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Based on observation and staff interview, the facility failed to ensure the building is maintained in accordance with NFPA LSC 101 2000 Edition. Sections 19-3.6.3.2 Corridor doors. . This deficient practice could affect all of the patients, as well as all staff and visitors, if the corridor doors are not maintained as functional as required by code.

Findings include:

Observations on April 4, 2011 during the tour at 1050 hours accompanied by the director of facility maintenance revealed that:

The kitchen corridor to dining corridor door did not close and latch in the door frame as required by code.

Based on interview the director of facility maintenance witnessed and acknowledged that the corridor door did not close and or latch as required by code on the date of survey April 4, 2011 during the tour at 1050 hours.

These findings were verified by the administrator and director of facility maintenance at the times of observation and the administrator at the exit conference on April 6, 2011 at 1400 hours.

Based on observation and staff interview, the facility failed to ensure the building is maintained in accordance with NFPA LSC 101 (2000) Edition. Section(s) 4.2.1 Occupant Protection. A structure shall be designed, constructed, and maintained to protect occupants who are not intimate with the initial fire development for the time needed to evacuate, relocate, or defend in place. 4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this code, such device, equipment, system, or other feature shall thereafter be maintained unless the code exempts such maintenance. 4.6.1.1 The authority having jurisdiction shall determine whether the provisions of the code are met. NFPA 1 (2000) Edition. 5-7.1 Where required elsewhere in this code or NFPA 101, smoke partitions shall be provided to limit the transfer of smoke(101:8.2.4.1) Ceiling tiles and ceiling assemblies. This deficient practice could affect all of the patients, as well as all staff and visitors, if the smoke barriers are not maintained as functional as required by code.

Findings include:

Observations on April 4 -6, 2011 during the tour accompanied by the director of facility maintenance revealed that:

Ceiling tile tracking and tiles were damaged and not maintained to original code required installation. Ceiling tiles had numerous unsealed hole penetrations throughout the facility. Wiring for cable and cameras and other devices are running through ceiling and walls leaving unsealed hole penetrations.

Examples include:

(1) On April 4, 2011 at 1050 hours during the tour accompanied by the director of facility maintenance revealed that there are unsealed hole penetrations ranging in size from half an inch up to four inches in size in the ceiling smoke barrier of the Nuclear medicine room area.

At this same time, based on interview, the director of facility maintenance acknowledged that the ceilings smoke barrier has unsealed hole penetrations and does not meet smoke barrier requirements required by code.

(2) On April 4, 2011 at 1100 hours during the tour accompanied by the director of facility maintenance revealed that there are unsealed hole penetrations ranging in size from half an inch up to four inches in size in the ceiling smoke barrier of the laboratory areas.

At this same time, based on interview, the director of facility maintenance acknowledged that the ceilings smoke barrier has unsealed hole penetrations and does not meet smoke barrier requirements required by code.

(3) On April 4, 2011 at 1125 hours during the tour accompanied by the director of facility maintenance revealed that there are unsealed hole penetrations ranging in size from half an inch up to four inches in size in the ceiling smoke barrier of the materials management areas.

At this same time, based on interview, the director of facility maintenance acknowledged that the ceilings smoke barrier has unsealed hole penetrations and does not meet smoke barrier requirements required by code.

(4) On April 4, 2011 at 1300 hours during the tour accompanied by the director of facility maintenance revealed that there are unsealed hole penetrations ranging in size from half an inch up to four inches in size in the ceiling smoke barrier of the 2 central areas.

At this same time, based on interview, the director of facility maintenance acknowledged that the ceilings smoke barrier has unsealed hole penetrations and does not meet smoke barrier requirements required by code.

(5) On April 5, 2011 at 1175 hours during the tour accompanied by the director of facility maintenance revealed that there are unsealed hole penetrations ranging in size from half an inch up to four inches in size in the ceiling smoke barrier of the 3 central Satellite pharmacy areas.

At this same time, based on interview, the director of facility maintenance acknowledged that the ceilings smoke barrier has unsealed hole penetrations and does not meet smoke barrier requirements required by code.

(6) On April 5, 2011 at 1300 hours during the tour accompanied by the director of facility maintenance revealed that there are unsealed hole penetrations ranging in size from half an inch up to four inches in size in the ceiling smoke barrier of the 3 patient storage room areas.

