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Based on observations made during tour and staff verification and interview, it was determined that the facility failed to ensure the building construction type met the requirements of at least a two hour fire rating regarding the floors and upper decking. This had the potential to affect all those utilizing the services of the facility.

The facility had a capacity of 568 with a census of 260 at the time of the survey.

Findings include:
On 08/22/11 at 2:17 PM a tour of the sixth floor was conducted with Staff L3. At 2:35 PM the ceiling above the drop-down ceiling in the E-building connector corridor near elevators 16, 17, and 18 was observed. An I-beam was observed to have an area approximately two yards in length to be without spray protectant. In addition, the corrugated steel between the I-beams were not completely protected from I-beam to I-beam.
On 08/23/11 at 8:25 AM a tour of the fourth floor was conducted. At 8:25 AM the ceiling of the fourth floor D-wing (South) electrical/mechanical room was observed. Corrugated steel that did not have fire-proofing treatment from wall to wall was observed.
On 08/23/11 at 10:10 AM a tour of the second floor was conducted. At 1:50 PM the ceiling in the E-building connector near the entrance to the core area was observed. Corrugated steel that did not have fire-proofing treatment from wall to wall was observed.
On 08/23/11 at 3:50 PM a tour was conducted of the main floor. At 3:55 PM the ceiling area in the corridor south of the main entrance and next to a durable medical equipment retailer just before a set of double doors was observed. Corrugated steel that did not have fire-proofing from I-beam to I-beam was observed. The side of the I-beam facing the corridor did not have fire proofing sprayed on to it.
These findings were confirmed by Staff L3 at the times of the observations during the tour. Staff L3 stated at the time of the observation of the main floor ceiling area that it looked like the section noted to be without fire-proofing had been missed.

Based on observation and staff verification, it was determined the facility failed to ensure the building construction type met the requirements of at least a two hour fire rating regarding the floors and upper steel fluted decking. This had the potential to affect all those utilizing this facility.

The facility has a capacity of 568 with a census of 260 at the time of the survey.

Findings include:

Tour of building 5 took place with staff members L2 and L5 on 08/22/11 through 08/24/11. During tour, observation was made of several areas above the ceiling tile on each floor of unprotected steel fluted decking. All steel I-beams were observed to have a fire resistive coating sprayed to cover them completely.

The surveyor questioned Staff L5 why the steel fluted deck had not been coated in order to provide a fire resistance rating. L5 stated the cement above the steel decking is what provides the fire resistive rating and not the steel itself. The statement from Staff L5 was confirmed with Staff L3 on 08/24/11 during interview at 8:50 AM.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that doors in corridor walls had no impediments to closing and/or were provided with a means suitable for keeping the doors closed. This could affect all individuals utilizing the services of the affected smoke compartments.

The facility has 568 beds with a census of 260 at the time of the survey.

Findings include:

Tour was conducted with Staff L4 on 08/22/11 from 1:40 PM until 5:00 PM; on 08/23/11 from 9:40 AM until 5:00 PM; and on 08/24/11 from 10:20 AM until 12:00 PM. Corridor doors were observed to not latch or to have impediments to closing as follows:

On unit 3A, the door to room 3AO01 had no latch; the latch on the door to room 304 did not work properly to hold the door in the closed position; a patient bath that was currently being used for storage had an item sitting in front of the door, preventing its closing.

In the basement, one of the double doors to room GFE04, a small storage room, rubbed on the other door and would not close and latch securely.

In the interventional radiology waiting room in the basement, there was a corridor door on a closer. There was a chair, occupied by a woman, sitting in front of and blocking the closing of, the door, when it was observed during tour on 08/23/11. Staff L4 moved the chair away from the door when the room was no longer occupied, and the door closed. On 08/24/11 at 11:40 AM the chair, unoccupied, was again observed propping the door open.

In the basement, a janitor closet located in the exit corridor between the women's center and endoscopy, had a door that was propped open with a plastic wet floor sign. When the sign was removed, the door swung closed and locked into position.

The above findings were confirmed by Staff L4 during the tours.

On 08/23/11 at 8:25 AM a tour of the fourth floor was conducted with Staff L3. The door to patient room 436 was observed to not latch. At 9:48 AM a tour of the second floor was conducted. The doors to patient rooms 421 and 419 did not latch. At 3:10 PM and 3:13 PM the doors to patient rooms 237 and 246 were observed to not latch.
On 08/24/11 at 9:39 a tour of the emergency department on the main floor was conducted with Staff L3. At 9:59 AM the doors to rooms #5, #6, #7, and #8 were observed to not latch. At 10:14 AM the doors to rooms #9 and #10 were observed to not latch. At 10:28 AM the doors to rooms #11, #12, and #13 were observed to not latch.
Staff #L3 confirmed the above findings at the times the observations were made.

