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Based on facility tour and staff interview it was determined this facility failed to ensure the common wall between nonconforming buildings was constructed with at least a two hour fire rating. This had the potential to affect all those who utilized these areas. The patient census was 86 at the beginning of the survey.

Findings include:

A facility tour took place on 03/03/14 through 03/04/14 with staff members A1, B2, C3, D4, E5 and F6. During tour of the two hour fire rated common wall which separates the hospital from the medical office building (MOB) on the first and second floors, observation was made of the following penetrations:

1) First floor: On 03/04/14 at approximately 8:13 A. M. an observation was made of one unsealed silver conduit with an optic fiber passing through and another unsealed conduit with a red wire passing through.

2) Second floor: On 03/03/14 at approximately 3:21 PM observation was made of a four inch silver conduit and a one inch silver conduit having the fire rated sealant fallen out.

These findings were confirmed by staff member A1 during tour.

Based on facility tour and staff interivew it was determined this facility failed to ensure the doors protecting corridor openings were constructed to resist the passage of smoke and positive latched shut. This had the potential to affect all those who utilized these areas. The patient census was 86 at the beginning of the survey.

Findings include:

A facility tour took place on 03/03/14 through 03/04/14 with staff members A1, B2, C3, D4, E5 and F6.

1) During tour of the second floor labor and delivery department on 03/03/14 at approximately 1:53 PM, observation was made of two patient room doors (#2319 and #2320) having a gap of approximately one half inch between the door leafs when in the closed position.

2) During tour of the third floor medical surgical unit on 03/03/14 at approximately 1:18 PM, observation was made of patient room #3219 that had a door which failed to positive latch shut.

These findings were confirmed by all staff members present during tour on 03/03/14.

Based on facility tour and staff interview it was determined this facility failed to ensure the smoke barriers were constructed with at least a one hour fire resistance rating. This had the potential to affect all those who utilized these areas of the buildings. The patient census was 86 at the beginning of the survey.

Findings include:

A facility tour took place on 03/03/14 through 03/04/14 with staff members A1, B2, C3, D4, E5 and F6. Penetrations were identified within the smoke barrier above the ceiling tiles in the following locations:

1) On 03/03/14 within the pharmacy at the northeast corner, observation was made at approximately 1:29 PM of an unsealed blue data cable in the northeast corner.

2) On 03/03/14 at the north wall of room #3501, observation was made at approximately 1:50 PM of an approximate one inch by two inch unsealed opening and three data cables which had the fire sealant pulled out.

3) On 03/04/14 at the south wall of room #1214, observation was made at approximately 9:35 AM of an approximate two and a half inch unsealed drain line and a curved conduit with the fire sealant missing.

4) On 03/04/14 at the east wall of the lab from the corridor side, observation was made at approximately 10:15 AM of an unsealed curved conduit with a white wire passing through.

5) On 03/04/14 within room #1753 at approximately 10:35 AM observation was made of a one inch unsealed conduit in the south wall having blue, orange and black wires passing through. At the west wall observation was made of an unsealed one and a half inch conduit with red wires passing through.

6) On 03/04/14 at approximately 10:44 AM, within the corridor on the east side of the emergency department and across from room 1792B, observation was made of an unsealed one inch conduit with a black wire passing through.

7) On 03/04/14 at approximately 11:00 AM, within the corridor on the south side of the cath lab across from room #11, observation was made of an unsealed one inch conduit with blue and white wires passing through.

8) On 03/04/14 at approximately 11:08 AM, at the east wall of Bay #14 within the emergency department, an observation was made of an unsealed conduit with a blue wire passing through.



These findings were confirmed by staff member A1 during tour on 03/03/14 and 03/04/14.

Based on facility tour and staff interview it was determined this facility failed to ensure the door openings in smoke barriers were constructed to resist the passage of smoke with at least a twenty minute fire resistance rating or are at least one and three quarter inch thick solid bonded wood core. This had the potential to affect all those who utilized these areas of the buildings. The patient census was 86 at the beginning of the survey.

