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Based on observation and interview, the facility failed to ensure the penetration in 1 of 2 fire barrier walls was maintained to ensure the fire resistance of the barrier. LSC 19.1.1.3 requires all health care facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of the occupants. LSC 8.3.5.1 requires penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Fire Stops. This deficient practice could affect half of the building occupants.

Findings include:

Based on an observation with the Facility Manager on 12/21/16 at 1:48 p.m., the Studio 41 fire barrier contained five separate unsealed penetrations ranging from a quarter inch to two and a half inches. Based on interview at the time of observation, the Facility Manager acknowledged the aforementioned condition and provided the measurements.

1. Based on record review and interview, the facility failed to build the facility to health care construction limitations in accordance with Table 19.1.6.1. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Director of Engineering and Facility Management on 12/20/16 between 8:35 a.m. and 10:29 a.m., the facility has three different sections with three different construction types. The "MotherBaby" is on the fourth story with a construction rating of II (000). The "Physical Therapy" is part of the four story building with a construction rating of II (111). No documentation was available for the floor/assembly construction ratings. Based on an interview at the time of record review, the Director of Engineering and Facility Management acknowledged the aforementioned condition.

2. Based on record review, observation and interview; the facility failed to maintain the limited noncombustible rating in accordance with Table 19.1.6.1. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Director of Engineering and Facility Management on 12/21/16 between 10:29 a.m. and 6:30 p.m., the cite plans indicated the 2nd floor "Interstitial Space" was constructed to II (222) rating. Based on observation, the 2nd floor "Interstitial Space" steel support beams had multiple spots measuring four inches by four inches where the protective coating was removed. Based on an interview at the time of record review, the Director of Engineering and Facility Management acknowledged the aforementioned condition and confirmed that bare metal was exposed.

Based on observation and interview, the facility failed to ensure 1 of 12 stairway exit exterior discharges was continuously maintained free of obstructions. This deficient practice could affect staff and visitors using the B1 exit stairway exit discharge.

Findings include:

Based on an observation with the Lead Mechanic on 12/21/16 at 3:15 p.m., the B1 stairway exit discharge was covered with at least two inches of snow and ice. Based on interview at the time of observation, the Lead Mechanic acknowledged the walkway should have been cleared and made the necessary contact to get the walkway cleared.

Based on observation and interview, the facility failed to ensure not more than one delayed egress lock device was provided in any egress path as permitted by 19.2.2.2.6. LSC 19.2.2.2.6(2) states only one locking device shall be permitted on each door. This deficient practice could affect staff and up to 2 patients.

Findings include:

Based on observation with the Facilities Manger on 12/21/16 at 5:00 p.m., the EEG/Sleep study egress door contained a locking panic bar and a deadbolt. Based on interview at the time of observation, the Facility Manager acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure 1 of 2 fire door sets were arranged to automatically close and latch. LSC 7.2.4.3.10 requires all fire door assemblies in horizontal exits shall be self-closing or automatic-closing. In addition NFPA 80 6.1.4.3.1 states the fire door shall latch upon closing. This deficient could affect half of the occupants.

Findings include:

Based on observation with the Facilities Manager on 12/21/16 at 1:40 p.m., the fire doors by Studio 41 failed to latch. Additionally, when the fire doors were closed, the doors left a three eighths inch gap. Based on interview at the time of observation, the Facility Manager confirmed the cross corridor doors were fire barrier doors and had 90 minute fire resistive labels.

1. Based on record review, observation and interview; the facility failed to ensure projections into 1 of 4 Sterile Core corridors met modifications allowed by 19.2.3.4. LSC 19.2.3.4(4)(b) allows wheeled equipment in the corridor provided that the health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency. This deficient practice could affect staff and up to 6 patients.

Findings include:

Based on record review with the Director of Engineering and Facility Management on 12/21/16 between 10:29 a.m. and 6:30 p.m., the written fire safety plan did not indicate clearing the hallway of wheeled medical equipment. Based on observation, a medial cart with wheels was in the corridor near the operating rooms. Based on interview at the time of observation, registered nurse was asked where the medical cart would go in an emergency, and she said the medical cart would stay in the corridor.

2. Based on observation and interview, the facility failed to maintain 1 of 11, 3rd floor corridors from obstructions per 19.2.3.5. LSC 19.2.3.45 requires aisles, corridors, and ramps to be arranged to avoid any obstructions to the convenient removal of nonambulatory persons carried on stretchers or on mattresses serving as stretchers. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Engineering and Facility Management on 12/21/16 at 10:54 a.m., a paper shredder was in the corridor outside of the Clinical Manager Engineering office. Based on interview at the time of observation, the Director of Engineering and Facility Management acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to provide latching hardware on suite separation doors on 1 of 1 "MotherBaby" suites in accordance with 19.2.5.7.3.1. LSC 19.2.5.7.3.1(A) occupants of habitable rooms within non-sleeping suites shall have exit access to a corridor complying with 19.3.6, or to a horizontal exit, directly from the suite. LSC 19.3.6.3.5 doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction. This deficient practice could affect staff and at least 8 patients.