Based on observation and staff verification, it was determined the facility failed to ensure accesses to all designated exits were marked by visible signs to provide direction to the exit discharge. This had the potential to affect all those utilizing this facility.

The facility has a capacity of 568 with a census of 260 at the time of the survey.

Findings include:

Tour of building 5 took place with staff members L2 and L5 on 08/22/11 through 08/24/11. During tour of the main floor and heading north in the cath lab corridor, observation was made of an exit sign at the end of the corridor and in front of the restrooms which lacked directional arrows pointing to the either of the designated exits to the right and to the left. The exit to the right was located around a corner which was not readily apparent.

This finding was verified by Staff L2 and Staff L5 during tour of this area on 08/22/11.

Based on observation and staff verification, it was determined the facility failed to ensure all smoke barriers were constructed with at least a one hour fire resistance rating. This had the potential to affect all those utilizing this facility.

The facility has a capacity of 568 with a census of 260 at the time of the survey.

Findings include:

Tour of building 5 took place with staff members L2 and L5 on 08/22/11 through 08/24/11. During tour, observation was made of several penetrations in the smoke barrier in the following locations:

Main floor:
*From within the lab facing the west wall, observation was made of one open end conduit.

First floor:
*From within the clean supply room facing the west wall, observation was made of two open end conduits.
*From within the staff break room facing the west wall, observation was made of three open end conduits with one also not sealed at the base where it penetrates the drywall. Also, one unsealed curved conduit was observed.
Additionally, on the opposite side of the smoke barrier, observation was made of a two inch hole through one layer of the drywall.

Second floor:
*From within the clean supply and equipment room facing the west wall and to the far right, observation was made of an approximate three inch hole at the top of the drywall. Also, one unsealed curved conduit was observed on the left half of the west wall.
*From within the file room facing the west wall, observation was made of two unsealed curved conduits.
*From within the dietary department dry storage room, observation was made of one unsealed conduit above the door. Additionally, above the refrigerator observation was made of an unsealed area around a six inch duct.

Third floor:
*Above the north smoke barrier doors observation was made of two small sections of drywall which were not sealed where the borders meet.

These findings were verified by Staff L5 during tour of this area.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that doors in smoke barriers were on closers and/or would swing closed in the event of fire emergency. This could affect all individuals utilizing the services of the affected smoke compartments.

The facility has a capacity of 568 with a census of 260 at the time of the survey.

Findings include:

Tour was conducted with Staff L4 on 08/22/11 from 1:40 PM until 5:00 PM, and on 08/23/11 from 9:40 AM until 5:00 PM. Observations were made of doors in smoke barriers that were not on closers and/or would not swing closed in the event of fire emergency, as follows:

In the A wing on the seventh floor, the door to the "recovery" room was located in the smoke barrier but the door was not on a self-closer nor tied into the fire system.

On the first floor, the conference room across from the nurses station on unit C was located in the smoke barrier and was on a self-closer but the door was propped open with a styrofoam cup used as a chock under the door.

In the basement, the door to the radiology conference room was located in the smoke barrier and was on a self-closer, but it was held open with a chock.

These findings were confirmed by Staff L4 during the tours.

On 08/24/11 at 9:00 AM a tour of the pediatric emergency room on the main floor was conducted with Staff L3. At 9:21 AM the door to room #8, which was part of a smoke barrier wall, was observed propped open with a chair and rubbish can. Staff L3 confirmed the finding at the time of the observation.

Based on observation and staff verification, it was determined the facility failed to ensure all smoke barriers doors were arranged so that each door swings in an opposite direction. This had the potential to affect all those utilizing this facility.

The facility has a capacity of 568 with a census of 260 at the time of the survey.

Findings include:

Tour of building 5 took place with staff members L2 and L5 on 08/22/11 through 08/24/11. During tour of the main floor west end smoke barrier, observation was made of both leafs of a double leaf smoke barrier door which opened in the same direction.

This finding was verified by Staff L2 and Staff L5 during tour of this area of the facility.

Based on observation and staff verification, it was determined the facility failed to ensure all hazardous areas were constructed with at least a one hour fire resistance rating. This had the potential to affect all those utilizing this facility.

The facility has a capacity of 568 with a census of 260 at the time of the survey.

