HospitalInspections.org

Based on observations, review of floor plans, and staff interviews, the facility failed to ensure the 2 hour fire rated barrier between buildings maintained the two hour fire resistance rating. This involved 3 floors of the building (floors 7, 4, and ground) and could affect all patients, staff, and visitors in the building. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:



21521


a) Tour of the seventh floor was begun on 11/04/13 with Staff AA, BB, CC, and DD from 11:40 A.M. to 3:01 P.M. with Staff AA, BB, CC, and DD. At 2:25 P.M. observation of the two hour fire wall in the nurse practitioner's office in four east revealed above the drop down ceiling an annular space around a pipe. Directly above the penetration and pipe the words " fire barrier " is stenciled. Review of the floor plan as provided by the facility also confirmed the presence of a two hour fire wall.
b) During the tour of the seventh floor that was begun on 11/04/13 with Staff AA, BB, CC, and DD and went from 11:40 A.M. to 3:01 P.M., in an interview Staff BB and EE confirmed the observation.
c) On 11/05/13 at 3:04 P.M. observation of the fire doors in the 2 hour fire rated wall that separated four west from four east revealed one fire door to be unrated.
On 11/05/13 at 3:04 P.M. in an interview, Staff BB and DD confirmed the observation.
d) Tour of three west was begun on 11/07/13 at 9:40 A.M. with Staff AA, BB, CC, and DD from 9:40 A.M. to 10:16 A.M. At 10:10 A.M. at the two hour fire barrier separating three west from three east and above the drop down ceiling above the double doors revealed an open conduit box and an open conduit box near stair N.
During the tour on 11/07/13 from 9:40 A.M. to 10:16 A.M. in an interview Staff BB and EE confirmed the observation.
e) On 11/08/13 at 10:46 P.M. observation of the doors in the two hour fire wall that separated the north building from the west building near stair P, revealed they were not rated two hours.
On 11/08/13 at 10:46 P.M. in an interview, Staff BB and EE confirmed the observation.
f) On 11/08/13 at 11:46 A.M. observation of the fire barrier between Administration and the West building, and near Stair D, a two inch conduit lumen was observed above the drop down ceiling and open to air.
On 11/08/13 at 11:46 A.M. in an interview BB and EE confirmed the observation.

g) During tour on 11/12/13 at 3:00 P.M. with Staff BB, CC, DD, and PP, the 1 and 1/2 hour fire rated door to the dry food storage area in the corridor between Stairwell O and H was tested. The fire door failed to latch into the frame during the testing. According to the facility floor plan, this door was located in a 2 hour fire rated barrier. Staff BB, CC, and DD verified the fire door failed to latch when tested at 3:00 P.M.

h) During tour on 11/13/13 at 9:15 A.M. with Staff BB, CC, and DD the fire doors located between the East and West Building leading into the dialysis unit failed to latch when tested. These doors were observed with a 1 and 1/2 hour fire rated label. The aforementioned staff at 9:15 A.M. verified the doors should have latched but failed to do so when tested.

Based on observations, review of floor plans, and staff interviews, the facility failed to ensure the 2 hour fire rated barrier between buildings maintained the two hour fire resistance rating. This involved 2 barriers and could affect all patients, staff, and visitors in those areas of the building. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:
a) On 11/08/13 at 10:25 A.M., during tour with Staff BB and EE, observation above the double doors in the two hour fire wall between the surgery building and the north building, near Stair S, two 2.5 conduits' lumens were open to air with gray wires coming from them.
On 11/08/13 at 10:25 A.M. in an interview Staff BB and EE confirmed the observation.
b) On 11/08/13 at 10:46 P.M., during tour with Staff BB and EE, observation of the doors in the two hour fire wall that separated the north building from the west building near stair P, revealed they were not rated two hours.
On 11/08/13 at 10:46 P.M. in an interview, Staff BB and EE confirmed the observation.

Based on observation, staff interview, and review of the facility's floor plans, the facility failed to ensure access to three exits were marked by an approved, readily visible sign in one area of the building. This could affect all patients, staff, and visitors in the building. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

During tour with Staff CC, DD, FF, and HH, the following areas were observed without exit signs when the exit pathway was not readily apparent, or failed to lead to an acceptable exit as follows:

Tour of the fourth floor was conducted on 11/06/13 at 9:13 A.M.

a) Tour of the third floor was conducted on 11/06/13 between 9:29 A.M. and 10:19 A.M.
The SC 3-5/FC 3-3 compartment for the Behavior Outpatient department revealed a group of rooms consisting of private meeting rooms, waiting room, and offices. The floor plan revealed this compartment contained 9695 square feet. An exit sign was observed posted above a doorway which led to a group of rooms. Observation of the rooms revealed only one door used for group therapy opened into the exit corridor. During tour the door was verified by Staff CC to be locked to prevent exiting into the hallway. This was verified with Staff CC at 9:50 A.M. on 11/06/13.

b) Tour of the second floor on 11/06/13 at 11:15 A.M. revealed a suite of rooms used by a home care agency. This compartment lacked a 2 hour fire separation between this agency and the facility. Tour inside the home care agency office revealed a mixture of offices, cubicles, and storage areas. Review of the floor plan revealed this office space was a total of 9753 square feet. This area lacked exit signs indicated the exit access doors from the suite.

c) Tour of the basement on 11/07/13 between 9:45 A.M. and 10:36 A.M. revealed an exit discharge door lacked a visible exit sign. Located in this same area was another room which could be entered in the event of a fire or smoke. However, this room lacked a visible means to exit.

The lack of these aforementioned exits and signs was verified with Staff DD at the time of the observations.

Based on observation and staff interview the facility failed to ensure access to one exit was marked by an approved, readily visible sign in one area of the building. This could affect all patients, staff, and visitors in that area of the building. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

On 11/07/13 at 3:20 P.M., on the second floor, in the north building, during tour with Staff BB, EE, and CC the path of egress from the second floor down to the dialysis area revealed the exit sign was turned so that it was not seen to see the egress path out of the building.

On 11/07/13 at 3:05 P.M. and at 3:20 P.M. Staff BB, EE, and CC confirmed the observation.

Based on observation and staff interview the facility failed to ensure access to two exits was marked by an approved, readily visible sign in two areas of the building. This could affect all patients, staff, and visitors in the building. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:
a) On 11/05/13 at 1:48 P.M., during a tour with Staff BB and EE, a patient sleeping suite was observed on four north. The suite did not reveal an exit sign on the path of egress.
On 11/05/13 at 1:48 P.M. in an interview Staff BB and EE confirmed the observations.
b) On 11/07/13 at 3:05 P.M., during tour with Staff BB, EE, and CC on the second floor, in the north building, near the gift shop, the path of egress from a point near the gift shop to the east horizontal exit and onto the catwalk, revealed the exit sign(s) were not visible.
On 11/07/13 at 3:05 P.M. and at 3:20 P.M. Staff BB, EE, and CC confirmed the observations.

Based on observations, review of facility floor plans, and staff interviews, the facility failed to ensure 4 smoke barriers on one floor of the facility maintained at least a one hour fire resistance rating. This could affect all staff, patients, and visitors. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

Tour was conducted with Staff BB, CC, and DD on 11/07/13 between 2:22 P.M. and 4:00 P.M., and on 11/12/13 between 1:00 P.M. and 1:20 P.M.

During this tour of the ground floor on 11/07/13 penetrations were observed in the one hour fire rated barrier as follows:
a) The corridor across from room 402 revealed a curved conduit (approximately 3/4 inch diameter) which was open around wiring.

b) Room 71 was observed with a one inch high by 2 feet long opening at the top of the smoke barrier at the corrugated decking. The bathroom in this room was observed with a three inch wide by ten inch long opening around a steel beam that passed into the barrier.

On 11/12/13 the following penetrations were observed
c) Outside Stairwell #1 a curved conduit (approximately 3/4 inch diameter) was observed open inside the conduit.

d) The one hour fire rated barrier located between SCG-12 (Smoke compartment) and SCG-13, near Stairwell T, was observed with three sets of smoke barrier doors. The corrugated decking at the top of the barrier was observed with a 1-2 inch high by 21 feet long opening along the top portion of the smoke barrier. One square metal conduit over one set of the fire doors was observed with a cloth rag stuffed into the conduit. When the cloth rag was removed by Staff CC, the conduit was observed open.

These penetrations were verified with Staff CC during the aforementioned tour at the time of the observations.

Based on observations, review of floor plans, and staff interviews, the facility failed to ensure one smoke barrier maintained the required fire resistance rating. This could affect all patients, staff, and visitors in the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:
On 11/04/13 at 2:38 P.M., during tour with Staff BB and DD, observation above the drop down ceiling of the smoke barrier in seven west in the corridor that connects stairwell L and M revealed two two inch pipes with annular spaces.
On 11/04/13 at 2:38 P.M. in an interview, Staff BB and DD confirmed the observation.

Based on observations, review of floor plans, and staff interviews, the facility failed to ensure three smoke barriers maintained the required fire resistance rating. This could affect all patients, staff, and visitors in the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:
a) On 11/05/13 at 1:26 P.M. on four north, a tour with Staff BB and DD revealed the smoke barrier above the drop down ceiling in the eastern corridor wall in the vacant patient room was observed. The observation revealed three one inch conduits with lumens that were open to air.
On 11/05/13 at 1:26 P.M. in an interview, Staff BB and DD confirmed the observation.

b) On 11/05/13 at 3:55 P.M. observation of the smoke barrier above the drop down ceiling in the 3 north, east corridor revealed a three inch conduit lumen open to air.
On 11/07/13 during tour, in an interview Staff BB and DD confirmed the observation.

c) On 11/07/13 at 3:40 P.M. observation above the drop down ceiling in two north across from room 342 revealed a fist sized opening around a communications conduit and sprinkler line.

On 11/07/13 at 3:40 P.M. in an interview, Staff BB and DD confirmed the observation.

Based on observations, staff interview, and review of the facility floor plans, the facility failed to ensure eight hazardous areas located in 3 areas of the facility maintained a one hour fire rated construction. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

a) On 11/04/13 at 2:29 P.M., tour with Staff BB and DD, on seven east in room 15, above the drop ceiling, a blue tip conduit with an unsealed lumen was observed. Review of the drawing revealed the room to be surrounded in one hour fire construction.
On 11/04/13 at 2:29 P.M. in an interview, Staff BB and DD confirmed the observation.
b) On 11/04/13 at 2:54 P.M. on seven east in room 0023, a soiled utility room, and above the drop down ceiling, three two inch holes were observed in the one hour rated construction. Review of the drawing revealed the room to be surrounded in one hour fire construction.
On 11/04/13 at 2:54 P.M. an interview, Staff BB and DD confirmed the observation.
c) On 11/05/13 at 2:09 P.M. in the clean utility room across from room 439 on four west, and above the drop down ceiling, a one inch conduit's lumen was observed open to air. Review of the drawing revealed the room was wrapped in one hour fire construction.
On 11/05/13 at 2:09 P.M. in an interview, BB and EE confirmed the observation.
d) On 11/05/13 at 2:15 P.M. in the clean utility room on four west, observation above the drop down ceiling on the eastern most wall, two white pipes and a metal conduit had annular spaces. Review of the drawing revealed the room to be surrounded in one hour fire construction.
On 11/05/13 at 2:15 P.M. in an interview, Staff BB and DD confirmed the observation.
e) On 11/07/13 at 2:37 P.M. observation of the door to the clean linen room on two east revealed it was not on a self closer. Review of the drawing revealed the room to be surrounded in one hour fire construction.
On 11/07/13 at 2:37 P.M. in an interview, Staff BB and DD confirmed the observation.
f) On 11/07/13 at 2:43 P.M. the door to the soiled utility room across from room 208 on two east was observed to have two half inch openings in it. Review of the drawing revealed the room to be surrounded in one hour fire construction.
On 11/07/13 at 2:43 P.M. in an interview, Staff BB and DD confirmed the observation.
g) On 11/07/13 at 4:35 P.M. observation of the doors from equipment room B to the corridor in the surgery building revealed the doors did not have a means suitable for keeping the door closed.
h) On 11/07/13 at 5:00 P.M. observation in the surgery building of the door on the soiled utility room to the corridor with certificates hanging on the wall revealed the doors did not have a means suitable for keeping the door closed and a sign was posted to remind staff to keep the door closed.
On 11/07/13 at 4:35 P.M. and at 5:00 P.M. in interviews, Staff BB and EE confirmed the observations.