Findings include:

Based on observation with the Director of Engineering and Facility Management on 12/21/16 between 10:29 a.m. and 6:30 p.m., the two operating rooms were within a suite. The cross corridor door enclosing the suite did not have latching hardware installed. Based on interview at the time of observation, the Director of Engineering and Facility Management acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure 1 of 12 stairway exit exterior discharges was arranged to be accessible in respect to changes in elevation. This deficient practice could affect staff and visitors using the B1 exit stairway exit discharge.

Findings include:

Based on an observation with the Lead Mechanic on 12/21/16 at 3:15 p.m., the B1 stairway exit discharge to the public way extended up a slope for at least 50 feet, then continued over a section of the facility to the opposite side and then onto the public way. Based on interview at the time of observation, the Lead Mechanic acknowledged the sloped walkway was not provided with handrails.

Based on observation and interview, the facility failed to ensure 1 of 1 exit and directional sign was displayed in accordance with LSC 7.10. LSC 7.10.1.2.1 states, exits shall be marked by an approved sign that is readily visible from any direction of exit access. The deficient practice could affect staff or visitors using the 4th floor D building (D3) stairs.
Findings include:

a) Based on observation with the Manager of Engineering, on 12/20/16 at 4:40 p.m., there was an exit sign mounted perpendicularly on the ceiling above the 4th floor D building (D3) stairway door that was blank on the east side of the sign. Based on interview at the time of the observations, the Manager of Engineering acknowledged exit marking was not visible to staff or visitors east in the 4th floor D building corridor.
b) Based on an observation with the Lead Mechanic on 12/21/16 at 3:15 p.m., the B1 stairway exit discharge to the public way extended up a slope for at least 50 feet, then continued over a section of the facility to the opposite side and then onto the public way. Based on interview at the time of observation, the Lead Mechanic acknowledged the B1 exterior exit discharge was not provided with exit signage.

Based on observation and interview, the facility failed to maintain protection of 1 of 1 stairway in accordance of 19.3.1. LSC 19.3.1 requires vertical opening shall be enclosed or protected in accordance with Section 8.6. LSC 8.6.1 requires every floor that separates stories in a building shall be constructed as a smoke barrier. LSC 8.7.1.3 requires doors in barriers required to have a fire resistive rating shall have a minimum ¾ hour fire protection rating and be self-closing or automatic closing. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Engineering and Facility Management on 12/20/16 between 2:56 p.m. and 6:00 p.m., the following was discovered:
a) the 4th floor E-Stair-C3 middle stairwell contained three separate half inch penetrations around support beams.
b) the 4th floor SW-Stair-D2 door did not have a fire resistive rating tag installed
c) the 3rd floor South Stairwell door did not have a fire resistive rating tag installed
d) the 3rd floor S-Stair-D3 door did not have a fire resistive rating tag installed
e) the 3rd floor W-Stair-B2 door did not have a fire resistive rating tag installed
Based on interview at the time of observations, the Director of Engineering and Facility Management acknowledged the aforementioned condition and confirmed all the stairwells are rated two hours construction.

Based on observation and interview, the facility failed to ensure the corridor door to 4 of over 25 hazardous areas, such as combustible storage rooms over 50 square feet, were smoke resistive and provided with a self-closing device which would cause the door to automatically close and latch into the door frame. This deficient practice could affect primarily staff and visitors on the 3rd and 4th floors.

Findings include:

Based on observations with the Director of Engineering and Facility Management, Manager of Engineering and Lead Mechanic, the following was noted:
a) On 12/20/16 at 4:04 p.m., the 4th floor General Storage room, there were over two hundred boxes.
b) On 12/20/16 at 4:26 p.m., the 4th floor Clinical Engineer Shop, there were over sixty large cardboard boxes. The corridor door left a quarter inch gap when closed.
c) On 12/21/16 at 11:05 a.m., in the 3rd floor Franciscan Physician Network Human Services office, there were 8 cardboard boxes of old personnel files and 5 cardboard boxes of insulated grocery bags.
d) On 12/21/16 at 11:33 a.m., in the 3rd floor Medical Practice President ' s office, there were 90 cardboard boxes stacked in the room.
Based on interview at the time of the observations, the Director of Engineering and Facility Management, Manager of Engineering and/or Lead Mechanic acknowledged the doors to these rooms were not provided with self-closing devices.

1. Based on record review and interview, the facility failed to ensure the humidity in 8 of 8 Operating Rooms were greater than 20 percent. NFPA 99 9.3.1.1 requires heating, cooling, ventilating, and process systems serving spaces or providing health care functions covered by this code or listed within ASHRAE 170, Ventilation of Health Care Facilities. ASHRAE 170, requires mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 20 percent or greater. This deficient practice could affect staff and up to 8 patients.