Findings include:

Tour of building 5 took place with staff members L2 and L5 on 08/22/11 through 08/24/11. During tour, observation was made of several penetrations in the bio hazard rooms and one hour fire rated walls of large storage rooms protected as hazardous areas in the following locations:

Main floor:
*Within the bio hazard room located in the southeast section of the main floor, observation was made of two unsealed insulated water lines.
*Within the soiled utility room at the west end, observation was made of two open end conduits and a one half inch by one foot gap between two drywall sections.

First floor:
*From within the clean supply room above the door, observation was made of two open end conduits. Additionally, observation was made of one unsealed water line located in the east section of the curved wall.
*From within the bio hazard room located at the west end of the floor, observation was made of an approximate five foot by one half inch gap between drywall sections.

Second floor:
*From within the clean supply and equipment room facing the door, observation was made of one unsealed curved conduit. Also, one unsealed water line was observed at the north wall.

Third floor:
*Within the west end soiled utility room, observation was made of an unsealed area at the top of a duct where it penetrated the drywall. Also, one unsealed conduit was observed near the north door.

These findings were verified by Staff L5 during tour of this area.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that two exit discharges from the building had a hard or paved surface to the common way. This could affect all individuals utilizing the services of the affected smoke compartments.

The facility has 568 beds with a census of 260 at the time of the survey.

Findings include:

Tour was conducted with Staff L4 on 08/23/11 from 9:40 AM until 5:00 PM. During tour of the basement, the stairway from the old cardiac catheterization area was followed to the exit discharge at the ground level. It was observed that the exit discharge ended at a concrete pad, after which there was a distance of approximately 15 feet of grass that would have to be crossed to get to the common way. This finding was confirmed with Staff L4 during the tour.

On 08/24/11 at 8:52 AM, during tour with Staff L3, the exit facing east from the center stairwell from the ambulatory care center was observed to end at a concrete pad, after which there was a distance of approximately 10 to 20 yards of grass that would have to be crossed to get to the common way.

Based on observation and staff verification, it was determined the facility failed to ensure the automatic sprinkler system was maintained in reliable operating condition specifically in regard to cleaning and ensuring all components of the sprinklers were intact. This had the potential to affect all those utilizing this facility.

The facility has a capacity of 568 with a census of 260 at the time of the survey.

Findings include:

Tour of building 5 took place with staff members L2 and L5 on 08/22/11 through 08/24/11. During tour, observation was made of several sprinkler heads missing the escutcheon rings and a large amount of dust and debris coated the sprinkler pendants in the following locations:

Ground floor:
*Within the housekeeping storage room four dirty sprinkler heads observed.

Main floor:
*Within the cath lab control room, dirty sprinkler heads were observed.

First floor:
*Within the restroom located at the north end across from the stairwell, observation was made of a dirty sprinkler head.
*Within the family waiting area at the north end, observation was made of two dirty sprinkler heads.
*Within room # 1002 observation was made of a missing escutcheon ring.
*Two dirty sprinkler heads were observed in the scrub area across from the medication room.
*Within the restroom located at the west end across from the stairwell, observation was made of a missing escutcheon ring.

Second floor:
*Within the open use family waiting area, observation was made of one missing escutcheon ring.
*Within the restroom located at the west end across from the stairwell, observation was made of a missing escutcheon ring.
*Within the dietary department and within the dry storage room, observation was made of one missing escutcheon ring. Within the dietary office, observation was made of one missing escutcheon ring. Within the dish area, observation was made of one missing escutcheon ring.

Third floor:
Within room # 3010, observation was made of a dirty sprinkler head.

These findings were verified by staff members L2 and L5 during tour of these areas. This surveyor questioned Staff L5 if the facility had a maintenance program for maintaining the sprinkler heads and Staff L5 stated not at this time.

Based on observation and staff verification, it was determined the facility failed to ensure the portable fire extinguishers were inspected monthly. This had the potential to affect all those utilizing the affected areas of the facility.

The facility has a capacity of 568 with a census of 260 at the time of the survey.

Findings include:

Tour of building 5 took place with staff members L2 and L5 on 08/22/11 through 08/24/11. During tour of the main floor, observation was made of three portable fire extinguishers which lacked the July 2011 monthly inspection. They were located by cath labs #1 and #3, and within the EP hallway.

This finding was verified by Staff L2 and Staff L5 during tour of these areas of the facility.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that two egress corridors were maintained free of obstructions to full instant use of the corridors. This could affect all individuals utilizing the services of the affected smoke compartments, who might need to use these egress corridors.