Based on observations and staff interviews, the facility failed to ensure stairway doors contained a fire resistance rating of at lease one hour due to missing or illegible fire rated labels. This affected 4 stairways and three floors of the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

A tour was conducted with Staff BB and EE on 11/05/13 at 10:52 A.M., on 11/05/13 at 11:12 A.M., on 11/05/13 at 11:49 A.M., on 11/05/13 at 12:08 P.M., and on 11/08/13 at 11:38 A.M. During this tour the following stairway doors were observed:

a) On 11/05/13 at 10:52 A.M. the fire door to exit stairway P on the fifth floor revealed a rating label painted over. Staff removed the label, and underneath the words " void " was written several times.
b) On 11/05/13 at 11:12 A.M. observation of the fire door to exit stairway O on the fifth floor revealed the rating label to be painted over, and the surveyor was unable to read the label.
c) On 11/05/13 at 11:49 A.M. observation of the fire door to exit stairway N on the fifth floor revealed the rating label to be painted over, and the surveyor was unable to read the label.
d) On 11/05/13 at 12:08 P.M. observation of the fire door to exit stairway R on the fourth floor revealed the rating label to be painted over, and the surveyor was unable to read the label.
e) On 11/08/13 at 11:38 A.M. observation of the fire door to exit stairway O on the first floor revealed the rating label to be painted over, and the surveyor was unable to read the label.
In interview with Staff BB and EE on 11/05/13 at 10:52 A.M., on 11/05/13 at 11:12 A.M., on 11/05/13 at 11:49 A.M., on 11/05/13 at 12:08 P.M., and on 11/08/13 at 11:38 A.M. in interviews Staff BB and EE confirmed the observations.

Based on observation, review of the floor plan, and staff interviews, the facility failed to ensure one exit access was arranged to ensure a continuous surface between the exit discharge and the public way. This could affect all patients, staff, and visitors in the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

A tour was conducted on 11/13/13 at 10:20 A.M. with Staff BB, CC, and DD. Observations of the exit discharge from Stairwell CC revealed a concrete pad outside the exit door. The pad was approximately 4 feet by 4 feet in diameter. The area beyond the concrete pad was observed leading up a steep hillside approximately 50 feet to the public way. The hillside was observed with smaller rocks and minimal grass. The exit to the public way lacked a continuous hard surface to the public way.

The floor evacuation plans revealed this exit discharge was used by patients, staff, and visitors in the Same Day Surgery building, the Emergency Department building, and the lower level of the main hospital building.

This was verified with Staff BB and CC at 10:20 A.M. on 11/13/13. Staff BB stated this exit discharge was present before the addition of the Emergency Department (ED) building, and the hillside was made steeper with the addition of the ED building.

Based on observations and staff interviews, the facility failed to ensure exit access doors were readily accessible with a single step operation to open the doors for exit This involved 4 of 8 operating rooms on the second floor. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

A tour was conducted with Staff FF of the operating rooms on the second floor on 11/07/13 from 9:00 A.M. to 9:40 A.M. According to Staff FF, this space was occupied by a tenant who leased space from the host facility. Staff FF verified the operating room area was not separated from the main hospital facility by a 2 hour fire rated barrier. Present during this tour was the tenant's Director of Surgical Services.

The following operating room exit access doors were observed with a slide bolt located approximately 6-8 inches above the door handles on the doors. This resulted in a minimum two step operation to exit the doors. On one of the doors, the slide bolt had to be lifted, slid to the right, and dropped into a metal slot before the door could be opened with the door handle.

Interview with the Director of Surgical Services at the time of observation revealed the doors were locked to prevent access into the operating rooms. During the tour, this person and Staff FF verified the doors required a minimum two step operation to open in order to exit the rooms.

Based on observations and staff interview, the facility failed to ensure smoke detectors were located greater than 36 inches from air diffusers. This could affect all staff, patients, and visitors in the building. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

A tour was conducted on 11/12/13 between 2:19 P.M. and 3:22 P.M. with Staff BB, CC, and DD.

During this tour, the following smoke detectors were observed located less than 36 inches from air diffusers:

a) In the hallway outside the cafeteria on the ground level by Stairwell H, and

b) Two smoke detectors on the ground level in the storage room labeled FC0-3 on the facility floor plan.


Interview with Staff CC during tour at 10:20 A.M. on 11/13/13 revealed the smoke detectors should be greater than 36 inches from air supply and air return diffusers. During tour Staff BB, CC, and DD verified the location of the aforementioned smoke detectors.

Based on observations and staff interview, the facility failed to ensure smoke detectors were located greater than 36 inches from air diffusers. This involved two floors of the facility and could affect all staff, patients, and visitors in those areas of the building. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

A tour was conducted in the Same Day Surgery building and the Emergency Department (ED)on 11/13/13 between 9:55 A.M. and 12:00 P.M. and between 12:55 P.M. and 2:18 P.M. with Staff BB, CC, and DD.

During this tour, the following smoke detectors were observed located less than 36 inches from air diffusers:

*In the Same Day Surgery building (SDS) , one smoke detector in lower level in Patient Admission Testing in the waiting room,
*In the SDS building, two smoke detectors in the ground floor waiting room.
*In the SDS building, on the ground floor, inside soiled utility room by bed 2 and the nurses' station
*By the blood bank, in the CT waiting room.
*Inside storage room 6A (previously the linear accelerator room), one smoke detector was observed
within 1 foot of an air supply diffuser.

In the ED building:
*On the ground level in the waiting room, and hallway near the waiting room,
*Inside the security office,
*In the ED nurses station, and
*In exam rooms 09, 08, 11, and 07

On the ground floor:
*Three smoke detectors in MRI in the control room, and
*In the hallway by the 2 hour fire wall leading to FCB-5 (according to the floor plan) at 9:55 A.M.

Interview with Staff DD during tour at 10:20 A.M. on 11/13/13 revealed the smoke detectors should be greater than 36 inches from air supply and air return diffusers. During tour Staff BB, CC, and DD verified the location of the aforementioned smoke detectors.

Based on observations, staff interview, and review of the facility's floor plan for fire compartments (FC) and smoke compartments (SC), the facility failed to ensure smoke detectors were located greater than 36 inches from air diffusers. This involved two floors of the facility and could affect all staff, patients, and visitors in those areas of the building. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

During tour of the facility with Staff CC, DD, FF, and HH, the following smoke detectors were observed located less than 36 inches from air diffusers:

On the Seventh floor on 11/05/13 at 11:34 A.M.:
*by Smoke compartment 7 near room 715.

On the Sixth floor on 11/05/13 between 1:06 P.M. and 1:55 P.M.:
*in the corridor by room 615, and
*in the elevator lobby near room 615 in Smoke Compartment 6-1.

On the Fifth floor on 11/05/13 between 2:00 P.M. and 3:43 P.M.:
*in the FC 5-3 hallway,
*2 in the day room, and
*2 in the nurses' station in SC 5-1 near Stair A in Center 5 wing.

On the 4th floor on 11/06/13 between 8:54 A.M. and 9:28 A.M.:
*In SC 4-5, 3 in the elevator lobby (2 detectors),
*In SC 4 outpatient clinic by Stair G, and
*In SC 4-2 in the elevator lobby by 3 elevators.

On the Third floor between 9:29 A.M. and 10:19 A.M.:
*In SC 3-2 by Stair B, and
*In open stairwell by FC 3-2.

On the Second floor on 11/06/13 between 10:46 A.M. and 11:35 A.M., and between 1:34 P.M. and 2:15 P.M.:
*In the SC 2-6/FC 2-7 compartment (Emergency Department) in the waiting room, in the security office, in the nurses' station, and just inside the entrance from the corridor located in the hallway between Stairway J and H.
*In the SC 2-10 compartment (1 detector), and
*In the SC 2-9 MRI area (1 detector)

On the First floor on 11/07/13 between 9:00 A.M. and and 9:40 A.M.. and between 2:15 P.M. and 3:22 P.M.:
*In SC 1-3 Lab area (2 detectors)
*SC 1-2 PACU (2 detectors),
*In FC 1-1 in the anesthesia work room,
*In the OR suite, in the central corridor by OR 22 and OR 28,
*In FC 1-3/SC 1-5 suite of rooms, and
*In FC1-4/SC 1-8 (4 smoke detectors)


In the Basement level on 11/07/13 between 10:02 A.M. and 10:17 A.M.:
*Two detectors in the fire compartment between the pharmacy and FCB-2 (2 detectors), and
*One detector in the pharmacy, and
*In the Environmental Services office and hallway outside the offices

Interview with Staff DD during tour on 11/05/13 at 11:34 A.M. revealed the smoke detectors should be greater than 36 inches from air supply and air return diffusers. During tour Staff CC, DD, FF, and HH verified the location of the aforementioned smoke detectors.

Based on observations and staff interviews, the facility failed to maintain the sprinkler system as required by the code in regards to missing escutcheon covers and dirty sprinkler heads. This involved 3 floors of the facility and could affect all patients, staff, and visitors in those areas of the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:





21521


Tour of the seventh floor was begun on 11/04/13 with Staff AA, BB, CC, and DD at from 11:40 A.M. to 3:01 P.M. with Staff AA, BB, CC, and DD.
a) At 11:58 A.M. a missing sprinkler escutcheon was observed in the medication room on seven west.
b) At 2:05 P.M. a missing sprinkler escutcheon was observed in room 726A and the sprinkler head over the nursing desk on seven west was observed to be dirty.
c) At 2:09 P.M. a dirty sprinkler head was observed in room 126.
d) At 2:13 P.M. on seven west in room 103 a dirty sprinkler head was observed.
During the tour of the seventh floor on 11/04/13 from 11:40 A.M. to 3:01 P.M. Staff BB and CC confirmed the observations in an interview.
On 11/08/13 at 9:00 A.M. the finding was again presented to Staff BB and CC.
e) On 11/05/13 from 8:20 A.M. to 9:54 A.M. a tour of the seventh floor was resumed with Staff AA, BB, CC, and EE. At 8:39 A.M. a women's bathroom between stairwell N and O was observed to have a missing sprinkler escutcheon.
f) At 9:29 A.M. shower rooms 005 and 006 on were observed to have missing sprinkler escutcheons.
Sixth Floor:
g) On 11/04/13 from 3:02 P.M. to 3:50 P.M. a tour was conducted of the sixth floor with Staff AA, BB, CC, and DD. At 3:50 P.M. a missing sprinkler escutcheon was observed in the housekeeping closet near Stair O.
In interviews during the tour on 11/04/13 from 3:02 P.M. to 3:50 P.M. of the sixth floor with Staff AA, BB, CC, and DD, they confirmed the observation.
On 11/08/13 at 9:00 A.M. the finding was again presented to Staff BB and CC.
Sixth Floor:
h) At 9:32 A.M. a staff only room on six east, near the smoke barrier, was observed to have a missing sprinkler escutcheon.
In interviews on 11/05/13 from 8:20 A.M. to 9:54 A.M. when a tour of the seventh floor was resumed with Staff AA, BB, CC, and EE, Staff BB and EE confirmed the observations.
On 11/08/13 at 9:00 A.M. the finding was again presented to Staff BB and CC.
Ground floor:
i) During tour on 11/12/13 2:18 P.M., at tour was conducted in the radiology read room suite with Staff BB, CC, and DD. This suite of rooms was observed with 4 missing escutcheon sprinkler head covers. These missing covers were verified with Staff BB and CC at the time of the observation.

Based on observations and staff interviews, the facility failed to maintain the sprinkler system as required by the code in regards to missing escutcheon covers and dirty sprinkler heads. This involved 3 floors of the facility and could affect all patients, staff, and visitors in those areas of the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

During tour of the facility with Staff CC, DD, FF, and HH, the following sprinkler heads were observed dirty or without escutcheon covers as follows:

Sixth floor on 11/05/13 between 1:06 P.M. and 1:55 P.M.:
* 3 sprinkler heads inside a physician's office Room 615 were observed without escutcheon covers

Second floor on 11/06/13 at 10:53 A.M.:
*cafeteria grill area (2 sprinkler heads observed with a heavy coating of greasy and dust)

Basement on 11/07/13 between 9:45 A.M. and 10:36 A.M.:
*In the pharmacy six sprinkler heads were observed with a heavy coating of dust and dirt, and
*In the engineering office one sprinkler head was observed dirty with a coating of dust and dirt

This was verified with Staff CC, DD, FF, and HH during the aforementioned tour at the times of observations.