Findings include:

Based on record review with the Director of Engineering and Facility Management on 12/20/16 between 10:19 a.m. and 4:49 p.m., no humidity documentation was available to review. Based on interview at the time of record review, the Director of Engineering and Facility Management acknowledged the aforementioned condition.

2. Based on observation and interview, the facility failed to maintain 1 of 1 IMCU and 1 of 1 "Med/Surg" local alarms in accordance with 5.1.9.3. NFPA 99 5.1.9.5 requires local alarms shall be installed to function of the air compressor system(s), medical-surgical vacuum pump system(s), WAGD systems, instrument air systems and proportioning systems. This deficient practice could affect staff and up to 36 patients.

Findings include:

Based on observation with the Director of Engineering and Facility Management on 12/20/16 between 12:30 p.m. and 6:00 p.m., the test button for the oxygen/air/vacuum local alarm outside patient room 7533 was pressed. When the button was pressed, the panel did not illuminate all lights nor sound the alarm. Furthermore, the test button for the oxygen/air/vacuum local alarm outside patient room 6533 was pressed. When the button was pressed, the panel did not illuminate all lights nor sound the alarm. Based on interview at the time of each observation, the Director of Engineering and Facility Management acknowledged each aforementioned condition.

Based on observation and interview, the facility failed to ensure 6 of at least 40 alcohol based hand rub (ABHR) dispensers were not installed within 1 inch of an ignition source. This deficient practice could affect at least 6 patients as well as staff and visitors.

Findings include:

Based on observations with the Manager of Engineering and Lead Mechanic on 12/21/16 from 1:50 p.m. to 2:05 p.m. in the 3rd floor patient suite area, ABHR dispensers were mounted on the wall directly above an ignition source such as an electrical outlet between the following patient suites:
a) 3529/3530
b) 3531/3532
c) 3533/3534
d) 3536/3537
e) 3537/3538
f) 3538/3539
Based on observation with the Director Engineering and Facility Management on 12/20/16 at 3:40 a.m., the fourth floor corridor had an ABHR dispenser above an outlet outside of patient room 4005.
Based on interview at the time of the observations, the Manager of Engineering and Lead Mechanic and Director Engineering and Facility Management acknowledged the dispensers were mounted directly above electric outlets.

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 17.7.4.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect staff and up to 18 residents in the smoke compartment.

Findings include:

Based on observation with the Director of Engineering and Facility Management on 12/20/16 at 1:08 p.m., a smoke detector was twelve inches away from an HVAC vent near patient room 7528.
Based on observation with the Director of Engineering and Facility Management on 12/21/16 at 1:52 p.m. and again at 5:31 p.m., three separate smoke detectors were twelve inches away from HVAC in the Sterile Core. Furthermore, a smoke detector was one inch away from an HVAC vent in the Cath Lab Soiled Utility room.
Based on interview at the time of each observation, the Director of Engineering and Facility Management acknowledged each aforementioned condition and provided the measurements.

Based on observation and interview, the facility failed to ensure the fire alarm system was maintained. This deficient practice would affect primarily dietary staff.

Findings include:

Based on observation with the Director, Engineering Facilities on 12/21/16 at 5:00 p.m., a programmed smoke detector inside the Dietary Electrical Supply Station room had a plastic cover over the smoke detector. Based on interview at the time of observation, the Director, Engineering Facilities did not know why there was a cover over this programmed smoke detector.

Based on record review and interview, the facility failed to provide a complete written policy for the protection of residents indicating procedures to be followed in the event the fire alarm system if it has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all occupants.

Findings include:

Based on record review with the Director of Engineering and Facility Management on 12/21/16 at 9:23 a.m., the facility provided fire watch documentation but it was incomplete. The plan failed to include contacting the insurance company and the person conducting the fire watch shall be trained and have no other duties while performing the fire watch. Based on an interview during record review, the Director of Engineering and Facility Management acknowledged the aforementioned condition.

1. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13, 2010 Edition, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. NFPA 13, Section 8.6.3.4, "Minimum Distance between Sprinklers", states sprinklers shall be spaced not less than 6 feet on center. In addition, LSC 4.6.7.5 requires existing life safety features that do not meet the requirements for new buildings, but exceed the requirements for existing buildings shall not be further diminished. This deficient practice could affect staff only.

Findings include:

Based on observations with the Manager of Engineering, the following was noted:
a) On 12/20/16 at 4:20 p.m., there were two sprinkler heads in the 4th floor D building dumbwaiter/electrical room that were 24 inches apart.
b) On 12/20/16 at 4:25 p.m., there were two sprinkler heads in the 4th floor D building copy room that were 44 inches apart.
Based on interview at the time of the observations, the Manager of Engineering acknowledged the distance of the sprinkler heads sets as being less than 72 inches in distance apart from each other.

2. Based on observation and interview, the facility failed to ensure the spray pattern for sprinkler heads were not obstructed in 1 of 1 Elevator Equipment 16 room and 1 of 1 Cath Lab Soiled Utility room in accordance with 19.3.5.1. NFPA 13, 2010 edition, Section 8.5.5.1, states sprinklers shall be located so as to minimize obstructions to discharge as defined in 8.5.5.2. and 8.5.5.3 or additional sprinklers shall be provided to ensure adequate coverage of the hazard. Section 8.5.5.2 and 8.5.5.3 do not permit continuous or noncontinuous obstructions less than or equal to 18 in. below the sprinkler deflector that prevent the pattern from fully developing. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Engineering and Facility Management on 12/21/16 at 4:25 p.m., the Elevator Equipment 16 contained a ceiling light. The ceiling box light was one inch away and lower than the deflector. Based on interview at the time of observation, the Director of Engineering and Facility Management acknowledged the aforementioned condition.

1. Based on observation and interview, the facility failed to maintain an undetermined number of fire hoses throughout 8 of 8 stories in accordance with 9.7.5. NFPA 25 7.1.4 states fire hoses shall be maintained in accordance with NFPA 1962, Standard for the Inspection, Care, Use of Fire Hose, Couplings, and Nozzles and the Service Testing of Fire Hose. NFPA 1962 8.2.1 states all appliances shall be visually inspected at least quarterly. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Director of Engineering and Facility Management on 12/20/16 between 12:30 p.m. and 6:00 p.m., fire hoses were discovered throughout the facility protected in a glass cabinet. The tag on the hoses indicated the last inspection was done in 2015. Based on interview at the time of first observation, the Director of Engineering and Facility Management acknowledged the aforementioned condition and confirmed no other documentation was available for review.

2. Based on observation and interview, the facility failed to maintain the ceiling construction in 1 of 1 "OR suite labor and delivery Janitor closet," and 1 of 1 "Store room off of Lobby," and "OR electrical closet." The ceiling tiles trap hot air and gases around the sprinkler and cause the sprinkler to operate at a specified temperature. NFPA 13, 2010 edition, 8.5.4.11 states the distance between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Engineering and Facility Management on 12/20/16 between 3:30 p.m. and 4:27 p.m., the following was discovered:
a) a one inch by ten inch penetration in the drop ceiling in the OR suite labor and delivery Janitor's closet
b) six of thirty seven ceiling tiles were missing in the "Store room off of Lobby"
Based on observation with the Director of Engineering and Facility Management on 12/21/16 between 10:29 a.m. and 6:30 p.m., the following was discovered:
c) a two inch gap in the drop ceiling in the OR electrical closet
Based on interview at the time of each observation, the Director of Engineering and Facility Management acknowledged each aforementioned condition and provided the measurements.

Based on record review and interview, the facility failed to provide a written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period in accordance with LSC, Section 9.7.5. LSC 9.7.5 requires sprinkler impairment procedures comply with NFPA 25, 2011 Edition, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 requires nine procedures that the impairment coordinator shall follow. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Director of Engineering and Facility Management on 12/21/16 at 9:23 a.m., the facility provided fire watch documentation but it was incomplete. The plan failed to include contacting the insurance company and the person conducting the fire watch shall be trained and have no other duties while performing the fire watch. Based on an interview record review, the Director of Engineering and Facility Management acknowledged the aforementioned condition.

1. Based on observation and interview, the facility failed to ensure 1 of 1, 1st floor D elevator portable fire extinguisher was installed correctly in accordance with 19.3.5.12. NFPA 10, the Standard for Portable Fire Extinguishers, 7.2.2, Procedures, requires periodic inspection or electronic monitoring of fire extinguishers shall include a check of six items. (3) Pressure gauge reading or indicator in the operable range or position. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Engineering and Facility Management on 12/21/16 at 3:40 p.m., the 1st floor D elevator fire extinguisher gauge indicated the fire extinguisher was undercharged. Based on interview at the time of observation, the Director of Engineering and Facility Management acknowledged the aforementioned condition.

2. Based on observation and interview, the facility failed to ensure 1 of 3 kitchen portable fire extinguishers which had been recharged was provided with a verification of service collar.
NFPA 10, Standard for Portable Fire Extinguishers at section 7.3.3.2.1 states each extinguisher that has undergone maintenance that includes internal examination or that has been recharged shall have a verification-of-service collar located around the neck of the container. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director, Engineering Facilities on 12/21/16 at 4:50 p.m., the K class portable fire extinguisher in the kitchen had a stick on label indicating it had been recharged after a 6 year maintenance test but lacked a verification of service collar. Based on interview at the time of observation, the Director, Engineering Facilities acknowledged the lack of service collar around the neck of the container.

3. Based on observation and interview, the facility failed to ensure 1 of 2 fire extinguishers in the 100 unit was readily accessible at all times. NFPA 10, Standard for Portable Fire Extinguishers, 6.1.3.1 requires that fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Engineering and Facility Management on 12/20/16 at 12:45 p.m., one fire extinguisher in the 6th floor Mechanical room was blocked by a large ladder and large directional equipment signs. Based on interview at the time of observation, the Director of Engineering and Facility Management acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to maintain protection for 1 of 11, 3rd floor corridor walls in accordance of 18.3.6.2. LSC 18.3.6.2, Construction of Corridor Walls, requires corridor walls shall form a barrier to limit the transfer of smoke. This deficient practice could affect staff and up to 5 patients.

Findings include:

Based on observation with the Director of Engineering and Facility Management on 12/21/16 at 12:04 p.m., the corridor near patient room 3008 contained a three eights inch penetration in the drywall. Based on interview at the time of observation, the Director of Engineering and Facility Management acknowledged the aforementioned condition.

1. Based on observation and interview, the facility failed to maintain protection of corridor doors in 8 of 8 stories in accordance of 19.3.6.3. This deficient practice could affect staff and at least 32 patients.

Findings include:

Based on observation with the Director of Engineering and Facility Management on 12/20/16 between 1:06 p.m. and 3:01 p.m., the following corridor doors were discovered:
a) a trash can impeded patient room 7531 from closing into the frame
b) patient room 4521 failed to latch into the frame
Based on observation with the Director of Engineering and Facility Management on 12/21/16 between 10:58 a.m. and 3:01 p.m., the following corridor doors were discovered:
c) a brick was being used as a door stop in the Engineering Secretary office
d) the Nurse's Outpatient Behavior Health office contained a three sixteenth inch gap between the Dutch door top and bottom half.
e) the Reception office contained a quarter inch gap between the Dutch door top and bottom half.
f) the x-ray reading room corridor door was propped open with a blood pressure monitor. Additionally, a lead vest impeded the door from latching.
g) a door stop was on the Intake Coordinator's E1004 door
Based on interview at the time of each observation, the Director of Engineering and Facility Management acknowledged each aforementioned condition.

2. Based on observation and interview, the facility failed to ensure 1 of 3, 1st floor sets of corridor doors would close to form a smoke resistant barrier. Centers for Medicare & Medicaid Services (CMS) requires sets of smoke barrier doors which swing in the same direction and equipped with an astragal to have a coordinator to ensure the door which must close first always closes first. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Engineering and Facility Management on 12/21/16 at 6:01 p.m., of the set of corridor smoke doors near Laundry room E1006, the corridor doors swing in the same direction with the one door equipped with an astragal. The door set was not equipped with a door closing coordinator to ensure the door equipped with an astragal closes last and forms a smoke resistant barrier. Based on interview at the time of observation, the Director of Engineering and Facility Management acknowledged the aforementioned corridor door set was not equipped with a door closing coordinator to ensure the door equipped with an astragal closes last and forms a smoke resistant barrier.

1. Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 1 ceiling and 2 of 5 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.5 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. This deficient practice could affect staff and up to 24 patients.

Findings include:

Based on observations with the Director of Engineering and Facility Management on 12/20/16 at 3:14 p.m., the following unsealed penetration was discovered:
a) a quarter inch around cables in the smoke barrier near patient room 4524. Additionally, a one and a half inch by fourteen inch gap around the HVAC going through the barrier.
Based on observations with the Director of Engineering and Facility Management on 12/21/16 between 11:46 a.m. and 6:00 p.m., the following unsealed penetrations were discovered:
b) the ceiling access panel was propped open by cardboard boxes in the "room across from Housekeeping Supervisor"
c) three separate half inch ceiling penetrations in the Case Management storage room
d) one inch gap around HVAC tubing in the OR smoke barrier
e) a six by six inch ceiling penetration in the Housekeeping Chapel Closet
f) multiple ceiling penetrations in the Maintenance Shop ranging from a quarter inch to five inch by twenty four inches.
Based on interview at the time of each observation, the Director of Engineering and Facility Management acknowledged each aforementioned condition and provided the measurements.

2. Based on observation and interview, the facility failed to install 1 of 1 smoke damper where HVAC continues through a smoke barrier in accordance with 19.3.7.3. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. LSC 8.5.5.4.1 states that air-conditioning, heating, ventilating ductwork, and related equipment, including smoke dampers and combination fire and smoke dampers, shall be installed in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems., and NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. This deficient practice could affect staff and up to 6 patients.

Findings include:

Based on observations with the Director of Engineering and Facility Management on 12/21/16 at 2:29 p.m., the OR Break room smoke barrier contained flexible HVAC tubing. The flexible HVAC tubing opened up on both sides of the smoke barrier. Based on interview at the time of observation, the Director of Engineering and Facility Management acknowledged the aforementioned condition and confirmed no smoke damper was installed.

Based on observation and interview, the facility failed to ensure 1 of 3, 1st floor sets of smoke barrier doors would restrict the movement of smoke for at least 20 minutes. LSC, Section 19.3.7.8 requires that doors in smoke barriers shall comply with LSC, Section 8.5.4. LSC, Section 8.5.4.1 requires doors in smoke barriers to close the opening leaving only the minimum clearance necessary for proper operation which is defined as 1/8 inch to restrict the movement of smoke. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Engineering and Facility Management on 12/21/16 at 5:02 p.m., when the St Francis Center set of smoke barrier doors were tested, one of the doors caught up on coordinating device and failed to close. Based on interview at the time of observation, the Director of Engineering and Facility Management acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure 1 of 1 openings in a smoke barrier door was constructed of fire-rating glazing or wired glass in a steel frame. This deficient practice could affect primarily staff.

Findings include:

Based on observations with the Manager of Engineering and Lead Mechanic on 12/21/16 at 11:20 a.m., the smoke barrier outside the 3rd floor "Indiana Lions Eye & Tissue Transplant" room continued to the outside wall into and through the room. An abandoned bathroom inside this room had a wooden 1 ¾ inch door with a door closer within the smoke barrier with a 10 inch x 16 inch wood louvered vent at the bottom. The door frame was provided with a paper sticker label at the top that indicated the door was inspected per NFPA 80 on 10/26/16 by Fire Door Solutions. Based on interview at the time of the observations, the Manager of Engineering and/or Lead Mechanic acknowledged the door opening in this smoke barrier door would not resist the passage of smoke.

Based on observation and interview, the facility failed to maintain 2 of 2 laundry chutes in accordance with NFPA 82. NFPA 82, 10.2.2.1 states if waste and linen chute discharge door is equipped with a fusible link, the following shall be conducted: (1) Inspect the link to ensure it is not painted or coated with dust or grease (2) Evaluate the condition of chains/cables, s-hooks, eyes, and other devices that operate as a result of link melting to verify working condition (3) Remove the link for testing every 4 years to ensure full closure and positive latching (4) Reinstall the link after testing is complete (5) Replace the link if damaged or painted with a link of the same size, temperature, and load rating. NFPA 82, 10.2.1 states chute loading and discharge doors shall be clear and unobstructed at all times. This deficient practice could affect staff only.

Findings include:
Based on observation with the Director of Engineering and Facility Management on 12/20/16 between 12:30 p.m. and 6:00 p.m., the fifth floor laundry chute discharge contained a fusible link and chain holding the door open. Additionally, soiled linen bags were backed up from the cart on the ground all the way back into the chute. Based on interview at the time of observation, the Director of Engineering and Facility Management acknowledged the aforementioned condition and confirmed no documentation regarding the link was available for review.

1. Based on record review and interview, the facility failed to ensure written fire safety plans that addressed preparation of floors for evacuation were not in conflict with each other or the LSC. LSC 7.14.1.2 states the provisions of 7.14, Elevators for Occupant-Controlled Evacuation Prior to Phase 1 Emergency Recall Operations shall not apply where the limited or supervised use of elevators for evacuation is part of a formal or informal evacuation strategy, including the relocation of patients in healthcare occupancies and the relocation or evacuation of occupants with disabilities in other occupancies. This deficient practice could affect all occupants in the event of an emergency involving evacuation of upper floors.

Findings include:

Based on a review of several plans on 12/21/16 at 9:30 a.m. with the Manager of Engineering and Director, Engineering Facilities, the "2016 Fire Safety Control Management Plan-Hammond/Dyer" stated, under the Fire Plan Elements section, "If a relocation or evacuation is deemed necessary, staff should, (4) If patients must be moved vertically, elevators provided with emergency power and with the permission of the Fire Department are used to move patients to lower floors." The "Fire Safety and Evacuation" plan with a PolicyStatID of 1502848 which was last revised on 04/30/15 and set to expire on 4/29/17 stated at G(4), "Elevators shall not be used except the Dyer Fire Department." Based on interview at the time review, the Manager of Engineering and Director, Engineering Facilities, acknowledged further review of the evacuation from upper floors was needed.

2. Based on record review and interview, the facility failed to provide a written plan that addressed all components of LSC 19.7.2.2. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
This deficient practice could affect any staff or visitor in the vicinity of the Café on the 1st floor.
Findings include:
Based on a review of the "Fire Safety and Evacuation" plan with a PolicyStatID of 1502848 which was last revised on 04/30/15 and set to expire on 4/29/17 on 12/21/16 at 9:30 a.m. with the Manager of Engineering and Director, Engineering Facilities, the plan in sections E and F did not address the K class fire extinguisher, its purpose or use in conjunction with the kitchen hood extinguishing system. The plan addressed only the use of fire extinguishers using the acronym "PASS", Class A, B, C and D fires and types of fire extinguishers used in the Lab such as ABC and Halon. Based on interview at the time review, the Manager of Engineering and Director, Engineering Facilities, acknowledged the use of the K class fire extinguisher was not addressed.