Findings include:

A facility tour took place on 03/03/14 through 03/04/14 with staff members A1, B2, C3, D4, E5 and F6. Doors were identified within the smoke barrier at the following locations being propped open with unapproved devices or being equipped with positive latching hardware which failed to latch shut.

1) On 03/03/14 at approximately 3:17 P.M. during a tour of the second floor at the east entrance double doors of the post-partum unit, observation was made the west leaf of the double doors failed to latch shut.

2) On 03/04/14 at approximately 10:00 A.M. during a tour of the first floor at the south double doors within the lobby located several feet behind the information desk, observation was made of the smoke barrier double doors failing to latch shut.

3) On 03/04/14 at approximately 10:45 AM during tour of the smoke barrier wall bordering room #1804, specifically the smoke barrier door of the room, observation was made of a rubber wedge placed at the bottom of the door which disabled the self closing device.


These findings were confirmed by A1, B2, C3, D4, E5, and F6 staff members during tour on 03/03/14 and 03/04/14.

Based on facility tour and staff interview it was determined this facility failed to ensure hazard areas were constructed with at least a one hour fire resistance rating. This had the potential to affect all those who utilized these areas. The patient census was 86 at the beginning of the survey.

Findings include:

Facility tour took place on 03/03/14 through 03/04/14 with staff members A1, B2, C3, D4, E5 and F6. Penetrations were identified within the hazard areas above the ceiling tiles in the following locations:

1) At approximately 2:05 P.M. on 03/03/14 within room #3712, observation was made in the north wall above the ceiling tile of an unsealed curved conduit. The door of the room was also noted to be propped open with a ten pound weight which disabled the self-closing device.

2) At approximately 3:00 P.M. on 03/03/14 within room #2271, observation was made in the west wall above the door of an approximate one and a half inch square opening in the wall which had a green flex conduit passing through.

3) At approximately 9:40 A.M. on 03/04/14 within storage room #1210, observation was made in the west and east walls of an open end conduit and an I-beam which had open areas around the annular space.

4) At approximately 11:03 A.M. on 03/04/14 within soiled utility storage room #1830, observation was made on the south wall, of an open end conduit with red wires and two unsealed white insulated water lines.

These findings were confirmed by staff member A1 during tour on 03/03/14 and 03/04/14.

Based on facility tour and staff interview it was determined this facility failed to ensure a safe access from the exit discharge to a paved common way. This had the potential to affect all those who utilized these areas. The patient census was 86 at the beginning of the survey.

Findings include:

A facility tour took place on 03/03/14 through 03/04/14 with staff members A1, B2, C3, D4, E5 and F6.

1) During tour of the northeast section of the hospital's first floor on 03/04/14 at approximately 10:00 AM and specifically by room #1281, observation was made at the exit discharge of an approximate ten foot by six foot cement stoop surrounded by a grassy area. It was estimated there was at least thirty feet of grass between the cement stoop and the nearest paved common way. Additionally, there had been snowfall and freezing temperatures for the past several weeks and although the exit discharge door could be opened the cement stoop was observed to have a layer of hard packed snow which scraped the bottom of the door when accessed. The grassy area between the cement stoop to the nearest common way was not cleared of snow.

2) During tour of the northeast section of the hospital's first floor on 03/04/14 at approximately 10:16 AM and specifically in the mechanical room, observation was made at the exit discharge of an approximate eight foot by six foot cement stoop surrounded by a grassy area. It was estimated there was at least fifty feet of grass between the cement stoop and the nearest paved common way. Additionally, there had been snowfall and freezing temperatures for the past several weeks and although the exit discharge door could be opened the cement stoop was observed to have a layer of hard packed snow which scraped the bottom of the door when accessed. The grassy area between the cement stoop to the nearest common way was not cleared of snow.

3) During tour of the northeast section of the hospital's first floor on 03/04/14 at approximately 10:27 AM and specifically in the switch gear room, observation was made at the exit discharge of an approximate eight foot by six foot cement stoop surrounded by a grassy area. It was estimated there was at least seventy five feet of grass between the cement stoop and the nearest paved common way. Additionally, there had been snowfall and freezing temperatures for the past several weeks and although the exit discharge door could be opened the cement stoop was observed to have a layer of hard packed snow which scraped the bottom of the door when accessed. The grassy area between the cement stoop to the nearest common way was not cleared of snow.


