three penetrations located around some wires.

This finding was verified by Staff member 3 during tour of the common wall on 08/14/10.

Based on observation during tour and staff verification it was determined this facility failed to ensure the vertical openings were constructed to provide at least a two hour fire resistance rating. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 156.

Findings include:

Tour of the facility took place on 08/11/10 through 08/14/10 with Staff members 1, 2, 3 and 4. During tour of the vertical openings, observation was made of one door in stairwell number six located on the second floor which lacked a fire resistance rating label.

This finding was verified by all staff present during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed to provide at least a one hour fire resistance rating. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 28.

Findings include:

Tour of the facility took place on 08/14/10 with Staff members 1, 4, 7, 8 and 9. During tour of the smoke/fire barriers, observation was made of penetrations through the barrier located above the ceiling tiles in the following location:

*Above the double doors located between the physical therapy exam rooms, an unsealed insulated line was observed penetrating through the block wall.

This finding was verified by Staff member 8 during tour on 08/14/10.

Based on observation during tour and staff verification it was determined this facility failed to ensure the fire/smoke barriers were constructed to provide at least a one hour fire resistance rating. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 156.

Findings include:


Tour of the facility took place on 08/11/10 through 08/14/10 with Staff members 1, 2, 3 and 4. During tour of the smoke/fire barriers, observation was made of several penetrations through the barrier located above the ceiling tiles in the following location:


First floor:
*Within the behavioral exam room, above the ceiling tile of the east wall, one round penetration and four, four inch conduits were observed to be sealed improperly.
*Within the hyperbaric room, observation was made of two penetrations in the south wall, one of which was located under a duct and the other was an approximate 18 by one half inch long penetration located to the right of a steel column where the drywall meets the upper deck.

These findings were verified by Staff member 3 during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed to provide at least a one hour fire resistance rating. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 156.

Findings include:

Tour of the facility took place on 08/11/10 through 08/14/10 with Staff members 1, 2, 3 and 4. During tour of the smoke/fire barriers, observation was made of several penetrations through the barrier located above the ceiling tiles in the following locations:

First floor:
*Within the cancer center file room, five penetrations were observed in the north, south and west walls.
*Near the elevators located outside of the southeast section of the radiology department and by the electric panel labeled as E1A, observation was made above the double doors and ceiling tile of unsealed penetrations and unsealed wires.
*Within the emergency room class room observation was made of an unrated window measuring approximately five by one feet.

Second floor:
*Multiple unsealed conduits located above the double doors to the left of stairwell number six.
*Within the surgical scheduler's office, the back wall was observed to have a one foot by six inch opening, one open end conduit and a two and a half inch unsealed penetration.
*Within the assistant director's office, observation was made of a large unsealed opening in the back wall.
*From the corridor side above the double doors leading into the sterile supply, observation was made of a two by four inch opening and from within the sterile room an approximate twelve by eighteen inch opening was observed.
*South of the elevators located in the recovery area, observation was made of three one by three inch unsealed openings with conduits passing through, one unsealed six inch sprinkler line and an approximate two foot section of unsealed corrugated upper deck.
*Above the door of the soiled utility room across from room P7, one open end conduit, one three inch round hole and a four inch square hole was observed.
*Within the main operating room corridor, north wall across from the elevators, observation was made of one open end conduit and a two by four inch penetration.
*Above the east surgery entrance doors across from phase one recovery, observation was made of one unsealed square channel penetrating the barrier.
*Within the same barrier just left to the above mentioned surgery doors one open end conduit and one round hole was observed.
*Observation was made of an approximate two by two foot opening located above the ceiling tile across from the physician's work room.
*Above the kitchen double doors observation was made of two unsealed flex conduits and one open end conduit.
*Just to the left of the kitchen doors, one open end conduit was observed.
*Within the cafe lobby area and above the fire strobe light, one open end conduit was observed.

Third floor:
*From within room 3115A, two open end conduits was observed in the south wall and a one inch square penetration was observed in the west wall.
*The north wall within the examination room had two open end conduits and one unsealed water line.
*The staff restroom across from the nurse director's office has a four by two inch penetration and penetrations around the metal studs.
*At the east end of the bridge deck and above the doors, observation was made of a three foot by one quarter inch gap between the drywall and a metal stud. Additionally, observation was made of two four inch conduits that had penetrations around them.

