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Based on observation, schematic review, and staff verification the facility failed to ensure its building separations were free of penetrations. This has the potential to affect all patients receiving services from the facility. The facility census was 195.

Findings include:

Observation of the Ground floor completed on 05/09/16 between the hours of 12:30 PM and 5:30 PM and schematic review revealed the following findings:

1. Observation above the drop ceiling in the corridor, above the double fire doors, from the hospital to the building where the Hyperbaric facility is located from the hospital side revealed multiple open ended conduits and open spaces around the conduits penetrating the fire rated wall with multiple data cables passing through. These findings were verified by Staff DD at 1:10 PM.

2. Observation above the drop ceiling in the small corridor to the lab from the South most corridor revealed two 3 1/2 inch holes with two 1/2 inch copper pipes passing through, and a 1 1/2 inch conduit open on the end above the door to the lab space. This finding was verified by Staff DD at 1:29 PM.

Observation of the 1st floor completed on 05/10/16 between the hours of 8:30 AM and 5:30 PM revealed the following findings:

1. Observation above the drop ceiling (on the hospital side), above the doors to the cancer center revealed a 3/4 inch conduit penetrating the 2 hours fire rated wall open on the end with gray data cable passing through. This findings was verified by Staff DD at 8:36 AM.

2. Observation above the drop ceiling in room 1216 revealed a 3 inch galvanized conduit with data cables passing through with open annular space and a 1/2 inch conduit open on the end both passing through the marked 3 hour fire rated wall. These findings were verified by Staff DD at 3:20 PM.

Based on review of facility schematics, observation of the facility and staff interview and confirmation, the facility failed to ensure that stairways, elevator shafts, chutes, and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least two hours connecting four stories or more. The facility census was 195 patients at the time of the survey. Potentially all patients and visitors could be adversely affected.

Findings Include:

On 05/09/16 the facility schematics were reviewed to reveal the presence of trash and linen chutes and chases. The schematic indicated the vertical openings were enclosed by two hour fire rated construction.

Tour of the facility was conducted with Staff AA, BB, DD and EE on 05/09/16 between 1:30 P.M. and 5:30 P.M. and on 05/10/16 and 05/11/16 between the hours of 8:30 A.M. and 5:00 P.M. Tour included observation of the two hour fire rated separation that surround vertical openings in the facility. The following observations are related to penetrations in the two hour fire rated construction:

1. Observation of the fourth floor penthouse revealed the top of the previously existing trash and linen chutes. On 05/10/16 at 9:25 A.M., interview of Staff FF was conducted regarding locations of sprinkler heads in the chutes at each floor. Staff FF could not confirm the locations of sprinkler heads in the trash and linen chutes and later provided pictures of the inside of the chutes. The pictures of the linen chute at level one, three and four indicated that portions of the metal chutes were roughly cut out to accommodate the placement of sprinkler heads. Pictures of the trash chute revealed sprinkle head placement at level one and three. Staff FF revealed that placement of the sprinkler heads was not at the chute door level but was between each level and located just below level two and level four and between level four and the penthouse. Interview of Staff FF, CC, DD and AA revealed there was no access panels at the chutes and that removal of outside wall surrounding the chutes was the only way to access the chutes and sprinkler heads. Staff could not confirm the integrity of the fire rated structure.

2. Observation above the ceiling tiles of the two hour fire rated barrier at stairwell 3SST2 on third floor, south, revealed a penetration approximately eight to ten inches in diameter on the corridor side of the stairwell.

3. Observation above the ceiling tiles of the two hour fire rated separation for a chase located on third floor at 3T1137, nourishment station, revealed the seams of gypsum board were not sealed with fire retardant sealer

4. Observation above the ceiling tiles of the two hour fire rated separation for a chase located on second floor near the heart cath lab revealed the presence of white dry wall sealer which staff confirmed had an unknown fire resistance rating.

Staff present on tour confirmed the observations.





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Tour of the ground floor was completed on 05/09/16 between the hours of 12:30 PM and 5:30 PM and the following observations were noted during the tour:

5. Observation of the chute doors located in the chute room of the new building revealed a 1/2 inch gap between the trash chute door and the chute. The doors were noted to be kept in a closed position and emptied throughout the day.

6. Observation above the door to the stairwell B-3 (GWST1) revealed a 1 inch hole as observed from the corridor side.

Tour of the ground and 1st floors were completed on 05/10/16 between the hours of 8:00 AM and 5:30 PM and the following observations were noted during the tour:

7. Observation of the trash chute door located in the trash chute room of the old building revealed the left side of the door was missing latching hardware the there was a 1 1/2 inch gap between the door and the chute. The door was noted to be kept in a closed position and emptied throughout the day.

8. Observation of the fire rated wall for a stairwell's South wall outside the Office of Patient Expenses (1E001) revealed a 3 inch sprinkler pipe with open annular space and a 1 inch hole above the sprinkler pipe.

9. Observation of the fire rated wall for the HVAC chase located in the North most corridor in the ED revealed a 1/2 inch gap to the right of an HVAC duct.

10. Observation of the fire rated wall for the HVAC chase located by the intersection of the West most corridor and South central corridor in the ED revealed a 2 inch gap to the left of a HVAC duct.

11. Observation of the fire rated wall for the HVAC chase located by the intersection of the West most corridor and South most corridor revealed a 1/4 inch gap to the left of the HVAC duct.

12. Observation of the chase located by the Ambulance entrance revealed a 3/4 inch conduit open the end with two light blue data cables passing through the 2 hour fire rated chase wall.

Tour of the 2nd floor completed on 05/10/16 between the hours of 5:00 PM and 5:30 PM through 05/11/16 between the hours of 9:20 AM and 2:30 PM revealed the following:

13. Observation of the HVAC chase located beside the East stairwell of 2 East revealed a 24 inch by 12 inch hole.

14. Observation of the chase located beside the shared offices (2T232) near the PACU area revealed a chase access panel pulled 3/8 inch out from the wall making a separation between the gypsum board and the panel visible.

The findings were verified by Staff at the time of the observations.

Based on observation and staff interview the facility failed to ensure exit egresses were marked with directional exit signs and failed to ensure non-exits were not marked as exit egresses. This has the potential to affect all patients receiving services from the facility. The facility census was 195 at the time of the validation survey.


Findings include:


1. Observation of the Pediatric ED area completed on 05/11/16 revealed an exit sign directing patients to the Adult ED area. Interview with Staff DD completed on 05/11/16 at 2:10 PM revealed the exit sign is wrong when directing patients to the Adult ED and the egress paths are at the ends of the corridor.

2. Observation of 2 South, East corridor on 05/12/16 revealed an exit sign with no directional chevron showing the direction of exit egress. When under the exit sign there was no sign noted showing the direction of the Exit access. This finding was verified by Staff DD at 12:00 PM.

Based on review of facility schematics, observation of the facility and staff interview and confirmation, the facility failed to ensure that smoke barriers were constructed to provide at least a one hour fire resistance rating and constructed in accordance with 8.3 and that windows were protected by fire-rated glazing or by wired glass panels in approved frames. The facility census was 195 patients at the time of the survey. Potentially all patients and visitors could be adversely affected.

Findings include:

On 05/09/16 the facility schematics were reviewed to reveal that each floor of the facility was divided into at least two smoke compartments by one hour smoke barrier walls. Tour of the facility was conducted with Staff AA, BB, DD and EE on 05/09/16 between 1:30 P.M. and 5:30 P.M. and on 05/10/16 and 05/11/16 between the hours of 8:30 A.M. and 5:00 P.M. Tour included observation of the smoke barrier walls which extended above the ceiling tiles on each floor of the facility. The following observations related to penetrations were noted;

Fourth Floor:
1. Smoke barrier doors located between the north and south corridors were noted to have a gap greater than one-eighth inch wide when in the closed position.

2. Smoke barriers doors at the entry to four north revealed a gap greater than one-eight inches when in the closed position. Observation above the ceiling tiles revealed open space surrounding duct work and a penetration approximately three inches diameter.

Third floor:

3. Located above door 3N041B, in a one hour smoke wall, a penetration approximately one inch by one half inch at duct work.

4. Located in staff break room, 3W185, near the window, a penetration approximately three to four inches in diameter with flex conduit through the penetration.

5. Located above the smoke doors to three west, a six to eight inch penetration noted at the balancing damper door.

6. Located in the smoke barrier wall near the respiratory therapy room, a one inch conduit with data line which penetrated the smoke barrier wall.

7. Located at smoke barrier doors, unsealed conduit with data lines penetrated the one hour rated smoke wall.

Second Floor:

8. Located above smoke doors, near cath lab 2, two metal sleeves penetrated the wall with unsealed space surrounding the metal sleeves.

The above findings were confirmed by staff who were present on tour.






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Tour of the garden level completed on 05/09/16 between the hours of 1:00 PM and 5:30 PM revealed the following findings.

1. Observation of the East fire rated wall of the Labs L-shaped room revealed four 3/4 inch conduits open on the end with blue data cables passing through.

2. Observation of the East fire rated wall of the Lab's space identified as GD002 revealed three 6 inch pneumatic tubes with open annular space penetrating the wall.

3. Observation of the fire rated wall in the corridor from the lab traveling East and West revealed Multiple penetrations varying in size and shape penetrating the South wall of the corridor to left of GS005 door.

4. Observation of the South wall of room identified as FR4 revealed multiple penetrations varying in size and shape penetrating the fire rated wall.