Based on observations and staff interviews, the facility failed to maintain the sprinkler system as required by the code in regards to missing escutcheon covers and dirty sprinkler heads. This affected 2 floors of the facility. This could affect all patients in the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

a) Tour of the seventh floor was begun on 11/04/13 with Staff AA, BB, CC, and DD at from 11:40 A.M. to 3:01 P.M. with Staff AA, BB, CC, and DD. At 11:40 A.M. a missing sprinkler escutcheon was observed in the clean receiving room near stairwell R in the North building.
b) During the tour of the seventh floor on 11/04/13 from 11:40 A.M. to 3:01 P.M. Staff BB and CC confirmed the observations in an interview.
On 11/08/13 at 9:00 A.M. the finding was again presented to Staff BB and CC.
c) On 11/07/13 from 2:15 P.M. to 4:15 P.M. a tour was conducted of the second floor with Staff AA, BB, CC, and EE. At 3:40 P.M., in two north, across from room 318, a sprinkler bulb was observed to be coated in dust.
During the tour on 11/07/13 from 2:15 P.M. to 4:15 P.M., in an interview, Staff BB and CC confirmed the observation.
d) On 11/08/13 at 11:00 A.M., on the first floor of the north building, in the human resources assistant manager's office a missing sprinkler escutcheon was observed.
On 11/08/13 at 11:00 A.M. Staff BB and CC confirmed the observation.

Based on observations and staff interviews, the facility failed to ensure one medical gas storage room door self-closed when tested. This could affect all patients, staff, and visitors in the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

A tour was conducted on 11/12/13 at 2:37 P.M. with Staff BB, CC, and DD on the ground level floor. The main egress corridor located outside FCO-3 compartment (on floor plan) and the ultrasound suite was observed with a room which opened into this corridor. The room was observed with multiple H-tanks of nitrous oxide gases (greater than 300 cubit feet). The door to the hallway was observed with a 1 and 1/2 hour fire rated label; however, failed to self close and latch into the frame when tested. This was verified with Staff BB, CC, and DD at the time of the tour. Staff CC stated the door should have closed and latched.

NFPA 101

Chapter 20

20.2.9.1

Emergency illumination is provided in accordance with section 7.9.

*Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency illumination was provided in accordance with section 7.9 with regards to monthly and annual testing. The facility had 12 treatment rooms with a census of nine patients at the time of the survey completed on 11/13/13. Potentially all patients, visitors and staff could be affected.

Findings included;

On 11/13/13 between 3:10 P.M. and 5:45 P.M. tour of the building was conducted with Staff II, FF and KK. The free standing emergency department was location on the ground floor of the building. Emergency services were available 24 hours per day, seven days per week.

Tour of the emergency department, radiology and cancer care center was conducted with Staff II, FF and KK, revealed the presence of battery backup lighting in the patient care areas. Review of testing documentation on 11/13/13 at 4:45 P.M. with Staff KK revealed that testing dates were noted but there was no indication of the length of time for the testing. Further review of the documentation revealed there was no documented evidence of a 90 minute test completed in the past 12 months.

Staff KK and II verified the facility testing documentation lacked the length of time tested each month as well when the 90 minute annual test was conducted.

NFPA 101

Chapter 39

39.2.10
Marking of Means of Egress.

Means of egress shall have signs in accordance with Section 7.10.

7.10.9.2
Testing

Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

*Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency illumination was provided in accordance with section 7.9 with regards to monthly and annual testing. The facility provided sleep studies for two patients on 11/13/13. Potentially all patients and staff could be affected.

Findings included:

On 11/13/13 between 10:30 A.M. and 11:00 A.M. tour of the building was conducted with Staff II and JJ. The facility contained four patient sleeping rooms used for sleep studies.

Tour of the facility with Staff II and JJ revealed the presence of battery backup egress lighting in the corridors. Review of testing documentation on 11/13/13 during the facility observation Staff JJ revealed that monthly testing dates were noted but there was no indication of the length of the testing.

Staff II and JJ verified the facility testing documentation lacked the length of time tested each month.

NFPA 25

Chapter 1

General Information

1-4 Responsibility of the Owner or Occupant.
1-4.1
The owner or occupant shall provide ready accessibility to components of water-based fire protection systems that require inspection, testing, or maintenance.
1-4.2*
The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Exception: Where the owner is not the occupant, the owner shall be permitted to pass on the authority for inspecting, testing, and maintaining the fire protection systems to the occupant, management firm, or managing individual through specific provisions in the lease, written use agreement, or management contract.

* Based on facility observation and staff interview and verification, the facility failed to ensure that a water-based fire protection system was periodically inspection, tested, and maintained and the equipment shown to be in good operating condition. Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. The outpatient therapy facility provided services for at least 30 patients on 11/13/13. Potentially all patients, staff and visitors could be affected.

Finding included:

On 11/13/13 between 11:50 A.M. and 1:50 P.M. tour of the facility was conducted with Staff II and LL. The outpatient facility was observed to be on the lower level ( below grade) of a business occupancy. Observation of the facility revealed the presence of sprinkler heads in the staff office area.

Review of facility documentation revealed no evidence of sprinkler inspection, testing or maintenance. Staff II was unaware the facility had a sprinkler system. Staff LL contacted the property maintenance staff who was unaware of the sprinkler system in the outpatient facility.

Observation above the ceiling tiles with Staff II revealed the sprinkler system was tied directly to the main line of the public water system.

Staff LL provided and reviewed the lease agreement and verified the sprinkler system was to be maintained by the property owner. Staff II and LL verified there was no documented evidence of any recent inspection, testing or maintenance of the sprinkler system.

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

NFPA 101

Chapter 38

38.7 OPERATING FEATURES

38.7.1 Drills.
In any business occupancy building occupied by more than 500 persons or more than 100 persons above or below the street level, employees and supervisory personnel shall be periodically instructed in accordance with Section 4.7 and shall hold drills periodically where practicable.

4.7* FIRE DRILLS
4.7.2* Drill Frequency.
Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.
4.7.5* Simulated Conditions.
Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

* Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that fire drills were held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. The outpatient therapy facility provided services for at least 30 patients on 11/13/13. Potentially all patients, staff and visitors could be affected.

Finding included:

On 11/13/13 between 11:50 A.M. and 1:50 P. M, tour of the facility was conducted with Staff II and LL. The outpatient facility was observed to be on the lower level ( below grade) of a business occupancy. Staff LL noted the evacuation route in case of fire. The second means of egress required exit through a set of fire doors and a large exercise room.

Review of documented fire drills revealed fire drills completed 01/08/13 and 11/06/13. There was no indication of what simulated conditions were practiced , what time the drills occurred or who participated in the fire drills. There was no indication if any training needs had been identified.

Staff II reviewed the documentation and verified more information was to be needed.

********************************************************************************
NFPA 38

38.2.9 Emergency Lighting

38.2.9.2
Emergency lighting in accordance with Section 7.9 shall be provided for all underground and windowless structures as defined in 3.3.205 and 3.3.212.

* Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency lighting in accordance with Section 7.9 was provided for all underground and windowless structures. The outpatient therapy facility provided services for at least 30 patients on 11/13/13. Potentially all patients, staff and visitors could be affected.

Finding included:

On 11/13/13 between 11:50 A.M. and 1:50 P. M, tour of the facility was conducted with Staff II and LL. The outpatient facility was observed to be on the lower level ( below grade) of a business occupancy. Observation of the facility revealed the presence of five battery back-up emergency lights in the exit pathways.

Review of documentation on 11/13/13 at 1:15 P.M. with Staff II and LL revealed monthly testing of emergency lighting noted only the lights were checked. There was no indication that testing was for 30 seconds each month and no documented evidence of a 90 minute annual test.

Staff II present at the document review verified the information failed to show testing had been completed in accordance with section 7.9.

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

NFPA 101

Chapter 38

38.2.2.5 Horizontal Exits.
Horizontal exits complying with 7.2.4 shall be permitted.

7.2.4.3.4
Any opening in such fire barriers shall be protected as provided in 8.2.3.2.3.

8.2.3.2.3* Opening Protectives.
8.2.3.2.3.1
Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:
(1) 2-hour fire barrier - 11/2-hour fire protection rating
(2) 1-hour fire barrier - 1-hour fire protection rating where used for vertical openings or exit enclosures, or 3/4-hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42

* Based on facility observation, review of facility information and staff interview and verification, the facility failed to ensure that every opening in a fire barrier was protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The outpatient therapy facility provided services for at least 30 patients on 11/13/13. Potentially all patients, staff and visitors could be affected.

Finding included:

On 11/13/13 between 11:50 A.M. and 1:50 P. M, tour of the facility was conducted with Staff II and LL. The outpatient facility was observed to be on the lower level ( below grade) of a business occupancy. Interview of Staff LL revealed the second means of egress from the lower level facility was through the occupied space next to the facility. It was a large, gym-like exercise room.

Review of the facility schematic revealed the presence of a two hour fire rated wall between the outpatient facility and the adjacent tenant. Observation of the fire rated barrier with Staff II, revealed two sets of two hour fire rated doors connected to the fire alarm system. Release of the door from the magnetic hold revealed that one set of fire rated doors failed to close. The door remained open by approximately eight inches.

Staff II present at the observation, verified the fire doors were to close and latch but did not operate properly.

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

NFPA 110
Standard for Emergency and Standby Power Systems

Chapter 6

6-3 Maintenance and Operational Testing.
6-3.1*
The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.
6-3.2
A routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the operational reliability of the system.
6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established.

* Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure the emergency power supply (EPS) was routinely maintained, tested and that a written schedule for routine maintenance and operational testing of the EPS was established. The outpatient therapy facility provided services for at least 30 patients on 11/13/13. Potentially all patients, staff and visitors could be affected.

Finding included:

On 11/13/13 between 11:50 A.M. and 1:50 P. M, tour of the facility was conducted with Staff II and LL. The outpatient facility was observed to be on the lower level ( below grade) of a business occupancy. Observation of the facility revealed the presence of five battery back-up emergency lights in the exit pathways. Interview of Staff LL revealed that emergency lighting was provided by an emergency generator during a power outage.

Review of facility documentation on 11/13/13 at 1:15 P.M. with Staff II and LL revealed monthly testing of the EPS was noted by a comment the generator was started. There was no indication how long the generator ran or if any load testing was conducted. Further review of the documentation revealed there as no indication of routine maintenance of the system.

Interview of Staff LL, present at the document review, revealed the building maintenance staff for the leased space was to ensure the EPS was maintained. Staff II and LL interviewed the building maintenance staff who verified there was no additional documented information regarding maintenance and operational testing of the generator.

NFPA 25
Standard for Inspection, Testing and Maintenance of Water Based Fire Protection Systems

2-2.1 Sprinklers

2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1*: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.


* Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that components of the automatic sprinkler system were inspected or tested quarterly in accordance with NFPA 25 inspection and testing requirements. The facility had 16 treatment rooms with a census of six patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included;

On 11/04/13 upon initiation of the life safety code survey, all records for testing, inspection and maintenance of the automatic sprinkler system for the facility was requested to be available for review.

On 11/12/13 between at 4:25 P.M. and 5:50 P.M. tour of the building was conducted with Staff II. Observation of the single story facility revealed the presence of an automatic sprinkler system throughout the building.

Review of facility documentation on 11/13/ 13 at 9:00 A. M. regarding quarterly inspection and testing of the sprinkler system revealed there was no documented evidence that quarterly inspection and testing was completed in May, June, July (second quarter) 2013. Review of quarterly testing dated 09/13/13 was documented as the test for June 2013. Staff II verified that no testing had been completed in June and could not address why the contracted technician labeled the third quarter test as a second quarter test.


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

NFPA 101

Chapter 20

20.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that required smoke barriers were constructed in accordance with Section 8.3 and had a fire resistance rating of not less than 1 hour. The facility had 16 treatment rooms with a census of six patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included;

On 11/12/13 between at 4:25 P.M. and 5:50 P.M. tour of the building was conducted with Staff II. Review of facility schematic revealed the single story facility had 18,515 square feet of space for outpatient areas. The schematic revealed the fully sprinkler building was divided by a one hour fire rated smoke barrier.

Observation of the fire rated barrier revealed the following penetrations:

1. Observation above the ceiling tiles in the patient bathroom located next to the decontamination room revealed a penetration in the fire rated barrier wall approximately four inches in diameter.

2. Observation above the ceiling tiles in room 10, revealed penetrations surrounding black sprinkler pipe.

3. Observation of fire rated corridor doors located in the fire rated barrier revealed a gap at the edges of the doors when in the closed position greater than one-eighth inch.

4. Observation of fire rated corridor doors, located in the front corridor of the facility, revealed a gap at the edges of the doors when in the closed position. The space was greater than one-eight inch at the bottom half of the door.

5. Observation above the ceiling tiles at the fire rated corridor doors in the front hall, revealed a penetration approximately one inch in diameter located next to a small wire sleeve. The penetration was immediately sealed with fire rated sealant

Staff II observed and verified the penetrations in the fire rated wall as well as the gaps in the corridor doors located in the one fire fire rated barrier.

NFPA 72
Chapter 7

7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

7-5.2 Maintenance, Inspection, and Testing Records.
7-5.2.1Records shall be retained until the next test and for 1 year thereafter.

* Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that smoke detector sensitivity testing was completed per NFPA 72 and that a written record of the testing was retained. The facility had a capacity for 1061 patients with a census of 401 patients at the time of the survey completed on 11/14/13. Potentially all patients, visitors and staff could be affected.

Findings included:

On 11/04/13 upon initiation of the life safety code survey, all records of smoke sensitivity testing for the facility smoke detection systems was requested to be available for review.

On 11/12/13 between 11:00 A.M. and 3:40 P.M. tour of the building was conducted with Staff AA, FF and MM. Observation of the four story facility revealed the presence of a smoke detection system.

Review of facility documentation on 11/14/ 13 at 1:00 P.M. regarding fire alarm testing revealed there was no documented evidence that smoke sensitivity ranges were tested. Interview of Staff DD on 11/14/13 at 3:45 P.M. revealed the facility had a self monitoring smoke detection system that would send a trouble signal if a smoke detector was out of the set range. Staff DD verified that because of the self monitoring capabilities of the smoke detectors, the facility did not print and maintain a record of the the sensitivity testing. At the time of the survey exit conference on 11/14/13 at 4:30 P.M. no printed record of the sensitivity testing was provided.

********************************************************************************
NFPA 25
Standard for Inspection, Testing and Maintenance of Water Based Fire Protection Systems

2-2.1 Sprinklers

2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1*: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.


* Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that components of the automatic sprinkler system was inspected or tested quarterly in accordance with NFPA 25 inspection and testing requirements. The facility had a capacity for 1061 patients with a census of 401 patients at the time of the survey completed on 11/14/13. Potentially all patients, visitors and staff could be affected.

Findings included:

On 11/04/13 upon initiation of the life safety code survey, all records for testing, inspection and maintenance of the automatic sprinkler system for the facility was requested to be available for review.

On 11/12/13 between 11:00 A.M. and 3:40 P.M. tour of the building was conducted with Staff AA, FF and MM. Observation of the four story facility revealed the presence of an automatic sprinkler system throughout the four story facility.

Review of facility documentation on 11/14/ 13 at 1:00 P.M. regarding quarterly testing and inspection of the sprinkler system revealed there was no documented evidence that quarterly inspection and testing was completed in July, August or September (third quarter) 2013.

Interview of Staff AA on 11/14/13 at 4:00 P.M. verified there was no documented evidence that third quarter inspection and testing of the sprinkler system had been conducted.

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

NFPA 99 Standard for Health Care Facilities

Chapter 8, Gas Equipment, Administration

8-6.2.5 Gases in Cylinders and Liquefied Gases in Containers.

8-6.2.5.1 Transfilling Cylinders.
(a) Mixing of compressed gases in cylinders shall be prohibited.
(b) Transfer of gaseous oxygen from one cylinder to another shall be in accordance with CGA Pamphlet P-2.5, Transfilling of High Pressure Gaseous Oxygen to Be Used for Respiration. Transfer of any gases from one cylinder to another in patient care areas of health care facilities shall be prohibited.
8-6.2.5.2 Transferring Liquid Oxygen.
Transferring of liquid oxygen from one container to another shall be accomplished at a location specifically designated for the transferring that is as follows:
(a) Separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction; and
(b) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring; and
(c) The area is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted.
Transferring shall be accomplished utilizing equipment designed to comply with the performance requirements and producers of CGA Pamphlet P-2.6, Transfilling of Low-Pressure Liquid Oxygen to be Used for Respiration, and adhering to those procedures.
The use and operation of small portable liquid oxygen systems shall comply with the requirements of CGA Pamphlet P-2.7, Guide for the Safe Storage, Handling and Use of Portable Liquid Oxygen Systems in Health Care Facilities.

* Based on facility observation and staff interview and verification, the facility failed to ensure that transfilling of cylinders was conducted in a location specifically designed for the transferring. The facility had a capacity for 1061 patients with a census of 401 patients at the time of the survey completed on 11/14/13. Potentially all patients, visitors and staff could be affected.

Findings included:

On 11/12/13 between 11:00 A.M. and 3:40 P.M. tour of the building was conducted with Staff AA, FF and MM. Observation of the cardiac rehabilitation unit on the ground floor revealed the presence of a large open area with exercise equipment. Two patients were in the area using the equipment.

Staff NN was interviewed regarding the use and storage of oxygen in the area. Staff NN verified that oxygen was kept in the area. Two large tanks of liquid oxygen were noted in an area along the wall in the same room. Located next to the tanks was a table with 12 small portable tanks used by patients. Staff NN revealed the smaller tanks were filled using the large tanks of liquid oxygen. Staff verified the tanks were filled at that location.

Staff NN provided documentation that revealed the tanks were 137 pound tanks of liquid oxygen. Staff verified that one tank was half full and the other tank was full. Staff present on tour verified the observation.

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

NFPA 99 Standard for Health Care Facilities

Chapter 4

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).

(a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
* 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 verification, the facility failed to ensure that enclosures were provided for manifold locations for oxidizing agents such as oxygen that were constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour. The facility had a capacity for 1061 patients with a census of 401 patients at the time of the survey completed on 11/14/13. Potentially all patients, visitors and staff could be affected.

Findings included:

On 11/12/13 between 11:00 A.M. and 3:40 P.M. tour of the building was conducted with Staff AA, FF and MM. Observation of the ambulatory surgical center located on the ground floor revealed the presence of an oxygen storage area. The storage area was a manifold location for oxygen cylinders used in the surgical area.

Observation inside the oxygen storage room revealed that above the door to the room, a penetration approximately two inches in diameter had been created for the insertion of a green flex cable. Staff present on the tour verified the penetration was in the one hour fire rated wall of the room.

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

NFPA 101

Chapter 21

21.7.5.5
Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.


* Based on facility observation and staff interview and verification, the facility failed to ensure that soiled linen or trash collection receptacles did not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space was not to exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) was not to be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) were to be located in a room protected as a hazardous area when not attended. The facility had a capacity for 1061 patients with a census of 401 patients at the time of the survey completed on 11/14/13. Potentially all patients, visitors and staff could be affected.

Findings included:

On 11/12/13 between 11:00 A.M. and 3:40 P.M. tour of the building was conducted with Staff AA, FF and MM. Observation outside the cardiac rehabilitation unit on the ground floor revealed a corridor that lead to a parking lot. The corridor was designated as an exit egress. Staff NN stated that patients using the cardiac rehabilitation room frequently used the corridor to exit the building and as a shortcut to the parking lot. Three patients were observed to use the corridor to exit the building.

Observation of the corridor revealed that a wheeled container, significantly larger than 32 gallons, used for trash collection was stored in a small alcove in the corridor. A second large wheeled container, significantly larger than 32 gallons, was used to collect soiled linen. The large soiled linen container stored in the corridor, narrowed the passageway.

Staff NN verified the large wheeled containers were typically maintained in the corridor. Staff present on tour verified the corridor was not an acceptable place for the storage of the containers.

On 11/14/13 at 11:30 A.M. another observation of the corridor with Staff BB and FF revealed that three containers, all significantly greater than 32 gallons were present in the corridor. Two containers were for soiled linen collection and the third was for trash collection. Staff FF present at both observations, verified the large wheeled containers were not to be stored in the corridor.

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

NFPA 101

Chapter 21

Ambulatory health care occupancies are separated from other tenants and occupancies by fire barriers with at least a 1 hour fire resistance rating. Doors in such barriers are solid bonded core wood of 1 inches or equivalent and are equipped with a positive latch and closing device. Vision panels, if provided in fire barriers or doors, are fixed fire window assemblies in accordance with 8.2.3.2.2.

*Based on facility observation and staff interview and verification, the facility failed to ensure the ambulatory health care occupancies was separated from other tenants and occupancies by fire barriers with at least a 1 hour fire resistance rating. Vision panels, if provided in fire barriers were to be fixed fire window assemblies in accordance with 8.2.3.2.2. The facility had a capacity for 1061 patients with a census of 401 patients at the time of the survey completed on 11/14/13. Potentially all patients, visitors and staff could be affected.

Findings included:

1. On 11/12/13 between 11:00 A.M. and 3:40 P.M. tour of the building was conducted with Staff AA, FF and MM. An ambulatory surgery center (ASC) was located on the ground floor of the building in an atrium. The ASC contained four operating rooms and two procedure rooms. Observation of the ASC revealed the separation wall between the ASC waiting area and the atrium consisted of glass panels in a steel frame. The Underwriters Laboratory (UL) rating on the window assembly was illegible.

Observation and verification by with Staff AA and MM revealed the glass panels had no fire resistance rating. Observation of the glass panel wall from the waiting room side revealed five sprinkler heads placed less than six feet apart. The sprinklers were cosmetically concealed in the ceiling with cap covers. Each covered sprinkler head was placed approximately six inches from the window assembly. Staff present verified the placement of the sprinkler heads was to form a water curtain for the window assembly and the one hour fire resisitant barrier.

Observation of the window assembly from the atrium side revealed the presence of one concealed sprinkler head located at the inset above the door to the waiting area. There were no additional sprinkler heads located at the window assembly as observed inside the ASC. Measurement of glass panels in the window assembly that were not provided direct sprinkler protection from the atrium side were as followed; four panels of glass 37 inches wide and 89 inches high and four panels of glass above the previously mentioned panels 37 inches wide and 45 inches high, one panel 36 inches wide and 89 inches high with a panel above 36 inches wide and 45 inches high.

A second story and occupancy was above the ASC. The occupancy above the ASC also had a window assembly that formed the atrium wall. Observation of the atrium ceiling revealed three sprinkler heads, placed approximately five feet away from the second story window assembly. The sprinkler heads were cosmetically capped. Staff present verified the placement of the sprinkler heads in the atrium ceiling were approximately 10 feet apart.

Observation of the ASC window assembly and placement of sprinkler heads from the atrium side were verified again on 11/14/13 at 11;20 A.M. with Staff BB, DD and FF.

2. On 11/12/13 at 12:45 P.M. observations above the ceiling tiles with Staff AA and MM were conducted of an identified one hour fire rated separation between the ASC and the Breast Health Center. The following penetrations were noted in the one hour fire rated barrier;

Located above the ceiling tiles in the ASC waiting area, a penetration surrounding a gray IT wire and a second penetration approximately one half inch in diameter.

Located in the one hour fire rated barrier was a non-fire rated window for the breast health receptionist. Observation above the ceiling tiles at the same reception window revealed penetrations surrounding copper pipe and a black wire.

Observation above the ceiling tiles at the ASC waiting room desk, revealed a penetration approximately 12 inches long and four inches wide near a large duct.

Observation above the ceiling tiles at the endoscopy nursing station, revealed the end of the one hour fire rated barrier. The space above the ceiling was open and no additional fire rated separation was observed. Staff present verified the observation.

On 11/14/13 at 10:00 A.M., Staff BB stated the schematic for the ASC was misread and that no one hour fire rated barrier existed between the ASC and the Breast Health Center.

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

NFPA 101

Chapter 21

21.2.9.1

Emergency illumination is provided in accordance with section 7.9.

*Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency illumination was provided in accordance with section 7.9 with regards to monthly and annual testing. The facility had a capacity for 1061 patients with a census of 401 patients at the time of the survey completed on 11/14/13. Potentially all patients and staff could be affected.

Findings included:

1. On 11/12/13 between 11:00 A.M. and 3:40 P.M. tour of the building was conducted with Staff AA, FF and MM. An ambulatory surgery center (ASC) was located on the ground floor of the building in an atrium. The ASC contained four operating rooms and two procedure rooms.

Tour of the surgical area with Staff MM and OO on 11/12/13 at 2:00 P.M. revealed the presence of battery backup task lighting in both procedure rooms and four operating rooms. Review of testing documentation on 11/14/13 at 3:34 P.M. with Staff AA and DD revealed that testing dates were noted but there was no indication of the length of the testing. Further review of the documentation revealed there was no documented evidence of a 90 minute test completed in the past 12 months.

Staff AA and DD verified the facility testing documentation lacked the length of time tested each month as well when the 90 minute annual test was conducted.

Based on observations, review of floor plans, and staff interviews, the facility failed to ensure the 2 hour fire rated barrier between buildings maintained the two hour fire resistance rating. This involved 3 floors of the building (floors 7, 4, and ground) and could affect all patients, staff, and visitors in the building. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:



21521


a) Tour of the seventh floor was begun on 11/04/13 with Staff AA, BB, CC, and DD from 11:40 A.M. to 3:01 P.M. with Staff AA, BB, CC, and DD. At 2:25 P.M. observation of the two hour fire wall in the nurse practitioner's office in four east revealed above the drop down ceiling an annular space around a pipe. Directly above the penetration and pipe the words " fire barrier " is stenciled. Review of the floor plan as provided by the facility also confirmed the presence of a two hour fire wall.
b) During the tour of the seventh floor that was begun on 11/04/13 with Staff AA, BB, CC, and DD and went from 11:40 A.M. to 3:01 P.M., in an interview Staff BB and EE confirmed the observation.
c) On 11/05/13 at 3:04 P.M. observation of the fire doors in the 2 hour fire rated wall that separated four west from four east revealed one fire door to be unrated.
On 11/05/13 at 3:04 P.M. in an interview, Staff BB and DD confirmed the observation.
d) Tour of three west was begun on 11/07/13 at 9:40 A.M. with Staff AA, BB, CC, and DD from 9:40 A.M. to 10:16 A.M. At 10:10 A.M. at the two hour fire barrier separating three west from three east and above the drop down ceiling above the double doors revealed an open conduit box and an open conduit box near stair N.
During the tour on 11/07/13 from 9:40 A.M. to 10:16 A.M. in an interview Staff BB and EE confirmed the observation.
e) On 11/08/13 at 10:46 P.M. observation of the doors in the two hour fire wall that separated the north building from the west building near stair P, revealed they were not rated two hours.
On 11/08/13 at 10:46 P.M. in an interview, Staff BB and EE confirmed the observation.
f) On 11/08/13 at 11:46 A.M. observation of the fire barrier between Administration and the West building, and near Stair D, a two inch conduit lumen was observed above the drop down ceiling and open to air.
On 11/08/13 at 11:46 A.M. in an interview BB and EE confirmed the observation.

g) During tour on 11/12/13 at 3:00 P.M. with Staff BB, CC, DD, and PP, the 1 and 1/2 hour fire rated door to the dry food storage area in the corridor between Stairwell O and H was tested. The fire door failed to latch into the frame during the testing. According to the facility floor plan, this door was located in a 2 hour fire rated barrier. Staff BB, CC, and DD verified the fire door failed to latch when tested at 3:00 P.M.

h) During tour on 11/13/13 at 9:15 A.M. with Staff BB, CC, and DD the fire doors located between the East and West Building leading into the dialysis unit failed to latch when tested. These doors were observed with a 1 and 1/2 hour fire rated label. The aforementioned staff at 9:15 A.M. verified the doors should have latched but failed to do so when tested.

Based on observations, review of floor plans, and staff interviews, the facility failed to ensure the 2 hour fire rated barrier between buildings maintained the two hour fire resistance rating. This involved 2 barriers and could affect all patients, staff, and visitors in those areas of the building. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:
a) On 11/08/13 at 10:25 A.M., during tour with Staff BB and EE, observation above the double doors in the two hour fire wall between the surgery building and the north building, near Stair S, two 2.5 conduits' lumens were open to air with gray wires coming from them.
On 11/08/13 at 10:25 A.M. in an interview Staff BB and EE confirmed the observation.
b) On 11/08/13 at 10:46 P.M., during tour with Staff BB and EE, observation of the doors in the two hour fire wall that separated the north building from the west building near stair P, revealed they were not rated two hours.
On 11/08/13 at 10:46 P.M. in an interview, Staff BB and EE confirmed the observation.

Based on observation, staff interview, and review of the facility's floor plans, the facility failed to ensure access to three exits were marked by an approved, readily visible sign in one area of the building. This could affect all patients, staff, and visitors in the building. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

During tour with Staff CC, DD, FF, and HH, the following areas were observed without exit signs when the exit pathway was not readily apparent, or failed to lead to an acceptable exit as follows:

Tour of the fourth floor was conducted on 11/06/13 at 9:13 A.M.

a) Tour of the third floor was conducted on 11/06/13 between 9:29 A.M. and 10:19 A.M.
The SC 3-5/FC 3-3 compartment for the Behavior Outpatient department revealed a group of rooms consisting of private meeting rooms, waiting room, and offices. The floor plan revealed this compartment contained 9695 square feet. An exit sign was observed posted above a doorway which led to a group of rooms. Observation of the rooms revealed only one door used for group therapy opened into the exit corridor. During tour the door was verified by Staff CC to be locked to prevent exiting into the hallway. This was verified with Staff CC at 9:50 A.M. on 11/06/13.

b) Tour of the second floor on 11/06/13 at 11:15 A.M. revealed a suite of rooms used by a home care agency. This compartment lacked a 2 hour fire separation between this agency and the facility. Tour inside the home care agency office revealed a mixture of offices, cubicles, and storage areas. Review of the floor plan revealed this office space was a total of 9753 square feet. This area lacked exit signs indicated the exit access doors from the suite.

c) Tour of the basement on 11/07/13 between 9:45 A.M. and 10:36 A.M. revealed an exit discharge door lacked a visible exit sign. Located in this same area was another room which could be entered in the event of a fire or smoke. However, this room lacked a visible means to exit.

The lack of these aforementioned exits and signs was verified with Staff DD at the time of the observations.

Based on observation and staff interview the facility failed to ensure access to one exit was marked by an approved, readily visible sign in one area of the building. This could affect all patients, staff, and visitors in that area of the building. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

On 11/07/13 at 3:20 P.M., on the second floor, in the north building, during tour with Staff BB, EE, and CC the path of egress from the second floor down to the dialysis area revealed the exit sign was turned so that it was not seen to see the egress path out of the building.

On 11/07/13 at 3:05 P.M. and at 3:20 P.M. Staff BB, EE, and CC confirmed the observation.

Based on observation and staff interview the facility failed to ensure access to two exits was marked by an approved, readily visible sign in two areas of the building. This could affect all patients, staff, and visitors in the building. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:
a) On 11/05/13 at 1:48 P.M., during a tour with Staff BB and EE, a patient sleeping suite was observed on four north. The suite did not reveal an exit sign on the path of egress.
On 11/05/13 at 1:48 P.M. in an interview Staff BB and EE confirmed the observations.
b) On 11/07/13 at 3:05 P.M., during tour with Staff BB, EE, and CC on the second floor, in the north building, near the gift shop, the path of egress from a point near the gift shop to the east horizontal exit and onto the catwalk, revealed the exit sign(s) were not visible.
On 11/07/13 at 3:05 P.M. and at 3:20 P.M. Staff BB, EE, and CC confirmed the observations.

Based on observations, review of facility floor plans, and staff interviews, the facility failed to ensure 4 smoke barriers on one floor of the facility maintained at least a one hour fire resistance rating. This could affect all staff, patients, and visitors. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

Tour was conducted with Staff BB, CC, and DD on 11/07/13 between 2:22 P.M. and 4:00 P.M., and on 11/12/13 between 1:00 P.M. and 1:20 P.M.

During this tour of the ground floor on 11/07/13 penetrations were observed in the one hour fire rated barrier as follows:
a) The corridor across from room 402 revealed a curved conduit (approximately 3/4 inch diameter) which was open around wiring.

b) Room 71 was observed with a one inch high by 2 feet long opening at the top of the smoke barrier at the corrugated decking. The bathroom in this room was observed with a three inch wide by ten inch long opening around a steel beam that passed into the barrier.

On 11/12/13 the following penetrations were observed
c) Outside Stairwell #1 a curved conduit (approximately 3/4 inch diameter) was observed open inside the conduit.

d) The one hour fire rated barrier located between SCG-12 (Smoke compartment) and SCG-13, near Stairwell T, was observed with three sets of smoke barrier doors. The corrugated decking at the top of the barrier was observed with a 1-2 inch high by 21 feet long opening along the top portion of the smoke barrier. One square metal conduit over one set of the fire doors was observed with a cloth rag stuffed into the conduit. When the cloth rag was removed by Staff CC, the conduit was observed open.

These penetrations were verified with Staff CC during the aforementioned tour at the time of the observations.

Based on observations, review of floor plans, and staff interviews, the facility failed to ensure one smoke barrier maintained the required fire resistance rating. This could affect all patients, staff, and visitors in the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:
On 11/04/13 at 2:38 P.M., during tour with Staff BB and DD, observation above the drop down ceiling of the smoke barrier in seven west in the corridor that connects stairwell L and M revealed two two inch pipes with annular spaces.
On 11/04/13 at 2:38 P.M. in an interview, Staff BB and DD confirmed the observation.

Based on observations, review of floor plans, and staff interviews, the facility failed to ensure three smoke barriers maintained the required fire resistance rating. This could affect all patients, staff, and visitors in the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:
a) On 11/05/13 at 1:26 P.M. on four north, a tour with Staff BB and DD revealed the smoke barrier above the drop down ceiling in the eastern corridor wall in the vacant patient room was observed. The observation revealed three one inch conduits with lumens that were open to air.
On 11/05/13 at 1:26 P.M. in an interview, Staff BB and DD confirmed the observation.

b) On 11/05/13 at 3:55 P.M. observation of the smoke barrier above the drop down ceiling in the 3 north, east corridor revealed a three inch conduit lumen open to air.
On 11/07/13 during tour, in an interview Staff BB and DD confirmed the observation.

c) On 11/07/13 at 3:40 P.M. observation above the drop down ceiling in two north across from room 342 revealed a fist sized opening around a communications conduit and sprinkler line.

On 11/07/13 at 3:40 P.M. in an interview, Staff BB and DD confirmed the observation.

Based on observations, staff interview, and review of the facility floor plans, the facility failed to ensure eight hazardous areas located in 3 areas of the facility maintained a one hour fire rated construction. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

a) On 11/04/13 at 2:29 P.M., tour with Staff BB and DD, on seven east in room 15, above the drop ceiling, a blue tip conduit with an unsealed lumen was observed. Review of the drawing revealed the room to be surrounded in one hour fire construction.
On 11/04/13 at 2:29 P.M. in an interview, Staff BB and DD confirmed the observation.
b) On 11/04/13 at 2:54 P.M. on seven east in room 0023, a soiled utility room, and above the drop down ceiling, three two inch holes were observed in the one hour rated construction. Review of the drawing revealed the room to be surrounded in one hour fire construction.
On 11/04/13 at 2:54 P.M. an interview, Staff BB and DD confirmed the observation.
c) On 11/05/13 at 2:09 P.M. in the clean utility room across from room 439 on four west, and above the drop down ceiling, a one inch conduit's lumen was observed open to air. Review of the drawing revealed the room was wrapped in one hour fire construction.
On 11/05/13 at 2:09 P.M. in an interview, BB and EE confirmed the observation.
d) On 11/05/13 at 2:15 P.M. in the clean utility room on four west, observation above the drop down ceiling on the eastern most wall, two white pipes and a metal conduit had annular spaces. Review of the drawing revealed the room to be surrounded in one hour fire construction.
On 11/05/13 at 2:15 P.M. in an interview, Staff BB and DD confirmed the observation.
e) On 11/07/13 at 2:37 P.M. observation of the door to the clean linen room on two east revealed it was not on a self closer. Review of the drawing revealed the room to be surrounded in one hour fire construction.
On 11/07/13 at 2:37 P.M. in an interview, Staff BB and DD confirmed the observation.
f) On 11/07/13 at 2:43 P.M. the door to the soiled utility room across from room 208 on two east was observed to have two half inch openings in it. Review of the drawing revealed the room to be surrounded in one hour fire construction.
On 11/07/13 at 2:43 P.M. in an interview, Staff BB and DD confirmed the observation.
g) On 11/07/13 at 4:35 P.M. observation of the doors from equipment room B to the corridor in the surgery building revealed the doors did not have a means suitable for keeping the door closed.
h) On 11/07/13 at 5:00 P.M. observation in the surgery building of the door on the soiled utility room to the corridor with certificates hanging on the wall revealed the doors did not have a means suitable for keeping the door closed and a sign was posted to remind staff to keep the door closed.
On 11/07/13 at 4:35 P.M. and at 5:00 P.M. in interviews, Staff BB and EE confirmed the observations.