The facility has 568 beds with a census of 260 at the time of the survey.

Findings include:

Tour was conducted with Staff L4 on 8/24/11 from 10:20 AM until 12:00 PM. Two exit egress corridors were observed with items stored in the corridors so that full instant use of the corridors could be compromised, as follows:

In the corridor between the womens' center and endoscopy, there were four carts with monitors on them, a cart with a box on it, a plastic bin, and a display board stored on one side of the corridor. Beyond the door, there was a wheeled basket cart that would block the swing of the door if it were opened.

In the women's center, there was a stationary table in the egress corridor.

These findings were confirmed by Staff L4 during the tour.

Suites of sleeping rooms shall not exceed 5000 square feet. 19.2.5.6

This requirement is NOT MET as evidenced by:

Based on observations made during tour, review of facility blueprints/floor plans, and staff interview, it was determined that the facility failed to ensure that one suite of sleeping rooms on the seventh floor and one suite of sleeping rooms on the sixth floor did not exceed 5000 square feet. This could affect all individuals in the affected smoke compartments.

The facility has a capacity of 568 with a census of 260 at the time of the survey.

Findings include:

Tour was conducted with Staff L4 on 08/22/11 from 1:40 PM until 5:00 PM. On the seventh floor, the neurological intensive care unit was observed to be a large suite that appeared to be greater than the allowable 5000 square feet for sleeping rooms. Staff L4 confirmed on 08/25/11 at 11:40 AM that this area of sleeping rooms was a suite and, after consulting facility floor plans, also confirmed that it exceeded 5000 square feet.

On 08/22/11 at 2:53 PM a tour of the C wing on the sixth floor was conducted with Staff L3. Review of a blueprint issued on 07/26/11 and observations made during the tour revealed the C wing to consist entirely of a suite of sleeping rooms with unlatching doors for pediatric intensive care. Review of the blueprint issued on 07/26/11 revealed the square footage to be 9609 square feet in area.





Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies. 19.2.5.9
This requirement is NOT MET as evidenced by:
Based on observations made during tour, staff interview, and review of facility blueprints/floor plans, it was determined that the facility failed to provide two approved exits for the second floor neonatal intensive care unit. This could affect all individuals in the affected smoke compartments.
The facility has a capacity of 568 with a census of 260 at the time of the survey.
Findings include:
On 08/23/11 at 2:10 PM a tour of the second floor D wing neonatal intensive care unit was conducted with Staff L3. The tour revealed an exit stairway on the east end of the wing's corridor. Traveling west from the exit stairway along the corridor, the tour revealed the corridor stopped at a suite of rooms that, according to the facility blueprints/floor plans issued on 07/26/11, was 1191 square feet in area. Within the suite, located on the south side of the wing, was the corridor's second stairwell exit. Continuing west along the D wing, the tour revealed a smoke barrier wall between the 1191 square foot suite and another suite of sleeping rooms that was 3324 square feet in area. In that suite, at the far end of the D Wing, on its north corner, was the wing's third exit. Thus, a person on the east side of the wing would have to pass through the 1,191 square foot suite to reach a second exit, and a person on the west side of the wing would have to pass through the 1,191 square foot suite to reach a second exit.

Based on observations made during tour and staff interviews, it was determined that the facility failed to meet the requirements of 39.2.8 and 7.8.1.4 in regard to exit discharge lighting for two of four exits. The facility also failed to meet the requirements of 39.2.1.1 and 7.7.1 in regard to a continuous surface to the public way for one of four exit discharges.

The facility has a capacity of 568 beds and a census of 260 patients at the time of the survey.

Findings include:

On 08/24/11 between 11:20 AM and 11:50 AM, a life safety code tour was conducted with Staff L2 and Staff L6. The facility did not ensure two of four exit discharges were illuminated so that failure of any single lighting fixture (bulb) would not leave the area in darkness. The exit discharge located on the east end of the building, that faced the nearby school, lacked any type of lighting. The closest light fixtures were observed located at the top of the two story building and approximately 40 feet each from the exit discharge. The exit discharge located near exam room #1 was observed with a single fixture at the top of the second story level. This fixture was located over a canopy that covered the exit discharge. This exit discharge was observed with approximately a five feet by five feet concrete pad. This concrete did not extend the additional ten feet to the parking lot, and the area between the pad and the parking lot was observed with grass. Staff L1 and Staff L6 verified the lack of adequate discharge lighting and continuous surface to the public way. Staff L6 stated the facility does provide outpatient therapy services to patients until approximately 7:00 PM.

