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Based on observation and interview, it was determined the facility failed to maintain building construction requirements in one location, affecting one of nine smoke compartments.

Findings include:

1. Observation on November 30, 2016, at 9:51 a.m. revealed one length of unprotected structural steel within the basement-level, elevator machine room.

Exit interview with Facilities Representative one, two and three between 12:15 p.m. and 12:30 p.m. on November 30, 2016, confirmed the building construction deficiency.

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in one location, affecting one of nine smoke compartments.

Findings include:

1. Observation on November 30, 2016, at 9:51 a.m. revealed one length of unprotected structural steel within the basement-level, elevator machine room.

Exit interview with Facilities Representative one, two and three between 12:15 p.m. and 12:30 p.m. on November 30, 2016, confirmed the building construction deficiency.

Based on observation and interview, it was determined the facility failed to maintain battery-operated lighting fixtures, affecting seven of nine smoke compartments.

Findings include:

1. Observation on November 30, 2016, at 9:44 a.m. revealed the facility lacked documentation to support battery-operated lighting fixture "bleed" or drain testing on an annual basis.

Exit interview with Facilities Representative one, two and three between 12:15 p.m. and 12:30 p.m. on November 30, 2016, confirmed the facility lacked battery-operated lighting fixture ninety minute testing.

Based on observation and interview, it was determined the facility failed to install and maintain illuminated exit signage in four locations, affecting four of nine smoke compartments.

Findings include:

1. Observation on November 30, 2016, between 10:03 a.m. and 10:07 a.m. revealed the following areas lacked illuminated exit signage:

a. 10:03 a.m., basement level, main corridor, above the smoke barrier separation doors.
b. 10:04 a.m., basement level, main corridor, beyond the smoke barrier separation doors, at the stair tower entrance.
c. 10:07 a.m., within the stair tower, at the first floor level.

Exit interview with Facilities Representative one, two and three between 12:15 p.m. and 12:30 p.m. on November 30, 2016, confirmed the facility lacked illuminated exit signage in the above locations.

Based on observation and interview, it was determined the facility failed to maintain the fire alarm system, affecting nine of nine smoke compartments.

Findings include:

1. Observation on November 30, 2016, at 9:56 a.m. revealed the facility lacked the required, semi-annual, fire alarm, visual inspection data.


Exit interview with Facilities Representative one, two and three between 12:15 p.m. and 12:30 p.m. on November 30, 2016, confirmed the facility lacked the required semi-annual, visual inspection data of the fire alarm system.

Based on observation and interview, it was determined the facility failed to install and maintain the automatic sprinkler system in two locations, affecting one of nine smoke compartments.

Findings include:

1. Observation on November 30, 2016, between 10:01 a.m. and 10:12 a.m. revealed the following areas lacked complete automatic sprinkler protection:

a. 10:01 a.m., the basement level, Main Mechanical Room duct work (in excess of four feet in width) lacked automatic sprinkler protection at one end.
b. 10:12 a.m., the basement level, stair tower B stairwell lacked automatic sprinkler protection beneath the landing.

Exit interview with Facilities Representative one, two and three between 12:15 p.m. and 12:30 p.m. on November 30, 2016, confirmed the automatic sprinkler system deficiencies.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system for three of four of the preceding three month periods, affecting nine of nine smoke compartments.

Findings include:

1. Observation on November 30, 2016, at 9:29 a.m. revealed the facility lacked automatic sprinkler system testing and maintenance documentation for the following quarters: third quarter of 2016, fourth quarter of 2015, and first quarter of 2016. REPEAT DEFICIENCY.

Exit interview with Facilities Representative one, two and three between 12:15 p.m. and 12:30 p.m. on November 30, 2016, confirmed the facility lacked the required automatic sprinkler system testing and maintenance documentation.

Based on observation and interview, it was determined the facility failed to construct smoke barrier walls to provide at least a one half hour fire resistance rating in three instance affecting four of nine smoke compartments within the facility.

Findings include:

1. Observation on November 30, 2016, between 9:40 a.m. and 11:20 a.m. revealed the following:

a. 9:40 a.m., the 2nd floor smoke barrier wall lacked an end wall cap, located above the cross corridor doors at room #2004.
b. 11:10 a.m., the first floor smoke barrier separation wall was incomplete in the vicinity of the Patient Admission Office.
c. 11:20 a.m., an unsealed gap within the smoke barrier separation wall was observed within the first floor, Patient Admission Office.

Exit interview with Facilities Representatives one, two and three between 12:15 p.m. and 12:30 p.m. on November 30, 2016, confirmed the incomplete smoke barrier wall deficiencies.

Based on documentation review, observation and interview, it was determined the facility failed to conduct one of twelve required fire drills, affecting nine of nine smoke compartments.

Findings include:

1. Observation on November 30, 2016, at 9:22 a.m. revealed the facility lacked a second quarter, second shift fire drill for the 2016 calendar year. Note: "drill" of June 01, 2016, entailed a fire pump and sprinkler system test/check, which did not involve patients or staff members.

Exit interview with Facilities Representative one, two and three between 12:15 p.m. and 12:30 p.m on November 30, 2016, confirmed the facility lacked a required fire drill.

Based on observation and interview, it was determined the facility failed to maintain the piped-in medical gas system, affecting nine of nine smoke compartments.

Findings include:

1. Observation on November 30, 2016, at 9:50 a.m. revealed the facility lacked documentation to support required annual testing of medical gas alarms and display panels.


Exit interview with Facilities Representative one, two and three between 12:15 p.m. and 12:30 p.m. on November 30, 2016, confirmed the facility lacked the above documentation.

Based on observation and interview, it was determined the facility failed to maintain the generator sets (2), affecting nine of nine smoke compartments.

Findings include:

1. Observation on November 30, 2016, at 9:42 a.m. revealed the facility lacked required, weekly, battery voltage readings.


Exit interview with Facilities Representative one, two and three between 12:15 p.m. and 12:30 p.m. on November 30, 2016, confirmed the facility lacked the required battery voltage readings.

Based on observation and interview it was determined the facility failed to provide electrical wiring and equipment in one instance, affecting one of nine smoke compartments within the facility.

Findings include:

1. Observation on November 30, 2016, at 10:40 a.m. revealed bared electrical wires hanging from two smoke dampers located near the Clinic Reception entrance.

Interview with facility DON and facility representative #1 on November 7, 2016, between 12:25 p.m. and 12:35 p.m. confirmed the bared wires.