Based on observations and staff interviews, the facility failed to ensure stairway doors contained a fire resistance rating of at lease one hour due to missing or illegible fire rated labels. This affected 4 stairways and three floors of the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

A tour was conducted with Staff BB and EE on 11/05/13 at 10:52 A.M., on 11/05/13 at 11:12 A.M., on 11/05/13 at 11:49 A.M., on 11/05/13 at 12:08 P.M., and on 11/08/13 at 11:38 A.M. During this tour the following stairway doors were observed:

a) On 11/05/13 at 10:52 A.M. the fire door to exit stairway P on the fifth floor revealed a rating label painted over. Staff removed the label, and underneath the words " void " was written several times.
b) On 11/05/13 at 11:12 A.M. observation of the fire door to exit stairway O on the fifth floor revealed the rating label to be painted over, and the surveyor was unable to read the label.
c) On 11/05/13 at 11:49 A.M. observation of the fire door to exit stairway N on the fifth floor revealed the rating label to be painted over, and the surveyor was unable to read the label.
d) On 11/05/13 at 12:08 P.M. observation of the fire door to exit stairway R on the fourth floor revealed the rating label to be painted over, and the surveyor was unable to read the label.
e) On 11/08/13 at 11:38 A.M. observation of the fire door to exit stairway O on the first floor revealed the rating label to be painted over, and the surveyor was unable to read the label.
In interview with Staff BB and EE on 11/05/13 at 10:52 A.M., on 11/05/13 at 11:12 A.M., on 11/05/13 at 11:49 A.M., on 11/05/13 at 12:08 P.M., and on 11/08/13 at 11:38 A.M. in interviews Staff BB and EE confirmed the observations.

Based on observation, review of the floor plan, and staff interviews, the facility failed to ensure one exit access was arranged to ensure a continuous surface between the exit discharge and the public way. This could affect all patients, staff, and visitors in the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

A tour was conducted on 11/13/13 at 10:20 A.M. with Staff BB, CC, and DD. Observations of the exit discharge from Stairwell CC revealed a concrete pad outside the exit door. The pad was approximately 4 feet by 4 feet in diameter. The area beyond the concrete pad was observed leading up a steep hillside approximately 50 feet to the public way. The hillside was observed with smaller rocks and minimal grass. The exit to the public way lacked a continuous hard surface to the public way.

The floor evacuation plans revealed this exit discharge was used by patients, staff, and visitors in the Same Day Surgery building, the Emergency Department building, and the lower level of the main hospital building.

This was verified with Staff BB and CC at 10:20 A.M. on 11/13/13. Staff BB stated this exit discharge was present before the addition of the Emergency Department (ED) building, and the hillside was made steeper with the addition of the ED building.

Based on observations and staff interviews, the facility failed to ensure exit access doors were readily accessible with a single step operation to open the doors for exit This involved 4 of 8 operating rooms on the second floor. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

A tour was conducted with Staff FF of the operating rooms on the second floor on 11/07/13 from 9:00 A.M. to 9:40 A.M. According to Staff FF, this space was occupied by a tenant who leased space from the host facility. Staff FF verified the operating room area was not separated from the main hospital facility by a 2 hour fire rated barrier. Present during this tour was the tenant's Director of Surgical Services.

The following operating room exit access doors were observed with a slide bolt located approximately 6-8 inches above the door handles on the doors. This resulted in a minimum two step operation to exit the doors. On one of the doors, the slide bolt had to be lifted, slid to the right, and dropped into a metal slot before the door could be opened with the door handle.

Interview with the Director of Surgical Services at the time of observation revealed the doors were locked to prevent access into the operating rooms. During the tour, this person and Staff FF verified the doors required a minimum two step operation to open in order to exit the rooms.

Based on observations and staff interview, the facility failed to ensure smoke detectors were located greater than 36 inches from air diffusers. This could affect all staff, patients, and visitors in the building. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

A tour was conducted on 11/12/13 between 2:19 P.M. and 3:22 P.M. with Staff BB, CC, and DD.

During this tour, the following smoke detectors were observed located less than 36 inches from air diffusers:

a) In the hallway outside the cafeteria on the ground level by Stairwell H, and

b) Two smoke detectors on the ground level in the storage room labeled FC0-3 on the facility floor plan.


Interview with Staff CC during tour at 10:20 A.M. on 11/13/13 revealed the smoke detectors should be greater than 36 inches from air supply and air return diffusers. During tour Staff BB, CC, and DD verified the location of the aforementioned smoke detectors.

Based on observations and staff interview, the facility failed to ensure smoke detectors were located greater than 36 inches from air diffusers. This involved two floors of the facility and could affect all staff, patients, and visitors in those areas of the building. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

A tour was conducted in the Same Day Surgery building and the Emergency Department (ED)on 11/13/13 between 9:55 A.M. and 12:00 P.M. and between 12:55 P.M. and 2:18 P.M. with Staff BB, CC, and DD.

During this tour, the following smoke detectors were observed located less than 36 inches from air diffusers:

*In the Same Day Surgery building (SDS) , one smoke detector in lower level in Patient Admission Testing in the waiting room,
*In the SDS building, two smoke detectors in the ground floor waiting room.
*In the SDS building, on the ground floor, inside soiled utility room by bed 2 and the nurses' station
*By the blood bank, in the CT waiting room.
*Inside storage room 6A (previously the linear accelerator room), one smoke detector was observed
within 1 foot of an air supply diffuser.

In the ED building:
*On the ground level in the waiting room, and hallway near the waiting room,
*Inside the security office,
*In the ED nurses station, and
*In exam rooms 09, 08, 11, and 07

On the ground floor:
*Three smoke detectors in MRI in the control room, and
*In the hallway by the 2 hour fire wall leading to FCB-5 (according to the floor plan) at 9:55 A.M.

Interview with Staff DD during tour at 10:20 A.M. on 11/13/13 revealed the smoke detectors should be greater than 36 inches from air supply and air return diffusers. During tour Staff BB, CC, and DD verified the location of the aforementioned smoke detectors.

Based on observations, staff interview, and review of the facility's floor plan for fire compartments (FC) and smoke compartments (SC), the facility failed to ensure smoke detectors were located greater than 36 inches from air diffusers. This involved two floors of the facility and could affect all staff, patients, and visitors in those areas of the building. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

During tour of the facility with Staff CC, DD, FF, and HH, the following smoke detectors were observed located less than 36 inches from air diffusers:

On the Seventh floor on 11/05/13 at 11:34 A.M.:
*by Smoke compartment 7 near room 715.

On the Sixth floor on 11/05/13 between 1:06 P.M. and 1:55 P.M.:
*in the corridor by room 615, and
*in the elevator lobby near room 615 in Smoke Compartment 6-1.

On the Fifth floor on 11/05/13 between 2:00 P.M. and 3:43 P.M.:
*in the FC 5-3 hallway,
*2 in the day room, and
*2 in the nurses' station in SC 5-1 near Stair A in Center 5 wing.

On the 4th floor on 11/06/13 between 8:54 A.M. and 9:28 A.M.:
*In SC 4-5, 3 in the elevator lobby (2 detectors),
*In SC 4 outpatient clinic by Stair G, and
*In SC 4-2 in the elevator lobby by 3 elevators.

On the Third floor between 9:29 A.M. and 10:19 A.M.:
*In SC 3-2 by Stair B, and
*In open stairwell by FC 3-2.

On the Second floor on 11/06/13 between 10:46 A.M. and 11:35 A.M., and between 1:34 P.M. and 2:15 P.M.:
*In the SC 2-6/FC 2-7 compartment (Emergency Department) in the waiting room, in the security office, in the nurses' station, and just inside the entrance from the corridor located in the hallway between Stairway J and H.
*In the SC 2-10 compartment (1 detector), and
*In the SC 2-9 MRI area (1 detector)

On the First floor on 11/07/13 between 9:00 A.M. and and 9:40 A.M.. and between 2:15 P.M. and 3:22 P.M.:
*In SC 1-3 Lab area (2 detectors)
*SC 1-2 PACU (2 detectors),
*In FC 1-1 in the anesthesia work room,
*In the OR suite, in the central corridor by OR 22 and OR 28,
*In FC 1-3/SC 1-5 suite of rooms, and
*In FC1-4/SC 1-8 (4 smoke detectors)


In the Basement level on 11/07/13 between 10:02 A.M. and 10:17 A.M.:
*Two detectors in the fire compartment between the pharmacy and FCB-2 (2 detectors), and
*One detector in the pharmacy, and
*In the Environmental Services office and hallway outside the offices

Interview with Staff DD during tour on 11/05/13 at 11:34 A.M. revealed the smoke detectors should be greater than 36 inches from air supply and air return diffusers. During tour Staff CC, DD, FF, and HH verified the location of the aforementioned smoke detectors.

Based on observations and staff interviews, the facility failed to maintain the sprinkler system as required by the code in regards to missing escutcheon covers and dirty sprinkler heads. This involved 3 floors of the facility and could affect all patients, staff, and visitors in those areas of the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:





21521


Tour of the seventh floor was begun on 11/04/13 with Staff AA, BB, CC, and DD at from 11:40 A.M. to 3:01 P.M. with Staff AA, BB, CC, and DD.
a) At 11:58 A.M. a missing sprinkler escutcheon was observed in the medication room on seven west.
b) At 2:05 P.M. a missing sprinkler escutcheon was observed in room 726A and the sprinkler head over the nursing desk on seven west was observed to be dirty.
c) At 2:09 P.M. a dirty sprinkler head was observed in room 126.
d) At 2:13 P.M. on seven west in room 103 a dirty sprinkler head was observed.
During the tour of the seventh floor on 11/04/13 from 11:40 A.M. to 3:01 P.M. Staff BB and CC confirmed the observations in an interview.
On 11/08/13 at 9:00 A.M. the finding was again presented to Staff BB and CC.
e) On 11/05/13 from 8:20 A.M. to 9:54 A.M. a tour of the seventh floor was resumed with Staff AA, BB, CC, and EE. At 8:39 A.M. a women's bathroom between stairwell N and O was observed to have a missing sprinkler escutcheon.
f) At 9:29 A.M. shower rooms 005 and 006 on were observed to have missing sprinkler escutcheons.
Sixth Floor:
g) On 11/04/13 from 3:02 P.M. to 3:50 P.M. a tour was conducted of the sixth floor with Staff AA, BB, CC, and DD. At 3:50 P.M. a missing sprinkler escutcheon was observed in the housekeeping closet near Stair O.
In interviews during the tour on 11/04/13 from 3:02 P.M. to 3:50 P.M. of the sixth floor with Staff AA, BB, CC, and DD, they confirmed the observation.
On 11/08/13 at 9:00 A.M. the finding was again presented to Staff BB and CC.
Sixth Floor:
h) At 9:32 A.M. a staff only room on six east, near the smoke barrier, was observed to have a missing sprinkler escutcheon.
In interviews on 11/05/13 from 8:20 A.M. to 9:54 A.M. when a tour of the seventh floor was resumed with Staff AA, BB, CC, and EE, Staff BB and EE confirmed the observations.
On 11/08/13 at 9:00 A.M. the finding was again presented to Staff BB and CC.
Ground floor:
i) During tour on 11/12/13 2:18 P.M., at tour was conducted in the radiology read room suite with Staff BB, CC, and DD. This suite of rooms was observed with 4 missing escutcheon sprinkler head covers. These missing covers were verified with Staff BB and CC at the time of the observation.

Based on observations and staff interviews, the facility failed to maintain the sprinkler system as required by the code in regards to missing escutcheon covers and dirty sprinkler heads. This involved 3 floors of the facility and could affect all patients, staff, and visitors in those areas of the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

During tour of the facility with Staff CC, DD, FF, and HH, the following sprinkler heads were observed dirty or without escutcheon covers as follows:

Sixth floor on 11/05/13 between 1:06 P.M. and 1:55 P.M.:
* 3 sprinkler heads inside a physician's office Room 615 were observed without escutcheon covers

Second floor on 11/06/13 at 10:53 A.M.:
*cafeteria grill area (2 sprinkler heads observed with a heavy coating of greasy and dust)

Basement on 11/07/13 between 9:45 A.M. and 10:36 A.M.:
*In the pharmacy six sprinkler heads were observed with a heavy coating of dust and dirt, and
*In the engineering office one sprinkler head was observed dirty with a coating of dust and dirt

This was verified with Staff CC, DD, FF, and HH during the aforementioned tour at the times of observations.

Based on observations and staff interviews, the facility failed to maintain the sprinkler system as required by the code in regards to missing escutcheon covers and dirty sprinkler heads. This affected 2 floors of the facility. This could affect all patients in the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

a) Tour of the seventh floor was begun on 11/04/13 with Staff AA, BB, CC, and DD at from 11:40 A.M. to 3:01 P.M. with Staff AA, BB, CC, and DD. At 11:40 A.M. a missing sprinkler escutcheon was observed in the clean receiving room near stairwell R in the North building.
b) During the tour of the seventh floor on 11/04/13 from 11:40 A.M. to 3:01 P.M. Staff BB and CC confirmed the observations in an interview.
On 11/08/13 at 9:00 A.M. the finding was again presented to Staff BB and CC.
c) On 11/07/13 from 2:15 P.M. to 4:15 P.M. a tour was conducted of the second floor with Staff AA, BB, CC, and EE. At 3:40 P.M., in two north, across from room 318, a sprinkler bulb was observed to be coated in dust.
During the tour on 11/07/13 from 2:15 P.M. to 4:15 P.M., in an interview, Staff BB and CC confirmed the observation.
d) On 11/08/13 at 11:00 A.M., on the first floor of the north building, in the human resources assistant manager's office a missing sprinkler escutcheon was observed.
On 11/08/13 at 11:00 A.M. Staff BB and CC confirmed the observation.

Based on observations and staff interviews, the facility failed to ensure one medical gas storage room door self-closed when tested. This could affect all patients, staff, and visitors in the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

A tour was conducted on 11/12/13 at 2:37 P.M. with Staff BB, CC, and DD on the ground level floor. The main egress corridor located outside FCO-3 compartment (on floor plan) and the ultrasound suite was observed with a room which opened into this corridor. The room was observed with multiple H-tanks of nitrous oxide gases (greater than 300 cubit feet). The door to the hallway was observed with a 1 and 1/2 hour fire rated label; however, failed to self close and latch into the frame when tested. This was verified with Staff BB, CC, and DD at the time of the tour. Staff CC stated the door should have closed and latched.

NFPA 101

Chapter 20

20.2.9.1

Emergency illumination is provided in accordance with section 7.9.

*Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency illumination was provided in accordance with section 7.9 with regards to monthly and annual testing. The facility had 12 treatment rooms with a census of nine patients at the time of the survey completed on 11/13/13. Potentially all patients, visitors and staff could be affected.

Findings included;

On 11/13/13 between 3:10 P.M. and 5:45 P.M. tour of the building was conducted with Staff II, FF and KK. The free standing emergency department was location on the ground floor of the building. Emergency services were available 24 hours per day, seven days per week.

Tour of the emergency department, radiology and cancer care center was conducted with Staff II, FF and KK, revealed the presence of battery backup lighting in the patient care areas. Review of testing documentation on 11/13/13 at 4:45 P.M. with Staff KK revealed that testing dates were noted but there was no indication of the length of time for the testing. Further review of the documentation revealed there was no documented evidence of a 90 minute test completed in the past 12 months.

Staff KK and II verified the facility testing documentation lacked the length of time tested each month as well when the 90 minute annual test was conducted.

NFPA 101

Chapter 39

39.2.10
Marking of Means of Egress.

Means of egress shall have signs in accordance with Section 7.10.

7.10.9.2
Testing

Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

*Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency illumination was provided in accordance with section 7.9 with regards to monthly and annual testing. The facility provided sleep studies for two patients on 11/13/13. Potentially all patients and staff could be affected.

Findings included:

On 11/13/13 between 10:30 A.M. and 11:00 A.M. tour of the building was conducted with Staff II and JJ. The facility contained four patient sleeping rooms used for sleep studies.

Tour of the facility with Staff II and JJ revealed the presence of battery backup egress lighting in the corridors. Review of testing documentation on 11/13/13 during the facility observation Staff JJ revealed that monthly testing dates were noted but there was no indication of the length of the testing.

Staff II and JJ verified the facility testing documentation lacked the length of time tested each month.

NFPA 25

Chapter 1

General Information

1-4 Responsibility of the Owner or Occupant.
1-4.1
The owner or occupant shall provide ready accessibility to components of water-based fire protection systems that require inspection, testing, or maintenance.
1-4.2*
The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Exception: Where the owner is not the occupant, the owner shall be permitted to pass on the authority for inspecting, testing, and maintaining the fire protection systems to the occupant, management firm, or managing individual through specific provisions in the lease, written use agreement, or management contract.

* Based on facility observation and staff interview and verification, the facility failed to ensure that a water-based fire protection system was periodically inspection, tested, and maintained and the equipment shown to be in good operating condition. Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. The outpatient therapy facility provided services for at least 30 patients on 11/13/13. Potentially all patients, staff and visitors could be affected.

Finding included:

On 11/13/13 between 11:50 A.M. and 1:50 P.M. tour of the facility was conducted with Staff II and LL. The outpatient facility was observed to be on the lower level ( below grade) of a business occupancy. Observation of the facility revealed the presence of sprinkler heads in the staff office area.

Review of facility documentation revealed no evidence of sprinkler inspection, testing or maintenance. Staff II was unaware the facility had a sprinkler system. Staff LL contacted the property maintenance staff who was unaware of the sprinkler system in the outpatient facility.

Observation above the ceiling tiles with Staff II revealed the sprinkler system was tied directly to the main line of the public water system.

Staff LL provided and reviewed the lease agreement and verified the sprinkler system was to be maintained by the property owner. Staff II and LL verified there was no documented evidence of any recent inspection, testing or maintenance of the sprinkler system.

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

NFPA 101

Chapter 38

38.7 OPERATING FEATURES

38.7.1 Drills.
In any business occupancy building occupied by more than 500 persons or more than 100 persons above or below the street level, employees and supervisory personnel shall be periodically instructed in accordance with Section 4.7 and shall hold drills periodically where practicable.

4.7* FIRE DRILLS
4.7.2* Drill Frequency.
Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.
4.7.5* Simulated Conditions.
Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

* Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that fire drills were held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. The outpatient therapy facility provided services for at least 30 patients on 11/13/13. Potentially all patients, staff and visitors could be affected.

Finding included:

On 11/13/13 between 11:50 A.M. and 1:50 P. M, tour of the facility was conducted with Staff II and LL. The outpatient facility was observed to be on the lower level ( below grade) of a business occupancy. Staff LL noted the evacuation route in case of fire. The second means of egress required exit through a set of fire doors and a large exercise room.

Review of documented fire drills revealed fire drills completed 01/08/13 and 11/06/13. There was no indication of what simulated conditions were practiced , what time the drills occurred or who participated in the fire drills. There was no indication if any training needs had been identified.

Staff II reviewed the documentation and verified more information was to be needed.

********************************************************************************
NFPA 38

38.2.9 Emergency Lighting

38.2.9.2
Emergency lighting in accordance with Section 7.9 shall be provided for all underground and windowless structures as defined in 3.3.205 and 3.3.212.

* Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency lighting in accordance with Section 7.9 was provided for all underground and windowless structures. The outpatient therapy facility provided services for at least 30 patients on 11/13/13. Potentially all patients, staff and visitors could be affected.

Finding included:

On 11/13/13 between 11:50 A.M. and 1:50 P. M, tour of the facility was conducted with Staff II and LL. The outpatient facility was observed to be on the lower level ( below grade) of a business occupancy. Observation of the facility revealed the presence of five battery back-up emergency lights in the exit pathways.

Review of documentation on 11/13/13 at 1:15 P.M. with Staff II and LL revealed monthly testing of emergency lighting noted only the lights were checked. There was no indication that testing was for 30 seconds each month and no documented evidence of a 90 minute annual test.

Staff II present at the document review verified the information failed to show testing had been completed in accordance with section 7.9.

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

NFPA 101

Chapter 38

38.2.2.5 Horizontal Exits.
Horizontal exits complying with 7.2.4 shall be permitted.

7.2.4.3.4
Any opening in such fire barriers shall be protected as provided in 8.2.3.2.3.

8.2.3.2.3* Opening Protectives.
8.2.3.2.3.1
Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:
(1) 2-hour fire barrier - 11/2-hour fire protection rating
(2) 1-hour fire barrier - 1-hour fire protection rating where used for vertical openings or exit enclosures, or 3/4-hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42

* Based on facility observation, review of facility information and staff interview and verification, the facility failed to ensure that every opening in a fire barrier was protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The outpatient therapy facility provided services for at least 30 patients on 11/13/13. Potentially all patients, staff and visitors could be affected.

Finding included:

On 11/13/13 between 11:50 A.M. and 1:50 P. M, tour of the facility was conducted with Staff II and LL. The outpatient facility was observed to be on the lower level ( below grade) of a business occupancy. Interview of Staff LL revealed the second means of egress from the lower level facility was through the occupied space next to the facility. It was a large, gym-like exercise room.

Review of the facility schematic revealed the presence of a two hour fire rated wall between the outpatient facility and the adjacent tenant. Observation of the fire rated barrier with Staff II, revealed two sets of two hour fire rated doors connected to the fire alarm system. Release of the door from the magnetic hold revealed that one set of fire rated doors failed to close. The door remained open by approximately eight inches.

Staff II present at the observation, verified the fire doors were to close and latch but did not operate properly.

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

NFPA 110
Standard for Emergency and Standby Power Systems

Chapter 6

6-3 Maintenance and Operational Testing.
6-3.1*
The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.
6-3.2
A routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the operational reliability of the system.
6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established.

* Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure the emergency power supply (EPS) was routinely maintained, tested and that a written schedule for routine maintenance and operational testing of the EPS was established. The outpatient therapy facility provided services for at least 30 patients on 11/13/13. Potentially all patients, staff and visitors could be affected.

Finding included:

On 11/13/13 between 11:50 A.M. and 1:50 P. M, tour of the facility was conducted with Staff II and LL. The outpatient facility was observed to be on the lower level ( below grade) of a business occupancy. Observation of the facility revealed the presence of five battery back-up emergency lights in the exit pathways. Interview of Staff LL revealed that emergency lighting was provided by an emergency generator during a power outage.

Review of facility documentation on 11/13/13 at 1:15 P.M. with Staff II and LL revealed monthly testing of the EPS was noted by a comment the generator was started. There was no indication how long the generator ran or if any load testing was conducted. Further review of the documentation revealed there as no indication of routine maintenance of the system.

Interview of Staff LL, present at the document review, revealed the building maintenance staff for the leased space was to ensure the EPS was maintained. Staff II and LL interviewed the building maintenance staff who verified there was no additional documented information regarding maintenance and operational testing of the generator.

NFPA 25
Standard for Inspection, Testing and Maintenance of Water Based Fire Protection Systems

2-2.1 Sprinklers

2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1*: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.


* Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that components of the automatic sprinkler system were inspected or tested quarterly in accordance with NFPA 25 inspection and testing requirements. The facility had 16 treatment rooms with a census of six patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included;

On 11/04/13 upon initiation of the life safety code survey, all records for testing, inspection and maintenance of the automatic sprinkler system for the facility was requested to be available for review.

On 11/12/13 between at 4:25 P.M. and 5:50 P.M. tour of the building was conducted with Staff II. Observation of the single story facility revealed the presence of an automatic sprinkler system throughout the building.

Review of facility documentation on 11/13/ 13 at 9:00 A. M. regarding quarterly inspection and testing of the sprinkler system revealed there was no documented evidence that quarterly inspection and testing was completed in May, June, July (second quarter) 2013. Review of quarterly testing dated 09/13/13 was documented as the test for June 2013. Staff II verified that no testing had been completed in June and could not address why the contracted technician labeled the third quarter test as a second quarter test.


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

NFPA 101

Chapter 20

20.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that required smoke barriers were constructed in accordance with Section 8.3 and had a fire resistance rating of not less than 1 hour. The facility had 16 treatment rooms with a census of six patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included;

On 11/12/13 between at 4:25 P.M. and 5:50 P.M. tour of the building was conducted with Staff II. Review of facility schematic revealed the single story facility had 18,515 square feet of space for outpatient areas. The schematic revealed the fully sprinkler building was divided by a one hour fire rated smoke barrier.

Observation of the fire rated barrier revealed the following penetrations:

1. Observation above the ceiling tiles in the patient bathroom located next to the decontamination room revealed a penetration in the fire rated barrier wall approximately four inches in diameter.

2. Observation above the ceiling tiles in room 10, revealed penetrations surrounding black sprinkler pipe.

3. Observation of fire rated corridor doors located in the fire rated barrier revealed a gap at the edges of the doors when in the closed position greater than one-eighth inch.

4. Observation of fire rated corridor doors, located in the front corridor of the facility, revealed a gap at the edges of the doors when in the closed position. The space was greater than one-eight inch at the bottom half of the door.

