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Based on observation and interview, the facility failed to maintain building construction type. Building construction type and stories as required by NFPA 101 (2012 edition), Sections meets Table 19.1.6.1, unless otherwise permitted by by NFPA 101 (2012 edition), Sections 19.1.6.2 through 19.1.6.7. This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 3/20/18 at 8:29 am, observation revealed the construciton type was not being maintained in the fifth floor, East, smoke compartment 1, electrical closet. The bottom flange of the steel beam was missing spray fireproofing material for approximately 6" on either side. The condition was confirmed at the time of discovery by concurrent interview with Staff Y (Senior Construction Manager) and Staff EE (Construction Manager).




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2. On 3/19/18 at 12:30 pm, observation revealed the construction type was not being maintained in the 6-W Mechanical Room. The bottom flange of the steel beam by the entrance door was missing spray fireproofing material for approximately 6 and several cross braces in various areas within the mechanical room were missing spray fireproofing. The condition was confirmed at the time of discovery by concurrent interview with Staff HH (Construction Manager-Life Safety) and Staff BB (Environmental Safety Manager).

Based on observation and interview, the facility failed to maintain the means of egress door in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.2.2.2.4 & 7.2.1.5.1. This deficiency had the potential to an undetermined number of staffs and visitors.

Findings include:

1. On 3/20/18 at 10:48 am, observation revealed in the center wing basement floor generator loop room that the generator loop room door was locked with a dead bolt and was not readily openable from the egress side.

This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.







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2. On 3/19/18 at 12:40 pm, observation revealed in the 6th floor 6W and 6C rooms there was no delayed egress signage on the doors.

This deficient practice was confirmed by Staff HH (Construction Manager - Life Safety), and Staff BB (Environmental Safety Manager) at the time of discovery.

Based on observation and staff interview, the facility did not ensure that doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility in accordance with NFPA 101 (2012 edition) section 19.2.2.2.7 and 19.2.2.2.8. This deficient practice could affect all inpatients and an undermined number of staff and visitors.

Findings include:

On 3/20/18 at 9:36 am, observation revealed in the Atrium second floor between smoke compartment 1 and smoke compartment 2 corridor that the 90 minute rated doors did not latch upon release of the hold open device. The condition was confirmed at the time of discovery by concurrent interview with Staff Y (Senior Construction Manager) and Staff EE (Construction Manager).

Based on observation and interview, the facility failed to maintain the means of egress signage in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.2.2.2.4 & 7.2.1.5.1. This deficiency had the potential to an undetermined number of staffs and visitors.

Findings include:

On 3/20/18 at 8:50 am, observation revealed in the 2-Tower Chapel that exit light over the exit door was not illuminated.

This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

Based on observation and interview, the facility failed to maintain hazardous area in accordance with the requirements of NFPA 101 - 2012 edition, sections 19.3.2.1 and 8.4. These deficiencies had the potential to affect an undetermined number of inpatients, staffs and visitors.

Findings include:

1. On 3/20/2018 at 10:30 am, observation revealed in the north wing first floor locksmith room RM-N1 that the room was used as storage also. Twenty card board boxes and twenty large paper book binders were stored inside this locksmith room. The hazardous room was protected with a sprinkler system but was not smoke tight. The locksmith room door was not equipped with an automatic or self closing device. This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

2. On 3/19/2018 at 2:54 pm, observation revealed on the seventh floor in the current vacated smoke compartment 3 that patent room #707 was used for storage. The room contained durable medical equipment, (2) "H" sized compressed air tanks and (6) "E" size oxygen tanks. The hazardous room was protected with a sprinkler system but was not smoke tight. The patient room door was not equipped with an automatic or self closing device. This deficient practice was confirmed by Staff Y (Senior Construction Manager) and Staff EE (Construction Manager) at the time of discovery.

3. On 3/19/2018 at 2:58 pm, observation revealed on the seventh floor in the current vacated smoke compartment 3 that patent room #705 was used for storage. The room contained a stack of (6) matress and (8) vinyl and foam bedside floor pads. The hazardous room was protected with a sprinkler system but was not smoke tight. The patient room door was not equipped with an automatic or self closing device. This deficient practice was confirmed by Staff Y (Senior Construction Manager) and Staff EE (Construction Manager) at the time of discovery.

Based on observation and interview, the facility failed to provide battery powered emergency lights in an anesthetizing location in accordance with the requirements of NFPA 101 (2012 edition), Section 19.3.2.3 , NFPA 99 (2012 edition), Section 6.3.2.2.11.1, 6.3.2.2.11.2, 6.3.2.2.11.3 & 6.3.2.2.11.4. This deficiency had the potential to affect an undetermined number of inpatients, staffs and visitors. This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

Findings include:

On 3/19/2018 at 3:38 PM, observation revealed in the tower wing basement floor endoscope suite that there were six endoscope procedure rooms. Procedure room number one was used to administer general anesthesia and deep sedation, and one or more battery powered lighting units were not provided inside the procedure room number one.

