HospitalInspections.org

Based on observation and interview, the facility failed to maintain a two hour barrier between two non-conforming buildings: an existing structure and a new structure built in 2007. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 12/01/15 at 11:22 AM a tour was conducted of the second floor with Staff Q and R.

1. On 12/01/15 at 12:05 PM observation above the drop down ceiling of the two hour barrier separating the building from an addition built in 2007 revealed at the western most end of the recovery area and in the middle of bay five, an open white tip conduit holding a grey wire, and an open half inch conduit holding blue wires. Observation above the drop down ceiling of the two hour barrier near the border between bay four and five revealed an open one inch conduit holding two blue wires, and in bay four, an open white tip one inch conduit holding two blue wires. On 12/01/15 at 12:05 PM in an interview, Staff R confirmed the finding.

2. On 12/01/15 at 12:12 PM observation above the drop down ceiling of the two hour barrier separating the building from an addition built in 2007 revealed over bay one in the recovery area revealed an open white tip conduit holding two wires. On 12/01/15 at 12:12 PM in an interview, Staff R confirmed the finding.

3. On 12/01/15 at 12:20 PM observation above the drop down ceiling of the two hour barrier near the double doors to the recovery area and separating the building from an addition built in 2007 revealed an open conduit holding two blue wires. On 12/01/15 at 12:20 PM in an interview, Staff R confirmed the finding.

4. On 12/01/15 at 12:23 PM observation above the drop down ceiling of the two hour barrier in recovery room bay 10 and separating the building from an addition built in 2007 revealed an open one inch conduit holding two blue wires, and two open one inch conduits holding no wires. On 12/01/15 at 12:23 PM in an interview, