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Based on observations and interview, the facility failed to maintain the two hour fire barrier between the Healthcare Occupancy and the Business Occupancy free of penetrations in 3 locations. The facility had a capacity of 1103 patients and a census of 593 patients.

Finding include:

Observations and interview on 12-11-12 and 12-12-12, revealed the following:

1. There was a hole (approximately 1 and 1/2 feet by 5 feet in size) located in the 2 hour separation wall, above the suspended ceiling in the Soiled Cart Lift Room #3009.

2. There was a center of conduit penetration (approximately 1/2 inch in size) located above the suspended ceiling in Barrier #1002Z.

3. There was a hole (approximately 2 inches in size) located in the 2 hour wall of Room #0111-HC.

4. There was a center of conduit penetration (approximately 1/2 inch in size) located in the 2 hour wall of Room #0111-HC.

Fire and Safety Supervisor A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to maintain a Type I protected construction type in 1 location of the facility by allowing a penetration in the ceiling to be present. The facility had a capacity of 1103 patients and a census of 593.

Findings include:

Observations and interview on 12-12-12 and 12-13-12, revealed the following:

1. There was a missing escutcheon ring around a sprinkler head in the Carver Tower Kitchen freezer. The absence of an escutcheon ring created a penetration in the ceiling.

2. There was a hole (approximately 3 inches in size) located in the ceiling near Room #9011.

3. There was a missing escutcheon ring around a sprinkler head located near door #4018-Z. The absence of an escutcheon ring created a penetration in the ceiling.



Fire and Safety Supervisor A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to maintain a Type I protected construction type in 13 locations of the facility by allowing wall penetrations to be present. The facility had a capacity of 1103 patients and a census of 593 patients.

Findings include:

Observations and interview on 12-11-12 and 12-13-12, revealed the following:

1. There was a hole (approximately 1 inch in size) located in the corridor wall near Room 41230.

2. There was a hole (approximately 4 inches in size) located in the corridor wall near Fire Door 00180-2.

3. There was a chair was holding the door open to Conference Room 4. By holding this door open, eliminates the rating of the corridor.

4. There was a penetration (approximately 1/2 inch in size) located around a power line that runs through the corridor wall in Room #41500.

5. There was an open pipe penetration (approximately 4 inches in size) located in the corridor wall of Room #31168.

6. There were 2 conduit penetrations (approximately 3/16 of an inch) located in the west wall of Room 00180-B.

7. There was a penetration (approximately 1 inch in size) located at the bottom of the ductwork that extends through the west wall of Room 00180-B.

8. There was a conduit penetration (approximately 2 inches in size) located in the southeast corner of Room 00180-B.

9. There was a pipe penetration (approximately 2 inches in size) extending through the west wall of Room 00182-C.

10. There was a hole (approximately 1 inch in size) located in the corridor wall in Room 41285-S.

11. There was a hole (approximately 1 inch in size) located on the 4th Floor Center for Advanced Reproductive Care, near Door 41005-Z1.

12. There was a hole (approximately 1 inch in size) located in the corridor wall near Room 41101.

13. There was a hole (approximately 1 inch in size) located in the corridor wall across from Housekeeping Room 31030-HC.

Hospital Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to maintain the door to 1 room in proper working order. The facility had a capacity of 1103 patients and a census of 593 patients.

Findings include:

Observations and interview on 12-11-12, revealed Corridor Door #51201 failed to close and latch properly when tested.

Hospital Staff A verified this observation at the time of the survey process.

Based on observations and interview, it was determined the facility failed to maintain a one hour fire resistive enclosure in 3 stairwell locations. The facility had a license capacity of 1103 patients and a census of 593 patients.

Findings include:

Observations and interview on 12-12-12, revealed the following:

1. Stairwell door #C731-S failed to properly close and latch.

2. A penetration (approximately 2 1/2 inches in size) located around a water pipe in the stairwell by door #C530-S.

3. Stairwell door #437-S failed to properly close and latch.

Hospital Staff A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to maintain 1 smoke barrier free of penetrations. The facility had a capacity of 1103 patients and a census of 593 residents.

Findings include:

Observations and interview on 12-11-12, revealed a center of conduit penetration (approximately 1 inch in size) located above the suspended ceiling, in Barrier #6011-Z.

Fire and Safety Staff A verified this observation at the time of the survey process.

Based on observations interview, the facility failed to maintain 6 smoke barrier doors to close properly. The facility had a capacity of 1103 patients and a census of 593 patients.

Findings include:

Observations and interview on 12-13-12, revealed the following:

1. The West leaf of door #S720Z did no open easily and would not close without forcing the door to close.

2. The East leaf of door #6000Z did not latch into the frame.

3. The closer for smoke door #W344-Z had been disconnected, so the door did not close automatically.

4. The East wing of smoke door #CC300-Z did not latch into the frame.

5. The South leaf of door #C117-Z did not latch into the frame.

6. The smoke door #B28-X does not close and needs a coordinator to allow the doors to close together.

Maintenance Staff A verified these observations at the time of the survey process.

(A.)
Based on observations and interview, the facility failed to maintain 1 hazardous room properly separated by allowing a penetrations to be present. The facility had a capacity of 1103 patients and a census of 593 patients.

Findings include:

Observations and interview on 12-11-12 and 12-12-12, revealed the following:

1. A center of conduit penetration (approximately 2 inches in size) located in the corridor wall of Room #4048 (I.T. Closet)

2. A pipe penetration (approximately 1/4 inch in size) located in the Housekeeping Storage Room #1040-HC.

3. A center of conduit penetration (approximately 2 inches in size) located in Room#3167-EC.

4. A hole (approximately 2 inches in size) located in Room #3167-EC. This hole was stuffed with a rag or piece of cloth like material.

5. Multiple conduit penetrations (ranging from 1/4 inch to 1/2 inch in size) located in Room #1200-EC.

6. Multiple conduit penetrations (ranging from 1/4 inch to 1/2 inch in size) located in Room #1200-TC.


Fire and Safety Supervisor A verified this observation at the time of the survey process.

(B.)
Based on observations and interview, the facility failed to maintain 2 hazardous rooms properly separated by failing to ensure the doors to these rooms close and latch properly. The facility had a capacity of 1103 patients and a census of 593 patients.

Findings include:

Observations and interview on 12-11-12, revealed the following:

1. The doors to Storage Room #3080 and #3041-Z failed to properly close and latch into the door frame.

2. The door to Storage Room #1120-A failed to be properly equipped with an automatic door closer.

Fire and Safety Supervisor A verified this observation at the time of the survey process.

(A.)
Based on observations and interview, the facility failed to comply with the exiting requirements for stairways and smokeproof towers by failing to maintain the door to an exit stairway. The facility had a license of 1103 patients and a census of 593 residents.

Findings include:

Observations and interview on 12-12-12, revealed Stairwell Door # 3761-S failed to close and latch into the door frame.

Hospital Staff A verified this observation at the time of the survey process.

(B.)
Based on observations and interview, the facility failed to comply with the exiting requirements for stairways and smokeproof towers by failing to maintain the stairway free of penetrations. The facility had a license of 1103 patients and a census of 593 residents.

Findings include:

Observations and interview on 12-12-12, revealed a hole (approximately 1 inch in size) in the 1st Floor Stairwell wall near Room #1761-MC.

Hospital Staff A verified this observation at the time of the survey process.

Based on observations and staff interview, the facility is not providing unobstructed corridors that have a clear path of egress. The facility is also not providing sufficient headroom within the egress corridors due to projections on the walls in one corridor. The facility had a license capacity of 1103 patients and a census of 593 patients.
Findings include:
Observations and interview on 12/13/12, revealed the following deficiencies with egress paths:
1. The door swing to Suite C31 was into the Suite and the door had a deadbolt on the exiting door.
2. There was a monitor by door #W101 in the corridor that was away from the wall approximately 11 inches.
According to the facility layout, this was a required exit.
Maintenance Staff A verified the observation at the time of the survey process.

Based on observations and interview, the facility failed to properly maintain 1 emergency light unit in the facility by failing to ensure this light unit works properly. The facility had a capacity of 1103 patients and a census of 593 patients.

Findings include:

Observations and interview on 12-12-12, revealed the emergency light unit located in the 5th Floor Surgery ICU Bay 3 Nurses Station failed to illuminate on battery back up power when tested.

Hospital Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to assure exit signs were properly displayed and visible throughout the facility at 2 locations. The facility had a capacity of 1103 patients and a census of 593 patients.

Findings include:

Observations and interview on 12-13-12 revealed the following:

1. The exit sign in the stairwell by door #C237-S was not illuminated at the time of the inspection.

2. There were two arrows on the exit sign by door #C021-S. One of these arrows were pointing at the wall.

According to the facility layout, these areas are designated as exits.

Maintenance Staff A verified these observations at the time of the survey process.

(A.)
Based on observations and interview, the facility failed to provide the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition, by allowing a fire alarm component to be obstructed. The facility had a license of 1103 patients and a census of 593 patients.

Findings include:

Observations and interview on 12-13-12, revealed the fire alarm pull station that is located near the south exit of Suite C41T was blocked by a file cabinet, not allowing full and easy access.

Maintenance Staff A verified this observation at the time of the survey process.

(B.)
Based on observations and interview, the facility failed to provide the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition, by failing to have the fire alarm system inspected 2 times per year. The facility had a license of 1103 patients and a census of 593 patients.

Findings include:

Observations and interview on 12-14-12, revealed the fire alarm system failed to have the "Annual" inspection completed by an outside inspection company. During an interview with Hospital Staff A, he stated that the fire alarm company is on the hospital property many times per year doing continuing maintenance to the system.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition by allowing smoke detectors to be installed too close to an Air Diffuser (HVAC System). The facility had a capacity of 1103 patients and a census of 593 patients.