Based on record review, interview and observation, the facility failed to maintain cooking facilities in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.2.6.1 and 9.2.3; NFPA 96 - 2011 edition, Table 11.4, Section 10.2.2, 10.5.1, 10.5.7, 11.6.1. and 11.6.13. These deficiencies had the potential to affect an undetermined number of inpatients, staffs and visitors.

Findings include:

1. On 3/19/2018 at 1:45 PM, review of the documents revealed that the facility did not inspect and clean the kitchen range hood system at least every six months as required by NFPA 96 - 2011 edition, Table 11.4. The kitchen range hood was inspected and cleaned on 6/13/2017 by Legacy Services Corporation within the last year.

2. On 3/19/2018 at 2:30 PM, observation revealed inside the tower wing first floor kitchen, that the name of the person that performed the hood system cleaning work on 6/13/2017 was not maintained in the certification sticker inside the kitchen.

3. On 3/19/2018 at 2:35 PM, observation revealed inside the tower wing first floor kitchen that a placard in a conspicuous location near the fire extinguisher was missing containing instruction to use the fire extinguisher after the fixed fire protection system's activation.

4. On 3/19/2018 at 2:37 PM, observation revealed inside the tower wing first floor kitchen that the manual activation for the kitchen-hood fire suppression system was not located in the path of egress and was not clearly identified on the hazard protected. Manual activation for the kitchen-hood fire suppression system was installed on the exterior side of the kitchen-hood metal enclosure.

These deficient practices were confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

Based on observation and interview, the facility failed to provide sprinkler coverage and install sprinklers in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.4.2.2, and 9.7: NFPA 13 - 2010 edition sections 8.15.10.3 and 8.6.5.2.1.1. These deficiencies had the potential to affect an undetermined number of inpatients, staffs and visitors.

Findings include:

1. On 3/19/2018 at 2:45 PM, observation revealed in the atrium wing basement floor electrical equipment room, that the electrical equipment room did not have sprinkler protection and was separated with a 2 hour rated fire barrier but used for storage also. Ten combustible cardboard boxes and ladders were stored inside the electrical equipment room. This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

2. On 3/19/2018 at 2:50 PM, observation revealed in the atrium wing basement emergency electrical switchgear room, that the emergency electrical switchgear room did not have sprinkler protection and was separated with a 2 hour rated fire barrier but used for storage also. Ten combustible cardboard boxes, ten ladders and large paint cans were stored inside the emergency electrical switchgear room. This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

3. On 3/20/2018 at 10:30 am, observation revealed in the center wing first floor electrical room, that the electrical room did not have sprinkler protection, was separated with 2 hour rated fire barrier but used for storage also. Four combustible cardboard boxes and two large moving carts with combustible trash on them were stored inside the electrical room. This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

4. On 3/20/2018 at 11:00 am, observation revealed on the center wing first floor in the store room that a continuous duct obstruction was located less than 18 in. (457 mm) below a sprinkler deflector. Also, in the same room, a 1 feet wide and 4 feet long light fixture obstruction was located less than 18 in. (457 mm) below another sprinkler deflector. These deficient practices were confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

5. On 3/20/2018 at 8:48 am, observation revealed in the Tower third floor, smoke compartment 2, electrical closet, that the room did not have sprinkler protection. This deficient practice was confirmed by Staff Y (Senior Construction Manager) and Staff EE (Construction Manager) at the time of discovery.

6. On 3/20/2018 at 8:58 am, observation revealed in the Tower third floor, smoke compartment 2, imaging equipment closet, that the room did not have sprinkler protection. This deficient practice was confirmed by Staff Y (Senior Construction Manager) and Staff EE (Construction Manager) at the time of discovery.

7. On 3/20/2018 at 9:48 am, observation revealed in the Tower second floor, smoke compartment 2, vacant shell space, that the room did not have sprinkler protection. The pendant fire protection sprinkler heads were located 20 feet below the ceiling of the room. This deficient practice was confirmed by Staff Y (Senior Construction Manager) and Staff EE (Construction Manager) at the time of discovery.





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8. On 3/19/2018 at 3:03 pm, observation revealed in the 2-North Mechanical Room that there was no sprinkler protection under the metal ducts that were greater than 4 feet in width. This deficient practice was confirmed by Staff HH (Construction Manager-Life Safety) and Staff BB (Environmental Safety Manager) at the time of discovery.

9. On 3/20/2018 at 8:40 am, observation revealed in the RM-C2-UDC Data Room that the sprinkler diffusers above the metal duct work were in direct contact with the metal duct. This deficient practice was confirmed by Staff HH (Construction Manager-Life Safety) and Staff BB (Environmental Safety Manager) at the time of discovery.