At this same time, based on interview, the director of facility maintenance acknowledged that the ceilings smoke barrier has unsealed hole penetrations and does not meet smoke barrier requirements required by code.

(7) On April 6, 2011 at 1075 hours during the tour accompanied by the director of facility maintenance revealed that there are unsealed hole penetrations ranging in size from half an inch up to four inches in size in the ceiling smoke barrier of the labor and delivery C section med storage room areas.

At this same time, based on interview, the director of facility maintenance acknowledged that the ceilings smoke barrier has unsealed hole penetrations and does not meet smoke barrier requirements required by code.

(8) On April 6, 2011 at 1100 hours during the tour accompanied by the director of facility maintenance revealed that there are unsealed hole penetrations ranging in size from half an inch up to four inches in size in the ceiling smoke barrier of the labor and delivery C section linen storage room areas.

At this same time, based on interview, the director of facility maintenance acknowledged that the ceilings smoke barrier has unsealed hole penetrations and does not meet smoke barrier requirements required by code.

(9) On April 6, 2011 at 1150 hours during the tour accompanied by the director of facility maintenance revealed that there are unsealed hole penetrations ranging in size from half an inch up to four inches in size in the ceiling smoke barrier of the operating decontamination room areas.

At this same time, based on interview, the director of facility maintenance acknowledged that the ceilings smoke barrier has unsealed hole penetrations and does not meet smoke barrier requirements required by code.

These findings were verified by the director of facility maintenance at the times of observation and the administrator and director of facility maintenance at the exit conference on April 6, 2011 at 1400 hours.

Based on observation and staff interview, the facility failed to ensure the building is maintained in accordance with NFPA LSC 101-(2000) Edition. Section(s) 4.2.1 Occupant Protection. A structure shall be designed, constructed, and maintained to protect occupants who are not intimate with the initial fire development for the time needed to evacuate, relocate, or defend in place. 4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this code, such device, equipment, system, or other feature shall thereafter be maintained unless the code exempts such maintenance. 4.6.1.1 The authority having jurisdiction shall determine whether the provisions of the code are met. NFPA 1 (2000) Edition. 7.5.1.1 Exits shall be located and exit egress shall be arranged so that exits are readily accessible at all times. This deficient practice could affect all of the patients, as well as all staff and visitors, if exit egress is not maintained as functional as required by code.

Findings include:

Observations on April 5, 2011 during the tour at 1150 hours accompanied by the director of plant operations revealed that:

The exit doorways are not kept clear and un-obstructed. The facility is storing five bariatric wheel chairs, and other patient care fold up beds for more than 30-minute intervals which completely blocks egress to the stairwell exit door. The exiting corridor is reduced and is not free of obstructions. These wheel carts and other obstructions may allow injury to occupants or firefighter's entering or exiting the facility in the event of a fire. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of a fire or other emergency. This was discovered at the number 4 stairwell of 7 central exit door.

Based on interview of the director of plant operations on April 5, 2011 during the tour at 1150 hours it was witnessed and acknowledged that the number 4 stairwell of 7 central exit door areas surveyed had equipment in the corridors that obstruct clear egress requirements as required by code on the date(s) of survey.

These findings were verified by the administrator and director of facility maintenance at the times of observation and the administrator at the exit conference on April 6, 2011 at 1400 hours.

Based on observation and staff interview, the facility failed to ensure the building is maintained in accordance with NFPA LSC 101-(2000) Edition. Section(s) 4.2.1 Occupant Protection. A structure shall be designed, constructed, and maintained to protect occupants who are not intimate with the initial fire development for the time needed to evacuate, relocate, or defend in place. 4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this code, such device, equipment, system, or other feature shall thereafter be maintained unless the code exempts such maintenance. 4.6.1.1 The authority having jurisdiction shall determine whether the provisions of the code are met. NFPA 1 (2000) Edition. 7.5.1.1 Exits shall be located and exit egress shall be arranged so that exits are readily accessible at all times. This deficient practice could affect all of the patients, as well as all staff and visitors, if exit egress is not maintained as functional as required by code.

Findings include:

Observations on April 4, 2011 during the tour at 1200 hours accompanied by the director of plant operations revealed that:

The exit corridors are not kept clear and un-obstructed. The facility is storing, equipment, chairs, and other patient care carts, some of which are plugged into hallway electrical wall outlets for more than 30-minute intervals. This condition is in the emergency room areas of the facility. The exiting corridor is reduced and is not free of obstructions. These carts and other obstructions may allow injury to occupants or firefighter's entering or exiting the facility in the event of a fire. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of a fire or other emergency. The corridors have signs marked A through U permanently placed on the walls. These areas have stretchers continuously parked for storage, treatment, and assessing patients in the corridor exit egress.

Based on interview of the director of plant operations on April 4, 2011 during the tour at 1200 hours it was witnessed and acknowledged that the areas surveyed had equipment in the corridors that obstruct clear egress requirements as required by code on the date(s) of survey.

These findings were verified by the administrator and director of facility maintenance at the times of observation and the administrator at the exit conference on April 6, 2011 at 1400 hours.

Based on observation and staff interview, the facility failed to ensure the building is maintained in accordance with NFPA LSC 101 Sections 19.3.2.4. (2000) Edition, Section(s) 4.2.1 Occupant Protection. A structure shall be designed, constructed, and maintained to protect occupants who are not intimate with the initial fire development for the time needed to evacuate, relocate, or defend in place. 4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this code, such device, equipment, system, or other feature shall thereafter be maintained unless the code exempts such maintenance. 4.6.1.1 The authority having jurisdiction shall determine whether the provisions of the code are met. NFPA 99 (1999) Edition. 4-5.1.1.2 (a) Storage requirements. This deficient practice could affect all of the patients, as well as all staff and visitors, if the use and storage of medical gasses continues in violation of code requirements.

Findings include:

Observations on April 5, 2011 during the tour at 1400 hours accompanied by the director of facility maintenance revealed that:

Six oxygen E -sized cylinders were stored in the exit door egress corridor of the minor care section of the emergency room waiting area. This storage presents two issues, the first issue is it is stored in a egress corridor doorway. The second issue is that the cylinders are not locked or in view of any staff at any time at this area of the waiting room which is accessible to the public including children.

Based on interview of the the director of facility maintenance on April 5, 2011 during the tour at 1400 hours, he was not aware of the unsecured or monitored storage at the exit egress door of the six oxygen E -sized cylinders.

These findings were verified by the administrator and director of facility maintenance at the times of observation and the administrator at the exit conference on April 6, 2011 at 1400 hours.

Based on observation and staff interview, the facility failed to ensure the building is maintained in accordance with NFPA LSC 101 2000 Edition. Sections 19-3.6.3.2 Corridor doors. . This deficient practice could affect all of the patients, as well as all staff and visitors, if the corridor doors are not maintained as functional as required by code.

Findings include:

Observations on April 4, 2011 during the tour at 1050 hours accompanied by the director of facility maintenance revealed that:

The kitchen corridor to dining corridor door did not close and latch in the door frame as required by code.

Based on interview the director of facility maintenance witnessed and acknowledged that the corridor door did not close and or latch as required by code on the date of survey April 4, 2011 during the tour at 1050 hours.

These findings were verified by the administrator and director of facility maintenance at the times of observation and the administrator at the exit conference on April 6, 2011 at 1400 hours.

Based on observation and staff interview, the facility failed to ensure the building is maintained in accordance with NFPA LSC 101 (2000) Edition. Section(s) 4.2.1 Occupant Protection. A structure shall be designed, constructed, and maintained to protect occupants who are not intimate with the initial fire development for the time needed to evacuate, relocate, or defend in place. 4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this code, such device, equipment, system, or other feature shall thereafter be maintained unless the code exempts such maintenance. 4.6.1.1 The authority having jurisdiction shall determine whether the provisions of the code are met. NFPA 1 (2000) Edition. 5-7.1 Where required elsewhere in this code or NFPA 101, smoke partitions shall be provided to limit the transfer of smoke(101:8.2.4.1) Ceiling tiles and ceiling assemblies. This deficient practice could affect all of the patients, as well as all staff and visitors, if the smoke barriers are not maintained as functional as required by code.

Findings include:

Observations on April 4 -6, 2011 during the tour accompanied by the director of facility maintenance revealed that:

Ceiling tile tracking and tiles were damaged and not maintained to original code required installation. Ceiling tiles had numerous unsealed hole penetrations throughout the facility. Wiring for cable and cameras and other devices are running through ceiling and walls leaving unsealed hole penetrations.

Examples include:

(1) On April 4, 2011 at 1050 hours during the tour accompanied by the director of facility maintenance revealed that there are unsealed hole penetrations ranging in size from half an inch up to four inches in size in the ceiling smoke barrier of the Nuclear medicine room area.

At this same time, based on interview, the director of facility maintenance acknowledged that the ceilings smoke barrier has unsealed hole penetrations and does not meet smoke barrier requirements required by code.

(2) On April 4, 2011 at 1100 hours during the tour accompanied by the director of facility maintenance revealed that there are unsealed hole penetrations ranging in size from half an inch up to four inches in size in the ceiling smoke barrier of the laboratory areas.

At this same time, based on interview, the director of facility maintenance acknowledged that the ceilings smoke barrier has unsealed hole penetrations and does not meet smoke barrier requirements required by code.

(3) On April 4, 2011 at 1125 hours during the tour accompanied by the director of facility maintenance revealed that there are unsealed hole penetrations ranging in size from half an inch up to four inches in size in the ceiling smoke barrier of the materials management areas.

At this same time, based on interview, the director of facility maintenance acknowledged that the ceilings smoke barrier has unsealed hole penetrations and does not meet smoke barrier requirements required by code.

(4) On April 4, 2011 at 1300 hours during the tour accompanied by the director of facility maintenance revealed that there are unsealed hole penetrations ranging in size from half an inch up to four inches in size in the ceiling smoke barrier of the 2 central areas.

At this same time, based on interview, the director of facility maintenance acknowledged that the ceilings smoke barrier has unsealed hole penetrations and does not meet smoke barrier requirements required by code.

(5) On April 5, 2011 at 1175 hours during the tour accompanied by the director of facility maintenance revealed that there are unsealed hole penetrations ranging in size from half an inch up to four inches in size in the ceiling smoke barrier of the 3 central Satellite pharmacy areas.

At this same time, based on interview, the director of facility maintenance acknowledged that the ceilings smoke barrier has unsealed hole penetrations and does not meet smoke barrier requirements required by code.

(6) On April 5, 2011 at 1300 hours during the tour accompanied by the director of facility maintenance revealed that there are unsealed hole penetrations ranging in size from half an inch up to four inches in size in the ceiling smoke barrier of the 3 patient storage room areas.

At this same time, based on interview, the director of facility maintenance acknowledged that the ceilings smoke barrier has unsealed hole penetrations and does not meet smoke barrier requirements required by code.

(7) On April 6, 2011 at 1075 hours during the tour accompanied by the director of facility maintenance revealed that there are unsealed hole penetrations ranging in size from half an inch up to four inches in size in the ceiling smoke barrier of the labor and delivery C section med storage room areas.

At this same time, based on interview, the director of facility maintenance acknowledged that the ceilings smoke barrier has unsealed hole penetrations and does not meet smoke barrier requirements required by code.

(8) On April 6, 2011 at 1100 hours during the tour accompanied by the director of facility maintenance revealed that there are unsealed hole penetrations ranging in size from half an inch up to four inches in size in the ceiling smoke barrier of the labor and delivery C section linen storage room areas.

At this same time, based on interview, the director of facility maintenance acknowledged that the ceilings smoke barrier has unsealed hole penetrations and does not meet smoke barrier requirements required by code.

(9) On April 6, 2011 at 1150 hours during the tour accompanied by the director of facility maintenance revealed that there are unsealed hole penetrations ranging in size from half an inch up to four inches in size in the ceiling smoke barrier of the operating decontamination room areas.

At this same time, based on interview, the director of facility maintenance acknowledged that the ceilings smoke barrier has unsealed hole penetrations and does not meet smoke barrier requirements required by code.

These findings were verified by the director of facility maintenance at the times of observation and the administrator and director of facility maintenance at the exit conference on April 6, 2011 at 1400 hours.

Based on observation and staff interview, the facility failed to ensure the building is maintained in accordance with NFPA LSC 101-(2000) Edition. Section(s) 4.2.1 Occupant Protection. A structure shall be designed, constructed, and maintained to protect occupants who are not intimate with the initial fire development for the time needed to evacuate, relocate, or defend in place. 4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this code, such device, equipment, system, or other feature shall thereafter be maintained unless the code exempts such maintenance. 4.6.1.1 The authority having jurisdiction shall determine whether the provisions of the code are met. NFPA 1 (2000) Edition. 7.5.1.1 Exits shall be located and exit egress shall be arranged so that exits are readily accessible at all times. This deficient practice could affect all of the patients, as well as all staff and visitors, if exit egress is not maintained as functional as required by code.