Based on observations made during tour and staff verification and interview, it was determined that the facility failed to ensure the building construction type met the requirements of at least a two hour fire rating regarding the floors and upper decking. This had the potential to affect all those utilizing the services of the facility.

The facility had a capacity of 568 with a census of 260 at the time of the survey.

Findings include:
On 08/22/11 at 2:17 PM a tour of the sixth floor was conducted with Staff L3. At 2:35 PM the ceiling above the drop-down ceiling in the E-building connector corridor near elevators 16, 17, and 18 was observed. An I-beam was observed to have an area approximately two yards in length to be without spray protectant. In addition, the corrugated steel between the I-beams were not completely protected from I-beam to I-beam.
On 08/23/11 at 8:25 AM a tour of the fourth floor was conducted. At 8:25 AM the ceiling of the fourth floor D-wing (South) electrical/mechanical room was observed. Corrugated steel that did not have fire-proofing treatment from wall to wall was observed.
On 08/23/11 at 10:10 AM a tour of the second floor was conducted. At 1:50 PM the ceiling in the E-building connector near the entrance to the core area was observed. Corrugated steel that did not have fire-proofing treatment from wall to wall was observed.
On 08/23/11 at 3:50 PM a tour was conducted of the main floor. At 3:55 PM the ceiling area in the corridor south of the main entrance and next to a durable medical equipment retailer just before a set of double doors was observed. Corrugated steel that did not have fire-proofing from I-beam to I-beam was observed. The side of the I-beam facing the corridor did not have fire proofing sprayed on to it.
These findings were confirmed by Staff L3 at the times of the observations during the tour. Staff L3 stated at the time of the observation of the main floor ceiling area that it looked like the section noted to be without fire-proofing had been missed.

Based on observation and staff verification, it was determined the facility failed to ensure the building construction type met the requirements of at least a two hour fire rating regarding the floors and upper steel fluted decking. This had the potential to affect all those utilizing this facility.

The facility has a capacity of 568 with a census of 260 at the time of the survey.

Findings include:

Tour of building 5 took place with staff members L2 and L5 on 08/22/11 through 08/24/11. During tour, observation was made of several areas above the ceiling tile on each floor of unprotected steel fluted decking. All steel I-beams were observed to have a fire resistive coating sprayed to cover them completely.

The surveyor questioned Staff L5 why the steel fluted deck had not been coated in order to provide a fire resistance rating. L5 stated the cement above the steel decking is what provides the fire resistive rating and not the steel itself. The statement from Staff L5 was confirmed with Staff L3 on 08/24/11 during interview at 8:50 AM.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that doors in corridor walls had no impediments to closing and/or were provided with a means suitable for keeping the doors closed. This could affect all individuals utilizing the services of the affected smoke compartments.

The facility has 568 beds with a census of 260 at the time of the survey.

Findings include:

Tour was conducted with Staff L4 on 08/22/11 from 1:40 PM until 5:00 PM; on 08/23/11 from 9:40 AM until 5:00 PM; and on 08/24/11 from 10:20 AM until 12:00 PM. Corridor doors were observed to not latch or to have impediments to closing as follows:

On unit 3A, the door to room 3AO01 had no latch; the latch on the door to room 304 did not work properly to hold the door in the closed position; a patient bath that was currently being used for storage had an item sitting in front of the door, preventing its closing.

In the basement, one of the double doors to room GFE04, a small storage room, rubbed on the other door and would not close and latch securely.

In the interventional radiology waiting room in the basement, there was a corridor door on a closer. There was a chair, occupied by a woman, sitting in front of and blocking the closing of, the door, when it was observed during tour on 08/23/11. Staff L4 moved the chair away from the door when the room was no longer occupied, and the door closed. On 08/24/11 at 11:40 AM the chair, unoccupied, was again observed propping the door open.

In the basement, a janitor closet located in the exit corridor between the women's center and endoscopy, had a door that was propped open with a plastic wet floor sign. When the sign was removed, the door swung closed and locked into position.

The above findings were confirmed by Staff L4 during the tours.

On 08/23/11 at 8:25 AM a tour of the fourth floor was conducted with Staff L3. The door to patient room 436 was observed to not latch. At 9:48 AM a tour of the second floor was conducted. The doors to patient rooms 421 and 419 did not latch. At 3:10 PM and 3:13 PM the doors to patient rooms 237 and 246 were observed to not latch.
On 08/24/11 at 9:39 a tour of the emergency department on the main floor was conducted with Staff L3. At 9:59 AM the doors to rooms #5, #6, #7, and #8 were observed to not latch. At 10:14 AM the doors to rooms #9 and #10 were observed to not latch. At 10:28 AM the doors to rooms #11, #12, and #13 were observed to not latch.
Staff #L3 confirmed the above findings at the times the observations were made.