Fourth floor:
*West of room 4226 and east of the double doors, observation was made of three penetrations and two open end conduits.
*Just around from stairwell number six and by the physical therapy entrance, four penetrations was observed which appeared to have the expandable spray foam insulation in them.
*West wall of the equipment room number 4107A was observed to have a one inch hole. Additionally, the south wall was observed to have two open end conduits.

These findings were verified by staff member 3 during tour from 08/11/10 to 08/14/10.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke/fire barriers were constructed to provide at least a one hour fire resistance rating. This had the potential to affect all those utilizing this facility. The patient census at the time of the survey was zero.

Findings include:

Tour of the facility took place on 08/14/10 with Staff members 1, 4, 7, 8 and 9. During tour of the smoke/fire barriers, observation was made of penetrations through the barrier located above the ceiling tiles in the following locations:

First floor:
*Within the marketing department office four penetrations were observed on the north wall.
*From the "ramp" side from the main entrance, being the back wall of the marketing department, a one and half inch open end conduit was observed.

These findings were verified by Staff member 8 during tour on 08/14/10.

Based on observation during tour and staff verification it was determined this facility failed to ensure the door openings in the two hour fire rated smoke/fire occupancy separation complied with the required fire rating of the doors and that they were equipped with an automatic or self closing device. This had the potential to affect all those utilizing this facility. The patient census at the time of the survey was zero.

Findings include:

Tour of the facility took place on 08/14/10 with Staff members 1, 4, 7, 8 and 9. During tour of the two hour fire rated smoke/fire occupancy separation, observation was made two doors in the marketing department office which lacked the appropriate fire resistance rating and the automatic or self closing devices.

These findings were verified by all staff present during tour on 08/14/10.

Based on observation of smoke/fire barrier doors and staff verification, it was determined this facility failed to ensure all smoke/fire doors closed and latched properly, were equipped with a fire resistance rating and all fire resistance rating labels were able to be visually verified. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 156.

Findings include:

Tour of the facility took place on 08/11/10 through 08/14/10 with Staff members 1, 2, 3 and 4. During tour observation was made of several doors that failed to have a fire resistance label that could be visually verified, doors in smoke/fire barriers that closed properly or doors that lacked a fire resistance label in the following areas:

First floor:
*Fire/smoke doors in the emergency department by bay number four was observed to have a gap greater than one eighth inch between the door panels when in the closed position.
*Several doors throughout the fire/smoke barriers was observed to have the fire resistance rating tag painted over and they were unable to be verified until the paint was removed.

Second floor:
*Fire/smoke doors in the cafe/lobby area was observed to have a gap greater than one eighth inch between the door panels when in the closed position.
*The door leading into the sterile processing decontamination room lacked a one hour fire rating label.
*Double doors of the bridge deck leading to 4 north was observed to have a gap greater than one eighth inch between the door panels when in the closed position.
*Several doors throughout the fire/smoke barriers was observed to have the fire resistance rating tag painted over and they were unable to be verified until the paint was removed.

These findings was verified by all staff present during tour.

Based on observation of smoke/fire barrier doors and staff verification, it was determined this facility failed to ensure all smoke/fire doors closed and latched properly, were equipped with a fire resistance rating and all fire resistance rating labels were able to be visually verified. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 156.

Findings include:

Tour of the facility took place on 08/11/10 through 08/14/10 with Staff members 1, 2, 3 and 4. During tour observation was made of two doors that failed to have a fire resistance label or positive latch shut in the following areas:

First floor:
*Within the behavioral health department, observation was made of a door in the two hour fire barrier leading into the kitchenette which lacked a fire resistance rating.
*The multipurpose room double doors located in the two hour fire barrier failed to positive latch shut.

These findings were verified by Staff member 3 during tour.