5. Observation of the North fire rated wall in the room identified as GT004 revealed 1 1/2 inch hole penetrating the wall.

Tour of the 1st and 2nd floors completed on 05/10/16 between the hours of 8:30 AM and 5:30 PM revealed the following findings.

1. Observation of the fire rated smoke wall above the door, from inside the dialysis space revealed a 3/4 inch blue conduit open on the end penetrating the wall.

2. Observation of the fire doors located in the fire rated smoke wall from 1 West to the family waiting area revealed the door failed to close to latching position when released from the hold open device.

3. Observation of the fire rated wall from the 1 East side of the double doors to 1 West revealed Multiple penetrations varying in size and shape, and multiple open ended conduits. Also large holes behind flex conduits below the wall that stops just above the drop ceiling were noted.

4. Observation of the West Chapel office wall revealed a 3/4 inch blue conduit penetrating the wall with open annular space.

5. Observation of the fire rated wall that runs between the chapel and the restrooms above the double doors revealed a 12 inch by 12 inch junction box, with multiple conduits traveling from the box and penetrating the fire rated wall, missing the cover.

6. Observation of the South fire rated wall of the Atrium, in the East most room area revealed a 3/4 inch conduit, penetrating the fire wall, open on the end with light blue data cables passing through.

7. Observation of the door from the ED registration area to the South Central Corridor that travels from East to West revealed it being held open on a self closer that was not attached to the fire alarm system.

8. Observation of the fire rated West wall in room 1T353B revealed a 3/4 inch conduit penetrating the wall, with light blue data cables, open on the end.

9. Observation of the South wall in the corridor outside 1 South above the double doors to the 1 South West Corridor revealed Multiple penetrations varying in size and shape.

10. Observation of the North fire rated wall for the outpatient radiology waiting room to radiology revealed a 3/4 inch conduit with open annular space and a 4 inch by 4 inch junction box missing a cover with conduits running from it and penetrating the fire wall.

11. Observation of the fire rated wall above the double doors from radiology to the new West building revealed a 14 inch space not sealed at deck above.

12. Observation of the fire rated wall above the double doors from 2 West to the family waiting area, on the 2 West side, revealed a large area of open space above the HVAC duct.

13. Observation of the fire rated wall above the double doors from 2 West's North corridor to the elevator area, on the 2 West side, revealed 4 inch by 4 inch junction box missing the cover with 3/4 inch conduit traveling from the junction box and penetrating the fire rated wall.

Tour of the 2nd floor was completed on 05/11/16 between the hours of 9:30 AM and 2:30 PM revealed the following findings.

1. Observation above the East door to the nursery revealed several penetrations varying in size and shape and not sealed at deck above to the right of the door.

2. Observation above the double doors from the family waiting area to the South corridor of 2 West, from the waiting area side revealed 12 inch by 12 inch junction box missing a cover with several conduits leading from it and penetrating the fire rated wall.

3. Observation above the double doors from the family waiting area to the corridor leading to 2 South, from the waiting area side revealed 1/2 inch conduit open on the end with open annular space.

4. Observation of the West wall in the OB nurses station/registration area revealed two 1 inch holes overlapping with 2 light blue data cable passing through.

5. Observation above the double doors from the corridor leading from 2 South to the OB family waiting area revealed 8 inch by 8 inch fire damper with no HVAC duct work attached and still in open position with unrated pink insulation stuffed in the open space. Also a 1/2 inch conduit open on the end stopping approximately 3 feet from fire wall.

6. Observation of the fire rated wall beside equipment room 2S018 revealed a 4 inch by 4 inch junction box missing a cover with conduits that penetrate the fire wall.

7. Observation of the fire rated wall above the double doors from 2 South to PACU revealed a 6 inch pneumatic tube with open space around.

8. Observation of the South PACU corridor fire rated wall, above the Fire Emergency Exit Plan sign, revealed a 1/2 inch conduit open on the end with a gray data cable passing through.

9. Observation above the double doors between the South PACU corridor and PACU revealed 12 inch by 12 inch junction box missing a cover with conduits leading from the box and penetrating the East fire wall.

10. Observation of the South wall of PACU staging room revealed two 3/4 inch conduits open on the end.

11. Observation of the East wall of Bay 8 in PACU revealed a 6 inch by 2 1/2 inch penetration in the far left corner.

12. Observation above the double doors from PACU to OR revealed three 5 inch conduits open on the end.

13. Observation of the South fire rated wall of Bay 7 revealed four 3/4 inch conduits open on the end.

14. Observation of the South and West walls of break room 2T236B revealed a 1/2 inch conduit open on the end and a 4 inch by 4 inch junction box missing a cover.

All the findings were verified by staff at the time of the observations.

Based on observation, and staff verification the facility failed to ensure the integrity of the 1/2 hour rated smoke barriers. This has the potential to affect all patients receiving services from the facility. The facility census was 29 at the time of the validation survey.

Findings include:

Observation above the double doors between the administration office hallway and the Adult inpatient unit completed on 05/11/16 revealed a 3/4 inch conduit with red data cables open on the end. This findings was verified by Staff DD at 3:55 PM.

Observation above the double doors from the adult inpatient unit to the adolescent inpatient unit completed on 05/11/16 revealed two 3/4 inch conduits open on end and a 1/2 inch conduit with red data cable open on the end. These findings were verified by Staff DD at 4:40 PM.

Observation of the double fire doors, in the adolescent inpatient unit, located on hold open devices completed on 05/11/16 revealed the doors did not close to latching when released from hold open devices. This finding was verified by Staff DD at 4:40 PM.

Based on review of facility schematics, observation of the facility and staff interview and confirmation, the facility failed to ensure that hazardous areas were protected in accordance with 8.4. The areas were to be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows (in accordance with 8.4). Doors were to be self-closing or automatic closing in accordance with 7.2.1.8. Hazardous areas were to be protected by a sprinkler system in accordance with 9.7. The facility census was 195 patients at the time of the survey. Potentially all patients and visitors could be adversely affected.

Findings include:

On 05/09/16 the facility schematics were reviewed to reveal hazardous areas such as storage and soiled utility rooms that were separated by one hour fire rated construction on each floor of the facility.

Tour of the facility was conducted with Staff AA, BB, DD and EE on 05/09/16 between 1:30 P.M. and 5:30 P.M. and on 05/10/16 and 05/11/16 between the hours of 8:30 A.M. and 5:00 P.M. The following observations are related to penetrations observed above the ceiling tiles in one hour fire rated separations surrounding hazardous areas;

Third Floor

1. Observation of a medication storage room, 3E145, revealed the one hour fire rated barrier had a penetration of one inch flex conduit with gray data lines through the conduit.

2. An equipment room, 3S153, noted on the schematic to have a one hour fire rated separation, had no self closing device on the door to the room.

3. An equipment room, 3S126B, had a penetration, approximately one inch in diameter in the one hour fire rated separation shared with a medication room, 3S125.

4. Observation of room 3W135B, revealed a one hour fire rated barrier with a penetration of one inch conduit with two data lines through the conduit.

5. Observation of a soiled utility room, 3S121, revealed the one hour fire rated barrier had a penetration approximately four inches square in the rated wall.

6. .Observation of room 3T080, revealed a one hour fire rated barrier with penetrations of an uncovered matrix control box and a conduit with wire through the conduit. Staff present at the observation could not confirm the matrix box was rated for placement in the one hour fire rated wall.

7. Observation of from inside equipment room, 3T153, revealed the one hour fire rated barrier had a penetration of a one inch conduit with data wires through it and one open junction box. There was unsealed space surrounding the conduit and junction box. Observation of the one hour rated wall outside room, 3T153 at the nursing station, above the tube station, a penetration approximately 32 inches in width and 4 feet in length.

8. Observation of a soiled utility room, 3T139, revealed the one hour fire rated barrier had a penetration of annular space surrounding hot water pipes.

9. Observation from inside a medication storage room, 3T133, revealed the one hour fire rated barrier had a penetrations of two, one inch conduits with wires through the conduits and a 12 inch box above the door with no cover and an unknown fire rating.

10. Observation from inside of a medical supply room, 3T132 above the ceiling tiles revealed a large, 12 inch pipe, labeled as a storm drain partially embedded in the one hour fire rated wall. Unsealed space, approximately six to eight feet in length along the pipe was
noted.

11. Storage room, 3T128, noted on the schematic to have a one hour fire rated separation, had no self closing device on the door to the room.

Second Floor

12. Observation above the ceiling tiles at three adjoining storage areas, which contained combustible medical supplies, revealed two conduits with unsealed space surrounding the conduits. The three adjoining storage areas had six wooden doors with no identifiable fire rating and no self closing devices in place.

13. Observation at the cath lab control room revealed five penetrations, approximately one half to one inch in size in the one jour fire rated wall. A matrix box, with an unknown fire resistance rating was embedded in the wall. Two conduits wit wires also penetrated the wall.

14. Observation over room 2T062, near the cath lab control room, of the one hour fire rated wall, a penetration approximately two inches in diameter.

15. Observation at cath lab storage room 2T074, revealed a penetration approximately one half inch in diameter in a wall labeled as a two hour fire rated barrier. A wall noted as one hour fire rated above the door to the same room had a matrix box ( unknown fire resistance rating) embedded in the same wall. A triangle shaped piece of gypsum board was missing at a large duct in the wall and an open ended conduit penetrated the wall.

16. Observation from inside storage room, 2T061, revealed the one hour fire rated barrier had penetrations of one inch conduit with wires through the conduit and three open junction boxes.