Based on observation and staff verification, it was determined the facility failed to ensure accesses to all designated exits were marked by visible signs to provide direction to the exit discharge. This had the potential to affect all those utilizing this facility.

The facility has a capacity of 568 with a census of 260 at the time of the survey.

Findings include:

Tour of building 5 took place with staff members L2 and L5 on 08/22/11 through 08/24/11. During tour of the main floor and heading north in the cath lab corridor, observation was made of an exit sign at the end of the corridor and in front of the restrooms which lacked directional arrows pointing to the either of the designated exits to the right and to the left. The exit to the right was located around a corner which was not readily apparent.

This finding was verified by Staff L2 and Staff L5 during tour of this area on 08/22/11.

Based on observation and staff verification, it was determined the facility failed to ensure all smoke barriers were constructed with at least a one hour fire resistance rating. This had the potential to affect all those utilizing this facility.

The facility has a capacity of 568 with a census of 260 at the time of the survey.

Findings include:

Tour of building 5 took place with staff members L2 and L5 on 08/22/11 through 08/24/11. During tour, observation was made of several penetrations in the smoke barrier in the following locations:

Main floor:
*From within the lab facing the west wall, observation was made of one open end conduit.

First floor:
*From within the clean supply room facing the west wall, observation was made of two open end conduits.
*From within the staff break room facing the west wall, observation was made of three open end conduits with one also not sealed at the base where it penetrates the drywall. Also, one unsealed curved conduit was observed.
Additionally, on the opposite side of the smoke barrier, observation was made of a two inch hole through one layer of the drywall.

Second floor:
*From within the clean supply and equipment room facing the west wall and to the far right, observation was made of an approximate three inch hole at the top of the drywall. Also, one unsealed curved conduit was observed on the left half of the west wall.
*From within the file room facing the west wall, observation was made of two unsealed curved conduits.
*From within the dietary department dry storage room, observation was made of one unsealed conduit above the door. Additionally, above the refrigerator observation was made of an unsealed area around a six inch duct.

Third floor:
*Above the north smoke barrier doors observation was made of two small sections of drywall which were not sealed where the borders meet.

These findings were verified by Staff L5 during tour of this area.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that doors in smoke barriers were on closers and/or would swing closed in the event of fire emergency. This could affect all individuals utilizing the services of the affected smoke compartments.

The facility has a capacity of 568 with a census of 260 at the time of the survey.

Findings include:

Tour was conducted with Staff L4 on 08/22/11 from 1:40 PM until 5:00 PM, and on 08/23/11 from 9:40 AM until 5:00 PM. Observations were made of doors in smoke barriers that were not on closers and/or would not swing closed in the event of fire emergency, as follows:

In the A wing on the seventh floor, the door to the "recovery" room was located in the smoke barrier but the door was not on a self-closer nor tied into the fire system.

On the first floor, the conference room across from the nurses station on unit C was located in the smoke barrier and was on a self-closer but the door was propped open with a styrofoam cup used as a chock under the door.

In the basement, the door to the radiology conference room was located in the smoke barrier and was on a self-closer, but it was held open with a chock.

These findings were confirmed by Staff L4 during the tours.

On 08/24/11 at 9:00 AM a tour of the pediatric emergency room on the main floor was conducted with Staff L3. At 9:21 AM the door to room #8, which was part of a smoke barrier wall, was observed propped open with a chair and rubbish can. Staff L3 confirmed the finding at the time of the observation.

Based on observation and staff verification, it was determined the facility failed to ensure all smoke barriers doors were arranged so that each door swings in an opposite direction. This had the potential to affect all those utilizing this facility.

The facility has a capacity of 568 with a census of 260 at the time of the survey.

Findings include:

Tour of building 5 took place with staff members L2 and L5 on 08/22/11 through 08/24/11. During tour of the main floor west end smoke barrier, observation was made of both leafs of a double leaf smoke barrier door which opened in the same direction.

This finding was verified by Staff L2 and Staff L5 during tour of this area of the facility.

Based on observation and staff verification, it was determined the facility failed to ensure all hazardous areas were constructed with at least a one hour fire resistance rating. This had the potential to affect all those utilizing this facility.

The facility has a capacity of 568 with a census of 260 at the time of the survey.