Based on observation of smoke/fire barrier doors and staff verification, it was determined this facility failed to ensure all smoke/fire doors were equipped with a fire resistance rating identification tag in order to visually verify the fire resistance rating of the door. This had the potential to affect all those utilizing this facility. The average patient census at the beginning of the survey was 25.

Findings include:
Tour of the facility took place on 08/14/10 with Staff members 1, 4, 7, 8 and 9. During tour of the two hour fire rated smoke/fire barriers, observation was made of the door which separated the rehab facility from another occupancy. This door lacked a fire resistance rating identification tag so verification of its fire resistance rating was not able to be confirmed.

This finding was verified by all staff present during tour on 08/14/10.

Based on observation during tour and staff verification it was determined this facility failed to ensure the hazardous areas were constructed to provide at least a one hour fire resistance rating and all doors are equipped with a self or automatic closing device. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 156.

Findings include:

Tour of the facility took place on 08/11/10 through 08/14/10 with Staff members 1, 2, 3 and 4. During tour of the hazardous areas, observation was made of several penetrations through the barrier located above the ceiling tiles and doors which lacked a fire resistance label in the following locations:

First floor:
*The soiled utility room door across from the cardiac rehab back door, lacked a fire resistance label.
*Within the soiled room by the charge specialist's office, observation was made of one open end conduit, one unsealed vent and another small unsealed penetration.
*The soiled utility room located within the emergency department next to GYN room number one was observed to lack drywall extending to the upper deck on the north, south and west walls.

Second floor:
*Within the soiled utility room of the west corridor of the kitchen, observation was made of five unsealed conduits.
*Within the air handling units in the cafe, one open end conduit was observed in the west wall.

Third floor:
*Soiled utility room across from room number 3316 lacked a self or automatic closing device.
*Four unsealed corrugated areas were observed where the drywall meets the upper deck in soiled room number 3016.

Fourth floor:
*Within the storage room across from room number 4017, observation was made of two open end conduits in the south wall, three unsealed conduits in the north wall and one unsealed conduit in the east wall.
*Within soiled utility room number 4107B, observation was made of three penetrations in the west wall and one penetration in the east wall. Three of four penetrations are open end conduits.
*Within the soiled utility room across from stairwell number 7, observation was made of three open end conduits and unsealed red wires.

Additionally, several doors throughout the hazardous areas was observed to have the fire resistance rating tag painted over and they were unable to be verified until the paint was removed.


These findings were verified by staff member 3 during tour of the facility.

Based on observation during tour and staff verification it was determined this facility failed to ensure all exit discharges were arranged to have the required lighting so as to never leave the area in darkness. This had the potential to affect all persons that utilize this area. The patient census at the beginning of the survey was 156.

Findings include:

Tour of the facility took place on 08/11/10 through 08/14/10 with Staff members 1, 2, 3 and 4. During tour of the exit discharges, observation was made of two exit discharges from the cath lab area, one of which lacked a light bulb in the one and only fixture located above the exit discharge door and the other which lacked any fixture at all.

This finding was verified by Staff members 1 and 4 during tour.

Based on observation and staff verification it was determined this facility failed to respond correctly to a fire alarm regarding the procedure of closing all patient room and corridor doors. This had the potential to affect all those who were present during the drill on that particular unit. The patient census was 156 at the beginning of the survey.

Findings include:

During tour of one of the nursing units on 08/11/10 a fire alarm was activated at 10:55 AM and an overhead page was heard announcing a problem in the MRI unit on the first floor. The staff began to close the corridor and patient room doors. After a few minutes and during the active fire alarm, this surveyor toured the wing and observation was made of four patient/corridor doors left open. The door to patient room 4019 was wide open three minutes after the alarm sounded. The directors door was ajar about one foot. The alarm was silenced at 10:59 AM. This surveyor continued around the corridor and made additional observations of a charting room door and a patient/family waiting room door left wide open. Observation was made of two people in the waiting room. Code red "all clear" was not sounded until 11:03 AM after these observations were made. Staff member 4 accompanied this surveyor during the active fire alarm and verified the four doors which were left open.

Based on automatic sprinkler system documentation review and staff verification it was determined this facility failed to ensure the automatic sprinkler system was inspected quarterly as required by the National Fire Protection Agency (NFPA) 25. This had the potential to affect all those utilizing this facility.

Findings include:

Documentation review for the sprinkler system took place on 08/10/10 with Staff number 1. During review observation was made of only one automatic sprinkler system test performed in 2010 by a professional outside company. A request was made from Staff member 1 for additional quarterly sprinkler system tests and Staff member 1 stated they were not aware a business occupancy had to have the sprinkler system checked quarterly.

Based on observation during tour and staff verification it was determined this facility failed to ensure the automatic sprinkler system was continuously maintained in regards to the dust on the sprinkler heads. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 156.

Findings include:

Tour of the facility took place on 08/11/10 to 08/14/10 with Staff numbers 1, 2, 3 and 4. During the tour observation was made of several sprinkler heads that were coated with dust in the following areas:

First floor:
*Within the radiology department.

Second floor:
*Within the kitchen area.

Fourth floor:
*Near room 4225
*Within the dark room

These findings were verified by all staff during tour.

Based on relative humidity (RH) documentation review and staff verification it was determined this facility failed to ensure the RH level was maintained in all operating rooms at the required 35% when in use. This had the potential to affect all those utilizing the operating rooms. The facility census was 156 at the beginning of the survey.

Findings include:

Review of the RH documentation took place on 08/10/10 with staff number 1. During review of the RH levels for eleven operating rooms observation was made of the RH levels being below the required 35% on multiple occasions in one or more operating rooms from December 2009 through February 2010. At times the RH levels were documented as being below 26%.

This finding was verified by Staff member 1 during review of the RH documentation.

Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The patient census was 156 at the time of the survey.

Findings include:

Tour of the facility took place on 08/11/10 to 08/14/10 with the Staff members 1, 2, 3 and 4. During the tour observation was made of several smoke detectors which were located near air flow devices in the following areas:

First floor:
*Within the corridor north of the behavioral health department by the mechanical room.
*Within the main lobby corridor.
*Beside stairwell number 7.
*Within the radiology control room.
*Soiled utility room left of GYN room number 1
*Within the emergency department class room.
*Within the security office.
*Near elevator number 22 by the gift shop storage.

Second floor:
*Within the Mylander conference room.
*Within the pharmacy break area.

Third floor:
*Within the labor and delivery room.
*By the vent next to the electrical room and room number 3319.
*Within soiled utility room 3016.

Fourth floor:
*Within soiled utility room 4107B.
*By stairwell number 5.
*By elevator number 3.
*By nurse's station in 4 west.
*By the janitor/clean utility room of 4 west.
*In office across from stair number 7 of 4 west.
*Within rooms numbers 4302 through 4316 of 4 west.

These findings were verified by Staff members 1, 2, 3 and 4 during tour.

Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The patient census was 25 at the time of the survey.

Findings include:

Tour of the facility took place on 08/14/10 with Staff members 1, 4, 7, 8 and 9. During tour of the rehab department, observation was made of five smoke detectors mounted within several inches of an air flow device in the following locations:

*In the corridor by rooms 2-051, 2-041, 2-021, 2-001 and 2-004.


This finding was verified by all staff members present during tour on 08/14/10.

Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The patient census was 28 at the time of the survey.

Findings include:

Tour of the facility took place on 08/14/10 with Staff members 1, 4, 7, 8 and 9. During tour of the outpatient rehab department, observation was made of two smoke detectors mounted within several inches of an air flow device in the following locations:

*In the corridor by the physical therapy gym and another by the physical therapy treatment room.


This finding was verified by all staff members present during tour on 08/14/10.

Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The patient census was zero at the time of the survey.

Findings include:

Tour of the facility took place on 08/14/10 with Staff members 1, 4, 7, 8 and 9. During tour of the marketing department office, observation was made of a smoke detector mounted within several inches of an air flow device.

This finding was verified by all staff members present during tour on 08/14/10.

Based on visual verification of the facility's two hour fire separation and staff verification it was determined this facility failed to ensure the common wall separating the nonconforming buildings was constructed with at least a two hour fire resistance rating. This had the potential to affect all those utilizing this area of the facility. The facility's census at the start of the survey was 156.