17. Observation at room 2T117, of the one hour fire rated wall, revealed a penetration approximately two inches wide and four inches in length.

18. Observation of double doors leading to the dirty room, 2T054, were observed to have a gap greater than one eight inch when in the closed position.

19. Observation of room 2T098, above the ceiling tiles, revealed two small junction boxes without covers . One red box, was not sealed in the space surrounding it and an open conduit with wire inside penetrated the one hour fire rated barrier.

Staff present on tour confirmed the observations.

















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Tour of the garden level completed on 05/09/16 between the hours of 12:30 PM and 5:30 PM revealed the following findings.

20. Observation of the south west corner of room GD026, from inside the room, revealed two blue 1/2 inch conduits open on the end with data cable passing through.

21. Observation of the West wall of room GD026 as seen from workstation GD053 revealed 1 inch conduit open on the end.

22. Observation of the door to identified hazardous area revealed the door having a self closer and the door being propped open with a chair.

23. Observation of the East wall of GD033 as seen from inside the room revealed a 1/2 inch green flex conduit with open annular space.

24. Observation of the East wall of GD033 as seen from the corridor revealed 3/4 inch conduit open on the end above the room door.

25. Observation of the Mechanical room near room GD033 revealed multiple penetrations and open ended conduits. Also the double doors with self closer's failed to close to latching position.

26. Observation of the East wall of the elevator room as seen from between the elevators near the IT room GS202 revealed 4 inch by 4 inch junction box missing a cover.

27. Observation of the West wall of the elevator room as seen from the IT room GS202 revealed multiple open ended conduits.

28. Observation of the North wall of Sterile supply as seen from the corridor at about half way down the wall revealed a 1 1/2 inch sprinkler line with open annular space.

Tour of the 1st floor completed on 05/10/16 between the hours of 8:30 AM and 5:30 PM revealed the following findings.

29. Observation of the door between the decontamination room 1N217A in the endoscopy area and the sterilization room revealed the door being propped open.

30. Observation of the West wall of the decontamination room 1N217A in the endoscopy area revealed multiple penetrations and a 3/4 inch conduit open on the end.

31. Observation of the West wall of the decontamination room 1N217A as seen from the corridor revealed two 3/8 inch conduits with open annular space above the door.

32. Observation of the North wall of the Clean Utility room 1N214 revealed 3/4 inch conduit open on the end.

33. Observation of the South wall of the Clean utility room as seen from the Pre-Op nurses station revealed 1/2 inch by 2 inch gap at the bottom of an HVAC duct.

34. Observation of the West wall of the supply room 1W125B as seen from the outside of the room revealed a 12 inch by 8 inch hole to the Left of an HVAC duct.

35. Observation of West wall of the supply room 1W125B as seen from inside the room revealed multiple penetrations varying in size and shape.

36. Observation of the South wall in the Nourishment room 1T284B revealed 14 inch by 10 inch penetration.

37. Observation of the West wall of the Soiled Utility room as seen from the corridor revealed a 3/4 inch conduit open on the end with light blue data cable passing through.

38. Observation of the South wall of the Nourishment room 1T284B, as seen from the nurses station revealed two 3/4 inch conduits with light blue data cables passing through open on the end.

39. Observation of the East wall of the Storage room 1T303 as seen from in the room revealed the wall was not sealed at the deck above.

40. Observation of the East and West walls of the Storage room 1T452B as seen from inside the room revealed four 3/4 inch conduits with light blue data cables open on the end, and a 5 inch by 5 inch penetration.

41. Observation of the West wall above the door of the Equipment room 1T459 as seen from inside the room revealed two 3/4 inch conduits open on the end.

42. Observation of the East wall of the Nourishment room 1T325B as seen from the corridor revealed 18 inch by 8 inch section of gypsum board missing.

43. Observation of the Soiled Utility room beside room 1T325A revealed the fire rated door was not on a self closer and was noted to be open when approached.

44. Observation of the West wall of the Staff Locker room 1S120 as seen from the corridor revealed no self closer on the door was noted to be in the open position.

45. Observation of the walls inside the Electrical room 1D057 revealed multiple open ended conduits. Staff DD identified the door the the hazardous room as not having a 3/4 hour fire rating.

46. Observation if the South wall of the Soiled Utility room 1D049 as seen from inside the room revealed a 3/8 inch flex conduit with open annular space.

47. Observation of the South wall of the Nuclear Med space as seen from the corridor revealed a 6 inch penetration and two 3/4 inch penetrations.

48. Observation of the South wall of the Shell space across from room 1D025 as seen from within the room revealed a 3/4 inch conduit with light blue data cables open on the end.

Tour of the 2nd floor completed on 05/11/16 between the hours of 9:30 AM and 2:30 PM revealed the following findings.

49. Observation North and South walls of the central supply room between OR #1 and OR #2 in OB revealed a 1/2 inch flex conduit open on the end and a 4 inch sprinkler pipe with open annular space.

50. Observation of the South wall of the Mechanical room by the OB OR's revealed a 1/2 inch conduit with a 2 inch annular space.

51. Observation of the West wall of the Storage room in the Nursery revealed a 12 inch by 8 inch hole that could be seen from the Storage room and the Electrical room 2N031.

52. Observation of the North wall of a hazardous area as seen from room 2T232 in the PACU area revealed a 1 inch conduit with light blue data cable open on the end.

53. Observation of the walls in the Equipment room 2T197 revealed multiple penetrations and open ended conduits.

54. Observation of the East wall of Equipment room 1T197 as seen from the corridor revealed 1/2 inch and 3/4 inch conduits open on the end.

55. Observation of the South wall of Equipment room 1T197 as seen from Holding room 1 revealed an 8 inch by 4 inch half circle hole to the right of an HVAC duct.

The findings were verified by staff at the time of the observations.

Based on observation and staff verification the facility failed to ensure doors in hazardous areas where not held open with hold open devices not attached to the fire alarm system and the doors closed to latching position. This has the potential to affect all patients receiving services from the facility. The facility census was 29.

Findings include:

Observation of the hazardous area located in the kitchen completed on 05/11/16 revealed the door on a self closer was being held open with a rubber triangle wedge. When the wedge was removed the door failed to close to a latching position.

These findings were verified by Staff DD at the time of the observation.

Based on schematic review, observation, and staff verification the facility failed to ensure the exit access corridor walls were free of penetrations and doors protecting the exit access corridor closed to latching position. This has the potential to affect all patients receiving services at the facility. The facility census was 195 at the time of the validation survey.

Findings include:

1. Observation of the wall and schematic review above the double doors of the Exit access corridor from the Alternacare side completed on 05/10/16 revealed two 1/2 inch flex conduits penetrating the 2 hour fire rated wall with open annular space.

2. Observation of the doors in the Exit access corridor by the Endoscopy area and Alternacare completed on 05/10/16 revealed the doors were on hold open devices that release when the fire alarm is activated. When the doors were released the observation revealed the doors traveling from the South corridor and the doors traveling from the East corridor did not close to a latching position.

The findings were verified by staff at the time of the observations.

Based on observation and staff verification the facility failed to ensure clear width of exit corridors. This has the potential to affect all patients receiving services from the facility. The facility census was 195 at the time of the validation survey.

Findings include:

Observation of the exit egress of Stair B-7 revealed patients traveling from the garden level have to open a large gate to access the exit on the 1st floor. This door swings into the path of egress causing less than 24 inches of width of the exit corridor. This finding was verified by Staff DD on 05/09/16 at 4:48 PM.

Based on observation and staff verification the facility failed to ensure the delayed egress doors from the adult ED to the pediatric ED released within 15 seconds. This has the potential to affect all patients receiving ED services. The facility census was 195 at the time of the validation survey.


Findings include:


1. Observation of double doors located in the South Central corridor of the ED completed on 05/10/16 were identified as exit egress doors. The sign on the door stated the door would release 15 seconds after the panic bar on the door was pushed. An attemp to open the door revealed the door did not open until staff scanned their security badges at the badge reader. Staff DD stated the doors must not be functioning on 05/10/16 at 2:05 PM.

Based on tour of the facility, review of facility documentation and staff interview and confirmation, the facility failed to ensure that fire drills included the transmission of a fire alarm signal and simulation of emergency fire conditions. The facility census was 195 patients at the time of the survey. Potentially all patients and visitors could be adversely affected.

Findings include:

On 05/11/16, at 2:40 P.M. during tour of the facility operating rooms, an interview was conducted with Staff T and U, who routinely work in the operating rooms. Interview was conducted regarding the fire drill procedure for that area. Staff stated that fire drills for the operating rooms was conducted by the educator for that area and occurred one to times per year. Staff confirmed the use of flammable skin preparations for surgery.

Interview of Staff CC regarding the educator's role for fire drill completion revealed the position had recently changed. Staff CC was not certain if the new educator had gotten procedures in place yet.

On 05/12/16, during review of facility documentation of fire drills for at least the last four quarters revealed there was no documented evidence of a fire drill conducted that included the operating rooms and the operating room staff.

Based on documentation review, and staff interview the facility failed to ensure fire drills were held at unexpected times and under varying conditions at least quarterly every shift. This has the potential to affect all patients receiving services from the facility. The facility census was 29 at the time of the survey.

Findings include:

Review of the fire drills for the last four quarters completed on 05/12/16 revealed the fire drills were held within an hour of each other every quarter and the fire drills on third shift were held within an hour of each other. The review also revealed no fire drill was completed for one quarter on second shift.

These findings were verified by Staff CC on 05/12/16.

Interview with Staff CC completed on 05/12/16 revealed that the fire drill on second shift was missing and Staff CC forgot to complete the fire drill that quarter.

Based on review of facility schematics, observation of the facility and staff interview and confirmation, the facility failed to ensure that automatic sprinkler systems were continuously maintained in reliable operating condition and were inspected and tested periodically. The facility census was 195 patients at the time of the survey. Potentially all patients and visitors could be adversely affected.

Findings include:

On 05/09/16 the facility schematics were reviewed to reveal the presence of existing trash and linen chutes.

Tour of the facility was conducted with Staff AA, BB, DD and EE on 05/09/16 between 1:30 P.M. and 5:30 P.M. and on 05/10/16 and 05/11/16 between the hours of 8:30 A.M. and 5:00 P.M. Tour of the penthouse in the North building included observation of the two hour fire rated separation that surrounded the trash and linen chutes. Observation from the exterior of the chute enclosures revealed automatic sprinkler pipe with shut off/control valves visible from near the top of the fire rated block enclosure. There was no access panel in the enclosure. Staff present on tour confirmed if work was required on the sprinkler system within the chutes, workers had to remove portions of the brick wall to perform the work.

During tour on 05/10/16 at 8:30 A.M., observation inside the trash and linen chutes on the third floor revealed there were no sprinkler heads visible. On 05/10/16 at 9:25 A.M., an interview of Staff FF (contracted personnel) was conducted regarding locations of sprinkler heads in the chutes at each floor. Staff FF could not confirm the locations of sprinkler heads in the trash and linen chutes and later provided pictures of the inside of the chutes. The pictures of the linen chute at level one, three and four indicated that portions of the metal chutes were roughly cut out to accommodate the placement of sprinkler heads. Sprinkler heads at each level were a different type. The sprinkler head at level four looked encased in dust and debris.

Pictures of the trash chute revealed sprinkle head placement at level one and three. Staff FF revealed that placement of the sprinkler heads was not at the chute door level but was between each level and located just below level two and level four and between level four and the penthouse. Interview of Staff FF, CC, DD and AA revealed there was no access panels at the chutes and that removal of outside wall surrounding the chutes was the only way to access the chutes and sprinkler heads.

Review of sprinkler system testing documents on 05/12/16 revealed no evidence the sprinkler system within the trash and linen chutes were routinely inspected, tested and maintained.

Based on schematic review, observation, and staff verification the facility failed to ensure the 1 hour rated walls around the linen and trash chute rooms were free of penetrations. This has the potential to affect all patients receiving services from the facility. The facility census was 195 at the time of the validation survey.


Findings include:


Observation and schematic review of the North wall of the trash and linen holding room completed on 05/09/16 revealed a 3/4 inch flex conduit open on the end with a white data cable passing through penetrating the 1 hour fire rated wall. This finding was verified by Staff DD on 05/09/16 at 2:50 PM.

Chapter 21, Existing Ambulatory Surgery
21.3, Protection

21.3.7.2
The ambulatory health care facility shall be divided into not less than two smoke compartments.
Exception No. 1: Facilities of less than 5000 ft2 (465 m2) and protected by an approved automatic smoke detection system.
Exception No. 2: Facilities of less than 10,000 ft2 (930 m2) and protected throughout by an approved, supervised automatic sprinkler system installed in accordance with Section 9.7.
Exception No. 3: An area in an adjoining occupancy shall be permitted to serve as a smoke compartment for the ambulatory health care facility if the following criteria are met:
(a) The separating wall and both compartments meet the requirements of 21.3.7.
(b) The ambulatory health care facility is less than 22,500 ft2 (2100 m2).
(c) Access from the ambulatory health care facility to the other occupancy is unrestricted.


Based on review of facility documentation, facility observation and staff interview and confirmation, the facility failed to ensure the ambulatory health care facility was divided into not less than two smoke compartments. Potentially all patients, staff and visitors could be affected. The facility provided surgical services for 28 patients on the day of the observation.

Findings include:

On 05/11/16 between 3:00 P.M. and 5:30 P.M. tour of the facility was conducted with Staff AA, BB and CC. Review of the facility certificate of occupancy revealed the facility was 22,574 square feet in size. Review of the facility schematic revealed a one hour smoke barrier. The one hour smoke barrier divided the facility into two smoke compartments.

Observation above the ceiling tiles of the smoke barrier wall , which extended from the front of the building to the back of the building, through rooms that included the staff break room, men's locker room, corridor to the recovery area, procedure rooms 8, 9 , 10 and to the north doors leading to the operating rooms revealed multiple penetrations. Little to no fire retardant sealant was visible in the areas observed.

Staff present at the observation confirmed the findings.



NFPA 99, Health Care Facilities
Chapter 4, Gas and Vacuum Systems

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
* Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.

Based on facility observation and staff interview and confirmation, the facility failed to ensure the enclosures were provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures were to be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Potentially all patients, staff and visitors could be affected. The facility provided surgical services for 28 patients on the day of the observation.

Findings include:

On 05/11/16 between 3:00 P.M. and 5:30 P.M. tour of the facility was conducted with Staff AA, BB and CC. Observation was conducted of the oxygen and medical gas storage location where the oxygen amount was greater than 3000 cubic feet. Penetrations were noted surrounding three pipes and wires located in the one hour fire rated construction of the walls. The door to the storage location had no visible fire resistance rating . Louvers were present in the lower third of the door which were open to the corridor.

Staff CC confirmed the observations.

NFPA101
Chapter 39, Existing Business Occupancies
39.3, Protection

39.3.2.1*
Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.
8.4 SPECIAL HAZARD PROTECTION
8.4.1.1*
Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by
8.4.1.3
Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

1. Based on facility observation and staff interview and confirmation, the facility failed to ensure that hazardous areas such as a storage area, soiled utility room and environmental closest was protected with a one hour fire resistant barrier without windows in accordance with Section 8.2. or the area was protected with an automatic extinguishing systems in accordance with Section 9.7. The facility provided services for an average daily census of 48 patients in the past week. Potentially all patients and visitors and could be adversely affected.

Findings include:

On 05/12/16, between 9:25 A.M. and 10:20 A.M. tour of the facility was conducted with Staff BB and DD. The following rooms and areas above the ceiling tiles were observed with staff present:

a. A storage room, approximately 12 feet long and 10 feet wide was noted to contain shelving units of combustible medical supplies. Observation above the ceiling tiles in the room revealed no enclosed one hour fire resistant construction for the room. The wooden door to the room had no identifiable fire resistance rating.

b. Observation above the ceiling tiles in a soiled utility room revealed multiple penetrations and lack of a complete one hour fire rated enclosure. The wooden door to the room had no fire resistance rating.

c. An small room identified as an environmental closet contained an electric hot water heater, four, five gallon buckets noted as latex paint, eight, one gallon cans identified as latex paint, one large box of toilet paper containing approximately 86 rolls of the paper and other miscellaneous containers of items needed for housekeeping. Also located in the room, was a portable fire extinguisher with a tag which noted the last inspection was July 3, 2007. Observation above the ceiling tiles in the room revealed three sides of the room were not enclosed with one hour fire resistant construction. The wooden door to the room had no identifiable fire resistance rating.

Staff present on tour confirmed the observations.



Chapter 7, Means of Egress
7.2.1.5 Locks, Latches, and Alarm Devices.

7.2.1.5.1
Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
7.2.1.5.
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.


2. Based on facility observation and staff interview and confirmation, the facility failed to ensure that doors were arranged to be opened readily from the egress side whenever the building was occupied. Locks, if provided, were not to require the use of special knowledge or effort for operation from the egress side and doors were to be operable with not more than one releasing operation. The facility provided services for an average daily census of 48 patients in the past week. Potentially all patients and visitors could be adversely affected.

Findings include:

On 05/12/16, between 9:25 A.M. and 10:20 A.M. tour of the facility was conducted with Staff BB and DD. Observation of the paths of egress from the facility revealed there were three noted exits. One of three exits was identified as the ambulance entrance and was also the staff entrance. An attempt to open the door revealed it was locked from the egress side. The door required the turn of a latch to release the lock before the door handle was pushed to open.

The third exit was located at the north end of the facility near a small room containing IT equipment. This door had the same locking arrangement as the ambulance entrance door.

Staff present on tour confirmed the observations.

**********************************************************************

NFPA 10, Standard for Portable Extinguishers
Chapter 4, Inspection, maintenance and Recharging

4-1.3
The owner or designated agent or occupant of a property in which fire extinguishers are located shall be responsible for such inspection, maintenance, and recharging.


3. Based on facility observation and staff interview and confirmation, the facility failed to ensure the designated agent or occupant of a property in which fire extinguishers are located was responsible for inspection, maintenance, and recharging. The facility provided services for an average daily census of 48 patients in the past week. Potentially all patients and visitors and could be adversely affected.

Findings include:

On 05/12/16, between 9:25 A.M. and 10:20 A.M. tour of the facility was conducted with Staff BB and DD. Observation of a small room identified as an environmental closet contained an electric hot water heater, four, five gallon buckets noted as latex paint, eight, one gallon cans identified as latex paint, one large box of toilet paper containing approximately 86 rolls of the paper and other miscellaneous containers of items needed for housekeeping. Also located in the room, secured to the wall, was a portable fire extinguisher. A tag on the extinguisher noted the last inspection was July 3, 2007. Staff present on tour confirmed they were unaware there was an extinguisher in the room.

Based on observation, schematic review, and staff verification the facility failed to ensure its building separations were free of penetrations. This has the potential to affect all patients receiving services from the facility. The facility census was 195.

Findings include:

Observation of the Ground floor completed on 05/09/16 between the hours of 12:30 PM and 5:30 PM and schematic review revealed the following findings:

1. Observation above the drop ceiling in the corridor, above the double fire doors, from the hospital to the building where the Hyperbaric facility is located from the hospital side revealed multiple open ended conduits and open spaces around the conduits penetrating the fire rated wall with multiple data cables passing through. These findings were verified by Staff DD at 1:10 PM.

2. Observation above the drop ceiling in the small corridor to the lab from the South most corridor revealed two 3 1/2 inch holes with two 1/2 inch copper pipes passing through, and a 1 1/2 inch conduit open on the end above the door to the lab space. This finding was verified by Staff DD at 1:29 PM.

Observation of the 1st floor completed on 05/10/16 between the hours of 8:30 AM and 5:30 PM revealed the following findings:

1. Observation above the drop ceiling (on the hospital side), above the doors to the cancer center revealed a 3/4 inch conduit penetrating the 2 hours fire rated wall open on the end with gray data cable passing through. This findings was verified by Staff DD at 8:36 AM.

2. Observation above the drop ceiling in room 1216 revealed a 3 inch galvanized conduit with data cables passing through with open annular space and a 1/2 inch conduit open on the end both passing through the marked 3 hour fire rated wall. These findings were verified by Staff DD at 3:20 PM.

Based on review of facility schematics, observation of the facility and staff interview and confirmation, the facility failed to ensure that stairways, elevator shafts, chutes, and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least two hours connecting four stories or more. The facility census was 195 patients at the time of the survey. Potentially all patients and visitors could be adversely affected.

Findings Include:

On 05/09/16 the facility schematics were reviewed to reveal the presence of trash and linen chutes and chases. The schematic indicated the vertical openings were enclosed by two hour fire rated construction.

Tour of the facility was conducted with Staff AA, BB, DD and EE on 05/09/16 between 1:30 P.M. and 5:30 P.M. and on 05/10/16 and 05/11/16 between the hours of 8:30 A.M. and 5:00 P.M. Tour included observation of the two hour fire rated separation that surround vertical openings in the facility. The following observations are related to penetrations in the two hour fire rated construction:

1. Observation of the fourth floor penthouse revealed the top of the previously existing trash and linen chutes. On 05/10/16 at 9:25 A.M., interview of Staff FF was conducted regarding locations of sprinkler heads in the chutes at each floor. Staff FF could not confirm the locations of sprinkler heads in the trash and linen chutes and later provided pictures of the inside of the chutes. The pictures of the linen chute at level one, three and four indicated that portions of the metal chutes were roughly cut out to accommodate the placement of sprinkler heads. Pictures of the trash chute revealed sprinkle head placement at level one and three. Staff FF revealed that placement of the sprinkler heads was not at the chute door level but was between each level and located just below level two and level four and between level four and the penthouse. Interview of Staff FF, CC, DD and AA revealed there was no access panels at the chutes and that removal of outside wall surrounding the chutes was the only way to access the chutes and sprinkler heads. Staff could not confirm the integrity of the fire rated structure.

2. Observation above the ceiling tiles of the two hour fire rated barrier at stairwell 3SST2 on third floor, south, revealed a penetration approximately eight to ten inches in diameter on the corridor side of the stairwell.

3. Observation above the ceiling tiles of the two hour fire rated separation for a chase located on third floor at 3T1137, nourishment station, revealed the seams of gypsum board were not sealed with fire retardant sealer

4. Observation above the ceiling tiles of the two hour fire rated separation for a chase located on second floor near the heart cath lab revealed the presence of white dry wall sealer which staff confirmed had an unknown fire resistance rating.

Staff present on tour confirmed the observations.





31007

Tour of the ground floor was completed on 05/09/16 between the hours of 12:30 PM and 5:30 PM and the following observations were noted during the tour:

5. Observation of the chute doors located in the chute room of the new building revealed a 1/2 inch gap between the trash chute door and the chute. The doors were noted to be kept in a closed position and emptied throughout the day.

6. Observation above the door to the stairwell B-3 (GWST1) revealed a 1 inch hole as observed from the corridor side.

Tour of the ground and 1st floors were completed on 05/10/16 between the hours of 8:00 AM and 5:30 PM and the following observations were noted during the tour:

7. Observation of the trash chute door located in the trash chute room of the old building revealed the left side of the door was missing latching hardware the there was a 1 1/2 inch gap between the door and the chute. The door was noted to be kept in a closed position and emptied throughout the day.

8. Observation of the fire rated wall for a stairwell's South wall outside the Office of Patient Expenses (1E001) revealed a 3 inch sprinkler pipe with open annular space and a 1 inch hole above the sprinkler pipe.

9. Observation of the fire rated wall for the HVAC chase located in the North most corridor in the ED revealed a 1/2 inch gap to the right of an HVAC duct.

10. Observation of the fire rated wall for the HVAC chase located by the intersection of the West most corridor and South central corridor in the ED revealed a 2 inch gap to the left of a HVAC duct.

11. Observation of the fire rated wall for the HVAC chase located by the intersection of the West most corridor and South most corridor revealed a 1/4 inch gap to the left of the HVAC duct.

12. Observation of the chase located by the Ambulance entrance revealed a 3/4 inch conduit open the end with two light blue data cables passing through the 2 hour fire rated chase wall.

Tour of the 2nd floor completed on 05/10/16 between the hours of 5:00 PM and 5:30 PM through 05/11/16 between the hours of 9:20 AM and 2:30 PM revealed the following:

13. Observation of the HVAC chase located beside the East stairwell of 2 East revealed a 24 inch by 12 inch hole.

14. Observation of the chase located beside the shared offices (2T232) near the PACU area revealed a chase access panel pulled 3/8 inch out from the wall making a separation between the gypsum board and the panel visible.

The findings were verified by Staff at the time of the observations.

Based on observation and staff interview the facility failed to ensure exit egresses were marked with directional exit signs and failed to ensure non-exits were not marked as exit egresses. This has the potential to affect all patients receiving services from the facility. The facility census was 195 at the time of the validation survey.


Findings include:


1. Observation of the Pediatric ED area completed on 05/11/16 revealed an exit sign directing patients to the Adult ED area. Interview with Staff DD completed on 05/11/16 at 2:10 PM revealed the exit sign is wrong when directing patients to the Adult ED and the egress paths are at the ends of the corridor.

2. Observation of 2 South, East corridor on 05/12/16 revealed an exit sign with no directional chevron showing the direction of exit egress. When under the exit sign there was no sign noted showing the direction of the Exit access. This finding was verified by Staff DD at 12:00 PM.

Based on review of facility schematics, observation of the facility and staff interview and confirmation, the facility failed to ensure that smoke barriers were constructed to provide at least a one hour fire resistance rating and constructed in accordance with 8.3 and that windows were protected by fire-rated glazing or by wired glass panels in approved frames. The facility census was 195 patients at the time of the survey. Potentially all patients and visitors could be adversely affected.

Findings include:

On 05/09/16 the facility schematics were reviewed to reveal that each floor of the facility was divided into at least two smoke compartments by one hour smoke barrier walls. Tour of the facility was conducted with Staff AA, BB, DD and EE on 05/09/16 between 1:30 P.M. and 5:30 P.M. and on 05/10/16 and 05/11/16 between the hours of 8:30 A.M. and 5:00 P.M. Tour included observation of the smoke barrier walls which extended above the ceiling tiles on each floor of the facility. The following observations related to penetrations were noted;

Fourth Floor:
1. Smoke barrier doors located between the north and south corridors were noted to have a gap greater than one-eighth inch wide when in the closed position.

2. Smoke barriers doors at the entry to four north revealed a gap greater than one-eight inches when in the closed position. Observation above the ceiling tiles revealed open space surrounding duct work and a penetration approximately three inches diameter.

Third floor:

3. Located above door 3N041B, in a one hour smoke wall, a penetration approximately one inch by one half inch at duct work.

4. Located in staff break room, 3W185, near the window, a penetration approximately three to four inches in diameter with flex conduit through the penetration.

5. Located above the smoke doors to three west, a six to eight inch penetration noted at the balancing damper door.

6. Located in the smoke barrier wall near the respiratory therapy room, a one inch conduit with data line which penetrated the smoke barrier wall.

7. Located at smoke barrier doors, unsealed conduit with data lines penetrated the one hour rated smoke wall.

Second Floor:

8. Located above smoke doors, near cath lab 2, two metal sleeves penetrated the wall with unsealed space surrounding the metal sleeves.

The above findings were confirmed by staff who were present on tour.






31007

Tour of the garden level completed on 05/09/16 between the hours of 1:00 PM and 5:30 PM revealed the following findings.

1. Observation of the East fire rated wall of the Labs L-shaped room revealed four 3/4 inch conduits open on the end with blue data cables passing through.

2. Observation of the East fire rated wall of the Lab's space identified as GD002 revealed three 6 inch pneumatic tubes with open annular space penetrating the wall.

3. Observation of the fire rated wall in the corridor from the lab traveling East and West revealed Multiple penetrations varying in size and shape penetrating the South wall of the corridor to left of GS005 door.

4. Observation of the South wall of room identified as FR4 revealed multiple penetrations varying in size and shape penetrating the fire rated wall.

5. Observation of the North fire rated wall in the room identified as GT004 revealed 1 1/2 inch hole penetrating the wall.

Tour of the 1st and 2nd floors completed on 05/10/16 between the hours of 8:30 AM and 5:30 PM revealed the following findings.

1. Observation of the fire rated smoke wall above the door, from inside the dialysis space revealed a 3/4 inch blue conduit open on the end penetrating the wall.

2. Observation of the fire doors located in the fire rated smoke wall from 1 West to the family waiting area revealed the door failed to close to latching position when released from the hold open device.

3. Observation of the fire rated wall from the 1 East side of the double doors to 1 West revealed Multiple penetrations varying in size and shape, and multiple open ended conduits. Also large holes behind flex conduits below the wall that stops just above the drop ceiling were noted.

4. Observation of the West Chapel office wall revealed a 3/4 inch blue conduit penetrating the wall with open annular space.

5. Observation of the fire rated wall that runs between the chapel and the restrooms above the double doors revealed a 12 inch by 12 inch junction box, with multiple conduits traveling from the box and penetrating the fire rated wall, missing the cover.

6. Observation of the South fire rated wall of the Atrium, in the East most room area revealed a 3/4 inch conduit, penetrating the fire wall, open on the end with light blue data cables passing through.

7. Observation of the door from the ED registration area to the South Central Corridor that travels from East to West revealed it being held open on a self closer that was not attached to the fire alarm system.

8. Observation of the fire rated West wall in room 1T353B revealed a 3/4 inch conduit penetrating the wall, with light blue data cables, open on the end.

9. Observation of the South wall in the corridor outside 1 South above the double doors to the 1 South West Corridor revealed Multiple penetrations varying in size and shape.

10. Observation of the North fire rated wall for the outpatient radiology waiting room to radiology revealed a 3/4 inch conduit with open annular space and a 4 inch by 4 inch junction box missing a cover with conduits running from it and penetrating the fire wall.

11. Observation of the fire rated wall above the double doors from radiology to the new West building revealed a 14 inch space not sealed at deck above.

12. Observation of the fire rated wall above the double doors from 2 West to the family waiting area, on the 2 West side, revealed a large area of open space above the HVAC duct.

13. Observation of the fire rated wall above the double doors from 2 West's North corridor to the elevator area, on the 2 West side, revealed 4 inch by 4 inch junction box missing the cover with 3/4 inch conduit traveling from the junction box and penetrating the fire rated wall.

Tour of the 2nd floor was completed on 05/11/16 between the hours of 9:30 AM and 2:30 PM revealed the following findings.

1. Observation above the East door to the nursery revealed several penetrations varying in size and shape and not sealed at deck above to the right of the door.

2. Observation above the double doors from the family waiting area to the South corridor of 2 West, from the waiting area side revealed 12 inch by 12 inch junction box missing a cover with several conduits leading from it and penetrating the fire rated wall.

3. Observation above the double doors from the family waiting area to the corridor leading to 2 South, from the waiting area side revealed 1/2 inch conduit open on the end with open annular space.

4. Observation of the West wall in the OB nurses station/registration area revealed two 1 inch holes overlapping with 2 light blue data cable passing through.

5. Observation above the double doors from the corridor leading from 2 South to the OB family waiting area revealed 8 inch by 8 inch fire damper with no HVAC duct work attached and still in open position with unrated pink insulation stuffed in the open space. Also a 1/2 inch conduit open on the end stopping approximately 3 feet from fire wall.

6. Observation of the fire rated wall beside equipment room 2S018 revealed a 4 inch by 4 inch junction box missing a cover with conduits that penetrate the fire wall.

7. Observation of the fire rated wall above the double doors from 2 South to PACU revealed a 6 inch pneumatic tube with open space around.

8. Observation of the South PACU corridor fire rated wall, above the Fire Emergency Exit Plan sign, revealed a 1/2 inch conduit open on the end with a gray data cable passing through.

9. Observation above the double doors between the South PACU corridor and PACU revealed 12 inch by 12 inch junction box missing a cover with conduits leading from the box and penetrating the East fire wall.

10. Observation of the South wall of PACU staging room revealed two 3/4 inch conduits open on the end.

11. Observation of the East wall of Bay 8 in PACU revealed a 6 inch by 2 1/2 inch penetration in the far left corner.

12. Observation above the double doors from PACU to OR revealed three 5 inch conduits open on the end.

13. Observation of the South fire rated wall of Bay 7 revealed four 3/4 inch conduits open on the end.

14. Observation of the South and West walls of break room 2T236B revealed a 1/2 inch conduit open on the end and a 4 inch by 4 inch junction box missing a cover.

All the findings were verified by staff at the time of the observations.

Based on observation, and staff verification the facility failed to ensure the integrity of the 1/2 hour rated smoke barriers. This has the potential to affect all patients receiving services from the facility. The facility census was 29 at the time of the validation survey.

Findings include:

Observation above the double doors between the administration office hallway and the Adult inpatient unit completed on 05/11/16 revealed a 3/4 inch conduit with red data cables open on the end. This findings was verified by Staff DD at 3:55 PM.

Observation above the double doors from the adult inpatient unit to the adolescent inpatient unit completed on 05/11/16 revealed two 3/4 inch conduits open on end and a 1/2 inch conduit with red data cable open on the end. These findings were verified by Staff DD at 4:40 PM.

Observation of the double fire doors, in the adolescent inpatient unit, located on hold open devices completed on 05/11/16 revealed the doors did not close to latching when released from hold open devices. This finding was verified by Staff DD at 4:40 PM.

Based on review of facility schematics, observation of the facility and staff interview and confirmation, the facility failed to ensure that hazardous areas were protected in accordance with 8.4. The areas were to be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows (in accordance with 8.4). Doors were to be self-closing or automatic closing in accordance with 7.2.1.8. Hazardous areas were to be protected by a sprinkler system in accordance with 9.7. The facility census was 195 patients at the time of the survey. Potentially all patients and visitors could be adversely affected.

Findings include:

On 05/09/16 the facility schematics were reviewed to reveal hazardous areas such as storage and soiled utility rooms that were separated by one hour fire rated construction on each floor of the facility.

Tour of the facility was conducted with Staff AA, BB, DD and EE on 05/09/16 between 1:30 P.M. and 5:30 P.M. and on 05/10/16 and 05/11/16 between the hours of 8:30 A.M. and 5:00 P.M. The following observations are related to penetrations observed above the ceiling tiles in one hour fire rated separations surrounding hazardous areas;

Third Floor

1. Observation of a medication storage room, 3E145, revealed the one hour fire rated barrier had a penetration of one inch flex conduit with gray data lines through the conduit.

2. An equipment room, 3S153, noted on the schematic to have a one hour fire rated separation, had no self closing device on the door to the room.

3. An equipment room, 3S126B, had a penetration, approximately one inch in diameter in the one hour fire rated separation shared with a medication room, 3S125.

4. Observation of room 3W135B, revealed a one hour fire rated barrier with a penetration of one inch conduit with two data lines through the conduit.

5. Observation of a soiled utility room, 3S121, revealed the one hour fire rated barrier had a penetration approximately four inches square in the rated wall.

6. .Observation of room 3T080, revealed a one hour fire rated barrier with penetrations of an uncovered matrix control box and a conduit with wire through the conduit. Staff present at the observation could not confirm the matrix box was rated for placement in the one hour fire rated wall.

7. Observation of from inside equipment room, 3T153, revealed the one hour fire rated barrier had a penetration of a one inch conduit with data wires through it and one open junction box. There was unsealed space surrounding the conduit and junction box. Observation of the one hour rated wall outside room, 3T153 at the nursing station, above the tube station, a penetration approximately 32 inches in width and 4 feet in length.

8. Observation of a soiled utility room, 3T139, revealed the one hour fire rated barrier had a penetration of annular space surrounding hot water pipes.

9. Observation from inside a medication storage room, 3T133, revealed the one hour fire rated barrier had a penetrations of two, one inch conduits with wires through the conduits and a 12 inch box above the door with no cover and an unknown fire rating.

10. Observation from inside of a medical supply room, 3T132 above the ceiling tiles revealed a large, 12 inch pipe, labeled as a storm drain partially embedded in the one hour fire rated wall. Unsealed space, approximately six to eight feet in length along the pipe was
noted.

11. Storage room, 3T128, noted on the schematic to have a one hour fire rated separation, had no self closing device on the door to the room.

Second Floor

12. Observation above the ceiling tiles at three adjoining storage areas, which contained combustible medical supplies, revealed two conduits with unsealed space surrounding the conduits. The three adjoining storage areas had six wooden doors with no identifiable fire rating and no self closing devices in place.

13. Observation at the cath lab control room revealed five penetrations, approximately one half to one inch in size in the one jour fire rated wall. A matrix box, with an unknown fire resistance rating was embedded in the wall. Two conduits wit wires also penetrated the wall.

14. Observation over room 2T062, near the cath lab control room, of the one hour fire rated wall, a penetration approximately two inches in diameter.

15. Observation at cath lab storage room 2T074, revealed a penetration approximately one half inch in diameter in a wall labeled as a two hour fire rated barrier. A wall noted as one hour fire rated above the door to the same room had a matrix box ( unknown fire resistance rating) embedded in the same wall. A triangle shaped piece of gypsum board was missing at a large duct in the wall and an open ended conduit penetrated the wall.

16. Observation from inside storage room, 2T061, revealed the one hour fire rated barrier had penetrations of one inch conduit with wires through the conduit and three open junction boxes.