Findings include:

Tour of building 5 took place with staff members L2 and L5 on 08/22/11 through 08/24/11. During tour, observation was made of several penetrations in the bio hazard rooms and one hour fire rated walls of large storage rooms protected as hazardous areas in the following locations:

Main floor:
*Within the bio hazard room located in the southeast section of the main floor, observation was made of two unsealed insulated water lines.
*Within the soiled utility room at the west end, observation was made of two open end conduits and a one half inch by one foot gap between two drywall sections.

First floor:
*From within the clean supply room above the door, observation was made of two open end conduits. Additionally, observation was made of one unsealed water line located in the east section of the curved wall.
*From within the bio hazard room located at the west end of the floor, observation was made of an approximate five foot by one half inch gap between drywall sections.

Second floor:
*From within the clean supply and equipment room facing the door, observation was made of one unsealed curved conduit. Also, one unsealed water line was observed at the north wall.

Third floor:
*Within the west end soiled utility room, observation was made of an unsealed area at the top of a duct where it penetrated the drywall. Also, one unsealed conduit was observed near the north door.

These findings were verified by Staff L5 during tour of this area.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that two exit discharges from the building had a hard or paved surface to the common way. This could affect all individuals utilizing the services of the affected smoke compartments.

The facility has 568 beds with a census of 260 at the time of the survey.

Findings include:

Tour was conducted with Staff L4 on 08/23/11 from 9:40 AM until 5:00 PM. During tour of the basement, the stairway from the old cardiac catheterization area was followed to the exit discharge at the ground level. It was observed that the exit discharge ended at a concrete pad, after which there was a distance of approximately 15 feet of grass that would have to be crossed to get to the common way. This finding was confirmed with Staff L4 during the tour.

On 08/24/11 at 8:52 AM, during tour with Staff L3, the exit facing east from the center stairwell from the ambulatory care center was observed to end at a concrete pad, after which there was a distance of approximately 10 to 20 yards of grass that would have to be crossed to get to the common way.

Based on observation and staff verification, it was determined the facility failed to ensure the automatic sprinkler system was maintained in reliable operating condition specifically in regard to cleaning and ensuring all components of the sprinklers were intact. This had the potential to affect all those utilizing this facility.

The facility has a capacity of 568 with a census of 260 at the time of the survey.

Findings include:

Tour of building 5 took place with staff members L2 and L5 on 08/22/11 through 08/24/11. During tour, observation was made of several sprinkler heads missing the escutcheon rings and a large amount of dust and debris coated the sprinkler pendants in the following locations:

Ground floor:
*Within the housekeeping storage room four dirty sprinkler heads observed.

Main floor:
*Within the cath lab control room, dirty sprinkler heads were observed.

First floor:
*Within the restroom located at the north end across from the stairwell, observation was made of a dirty sprinkler head.
*Within the family waiting area at the north end, observation was made of two dirty sprinkler heads.
*Within room # 1002 observation was made of a missing escutcheon ring.
*Two dirty sprinkler heads were observed in the scrub area across from the medication room.
*Within the restroom located at the west end across from the stairwell, observation was made of a missing escutcheon ring.

Second floor:
*Within the open use family waiting area, observation was made of one missing escutcheon ring.
*Within the restroom located at the west end across from the stairwell, observation was made of a missing escutcheon ring.
*Within the dietary department and within the dry storage room, observation was made of one missing escutcheon ring. Within the dietary office, observation was made of one missing escutcheon ring. Within the dish area, observation was made of one missing escutcheon ring.

Third floor:
Within room # 3010, observation was made of a dirty sprinkler head.

These findings were verified by staff members L2 and L5 during tour of these areas. This surveyor questioned Staff L5 if the facility had a maintenance program for maintaining the sprinkler heads and Staff L5 stated not at this time.

Based on observation and staff verification, it was determined the facility failed to ensure the portable fire extinguishers were inspected monthly. This had the potential to affect all those utilizing the affected areas of the facility.

The facility has a capacity of 568 with a census of 260 at the time of the survey.

Findings include:

Tour of building 5 took place with staff members L2 and L5 on 08/22/11 through 08/24/11. During tour of the main floor, observation was made of three portable fire extinguishers which lacked the July 2011 monthly inspection. They were located by cath labs #1 and #3, and within the EP hallway.

This finding was verified by Staff L2 and Staff L5 during tour of these areas of the facility.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that two egress corridors were maintained free of obstructions to full instant use of the corridors. This could affect all individuals utilizing the services of the affected smoke compartments, who might need to use these egress corridors.