Findings include:

Tour of the facility took place on 08/11/10 through 08/14/10 with Staff members 1, 2, 3 and 4. During tour of the common wall in the corridor near the vending machines which separates the Prospect building from the cardiac building, observation was made above the double doors and ceiling tile, of three penetrations located around some wires.

This finding was verified by Staff member 3 during tour of the common wall on 08/14/10.

Based on observation during tour and staff verification it was determined this facility failed to ensure the vertical openings were constructed to provide at least a two hour fire resistance rating. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 156.

Findings include:

Tour of the facility took place on 08/11/10 through 08/14/10 with Staff members 1, 2, 3 and 4. During tour of the vertical openings, observation was made of one door in stairwell number six located on the second floor which lacked a fire resistance rating label.

This finding was verified by all staff present during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed to provide at least a one hour fire resistance rating. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 28.

Findings include:

Tour of the facility took place on 08/14/10 with Staff members 1, 4, 7, 8 and 9. During tour of the smoke/fire barriers, observation was made of penetrations through the barrier located above the ceiling tiles in the following location:

*Above the double doors located between the physical therapy exam rooms, an unsealed insulated line was observed penetrating through the block wall.

This finding was verified by Staff member 8 during tour on 08/14/10.

Based on observation during tour and staff verification it was determined this facility failed to ensure the fire/smoke barriers were constructed to provide at least a one hour fire resistance rating. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 156.

Findings include:


Tour of the facility took place on 08/11/10 through 08/14/10 with Staff members 1, 2, 3 and 4. During tour of the smoke/fire barriers, observation was made of several penetrations through the barrier located above the ceiling tiles in the following location:


First floor:
*Within the behavioral exam room, above the ceiling tile of the east wall, one round penetration and four, four inch conduits were observed to be sealed improperly.
*Within the hyperbaric room, observation was made of two penetrations in the south wall, one of which was located under a duct and the other was an approximate 18 by one half inch long penetration located to the right of a steel column where the drywall meets the upper deck.

These findings were verified by Staff member 3 during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed to provide at least a one hour fire resistance rating. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 156.

Findings include:

Tour of the facility took place on 08/11/10 through 08/14/10 with Staff members 1, 2, 3 and 4. During tour of the smoke/fire barriers, observation was made of several penetrations through the barrier located above the ceiling tiles in the following locations:

First floor:
*Within the cancer center file room, five penetrations were observed in the north, south and west walls.
*Near the elevators located outside of the southeast section of the radiology department and by the electric panel labeled as E1A, observation was made above the double doors and ceiling tile of unsealed penetrations and unsealed wires.
*Within the emergency room class room observation was made of an unrated window measuring approximately five by one feet.

Second floor:
*Multiple unsealed conduits located above the double doors to the left of stairwell number six.
*Within the surgical scheduler's office, the back wall was observed to have a one foot by six inch opening, one open end conduit and a two and a half inch unsealed penetration.
*Within the assistant director's office, observation was made of a large unsealed opening in the back wall.
*From the corridor side above the double doors leading into the sterile supply, observation was made of a two by four inch opening and from within the sterile room an approximate twelve by eighteen inch opening was observed.
*South of the elevators located in the recovery area, observation was made of three one by three inch unsealed openings with conduits passing through, one unsealed six inch sprinkler line and an approximate two foot section of unsealed corrugated upper deck.
*Above the door of the soiled utility room across from room P7, one open end conduit, one three inch round hole and a four inch square hole was observed.
*Within the main operating room corridor, north wall across from the elevators, observation was made of one open end conduit and a two by four inch penetration.
*Above the east surgery entrance doors across from phase one recovery, observation was made of one unsealed square channel penetrating the barrier.
*Within the same barrier just left to the above mentioned surgery doors one open end conduit and one round hole was observed.
*Observation was made of an approximate two by two foot opening located above the ceiling tile across from the physician's work room.
*Above the kitchen double doors observation was made of two unsealed flex conduits and one open end conduit.
*Just to the left of the kitchen doors, one open end conduit was observed.
*Within the cafe lobby area and above the fire strobe light, one open end conduit was observed.