17. Observation at room 2T117, of the one hour fire rated wall, revealed a penetration approximately two inches wide and four inches in length.

18. Observation of double doors leading to the dirty room, 2T054, were observed to have a gap greater than one eight inch when in the closed position.

19. Observation of room 2T098, above the ceiling tiles, revealed two small junction boxes without covers . One red box, was not sealed in the space surrounding it and an open conduit with wire inside penetrated the one hour fire rated barrier.

Staff present on tour confirmed the observations.

















31007



Tour of the garden level completed on 05/09/16 between the hours of 12:30 PM and 5:30 PM revealed the following findings.

20. Observation of the south west corner of room GD026, from inside the room, revealed two blue 1/2 inch conduits open on the end with data cable passing through.

21. Observation of the West wall of room GD026 as seen from workstation GD053 revealed 1 inch conduit open on the end.

22. Observation of the door to identified hazardous area revealed the door having a self closer and the door being propped open with a chair.

23. Observation of the East wall of GD033 as seen from inside the room revealed a 1/2 inch green flex conduit with open annular space.

24. Observation of the East wall of GD033 as seen from the corridor revealed 3/4 inch conduit open on the end above the room door.

25. Observation of the Mechanical room near room GD033 revealed multiple penetrations and open ended conduits. Also the double doors with self closer's failed to close to latching position.

26. Observation of the East wall of the elevator room as seen from between the elevators near the IT room GS202 revealed 4 inch by 4 inch junction box missing a cover.

27. Observation of the West wall of the elevator room as seen from the IT room GS202 revealed multiple open ended conduits.

28. Observation of the North wall of Sterile supply as seen from the corridor at about half way down the wall revealed a 1 1/2 inch sprinkler line with open annular space.

Tour of the 1st floor completed on 05/10/16 between the hours of 8:30 AM and 5:30 PM revealed the following findings.

29. Observation of the door between the decontamination room 1N217A in the endoscopy area and the sterilization room revealed the door being propped open.

30. Observation of the West wall of the decontamination room 1N217A in the endoscopy area revealed multiple penetrations and a 3/4 inch conduit open on the end.

31. Observation of the West wall of the decontamination room 1N217A as seen from the corridor revealed two 3/8 inch conduits with open annular space above the door.

32. Observation of the North wall of the Clean Utility room 1N214 revealed 3/4 inch conduit open on the end.

33. Observation of the South wall of the Clean utility room as seen from the Pre-Op nurses station revealed 1/2 inch by 2 inch gap at the bottom of an HVAC duct.

34. Observation of the West wall of the supply room 1W125B as seen from the outside of the room revealed a 12 inch by 8 inch hole to the Left of an HVAC duct.

35. Observation of West wall of the supply room 1W125B as seen from inside the room revealed multiple penetrations varying in size and shape.

36. Observation of the South wall in the Nourishment room 1T284B revealed 14 inch by 10 inch penetration.

37. Observation of the West wall of the Soiled Utility room as seen from the corridor revealed a 3/4 inch conduit open on the end with light blue data cable passing through.

38. Observation of the South wall of the Nourishment room 1T284B, as seen from the nurses station revealed two 3/4 inch conduits with light blue data cables passing through open on the end.

39. Observation of the East wall of the Storage room 1T303 as seen from in the room revealed the wall was not sealed at the deck above.

40. Observation of the East and West walls of the Storage room 1T452B as seen from inside the room revealed four 3/4 inch conduits with light blue data cables open on the end, and a 5 inch by 5 inch penetration.

41. Observation of the West wall above the door of the Equipment room 1T459 as seen from inside the room revealed two 3/4 inch conduits open on the end.

42. Observation of the East wall of the Nourishment room 1T325B as seen from the corridor revealed 18 inch by 8 inch section of gypsum board missing.

43. Observation of the Soiled Utility room beside room 1T325A revealed the fire rated door was not on a self closer and was noted to be open when approached.

44. Observation of the West wall of the Staff Locker room 1S120 as seen from the corridor revealed no self closer on the door was noted to be in the open position.

45. Observation of the walls inside the Electrical room 1D057 revealed multiple open ended conduits. Staff DD identified the door the the hazardous room as not having a 3/4 hour fire rating.

46. Observation if the South wall of the Soiled Utility room 1D049 as seen from inside the room revealed a 3/8 inch flex conduit with open annular space.

47. Observation of the South wall of the Nuclear Med space as seen from the corridor revealed a 6 inch penetration and two 3/4 inch penetrations.

48. Observation of the South wall of the Shell space across from room 1D025 as seen from within the room revealed a 3/4 inch conduit with light blue data cables open on the end.

Tour of the 2nd floor completed on 05/11/16 between the hours of 9:30 AM and 2:30 PM revealed the following findings.

49. Observation North and South walls of the central supply room between OR #1 and OR #2 in OB revealed a 1/2 inch flex conduit open on the end and a 4 inch sprinkler pipe with open annular space.

50. Observation of the South wall of the Mechanical room by the OB OR's revealed a 1/2 inch conduit with a 2 inch annular space.

51. Observation of the West wall of the Storage room in the Nursery revealed a 12 inch by 8 inch hole that could be seen from the Storage room and the Electrical room 2N031.

52. Observation of the North wall of a hazardous area as seen from room 2T232 in the PACU area revealed a 1 inch conduit with light blue data cable open on the end.

53. Observation of the walls in the Equipment room 2T197 revealed multiple penetrations and open ended conduits.

54. Observation of the East wall of Equipment room 1T197 as seen from the corridor revealed 1/2 inch and 3/4 inch conduits open on the end.

55. Observation of the South wall of Equipment room 1T197 as seen from Holding room 1 revealed an 8 inch by 4 inch half circle hole to the right of an HVAC duct.

The findings were verified by staff at the time of the observations.

Based on observation and staff verification the facility failed to ensure doors in hazardous areas where not held open with hold open devices not attached to the fire alarm system and the doors closed to latching position. This has the potential to affect all patients receiving services from the facility. The facility census was 29.

Findings include:

Observation of the hazardous area located in the kitchen completed on 05/11/16 revealed the door on a self closer was being held open with a rubber triangle wedge. When the wedge was removed the door failed to close to a latching position.

These findings were verified by Staff DD at the time of the observation.

Based on schematic review, observation, and staff verification the facility failed to ensure the exit access corridor walls were free of penetrations and doors protecting the exit access corridor closed to latching position. This has the potential to affect all patients receiving services at the facility. The facility census was 195 at the time of the validation survey.

Findings include:

1. Observation of the wall and schematic review above the double doors of the Exit access corridor from the Alternacare side completed on 05/10/16 revealed two 1/2 inch flex conduits penetrating the 2 hour fire rated wall with open annular space.

2. Observation of the doors in the Exit access corridor by the Endoscopy area and Alternacare completed on 05/10/16 revealed the doors were on hold open devices that release when the fire alarm is activated. When the doors were released the observation revealed the doors traveling from the South corridor and the doors traveling from the East corridor did not close to a latching position.

The findings were verified by staff at the time of the observations.

Based on observation and staff verification the facility failed to ensure clear width of exit corridors. This has the potential to affect all patients receiving services from the facility. The facility census was 195 at the time of the validation survey.

Findings include:

Observation of the exit egress of Stair B-7 revealed patients traveling from the garden level have to open a large gate to access the exit on the 1st floor. This door swings into the path of egress causing less than 24 inches of width of the exit corridor. This finding was verified by Staff DD on 05/09/16 at 4:48 PM.

Based on observation and staff verification the facility failed to ensure the delayed egress doors from the adult ED to the pediatric ED released within 15 seconds. This has the potential to affect all patients receiving ED services. The facility census was 195 at the time of the validation survey.


Findings include:


1. Observation of double doors located in the South Central corridor of the ED completed on 05/10/16 were identified as exit egress doors. The sign on the door stated the door would release 15 seconds after the panic bar on the door was pushed. An attemp to open the door revealed the door did not open until staff scanned their security badges at the badge reader. Staff DD stated the doors must not be functioning on 05/10/16 at 2:05 PM.

Based on tour of the facility, review of facility documentation and staff interview and confirmation, the facility failed to ensure that fire drills included the transmission of a fire alarm signal and simulation of emergency fire conditions. The facility census was 195 patients at the time of the survey. Potentially all patients and visitors could be adversely affected.

Findings include:

On 05/11/16, at 2:40 P.M. during tour of the facility operating rooms, an interview was conducted with Staff T and U, who routinely work in the operating rooms. Interview was conducted regarding the fire drill procedure for that area. Staff stated that fire drills for the operating rooms was conducted by the educator for that area and occurred one to times per year. Staff confirmed the use of flammable skin preparations for surgery.

Interview of Staff CC regarding the educator's role for fire drill completion revealed the position had recently changed. Staff CC was not certain if the new educator had gotten procedures in place yet.

On 05/12/16, during review of facility documentation of fire drills for at least the last four quarters revealed there was no documented evidence of a fire drill conducted that included the operating rooms and the operating room staff.

Based on documentation review, and staff interview the facility failed to ensure fire drills were held at unexpected times and under varying conditions at least quarterly every shift. This has the potential to affect all patients receiving services from the facility. The facility census was 29 at the time of the survey.

Findings include:

Review of the fire drills for the last four quarters completed on 05/12/16 revealed the fire drills were held within an hour of each other every quarter and the fire drills on third shift were held within an hour of each other. The review also revealed no fire drill was completed for one quarter on second shift.

These findings were verified by Staff CC on 05/12/16.

Interview with Staff CC completed on 05/12/16 revealed that the fire drill on second shift was missing and Staff CC forgot to complete the fire drill that quarter.

Based on review of facility schematics, observation of the facility and staff interview and confirmation, the facility failed to ensure that automatic sprinkler systems were continuously maintained in reliable operating condition and were inspected and tested periodically. The facility census was 195 patients at the time of the survey. Potentially all patients and visitors could be adversely affected.

Findings include:

On 05/09/16 the facility schematics were reviewed to reveal the presence of existing trash and linen chutes.

Tour of the facility was conducted with Staff AA, BB, DD and EE on 05/09/16 between 1:30 P.M. and 5:30 P.M. and on 05/10/16 and 05/11/16 between the hours of 8:30 A.M. and 5:00 P.M. Tour of the penthouse in the North building included observation of the two hour fire rated separation that surrounded the trash and linen chutes. Observation from the exterior of the chute enclosures revealed automatic sprinkler pipe with shut off/control valves visible from near the top of the fire rated block enclosure. There was no access panel in the enclosure. Staff present on tour confirmed if work was required on the sprinkler system within the chutes, workers had to remove portions of the brick wall to perform the work.

During tour on 05/10/16 at 8:30 A.M., observation inside the trash and linen chutes on the third floor revealed there were no sprinkler heads visible. On 05/10/16 at 9:25 A.M., an interview of Staff FF (contracted personnel) was conducted regarding locations of sprinkler heads in the chutes at each floor. Staff FF could not confirm the locations of sprinkler heads in the trash and linen chutes and later provided pictures of the inside of the chutes. The pictures of the linen chute at level one, three and four indicated that portions of the metal chutes were roughly cut out to accommodate the placement of sprinkler heads. Sprinkler heads at each level were a different type. The sprinkler head at level four looked encased in dust and debris.

Pictures of the trash chute revealed sprinkle head placement at level one and three. Staff FF revealed that placement of the sprinkler heads was not at the chute door level but was between each level and located just below level two and level four and between level four and the penthouse. Interview of Staff FF, CC, DD and AA revealed there was no access panels at the chutes and that removal of outside wall surrounding the chutes was the only way to access the chutes and sprinkler heads.

Review of sprinkler system testing documents on 05/12/16 revealed no evidence the sprinkler system within the trash and linen chutes were routinely inspected, tested and maintained.

Based on schematic review, observation, and staff verification the facility failed to ensure the 1 hour rated walls around the linen and trash chute rooms were free of penetrations. This has the potential to affect all patients receiving services from the facility. The facility census was 195 at the time of the validation survey.


Findings include:


Observation and schematic review of the North wall of the trash and linen holding room completed on 05/09/16 revealed a 3/4 inch flex conduit open on the end with a white data cable passing through penetrating the 1 hour fire rated wall. This finding was verified by Staff DD on 05/09/16 at 2:50 PM.

Chapter 21, Existing Ambulatory Surgery
21.3, Protection

21.3.7.2
The ambulatory health care facility shall be divided into not less than two smoke compartments.
Exception No. 1: Facilities of less than 5000 ft2 (465 m2) and protected by an approved automatic smoke detection system.
Exception No. 2: Facilities of less than 10,000 ft2 (930 m2) and protected throughout by an approved, supervised automatic sprinkler system installed in accordance with Section 9.7.
Exception No. 3: An area in an adjoining occupancy shall be permitted to serve as a smoke compartment for the ambulatory health care facility if the following criteria are met:
(a) The separating wall and both compartments meet the requirements of 21.3.7.
(b) The ambulatory health care facility is less than 22,500 ft2 (2100 m2).
(c) Access from the ambulatory health care facility to the other occupancy is unrestricted.


Based on review of facility documentation, facility observation and staff interview and confirmation, the facility failed to ensure the ambulatory health care facility was divided into not less than two smoke compartments. Potentially all patients, staff and visitors could be affected. The facility provided surgical services for 28 patients on the day of the observation.

Findings include:

On 05/11/16 between 3:00 P.M. and 5:30 P.M. tour of the facility was conducted with Staff AA, BB and CC. Review of the facility certificate of occupancy revealed the facility was 22,574 square feet in size. Review of the facility schematic revealed a one hour smoke barrier. The one hour smoke barrier divided the facility into two smoke compartments.

Observation above the ceiling tiles of the smoke barrier wall , which extended from the front of the building to the back of the building, through rooms that included the staff break room, men's locker room, corridor to the recovery area, procedure rooms 8, 9 , 10 and to the north doors leading to the operating rooms revealed multiple penetrations. Little to no fire retardant sealant was visible in the areas observed.

Staff present at the observation confirmed the findings.



NFPA 99, Health Care Facilities
Chapter 4, Gas and Vacuum Systems

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
* Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.

Based on facility observation and staff interview and confirmation, the facility failed to ensure the enclosures were provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures were to be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Potentially all patients, staff and visitors could be affected. The facility provided surgical services for 28 patients on the day of the observation.

Findings include:

On 05/11/16 between 3:00 P.M. and 5:30 P.M. tour of the facility was conducted with Staff AA, BB and CC. Observation was conducted of the oxygen and medical gas storage location where the oxygen amount was greater than 3000 cubic feet. Penetrations were noted surrounding three pipes and wires located in the one hour fire rated construction of the walls. The door to the storage location had no visible fire resistance rating . Louvers were present in the lower third of the door which were open to the corridor.

Staff CC confirmed the observations.

NFPA101
Chapter 39, Existing Business Occupancies
39.3, Protection

39.3.2.1*
Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.
8.4 SPECIAL HAZARD PROTECTION
8.4.1.1*
Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by
8.4.1.3
Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

1. Based on facility observation and staff interview and confirmation, the facility failed to ensure that hazardous areas such as a storage area, soiled utility room and environmental closest was protected with a one hour fire resistant barrier without windows in accordance with Section 8.2. or the area was protected with an automatic extinguishing systems in accordance with Section 9.7. The facility provided services for an average daily census of 48 patients in the past week. Potentially all patients and visitors and could be adversely affected.

Findings include:

On 05/12/16, between 9:25 A.M. and 10:20 A.M. tour of the facility was conducted with Staff BB and DD. The following rooms and areas above the ceiling tiles were observed with staff present:

a. A storage room, approximately 12 feet long and 10 feet wide was noted to contain shelving units of combustible medical supplies. Observation above the ceiling tiles in the room revealed no enclosed one hour fire resistant construction for the room. The wooden door to the room had no identifiable fire resistance rating.

b. Observation above the ceiling tiles in a soiled utility room revealed multiple penetrations and lack of a complete one hour fire rated enclosure. The wooden door to the room had no fire resistance rating.

c. An small room identified as an environmental closet contained an electric hot water heater, four, five gallon buckets noted as latex paint, eight, one gallon cans identified as latex paint, one large box of toilet paper containing approximately 86 rolls of the paper and other miscellaneous containers of items needed for housekeeping. Also located in the room, was a portable fire extinguisher with a tag which noted the last inspection was July 3, 2007. Observation above the ceiling tiles in the room revealed three sides of the room were not enclosed with one hour fire resistant construction. The wooden door to the room had no identifiable fire resistance rating.

Staff present on tour confirmed the observations.



Chapter 7, Means of Egress
7.2.1.5 Locks, Latches, and Alarm Devices.

7.2.1.5.1
Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
7.2.1.5.
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.


2. Based on facility observation and staff interview and confirmation, the facility failed to ensure that doors were arranged to be opened readily from the egress side whenever the building was occupied. Locks, if provided, were not to require the use of special knowledge or effort for operation from the egress side and doors were to be operable with not more than one releasing operation. The facility provided services for an average daily census of 48 patients in the past week. Potentially all patients and visitors could be adversely affected.

Findings include:

On 05/12/16, between 9:25 A.M. and 10:20 A.M. tour of the facility was conducted with Staff BB and DD. Observation of the paths of egress from the facility revealed there were three noted exits. One of three exits was identified as the ambulance entrance and was also the staff entrance. An attempt to open the door revealed it was locked from the egress side. The door required the turn of a latch to release the lock before the door handle was pushed to open.

The third exit was located at the north end of the facility near a small room containing IT equipment. This door had the same locking arrangement as the ambulance entrance door.

Staff present on tour confirmed the observations.

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NFPA 10, Standard for Portable Extinguishers
Chapter 4, Inspection, maintenance and Recharging

4-1.3
The owner or designated agent or occupant of a property in which fire extinguishers are located shall be responsible for such inspection, maintenance, and recharging.


3. Based on facility observation and staff interview and confirmation, the facility failed to ensure the designated agent or occupant of a property in which fire extinguishers are located was responsible for inspection, maintenance, and recharging. The facility provided services for an average daily census of 48 patients in the past week. Potentially all patients and visitors and could be adversely affected.

Findings include:

On 05/12/16, between 9:25 A.M. and 10:20 A.M. tour of the facility was conducted with Staff BB and DD. Observation of a small room identified as an environmental closet contained an electric hot water heater, four, five gallon buckets noted as latex paint, eight, one gallon cans identified as latex paint, one large box of toilet paper containing approximately 86 rolls of the paper and other miscellaneous containers of items needed for housekeeping. Also located in the room, secured to the wall, was a portable fire extinguisher. A tag on the extinguisher noted the last inspection was July 3, 2007. Staff present on tour confirmed they were unaware there was an extinguisher in the room.