Based on observation and interview, the facility failed to ensure 1 of 1 Retirement Benefit Services office and 1 of 1 Chapel was maintained in accordance with 19.7.5.6. LSC 19.7.5.6 prohibits combustible decorations unless an exception was met. This deficient practice could affect staff and up to 25 occupants.

Findings include:

Based on observations with the Director of Engineering and Facility Management on 12/20/16 at 4:15 p.m. and again at 4:04 p.m., four candles were in the Retirement Benefit Services office. Furthermore, eight candles were in the chapel. Based on interview at the time of each observation, the Director of Engineering and Facility Management acknowledged each aforementioned condition and was unable to provide any documentation.

Based on observation and interview, the facility failed to ensure trash receptacles near 1 of 1 Patient room 6520 and 1 of 1 Patient room 4530 was maintained in accordance with 19.7.5.7. This deficient practice could affect staff and up to 36 patients.

Findings include:

Based on observation with the Director of Engineering and Facility Management on 12/20/16 at 1:55 p.m. and again at 2:45 p.m., there was a twenty five gallon paperwork container next to a fifteen gallon trash can at the Nurses' station open to the corridor near patient room 6520. Furthermore, there was a twenty five gallon paperwork container next to a twenty five gallon trash can at the Nurses' station open to the corridor near patient room 4530. Based on interview at the time of each observation, the Director of Engineering and Facility Management acknowledged each aforementioned condition, provided the gallons per container, and was unable to provide the documentation that the paperwork contained met FM Approval Standard 6921 for the 19.7.5.7.2.

Based on observation and interview, the facility failed to ensure its policy regarding the use of space heaters was followed. This deficient practice could affect primarily staff only.

Findings include:

Based on observations with the Manager of Engineering, the following was noted:
a) On 12/20/16 at 2:53 p.m., in the 4th floor "Ortho" room, there was a space heater plugged into an electrical outlet with a label stating "Equipment checked-11/29/11".
b) On 12/20/16 at 4:20 p.m., in the 4th floor D building Revenue Management Director's office, there was a space heater plugged into an electrical outlet under the desk.
c) On 12/20/16 at 4:25 p.m., in the 4th floor D building RMD Pricer/CBR Analyst office, there was a space heater plugged into an electrical outlet under the desk near the window.
d) On 12/20/16 at 4:35 p.m., in the 4th floor D building Employee Assistance Program office, there was a space heater plugged into an electrical outlet.
e) On 12/21/16 at 11:05 a.m., in the 3rd floor Franciscan Physician Network Human Services office, there was a space heater plugged into an electrical outlet under the desk.
Based on observation with the Director Engineering and Facility Management, the following was noted:
f) On 12/21/16 at 10:55 a.m., in the 3rd floor Fire Room 1, there was a space heater
Based on interview at the time of the first observation, the Manager of Engineering and Director Engineering and Facility Management acknowledged the discovered space heaters and indicated it is the hospital's policy not to allow space heaters in employee areas. The subsequent discoveries of the additional space heaters were also acknowledged at the times of observation.

Based on observation and interview, the facility failed to ensure there were battery-powered lighting for 8 of 8 Operating Rooms using general anesthesia. NFPA 99 2012 edition 6.3.2.2.11.1 states one or more battery-powered lights shall be provide within locations where deep sedation and general anesthesia is administered. 6.3.2.2.11.2 states the lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room. This deficient practice could affect staff and up to eight patients.

Findings include:

Based on observation with the Director of Engineering and Facility Management on 12/20/16 at 3:22 p.m., two operating rooms in the "MotherBaby" area did not have battery operated emergency lighting. Based on interview at the time of observation, the Director of Engineering and Facility Management acknowledged the aforementioned condition and confirmed that of all eight operating rooms use general anesthesia and no battery operated emergency light is installed.

Based on record review and interview, the facility failed to protect 8 of 8 wet location Operating Rooms in accordance with 6.3.2.2.8. 2012 Health Care Facilities Code 99 6.3.2.2.2.8.4 states that operating rooms shall be considered to be a wet location unless a risk assessment conducted by the health care governing body determines otherwise. HCFC 6.3.2.2.8 requires wet procedure locations shall be provided with special protection against electrical shock. This deficient practice could affect staff and up to 8 patients.

Findings include:Based on record review with the Director of Engineering and Facility Management on 12/20/16 between 12:30 p.m. and 6:00 p.m., no risk assessment documentation was available for review. Based on interview at the time of record review, the Director of Engineering and Facility Management the aforementioned condition and confirmed that the electrical protection had been previously removed and no risk assessment had been performed.