These findings were confirmed by staff members A1, B2, C3, D4, E5 and F6 during tour on 03/04/14.

Based on facility tour and staff interview it was determined this facility failed to ensure all smoke detectors were not mounted near air flow devices. This had the potential to affect all those who utilized these areas. The patient census was 86 at the beginning of the survey.

Findings include:

A facility tour took place on 03/03/14 through 03/04/14 with staff members A1, B2, C3, D4, E5 and F6.

1) During tour of the third floor on 03/03/14 at approximately 1:23 PM, specifically in the corridor between the restroom and volunteer's office, observation was made of a smoke detector mounted near an air flow device.

2) During tour of the second floor on 03/03/14 at approximately 3:21 PM, specifically in the connector bridge at the two hour fire rated separation just outside the medical office building, observation was made of a smoke detector mounted near an air flow device.

3) During tour of the first floor radiology area on 03/04/14 at approximately 10:35 AM, specifically in room #1753 and in an unidentified room adjacent to room #1753, observation was made of two smoke detectors mounted near air flow devices.

These findings were verified by staff members A1, B2, C3, D4, E5 and F6 during tour.

Based on facility tour and staff interview it was determined this facility failed to ensure all portable fire extinguishers were mounted properly. This had the potential to affect all those who utilized these areas of the buildings. The patient census was 86 at the beginning of the survey.

Findings include:

A first floor facility tour took place on 03/04/14 with staff members A1, B2, C3, D4, E5 and F6.

1) During tour of the first floor switch gear room at approximately 10:27 AM, observation was made of portable fire extinguisher's located at each exit, mounted greater than five feet from the floor.

2) During tour of the first floor security room adjacent to the emergency department at approximately 11:35 AM, observation was made of a portable fire extinguisher placed on the floor.

These findings were confirmed by staff members A1, B2, C3, D4, E5 and F6 during tour.

Based on facility tour and staff interview it was determined this facility failed to ensure the common wall between nonconforming buildings was constructed with at least a two hour fire rating. This had the potential to affect all those who utilized these areas. The patient census was 86 at the beginning of the survey.

Findings include:

A facility tour took place on 03/03/14 through 03/04/14 with staff members A1, B2, C3, D4, E5 and F6. During tour of the two hour fire rated common wall which separates the hospital from the medical office building (MOB) on the first and second floors, observation was made of the following penetrations:

1) First floor: On 03/04/14 at approximately 8:13 A. M. an observation was made of one unsealed silver conduit with an optic fiber passing through and another unsealed conduit with a red wire passing through.

2) Second floor: On 03/03/14 at approximately 3:21 PM observation was made of a four inch silver conduit and a one inch silver conduit having the fire rated sealant fallen out.

These findings were confirmed by staff member A1 during tour.

Based on facility tour and staff interivew it was determined this facility failed to ensure the doors protecting corridor openings were constructed to resist the passage of smoke and positive latched shut. This had the potential to affect all those who utilized these areas. The patient census was 86 at the beginning of the survey.

Findings include:

A facility tour took place on 03/03/14 through 03/04/14 with staff members A1, B2, C3, D4, E5 and F6.

1) During tour of the second floor labor and delivery department on 03/03/14 at approximately 1:53 PM, observation was made of two patient room doors (#2319 and #2320) having a gap of approximately one half inch between the door leafs when in the closed position.

2) During tour of the third floor medical surgical unit on 03/03/14 at approximately 1:18 PM, observation was made of patient room #3219 that had a door which failed to positive latch shut.

These findings were confirmed by all staff members present during tour on 03/03/14.

Based on facility tour and staff interview it was determined this facility failed to ensure the smoke barriers were constructed with at least a one hour fire resistance rating. This had the potential to affect all those who utilized these areas of the buildings. The patient census was 86 at the beginning of the survey.