Based on observation, interview and record review, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 19.3.5 and 9.7.5, NFPA 25 - 2011 edition, Sections 5.2.1, 5.2.1.1.1, 13.2.7.2, 13.3.2.1.1, 13.6.1, 13.6.1.1.1, 13.4.2.1, 14.2.1 & Table 5.1.1.2, 13.1.1.2. These deficiencies had the potential to affect 236 of the 236 inpatients, as well as an undetermined number of staffs and visitors.

Findings include:

1. On 3/19/2018 at 11:50 am, during review of the facility monthly fire sprinkler system inspection records it was discovered that the facility did not inspect the gauges every month within the last year. This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

2. On 3/19/2018 at 11:55 am, during review of the facility monthly fire sprinkler system inspection records it was discovered that the facility did not inspect the back flow prevention valve and assemblies every month within the last year. This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

3. On 3/19/2018 at 12:00 PM, during a review of facility documents entitled "Peerless Pipe Protection" dated 2/20/2013, it was discovered that the sprinkler system gauges had not been replaced or calibrated within the last five years. This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

4. On 3/19/2018 at 12:05 PM, during a review of facility documents entitled "Peerless Pipe Protection" dated 2/20/2013, it was discovered that the sprinkler system piping had not been internally inspected for the presence of foreign organic and inorganic material within the last five years. This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

5. On 3/19/2018 at 3:30 PM, observation revealed in the tower wing basement level corridor alcove near room number 7 that a sprinkler head had lint and other foreign materials on it. This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

6. On 3/20/2018 at 10:10 am, observation revealed in the north wing first floor forensic nurse examiner room that a sprinkler head had lint and other foreign materials on it. This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

7. On 3/20/2018 at 10:15 am, observation revealed in the north wing first floor environmental services room RM-N1-0PO5 that a sprinkler head had lint and other foreign materials on it. This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

8. On 3/20/2018 at 10:20 am, observation revealed in the north wing first floor staff room that a sprinkler head had lint and other foreign materials on it. This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

9. On 3/19/2018 and 3/20/2018, observation revealed throughout the facility that the fire protection sprinkler system gauges were not labeled based on the installation or calibration date. This deficient practice was confirmed by Staff Y (Senior Construction Manager), Staff EE (Construction Manager) at the time of discovery.









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10. On 3/19/2018 at 2:30 pm, observation revealed in th 3-North Anti Pardom Clean Room there was a missing escutcheon ring just inside the entrance door. This deficient practice was confirmed by Staff HH (Construction Manager-Life Safety) and Staff BB (Environmental Safety Manager) at the time of discovery.

Based on observation and staff interview, the facility did not maintain corridor doors in accordance with NFPA 101 (2012 edition), 19.3.6.3.5. Doors shall be provided with a means for keeping the door closed. This deficient practice could affect an undeterminable number of residents, staff and visitors.

On 3/20/18 at 11:10 am, observation revealed the inactive leaf on the corridor closet doors was not automatically positive latching. If the inactive leaf was not manually latched, both closet doors would not positively latch and stay closed. This condition was confirmed at the time of discovery with Staff BB (Environmental Safety Manager).

Based on observation and interview, the facility failed to provide smoke barrier doors with 1-3/4 inch thick solid bonded wood-core doors or construction that resists fire for 20 minutes in accordance with NFPA 101 (2012 edition), 19.3.7.6 and 8.5. This deficient practice could affect all of the patients, as well as an undetermined number of staff and visitors.

Findings include:

On 3/19/18 at 1:15 pm, observation in the Tower tenth floor corridor between smoke compartment 2 and smoke compartment 3 revealed a pair of metal double smoke barrier doors that did not close to prevent the passage of smoke between the compartments. This deficient practice was confirmed by Staff Y (Senior Construction Manager) and Staff EE (Construction Manager) at the time of discovery.

Based on observation and interview, the facility failed to provide proper distribution of the trash utility containers in accordance with the requirements of NFPA 101 - 2012 edition, section 19.7.5.7.1. This deficiency had the potential to affect an undetermined number of inpatients, staffs and visitors.

FINDINGS INCLUDE:

On 03/19/2018 at 3:45 PM, observation revealed in the tower wing first floor staff lounge room that, that one 45 gallon capacity trash container and one 15 gallon capacity trash container full of combustible trash were stored within 5 feet of each other and they together exceeded 32 gallons in a 64 square foot area.

This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

Based on observation and staff interview, the facility did not ensure that extension cords were not used as a substitute for fixed wiring of a structure and that extension cords used temporarily were removed immediately upon completion of the purpose for which it was used, per NFPA 101 (2012 edition), 39.5.1, 9.1.2, and NFPA 70 (2011 edition. These deficient practices could affect an undermined number of patients, staff and visitors.