5. Observation above the ceiling tiles at the fire rated corridor doors in the front hall, revealed a penetration approximately one inch in diameter located next to a small wire sleeve. The penetration was immediately sealed with fire rated sealant

Staff II observed and verified the penetrations in the fire rated wall as well as the gaps in the corridor doors located in the one fire fire rated barrier.

NFPA 72
Chapter 7

7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

7-5.2 Maintenance, Inspection, and Testing Records.
7-5.2.1Records shall be retained until the next test and for 1 year thereafter.

* Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that smoke detector sensitivity testing was completed per NFPA 72 and that a written record of the testing was retained. The facility had a capacity for 1061 patients with a census of 401 patients at the time of the survey completed on 11/14/13. Potentially all patients, visitors and staff could be affected.

Findings included:

On 11/04/13 upon initiation of the life safety code survey, all records of smoke sensitivity testing for the facility smoke detection systems was requested to be available for review.

On 11/12/13 between 11:00 A.M. and 3:40 P.M. tour of the building was conducted with Staff AA, FF and MM. Observation of the four story facility revealed the presence of a smoke detection system.

Review of facility documentation on 11/14/ 13 at 1:00 P.M. regarding fire alarm testing revealed there was no documented evidence that smoke sensitivity ranges were tested. Interview of Staff DD on 11/14/13 at 3:45 P.M. revealed the facility had a self monitoring smoke detection system that would send a trouble signal if a smoke detector was out of the set range. Staff DD verified that because of the self monitoring capabilities of the smoke detectors, the facility did not print and maintain a record of the the sensitivity testing. At the time of the survey exit conference on 11/14/13 at 4:30 P.M. no printed record of the sensitivity testing was provided.

********************************************************************************
NFPA 25
Standard for Inspection, Testing and Maintenance of Water Based Fire Protection Systems

2-2.1 Sprinklers

2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1*: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.


* Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that components of the automatic sprinkler system was inspected or tested quarterly in accordance with NFPA 25 inspection and testing requirements. The facility had a capacity for 1061 patients with a census of 401 patients at the time of the survey completed on 11/14/13. Potentially all patients, visitors and staff could be affected.

Findings included:

On 11/04/13 upon initiation of the life safety code survey, all records for testing, inspection and maintenance of the automatic sprinkler system for the facility was requested to be available for review.

On 11/12/13 between 11:00 A.M. and 3:40 P.M. tour of the building was conducted with Staff AA, FF and MM. Observation of the four story facility revealed the presence of an automatic sprinkler system throughout the four story facility.

Review of facility documentation on 11/14/ 13 at 1:00 P.M. regarding quarterly testing and inspection of the sprinkler system revealed there was no documented evidence that quarterly inspection and testing was completed in July, August or September (third quarter) 2013.

Interview of Staff AA on 11/14/13 at 4:00 P.M. verified there was no documented evidence that third quarter inspection and testing of the sprinkler system had been conducted.

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

NFPA 99 Standard for Health Care Facilities

Chapter 8, Gas Equipment, Administration

8-6.2.5 Gases in Cylinders and Liquefied Gases in Containers.

8-6.2.5.1 Transfilling Cylinders.
(a) Mixing of compressed gases in cylinders shall be prohibited.
(b) Transfer of gaseous oxygen from one cylinder to another shall be in accordance with CGA Pamphlet P-2.5, Transfilling of High Pressure Gaseous Oxygen to Be Used for Respiration. Transfer of any gases from one cylinder to another in patient care areas of health care facilities shall be prohibited.
8-6.2.5.2 Transferring Liquid Oxygen.
Transferring of liquid oxygen from one container to another shall be accomplished at a location specifically designated for the transferring that is as follows:
(a) Separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction; and
(b) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring; and
(c) The area is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted.
Transferring shall be accomplished utilizing equipment designed to comply with the performance requirements and producers of CGA Pamphlet P-2.6, Transfilling of Low-Pressure Liquid Oxygen to be Used for Respiration, and adhering to those procedures.
The use and operation of small portable liquid oxygen systems shall comply with the requirements of CGA Pamphlet P-2.7, Guide for the Safe Storage, Handling and Use of Portable Liquid Oxygen Systems in Health Care Facilities.

* Based on facility observation and staff interview and verification, the facility failed to ensure that transfilling of cylinders was conducted in a location specifically designed for the transferring. The facility had a capacity for 1061 patients with a census of 401 patients at the time of the survey completed on 11/14/13. Potentially all patients, visitors and staff could be affected.

Findings included:

On 11/12/13 between 11:00 A.M. and 3:40 P.M. tour of the building was conducted with Staff AA, FF and MM. Observation of the cardiac rehabilitation unit on the ground floor revealed the presence of a large open area with exercise equipment. Two patients were in the area using the equipment.

Staff NN was interviewed regarding the use and storage of oxygen in the area. Staff NN verified that oxygen was kept in the area. Two large tanks of liquid oxygen were noted in an area along the wall in the same room. Located next to the tanks was a table with 12 small portable tanks used by patients. Staff NN revealed the smaller tanks were filled using the large tanks of liquid oxygen. Staff verified the tanks were filled at that location.

Staff NN provided documentation that revealed the tanks were 137 pound tanks of liquid oxygen. Staff verified that one tank was half full and the other tank was full. Staff present on tour verified the observation.

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

NFPA 99 Standard for Health Care Facilities

Chapter 4

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).

(a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
* 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 verification, the facility failed to ensure that enclosures were provided for manifold locations for oxidizing agents such as oxygen that were constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour. The facility had a capacity for 1061 patients with a census of 401 patients at the time of the survey completed on 11/14/13. Potentially all patients, visitors and staff could be affected.

Findings included:

On 11/12/13 between 11:00 A.M. and 3:40 P.M. tour of the building was conducted with Staff AA, FF and MM. Observation of the ambulatory surgical center located on the ground floor revealed the presence of an oxygen storage area. The storage area was a manifold location for oxygen cylinders used in the surgical area.

Observation inside the oxygen storage room revealed that above the door to the room, a penetration approximately two inches in diameter had been created for the insertion of a green flex cable. Staff present on the tour verified the penetration was in the one hour fire rated wall of the room.

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

NFPA 101

Chapter 21

21.7.5.5
Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.


* Based on facility observation and staff interview and verification, the facility failed to ensure that soiled linen or trash collection receptacles did not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space was not to exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) was not to be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) were to be located in a room protected as a hazardous area when not attended. The facility had a capacity for 1061 patients with a census of 401 patients at the time of the survey completed on 11/14/13. Potentially all patients, visitors and staff could be affected.

Findings included:

On 11/12/13 between 11:00 A.M. and 3:40 P.M. tour of the building was conducted with Staff AA, FF and MM. Observation outside the cardiac rehabilitation unit on the ground floor revealed a corridor that lead to a parking lot. The corridor was designated as an exit egress. Staff NN stated that patients using the cardiac rehabilitation room frequently used the corridor to exit the building and as a shortcut to the parking lot. Three patients were observed to use the corridor to exit the building.

Observation of the corridor revealed that a wheeled container, significantly larger than 32 gallons, used for trash collection was stored in a small alcove in the corridor. A second large wheeled container, significantly larger than 32 gallons, was used to collect soiled linen. The large soiled linen container stored in the corridor, narrowed the passageway.

Staff NN verified the large wheeled containers were typically maintained in the corridor. Staff present on tour verified the corridor was not an acceptable place for the storage of the containers.

On 11/14/13 at 11:30 A.M. another observation of the corridor with Staff BB and FF revealed that three containers, all significantly greater than 32 gallons were present in the corridor. Two containers were for soiled linen collection and the third was for trash collection. Staff FF present at both observations, verified the large wheeled containers were not to be stored in the corridor.

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

NFPA 101

Chapter 21

Ambulatory health care occupancies are separated from other tenants and occupancies by fire barriers with at least a 1 hour fire resistance rating. Doors in such barriers are solid bonded core wood of 1 inches or equivalent and are equipped with a positive latch and closing device. Vision panels, if provided in fire barriers or doors, are fixed fire window assemblies in accordance with 8.2.3.2.2.

*Based on facility observation and staff interview and verification, the facility failed to ensure the ambulatory health care occupancies was separated from other tenants and occupancies by fire barriers with at least a 1 hour fire resistance rating. Vision panels, if provided in fire barriers were to be fixed fire window assemblies in accordance with 8.2.3.2.2. The facility had a capacity for 1061 patients with a census of 401 patients at the time of the survey completed on 11/14/13. Potentially all patients, visitors and staff could be affected.

Findings included:

1. On 11/12/13 between 11:00 A.M. and 3:40 P.M. tour of the building was conducted with Staff AA, FF and MM. An ambulatory surgery center (ASC) was located on the ground floor of the building in an atrium. The ASC contained four operating rooms and two procedure rooms. Observation of the ASC revealed the separation wall between the ASC waiting area and the atrium consisted of glass panels in a steel frame. The Underwriters Laboratory (UL) rating on the window assembly was illegible.

Observation and verification by with Staff AA and MM revealed the glass panels had no fire resistance rating. Observation of the glass panel wall from the waiting room side revealed five sprinkler heads placed less than six feet apart. The sprinklers were cosmetically concealed in the ceiling with cap covers. Each covered sprinkler head was placed approximately six inches from the window assembly. Staff present verified the placement of the sprinkler heads was to form a water curtain for the window assembly and the one hour fire resisitant barrier.

Observation of the window assembly from the atrium side revealed the presence of one concealed sprinkler head located at the inset above the door to the waiting area. There were no additional sprinkler heads located at the window assembly as observed inside the ASC. Measurement of glass panels in the window assembly that were not provided direct sprinkler protection from the atrium side were as followed; four panels of glass 37 inches wide and 89 inches high and four panels of glass above the previously mentioned panels 37 inches wide and 45 inches high, one panel 36 inches wide and 89 inches high with a panel above 36 inches wide and 45 inches high.

A second story and occupancy was above the ASC. The occupancy above the ASC also had a window assembly that formed the atrium wall. Observation of the atrium ceiling revealed three sprinkler heads, placed approximately five feet away from the second story window assembly. The sprinkler heads were cosmetically capped. Staff present verified the placement of the sprinkler heads in the atrium ceiling were approximately 10 feet apart.

Observation of the ASC window assembly and placement of sprinkler heads from the atrium side were verified again on 11/14/13 at 11;20 A.M. with Staff BB, DD and FF.

2. On 11/12/13 at 12:45 P.M. observations above the ceiling tiles with Staff AA and MM were conducted of an identified one hour fire rated separation between the ASC and the Breast Health Center. The following penetrations were noted in the one hour fire rated barrier;

Located above the ceiling tiles in the ASC waiting area, a penetration surrounding a gray IT wire and a second penetration approximately one half inch in diameter.

Located in the one hour fire rated barrier was a non-fire rated window for the breast health receptionist. Observation above the ceiling tiles at the same reception window revealed penetrations surrounding copper pipe and a black wire.

Observation above the ceiling tiles at the ASC waiting room desk, revealed a penetration approximately 12 inches long and four inches wide near a large duct.

Observation above the ceiling tiles at the endoscopy nursing station, revealed the end of the one hour fire rated barrier. The space above the ceiling was open and no additional fire rated separation was observed. Staff present verified the observation.

On 11/14/13 at 10:00 A.M., Staff BB stated the schematic for the ASC was misread and that no one hour fire rated barrier existed between the ASC and the Breast Health Center.

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

NFPA 101

Chapter 21

21.2.9.1

Emergency illumination is provided in accordance with section 7.9.

*Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency illumination was provided in accordance with section 7.9 with regards to monthly and annual testing. The facility had a capacity for 1061 patients with a census of 401 patients at the time of the survey completed on 11/14/13. Potentially all patients and staff could be affected.

Findings included:

1. On 11/12/13 between 11:00 A.M. and 3:40 P.M. tour of the building was conducted with Staff AA, FF and MM. An ambulatory surgery center (ASC) was located on the ground floor of the building in an atrium. The ASC contained four operating rooms and two procedure rooms.

Tour of the surgical area with Staff MM and OO on 11/12/13 at 2:00 P.M. revealed the presence of battery backup task lighting in both procedure rooms and four operating rooms. Review of testing documentation on 11/14/13 at 3:34 P.M. with Staff AA and DD revealed that testing dates were noted but there was no indication of the length of the testing. Further review of the documentation revealed there was no documented evidence of a 90 minute test completed in the past 12 months.

Staff AA and DD verified the facility testing documentation lacked the length of time tested each month as well when the 90 minute annual test was conducted.