Findings include:

A facility tour took place on 03/03/14 through 03/04/14 with staff members A1, B2, C3, D4, E5 and F6. Penetrations were identified within the smoke barrier above the ceiling tiles in the following locations:

1) On 03/03/14 within the pharmacy at the northeast corner, observation was made at approximately 1:29 PM of an unsealed blue data cable in the northeast corner.

2) On 03/03/14 at the north wall of room #3501, observation was made at approximately 1:50 PM of an approximate one inch by two inch unsealed opening and three data cables which had the fire sealant pulled out.

3) On 03/04/14 at the south wall of room #1214, observation was made at approximately 9:35 AM of an approximate two and a half inch unsealed drain line and a curved conduit with the fire sealant missing.

4) On 03/04/14 at the east wall of the lab from the corridor side, observation was made at approximately 10:15 AM of an unsealed curved conduit with a white wire passing through.

5) On 03/04/14 within room #1753 at approximately 10:35 AM observation was made of a one inch unsealed conduit in the south wall having blue, orange and black wires passing through. At the west wall observation was made of an unsealed one and a half inch conduit with red wires passing through.

6) On 03/04/14 at approximately 10:44 AM, within the corridor on the east side of the emergency department and across from room 1792B, observation was made of an unsealed one inch conduit with a black wire passing through.

7) On 03/04/14 at approximately 11:00 AM, within the corridor on the south side of the cath lab across from room #11, observation was made of an unsealed one inch conduit with blue and white wires passing through.

8) On 03/04/14 at approximately 11:08 AM, at the east wall of Bay #14 within the emergency department, an observation was made of an unsealed conduit with a blue wire passing through.



These findings were confirmed by staff member A1 during tour on 03/03/14 and 03/04/14.

Based on facility tour and staff interview it was determined this facility failed to ensure the door openings in smoke barriers were constructed to resist the passage of smoke with at least a twenty minute fire resistance rating or are at least one and three quarter inch thick solid bonded wood core. This had the potential to affect all those who utilized these areas of the buildings. The patient census was 86 at the beginning of the survey.

Findings include:

A facility tour took place on 03/03/14 through 03/04/14 with staff members A1, B2, C3, D4, E5 and F6. Doors were identified within the smoke barrier at the following locations being propped open with unapproved devices or being equipped with positive latching hardware which failed to latch shut.

1) On 03/03/14 at approximately 3:17 P.M. during a tour of the second floor at the east entrance double doors of the post-partum unit, observation was made the west leaf of the double doors failed to latch shut.

2) On 03/04/14 at approximately 10:00 A.M. during a tour of the first floor at the south double doors within the lobby located several feet behind the information desk, observation was made of the smoke barrier double doors failing to latch shut.

3) On 03/04/14 at approximately 10:45 AM during tour of the smoke barrier wall bordering room #1804, specifically the smoke barrier door of the room, observation was made of a rubber wedge placed at the bottom of the door which disabled the self closing device.


These findings were confirmed by A1, B2, C3, D4, E5, and F6 staff members during tour on 03/03/14 and 03/04/14.

Based on facility tour and staff interview it was determined this facility failed to ensure hazard areas were constructed with at least a one hour fire resistance rating. This had the potential to affect all those who utilized these areas. The patient census was 86 at the beginning of the survey.

Findings include:

Facility tour took place on 03/03/14 through 03/04/14 with staff members A1, B2, C3, D4, E5 and F6. Penetrations were identified within the hazard areas above the ceiling tiles in the following locations:

1) At approximately 2:05 P.M. on 03/03/14 within room #3712, observation was made in the north wall above the ceiling tile of an unsealed curved conduit. The door of the room was also noted to be propped open with a ten pound weight which disabled the self-closing device.

2) At approximately 3:00 P.M. on 03/03/14 within room #2271, observation was made in the west wall above the door of an approximate one and a half inch square opening in the wall which had a green flex conduit passing through.

3) At approximately 9:40 A.M. on 03/04/14 within storage room #1210, observation was made in the west and east walls of an open end conduit and an I-beam which had open areas around the annular space.

4) At approximately 11:03 A.M. on 03/04/14 within soiled utility storage room #1830, observation was made on the south wall, of an open end conduit with red wires and two unsealed white insulated water lines.