Findings include:

Observations and interview on 12-12-12 and 12-13-12, revealed the smoke detectors at the following locations were installed closer than 3 feet away from an HVAC Air Diffuser.

1. Near 7326-B-1
2. Across from Room #3322.
3. In Room #0431.
4. In Room #7326.
5. In Room #4358.
6. In Room #4338.
7. In Room #4334.
8. In the corridor near Resident Room #3370.
9. In the corridor near Resident Room #3336.
10. In Room #3345.
11. In Room #3323.
12. In Room #3322.
13. In the corridor near Office #0337.
14. In Room #0430.

Hospital Staff A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to provide a sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13, Standard for the Installation of Sprinkler Systems, 1999 edition, by allowing mixed sprinkler heads to be located in the same smoke zone. The facility had a capacity of 1103 patients and a census of 593 patients.

Findings include:

Observations and interview on 12-12-12, revealed a fusible link sprinkler head installed by the fires doors of the corridor #4906-Z that was intermixed with quick response sprinkler heads in the Atrium.

Hospital Maintenance Staff A verified this observation at the time of the survey process.

(A.)
Based on observations and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by allowing sprinkler heads to be painted. The facility had a capacity of 1103 patients and a census of 593 patients.

Findings include:

Observations and interview on 12-13-12, revealed a fusible link sprinkler head that was painted in the stairwell near Door # 6351-S.

Hospital Staff A verified this observation at the time of the survey process.

(B.)
Based on observations and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by allowing storage to be closer than 18 inches from a sprinkler head. The facility had a capacity of 1103 patients and a census of 593 patients.

Findings include:

Observations and interview on 12-13-12, revealed storage items that were closer than 18 inches from the bottom of the sprinkler head in Room #8327-1.

Hospital Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility is not maintaining the appliances in the kitchen in compliance with the National Fire Protection Association (NFPA) 96. The facility had a license of 1103 residents and a census of 593 residents.

Findings include:

Observations and interview on 12-11-12, revealed the following:

1. The 5th Floor Melrose Kitchen "Fry Master" near Door #50005 was not locked into place to keep the machine from extending past the gas line attached to the machine.

2. The 5th Floor Melrose Kitchen "Main Grill" was not locked into place to keep the Grill from extending past the gas line attached to the machine.

Hospital Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to provide curtains and blinds that were flame retardant materials meeting the provisions of 10.3.1 of National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition by allowing vinyl mini-blinds to be in use. The facility had a license of 1103 patients and a census of 593 patients.

Findings include:

Observations and interview on 12-12-12, revealed a vinyl mini-blind window covering in Room #8373-B.

Hospital Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to properly store soiled linen or trash collection receptacles that have a capacity of greater than 32 gallons. The facility had a capacity of 1103 patients and a census of 593 patients.

Findings include:

Observation and interview on 12-13-12, revealed the facility was using a 96 gallon receptacle and was improperly storing this receptacle near exit door W135-S.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to properly maintain the storage of compressed medical gases in one location in accordance with Section 4.3.1.1.2, NFPA 99, Health Care Facilities, 1999 edition by allowing 1 oxygen bottle to be unsecured. The facility had a license of 1103 residents and a census of 593 residents.

Findings include:

Observations and interview on 12-11-12, revealed 1 oxygen bottle that was not properly secured in Room #3041-Z

Fire and Safety Supervisor A verified this observation at the time of the survey process.

(A.)
Based on observations and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition by allowing a light to be controlled by a switch in an area that is required to have 24 hour emergency back up lighting. The facility had a capacity of 1103 patients and a census of 593 patients.

Findings include:

Observations and interview on 12-11-12, revealed the light located in the Medicine Room was controlled by a light switch. This light act as an emergency light because it is wired into the emergency light circuit of the generator. There was not a battery back up emergency light at this location. This lights shall have the capability of staying lit at all times, not controlled by a switch.

Fire and Safety Supervisor A verified these observations at the time of the survey process.

(B.)
Based on observations and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition by failing to install Ground Fault Circuit Interrupter electrical outlets in a required area. The facility had a capacity of 1103 patients and a census of 593 patients..

Findings include:

Observations and interview on 12-12-12, revealed the absence of a required GFCI electrical outlets in the following locations:

1. Near the sink in Linen Room 1059.
2. In the Laboratory, near the eye wash stations.
3. In Room #5202 near the sink.

Fire and Safety Supervisor A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to have an Alcohol Based Hand Rub dispenser properly located at 1 location. The facility has a capacity of 1103 patients and a census of 593 patients.

Findings include:

Observations and interview on 12-11-12, revealed an Alcohol Based Hand Rub dispenser that was located above an electrical source (electrical outlet) near Room #5104.

Fire and Safety Supervisor A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to have an Alcohol Based Hand Rub dispenser properly located at 1 location. The facility has a capacity of 1103 patients and a census of 593 patients.

Findings include:

Observations and interview on 12-11-12, revealed an Alcohol Based Hand Rub dispenser that was located above an electrical source (electrical outlet) near Room #5104.

Fire and Safety Supervisor A verified these observations at the time of the survey process.