Based on record review and interview, the facility failed to ensure 1 of 1 Hammond Rehabilitation emergency diesel powered generator was allowed a 5 minute cool down period after a load test. Chapter 6.4.4.1.1.4(a) of 2012 NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, Chapter 8. NFPA 110, 6.4.2.1.5.9 Time Delay on Engine Shutdown requires that a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shutdown. This delay provides additional engine cool down. This time delay shall not be required on small (15 kW or less) air-cooled prime movers. This deficient practice could affect all residents, as well as staff and visitors in the facility.

Findings include:

Based on record review with the Facilities Manager on 12/20/16 at 10:46 a.m., the generator log form documented the generator was tested monthly for at least 30 minutes under load, however, there was no documentation on the form that showed the generator had a cool down time following its load test. Based on interview at the time of record review, the Facilities Manager acknowledged the aforementioned condition.

1. Based on observation and interview, the facility failed to ensure 9 of 9 flexible cords were not used as a substitute for fixed wiring according to 9.1.2. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects staff only.

Findings include:

Based on observation with the Director of Engineering and Facility Management on 12/20/16 at 12:55 p.m. and again at 4:19 p.m., the following was discovered:
a) a surge protector was powering an extension cord which was powering a surge protector powering computer equipment in the "Office across from Elevator 14."
b) a surge protector was powering a coffee pot and microwave in the Clinical Engineer office.
Based on observation with the Director of Engineering and Facility Management on 12/21/16 between 10:53 a.m. to 11:55 a.m., the following was discovered:
c) an extension cord was powering a surge protector powering computer equipment in the Manager of Clinical Engineering office
d) a surge protector was powering a coffee pot in the Franciscan Physician Network Employee Lounge. Additionally, a surge protector was powering a microwave.
e) a surge protector was powering a refrigerator in the Nursing Infomatics room
f) a surge protector was powering a toaster and a toaster oven in the Transport office
Based on interview at the time of each observation, the Director of Engineering and Facility Management acknowledged each aforementioned condition.

2. Based on observation and interview, the facility failed to ensure 1 of 1 Room 3 Behavior Health and 1 of 1 Anesthesia Call room bathroom sink was provided with a ground fault circuit interrupter (GFCI) protection against electric shock. LSC sections 9.1.2 requires all electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, Article 210.8 Ground-Fault Circuit-Interrupter Protection for Personnel, in 210.8(A), Dwelling Units, requires ground-fault circuit-interrupter (GFCI) protection for all personnel in bathrooms and kitchens where the receptacles are intended to serve the countertop surfaces. Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could affect staff and up to 10 patients.

Findings include:

Based on observation with the Director of Engineering and Facility Management on 12/21/16 at 11:25 a.m., Room 3 Behavior Health had one receptacle within three feet of the hand sink. When the GFCI tester button was pressed, power was not interrupted on the GFCI receptacle. Furthermore, the Anesthesia Call room had one receptacle within three feet of the hand sink. When the GFCI tester button was pressed, power was not interrupted on the GFCI receptacle. Based on interview at the time of each observation, the Director of Engineering and Facility Management acknowledged each aforementioned condition.

Based on observation and interview, the facility failed to ensure the penetration in 2 of 5 fire barrier walls was maintained to ensure the fire resistance of the barrier. LSC 19.1.1.3 requires all health care facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of the occupants. LSC 8.3.5.1 requires penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Fire Stops. This deficient practice could affect staff only.

Findings include:

Based on an observation with the Director of Engineering and Facility Management on 12/21/16 at 3:55 p.m. then again at 6:16 p.m., the Business/Health Care Fire Separation by the Chapel there was a six inch by six inch piece of drywall removed. Additionally, a three quarter inch gap inside conduit was not sealed above the drop ceiling. Also, a one and a quarter inch penetration was discovered in the 1st floor A Building / B Buiding separation above the drop ceiling. Based on interview at the time of each observation, the Director of Engineering and Facility Management acknowledged each aforementioned condition and provided the measurements.

Based on observation and interview, the facility failed to ensure 2 of 5 fire door sets were arranged to automatically close and latch. LSC 7.2.4.3.10 requires all fire door assemblies in horizontal exits shall be self-closing or automatic-closing. In addition NFPA 80 at 6.1.4.3.1 states the fire door shall latch upon closing. This deficient could affect staff and up to 12 patients.

Findings include:

Based on observation with the Director of Engineering and Facility Management on 12/21/16 at 3:07 p.m. and again at 4:22 p.m., the fire doors by patient room 2017 failed to latch. Furthermore, the 1st floor POV/ Health Care separation fire doors failed to latch. Based on interview at the time of each observation, the Director of Engineering and Facility Management confirmed the cross corridor doors were fire barrier doors and had 90 minute fire resistive labels.

Based on record review and interview, the facility failed to maintain 1 of 1 sprinkler system in accordance with LSC 9.7.5. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 edition, Table 5.1.1.2 indicates the required frequency of inspection and testing. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Facility Manager on 12/20/16 at 1:30 p.m., the sprinkler system was inspected annually only. Based on interview at the time of record review, the Facility Manager acknowledged the aforementioned condition.