Findings include:

Observations on April 5, 2011 during the tour at 1150 hours accompanied by the director of plant operations revealed that:

The exit doorways are not kept clear and un-obstructed. The facility is storing five bariatric wheel chairs, and other patient care fold up beds for more than 30-minute intervals which completely blocks egress to the stairwell exit door. The exiting corridor is reduced and is not free of obstructions. These wheel carts and other obstructions may allow injury to occupants or firefighter's entering or exiting the facility in the event of a fire. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of a fire or other emergency. This was discovered at the number 4 stairwell of 7 central exit door.

Based on interview of the director of plant operations on April 5, 2011 during the tour at 1150 hours it was witnessed and acknowledged that the number 4 stairwell of 7 central exit door areas surveyed had equipment in the corridors that obstruct clear egress requirements as required by code on the date(s) of survey.

These findings were verified by the administrator and director of facility maintenance at the times of observation and the administrator at the exit conference on April 6, 2011 at 1400 hours.

Based on observation and staff interview, the facility failed to ensure the building is maintained in accordance with NFPA LSC 101-(2000) Edition. Section(s) 4.2.1 Occupant Protection. A structure shall be designed, constructed, and maintained to protect occupants who are not intimate with the initial fire development for the time needed to evacuate, relocate, or defend in place. 4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this code, such device, equipment, system, or other feature shall thereafter be maintained unless the code exempts such maintenance. 4.6.1.1 The authority having jurisdiction shall determine whether the provisions of the code are met. NFPA 1 (2000) Edition. 7.5.1.1 Exits shall be located and exit egress shall be arranged so that exits are readily accessible at all times. This deficient practice could affect all of the patients, as well as all staff and visitors, if exit egress is not maintained as functional as required by code.

Findings include:

Observations on April 4, 2011 during the tour at 1200 hours accompanied by the director of plant operations revealed that:

The exit corridors are not kept clear and un-obstructed. The facility is storing, equipment, chairs, and other patient care carts, some of which are plugged into hallway electrical wall outlets for more than 30-minute intervals. This condition is in the emergency room areas of the facility. The exiting corridor is reduced and is not free of obstructions. These carts and other obstructions may allow injury to occupants or firefighter's entering or exiting the facility in the event of a fire. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of a fire or other emergency. The corridors have signs marked A through U permanently placed on the walls. These areas have stretchers continuously parked for storage, treatment, and assessing patients in the corridor exit egress.

Based on interview of the director of plant operations on April 4, 2011 during the tour at 1200 hours it was witnessed and acknowledged that the areas surveyed had equipment in the corridors that obstruct clear egress requirements as required by code on the date(s) of survey.

These findings were verified by the administrator and director of facility maintenance at the times of observation and the administrator at the exit conference on April 6, 2011 at 1400 hours.

Based on observation and staff interview, the facility failed to ensure the building is maintained in accordance with NFPA LSC 101 Sections 19.3.2.4. (2000) Edition, Section(s) 4.2.1 Occupant Protection. A structure shall be designed, constructed, and maintained to protect occupants who are not intimate with the initial fire development for the time needed to evacuate, relocate, or defend in place. 4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this code, such device, equipment, system, or other feature shall thereafter be maintained unless the code exempts such maintenance. 4.6.1.1 The authority having jurisdiction shall determine whether the provisions of the code are met. NFPA 99 (1999) Edition. 4-5.1.1.2 (a) Storage requirements. This deficient practice could affect all of the patients, as well as all staff and visitors, if the use and storage of medical gasses continues in violation of code requirements.

Findings include:

Observations on April 5, 2011 during the tour at 1400 hours accompanied by the director of facility maintenance revealed that:

Six oxygen E -sized cylinders were stored in the exit door egress corridor of the minor care section of the emergency room waiting area. This storage presents two issues, the first issue is it is stored in a egress corridor doorway. The second issue is that the cylinders are not locked or in view of any staff at any time at this area of the waiting room which is accessible to the public including children.

Based on interview of the the director of facility maintenance on April 5, 2011 during the tour at 1400 hours, he was not aware of the unsecured or monitored storage at the exit egress door of the six oxygen E -sized cylinders.

These findings were verified by the administrator and director of facility maintenance at the times of observation and the administrator at the exit conference on April 6, 2011 at 1400 hours.