The facility has 568 beds with a census of 260 at the time of the survey.

Findings include:

Tour was conducted with Staff L4 on 8/24/11 from 10:20 AM until 12:00 PM. Two exit egress corridors were observed with items stored in the corridors so that full instant use of the corridors could be compromised, as follows:

In the corridor between the womens' center and endoscopy, there were four carts with monitors on them, a cart with a box on it, a plastic bin, and a display board stored on one side of the corridor. Beyond the door, there was a wheeled basket cart that would block the swing of the door if it were opened.

In the women's center, there was a stationary table in the egress corridor.

These findings were confirmed by Staff L4 during the tour.

Suites of sleeping rooms shall not exceed 5000 square feet. 19.2.5.6

This requirement is NOT MET as evidenced by:

Based on observations made during tour, review of facility blueprints/floor plans, and staff interview, it was determined that the facility failed to ensure that one suite of sleeping rooms on the seventh floor and one suite of sleeping rooms on the sixth floor did not exceed 5000 square feet. This could affect all individuals in the affected smoke compartments.

The facility has a capacity of 568 with a census of 260 at the time of the survey.

Findings include:

Tour was conducted with Staff L4 on 08/22/11 from 1:40 PM until 5:00 PM. On the seventh floor, the neurological intensive care unit was observed to be a large suite that appeared to be greater than the allowable 5000 square feet for sleeping rooms. Staff L4 confirmed on 08/25/11 at 11:40 AM that this area of sleeping rooms was a suite and, after consulting facility floor plans, also confirmed that it exceeded 5000 square feet.

On 08/22/11 at 2:53 PM a tour of the C wing on the sixth floor was conducted with Staff L3. Review of a blueprint issued on 07/26/11 and observations made during the tour revealed the C wing to consist entirely of a suite of sleeping rooms with unlatching doors for pediatric intensive care. Review of the blueprint issued on 07/26/11 revealed the square footage to be 9609 square feet in area.





Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies. 19.2.5.9
This requirement is NOT MET as evidenced by:
Based on observations made during tour, staff interview, and review of facility blueprints/floor plans, it was determined that the facility failed to provide two approved exits for the second floor neonatal intensive care unit. This could affect all individuals in the affected smoke compartments.
The facility has a capacity of 568 with a census of 260 at the time of the survey.
Findings include:
On 08/23/11 at 2:10 PM a tour of the second floor D wing neonatal intensive care unit was conducted with Staff L3. The tour revealed an exit stairway on the east end of the wing's corridor. Traveling west from the exit stairway along the corridor, the tour revealed the corridor stopped at a suite of rooms that, according to the facility blueprints/floor plans issued on 07/26/11, was 1191 square feet in area. Within the suite, located on the south side of the wing, was the corridor's second stairwell exit. Continuing west along the D wing, the tour revealed a smoke barrier wall between the 1191 square foot suite and another suite of sleeping rooms that was 3324 square feet in area. In that suite, at the far end of the D Wing, on its north corner, was the wing's third exit. Thus, a person on the east side of the wing would have to pass through the 1,191 square foot suite to reach a second exit, and a person on the west side of the wing would have to pass through the 1,191 square foot suite to reach a second exit.

Based on observations made during tour and staff interviews, it was determined that the facility failed to meet the requirements of 39.2.8 and 7.8.1.4 in regard to exit discharge lighting for two of four exits. The facility also failed to meet the requirements of 39.2.1.1 and 7.7.1 in regard to a continuous surface to the public way for one of four exit discharges.

The facility has a capacity of 568 beds and a census of 260 patients at the time of the survey.

Findings include:

On 08/24/11 between 11:20 AM and 11:50 AM, a life safety code tour was conducted with Staff L2 and Staff L6. The facility did not ensure two of four exit discharges were illuminated so that failure of any single lighting fixture (bulb) would not leave the area in darkness. The exit discharge located on the east end of the building, that faced the nearby school, lacked any type of lighting. The closest light fixtures were observed located at the top of the two story building and approximately 40 feet each from the exit discharge. The exit discharge located near exam room #1 was observed with a single fixture at the top of the second story level. This fixture was located over a canopy that covered the exit discharge. This exit discharge was observed with approximately a five feet by five feet concrete pad. This concrete did not extend the additional ten feet to the parking lot, and the area between the pad and the parking lot was observed with grass. Staff L1 and Staff L6 verified the lack of adequate discharge lighting and continuous surface to the public way. Staff L6 stated the facility does provide outpatient therapy services to patients until approximately 7:00 PM.