Third floor:
*From within room 3115A, two open end conduits was observed in the south wall and a one inch square penetration was observed in the west wall.
*The north wall within the examination room had two open end conduits and one unsealed water line.
*The staff restroom across from the nurse director's office has a four by two inch penetration and penetrations around the metal studs.
*At the east end of the bridge deck and above the doors, observation was made of a three foot by one quarter inch gap between the drywall and a metal stud. Additionally, observation was made of two four inch conduits that had penetrations around them.

Fourth floor:
*West of room 4226 and east of the double doors, observation was made of three penetrations and two open end conduits.
*Just around from stairwell number six and by the physical therapy entrance, four penetrations was observed which appeared to have the expandable spray foam insulation in them.
*West wall of the equipment room number 4107A was observed to have a one inch hole. Additionally, the south wall was observed to have two open end conduits.

These findings were verified by staff member 3 during tour from 08/11/10 to 08/14/10.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke/fire barriers were constructed to provide at least a one hour fire resistance rating. This had the potential to affect all those utilizing this facility. The patient census at the time of the survey was zero.

Findings include:

Tour of the facility took place on 08/14/10 with Staff members 1, 4, 7, 8 and 9. During tour of the smoke/fire barriers, observation was made of penetrations through the barrier located above the ceiling tiles in the following locations:

First floor:
*Within the marketing department office four penetrations were observed on the north wall.
*From the "ramp" side from the main entrance, being the back wall of the marketing department, a one and half inch open end conduit was observed.

These findings were verified by Staff member 8 during tour on 08/14/10.

Based on observation during tour and staff verification it was determined this facility failed to ensure the door openings in the two hour fire rated smoke/fire occupancy separation complied with the required fire rating of the doors and that they were equipped with an automatic or self closing device. This had the potential to affect all those utilizing this facility. The patient census at the time of the survey was zero.

Findings include:

Tour of the facility took place on 08/14/10 with Staff members 1, 4, 7, 8 and 9. During tour of the two hour fire rated smoke/fire occupancy separation, observation was made two doors in the marketing department office which lacked the appropriate fire resistance rating and the automatic or self closing devices.

These findings were verified by all staff present during tour on 08/14/10.

Based on observation of smoke/fire barrier doors and staff verification, it was determined this facility failed to ensure all smoke/fire doors closed and latched properly, were equipped with a fire resistance rating and all fire resistance rating labels were able to be visually verified. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 156.

Findings include:

Tour of the facility took place on 08/11/10 through 08/14/10 with Staff members 1, 2, 3 and 4. During tour observation was made of several doors that failed to have a fire resistance label that could be visually verified, doors in smoke/fire barriers that closed properly or doors that lacked a fire resistance label in the following areas:

First floor:
*Fire/smoke doors in the emergency department by bay number four was observed to have a gap greater than one eighth inch between the door panels when in the closed position.
*Several doors throughout the fire/smoke barriers was observed to have the fire resistance rating tag painted over and they were unable to be verified until the paint was removed.

Second floor:
*Fire/smoke doors in the cafe/lobby area was observed to have a gap greater than one eighth inch between the door panels when in the closed position.
*The door leading into the sterile processing decontamination room lacked a one hour fire rating label.
*Double doors of the bridge deck leading to 4 north was observed to have a gap greater than one eighth inch between the door panels when in the closed position.
*Several doors throughout the fire/smoke barriers was observed to have the fire resistance rating tag painted over and they were unable to be verified until the paint was removed.

These findings was verified by all staff present during tour.

Based on observation of smoke/fire barrier doors and staff verification, it was determined this facility failed to ensure all smoke/fire doors closed and latched properly, were equipped with a fire resistance rating and all fire resistance rating labels were able to be visually verified. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 156.

Findings include:

Tour of the facility took place on 08/11/10 through 08/14/10 with Staff members 1, 2, 3 and 4. During tour observation was made of two doors that failed to have a fire resistance label or positive latch shut in the following areas:

First floor:
*Within the behavioral health department, observation was made of a door in the two hour fire barrier leading into the kitchenette which lacked a fire resistance rating.
*The multipurpose room double doors located in the two hour fire barrier failed to positive latch shut.