These findings were confirmed by staff member A1 during tour on 03/03/14 and 03/04/14.

Based on facility tour and staff interview it was determined this facility failed to ensure a safe access from the exit discharge to a paved common way. This had the potential to affect all those who utilized these areas. The patient census was 86 at the beginning of the survey.

Findings include:

A facility tour took place on 03/03/14 through 03/04/14 with staff members A1, B2, C3, D4, E5 and F6.

1) During tour of the northeast section of the hospital's first floor on 03/04/14 at approximately 10:00 AM and specifically by room #1281, observation was made at the exit discharge of an approximate ten foot by six foot cement stoop surrounded by a grassy area. It was estimated there was at least thirty feet of grass between the cement stoop and the nearest paved common way. Additionally, there had been snowfall and freezing temperatures for the past several weeks and although the exit discharge door could be opened the cement stoop was observed to have a layer of hard packed snow which scraped the bottom of the door when accessed. The grassy area between the cement stoop to the nearest common way was not cleared of snow.

2) During tour of the northeast section of the hospital's first floor on 03/04/14 at approximately 10:16 AM and specifically in the mechanical room, observation was made at the exit discharge of an approximate eight foot by six foot cement stoop surrounded by a grassy area. It was estimated there was at least fifty feet of grass between the cement stoop and the nearest paved common way. Additionally, there had been snowfall and freezing temperatures for the past several weeks and although the exit discharge door could be opened the cement stoop was observed to have a layer of hard packed snow which scraped the bottom of the door when accessed. The grassy area between the cement stoop to the nearest common way was not cleared of snow.

3) During tour of the northeast section of the hospital's first floor on 03/04/14 at approximately 10:27 AM and specifically in the switch gear room, observation was made at the exit discharge of an approximate eight foot by six foot cement stoop surrounded by a grassy area. It was estimated there was at least seventy five feet of grass between the cement stoop and the nearest paved common way. Additionally, there had been snowfall and freezing temperatures for the past several weeks and although the exit discharge door could be opened the cement stoop was observed to have a layer of hard packed snow which scraped the bottom of the door when accessed. The grassy area between the cement stoop to the nearest common way was not cleared of snow.


These findings were confirmed by staff members A1, B2, C3, D4, E5 and F6 during tour on 03/04/14.

Based on facility tour and staff interview it was determined this facility failed to ensure all smoke detectors were not mounted near air flow devices. This had the potential to affect all those who utilized these areas. The patient census was 86 at the beginning of the survey.

Findings include:

A facility tour took place on 03/03/14 through 03/04/14 with staff members A1, B2, C3, D4, E5 and F6.

1) During tour of the third floor on 03/03/14 at approximately 1:23 PM, specifically in the corridor between the restroom and volunteer's office, observation was made of a smoke detector mounted near an air flow device.

2) During tour of the second floor on 03/03/14 at approximately 3:21 PM, specifically in the connector bridge at the two hour fire rated separation just outside the medical office building, observation was made of a smoke detector mounted near an air flow device.

3) During tour of the first floor radiology area on 03/04/14 at approximately 10:35 AM, specifically in room #1753 and in an unidentified room adjacent to room #1753, observation was made of two smoke detectors mounted near air flow devices.

These findings were verified by staff members A1, B2, C3, D4, E5 and F6 during tour.

Based on facility tour and staff interview it was determined this facility failed to ensure all portable fire extinguishers were mounted properly. This had the potential to affect all those who utilized these areas of the buildings. The patient census was 86 at the beginning of the survey.

Findings include:

A first floor facility tour took place on 03/04/14 with staff members A1, B2, C3, D4, E5 and F6.

1) During tour of the first floor switch gear room at approximately 10:27 AM, observation was made of portable fire extinguisher's located at each exit, mounted greater than five feet from the floor.

2) During tour of the first floor security room adjacent to the emergency department at approximately 11:35 AM, observation was made of a portable fire extinguisher placed on the floor.

These findings were confirmed by staff members A1, B2, C3, D4, E5 and F6 during tour.