Findings include:

1. On 3/20/18 at 9:45 am, observation revealed in the Consult Room that a refrigerator was plugged into a power strip. This condition was confirmed at the time of discovery with Staff BB (Environmental Safety Manager).

2. On 3/20/18 at 9:50 am, observation revealed in the Physician Reading Room that a refrigerator was plugged into a power strip. This condition was confirmed at the time of discovery with Staff BB (Environmental Safety Manager).

3. On 3/20/18 at 10:05 am, observation revealed in the Mechanical Storage Room that the circuit breakers were painted red. This condition was confirmed at the time of discovery with Staff BB (Environmental Safety Manager).

4. On 3/20/18 at 10:10 am, observation revealed in the General Office that a refrigerator was plugged into a power strip. This condition was confirmed at the time of discovery with Staff BB (Environmental Safety Manager).

Based on observation and interview, the facility failed to maintain the electrical raceway in accordance with the requirements of NFPA 101 - 2012 edition, Sections 9.1.2 and NFPA 70 - 2011 edition sections 314.28(C). This deficiency had the potential to affect an undetermined number of inpatients, staffs and visitors.

Findings include:

On 3/19/2018 at 2:52 PM, observation revealed in the atrium wing basement emergency electrical switchgear room, that a 4"x 4" electrical junction box in the wall that had energized wires inside, did not have a cover.

This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

Based on interview and observation, the facility failed to provide an emergency electrical generator with a remote stop in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.5.1.1 & 9.1.3.1; NFPA 110 - 2010 edition, Sections 5.6.5.6 and 5.6.5.6.1. This deficiency had the potential to affect 236 of the 236 inpatients, as well as an undetermined number of staffs and visitors.

FINDINGS INCLUDE:

On 3/20/18 at 10:46 am, observation revealed in the center wing basement floor generator and boiler room that the emergency generator GEN-PP01's prime movers were located inside the generator room and the remote manual stop station was not provided outside the generator room.

This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

Based on observation and interview, the facility failed to visually inspect the emergency generator remote annunciator in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.5, 9.1, 9.1.3, 19.3.2.3 and 9.1.3.1, and NFPA 99-2012 edition, Section 6.4.1.1.17 and 6.4.1.1.17.5 . This deficiency had the potential to affect 236 of the 236 inpatients, as well as an undetermined number of staffs and visitors.

Finding include:

On 3/20/18 at 10:40 am, observation revealed in the center wing first floor mechanic's shop room that the remote alarm annunciators for the emergency generators were not readily observable and audible as this mechanic's shop room was not occupied by operating personnel for 24 hours a day and 7 days in a week.

This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

Based on record review and interview, the facility failed to visually inspect the emergency generator in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.5, 9.1, 9.1.3, 19.3.2.3 and 9.1.3.1, as well as 110 - 2010 edition, Sections 8.4 and 8.4.1. This deficiency had the potential to affect 236 of the 236 inpatients, as well as an undetermined number of staffs and visitors.

Finding include:

On 3/19/18 at 1:26 PM, the facility emergency generator record review revealed that the facility only weekly inspected the emergency generator's battery system. There was no documentation showing that the weekly inspection for the emergency generators was conducted for the main fuel tank level, day tank level, day tank float switch, supply or transfer pump operation, solenoid valve operation, water in the fuel system, oil level, lube oil heater operation, cooling system level, adequate fresh air through radiator, conditions of hoses and connections, jacket water heater, exhaust system leakage, condensate drain trap, prime mover general condition and electrical system inspections.

This deficient practice was confirmed by Staff Z (Director of Safety), Staff AA (Safety Consultant), Staff CC (Facilities Manager) & Staff EE (Engineering Supervisor) at the time of discovery.

Based on observation and staff interview, the facility did not ensure that extension cords were not used as a substitute for fixed wiring of a structure and that extension cords used temporarily were removed immediately upon completion of the purpose for which it was used, per NFPA 99 (2012 edition), 10.2.4 and NFPA 70 (2011 edition), 400.8. This deficient practice could affect all inpatients and an undermined number of staff and visitors.

Findings include:

1. On 3/20/18 at 9:57 am, observation revealed in the Tower second floor smoke compartment 3 security office that (2) extension cords were used to power (2) two-way radio chargers, (2) car battery jumpers and (9) flashlights. The condition was confirmed at the time of discovery by concurrent interview with Staff Y (Senior Construction Manager) and Staff EE (Construction Manager).


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2. On 3/19/18 at 12:50 pm, observation revealed in the MR-N5-OC1 room that an electric floor fan was plugged into a power strip. This condition was confirmed at the time of discovery by concurrent interview with Staff HH (Construction Manager-Life Safety) and Staff BB (Environmental Safety Manager).