These findings were verified by Staff member 3 during tour.

Based on observation of smoke/fire barrier doors and staff verification, it was determined this facility failed to ensure all smoke/fire doors were equipped with a fire resistance rating identification tag in order to visually verify the fire resistance rating of the door. This had the potential to affect all those utilizing this facility. The average patient census at the beginning of the survey was 25.

Findings include:
Tour of the facility took place on 08/14/10 with Staff members 1, 4, 7, 8 and 9. During tour of the two hour fire rated smoke/fire barriers, observation was made of the door which separated the rehab facility from another occupancy. This door lacked a fire resistance rating identification tag so verification of its fire resistance rating was not able to be confirmed.

This finding was verified by all staff present during tour on 08/14/10.

Based on observation during tour and staff verification it was determined this facility failed to ensure the hazardous areas were constructed to provide at least a one hour fire resistance rating and all doors are equipped with a self or automatic closing device. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 156.

Findings include:

Tour of the facility took place on 08/11/10 through 08/14/10 with Staff members 1, 2, 3 and 4. During tour of the hazardous areas, observation was made of several penetrations through the barrier located above the ceiling tiles and doors which lacked a fire resistance label in the following locations:

First floor:
*The soiled utility room door across from the cardiac rehab back door, lacked a fire resistance label.
*Within the soiled room by the charge specialist's office, observation was made of one open end conduit, one unsealed vent and another small unsealed penetration.
*The soiled utility room located within the emergency department next to GYN room number one was observed to lack drywall extending to the upper deck on the north, south and west walls.

Second floor:
*Within the soiled utility room of the west corridor of the kitchen, observation was made of five unsealed conduits.
*Within the air handling units in the cafe, one open end conduit was observed in the west wall.

Third floor:
*Soiled utility room across from room number 3316 lacked a self or automatic closing device.
*Four unsealed corrugated areas were observed where the drywall meets the upper deck in soiled room number 3016.

Fourth floor:
*Within the storage room across from room number 4017, observation was made of two open end conduits in the south wall, three unsealed conduits in the north wall and one unsealed conduit in the east wall.
*Within soiled utility room number 4107B, observation was made of three penetrations in the west wall and one penetration in the east wall. Three of four penetrations are open end conduits.
*Within the soiled utility room across from stairwell number 7, observation was made of three open end conduits and unsealed red wires.

Additionally, several doors throughout the hazardous areas was observed to have the fire resistance rating tag painted over and they were unable to be verified until the paint was removed.


These findings were verified by staff member 3 during tour of the facility.

Based on observation during tour and staff verification it was determined this facility failed to ensure all exit discharges were arranged to have the required lighting so as to never leave the area in darkness. This had the potential to affect all persons that utilize this area. The patient census at the beginning of the survey was 156.

Findings include:

Tour of the facility took place on 08/11/10 through 08/14/10 with Staff members 1, 2, 3 and 4. During tour of the exit discharges, observation was made of two exit discharges from the cath lab area, one of which lacked a light bulb in the one and only fixture located above the exit discharge door and the other which lacked any fixture at all.

This finding was verified by Staff members 1 and 4 during tour.

Based on observation and staff verification it was determined this facility failed to respond correctly to a fire alarm regarding the procedure of closing all patient room and corridor doors. This had the potential to affect all those who were present during the drill on that particular unit. The patient census was 156 at the beginning of the survey.

Findings include:

During tour of one of the nursing units on 08/11/10 a fire alarm was activated at 10:55 AM and an overhead page was heard announcing a problem in the MRI unit on the first floor. The staff began to close the corridor and patient room doors. After a few minutes and during the active fire alarm, this surveyor toured the wing and observation was made of four patient/corridor doors left open. The door to patient room 4019 was wide open three minutes after the alarm sounded. The directors door was ajar about one foot. The alarm was silenced at 10:59 AM. This surveyor continued around the corridor and made additional observations of a charting room door and a patient/family waiting room door left wide open. Observation was made of two people in the waiting room. Code red "all clear" was not sounded until 11:03 AM after these observations were made. Staff member 4 accompanied this surveyor during the active fire alarm and verified the four doors which were left open.

Based on automatic sprinkler system documentation review and staff verification it was determined this facility failed to ensure the automatic sprinkler system was inspected quarterly as required by the National Fire Protection Agency (NFPA) 25. This had the potential to affect all those utilizing this facility.

Findings include:

Documentation review for the sprinkler system took place on 08/10/10 with Staff number 1. During review observation was made of only one automatic sprinkler system test performed in 2010 by a professional outside company. A request was made from Staff member 1 for additional quarterly sprinkler system tests and Staff member 1 stated they were not aware a business occupancy had to have the sprinkler system checked quarterly.

Based on observation during tour and staff verification it was determined this facility failed to ensure the automatic sprinkler system was continuously maintained in regards to the dust on the sprinkler heads. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 156.

Findings include:

Tour of the facility took place on 08/11/10 to 08/14/10 with Staff numbers 1, 2, 3 and 4. During the tour observation was made of several sprinkler heads that were coated with dust in the following areas:

First floor:
*Within the radiology department.

Second floor:
*Within the kitchen area.

Fourth floor:
*Near room 4225
*Within the dark room

These findings were verified by all staff during tour.

Based on relative humidity (RH) documentation review and staff verification it was determined this facility failed to ensure the RH level was maintained in all operating rooms at the required 35% when in use. This had the potential to affect all those utilizing the operating rooms. The facility census was 156 at the beginning of the survey.

Findings include:

Review of the RH documentation took place on 08/10/10 with staff number 1. During review of the RH levels for eleven operating rooms observation was made of the RH levels being below the required 35% on multiple occasions in one or more operating rooms from December 2009 through February 2010. At times the RH levels were documented as being below 26%.

This finding was verified by Staff member 1 during review of the RH documentation.

Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The patient census was 156 at the time of the survey.

Findings include:

Tour of the facility took place on 08/11/10 to 08/14/10 with the Staff members 1, 2, 3 and 4. During the tour observation was made of several smoke detectors which were located near air flow devices in the following areas:

First floor:
*Within the corridor north of the behavioral health department by the mechanical room.
*Within the main lobby corridor.
*Beside stairwell number 7.
*Within the radiology control room.
*Soiled utility room left of GYN room number 1
*Within the emergency department class room.
*Within the security office.
*Near elevator number 22 by the gift shop storage.

Second floor:
*Within the Mylander conference room.
*Within the pharmacy break area.

Third floor:
*Within the labor and delivery room.
*By the vent next to the electrical room and room number 3319.
*Within soiled utility room 3016.

Fourth floor:
*Within soiled utility room 4107B.
*By stairwell number 5.
*By elevator number 3.
*By nurse's station in 4 west.
*By the janitor/clean utility room of 4 west.
*In office across from stair number 7 of 4 west.
*Within rooms numbers 4302 through 4316 of 4 west.

These findings were verified by Staff members 1, 2, 3 and 4 during tour.

Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The patient census was 25 at the time of the survey.

Findings include:

Tour of the facility took place on 08/14/10 with Staff members 1, 4, 7, 8 and 9. During tour of the rehab department, observation was made of five smoke detectors mounted within several inches of an air flow device in the following locations:

*In the corridor by rooms 2-051, 2-041, 2-021, 2-001 and 2-004.


This finding was verified by all staff members present during tour on 08/14/10.

Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The patient census was 28 at the time of the survey.

Findings include:

Tour of the facility took place on 08/14/10 with Staff members 1, 4, 7, 8 and 9. During tour of the outpatient rehab department, observation was made of two smoke detectors mounted within several inches of an air flow device in the following locations:

*In the corridor by the physical therapy gym and another by the physical therapy treatment room.


This finding was verified by all staff members present during tour on 08/14/10.

Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The patient census was zero at the time of the survey.

Findings include:

Tour of the facility took place on 08/14/10 with Staff members 1, 4, 7, 8 and 9. During tour of the marketing department office, observation was made of a smoke detector mounted within several inches of an air flow device.

This finding was verified by all staff members present during tour on 08/14/10.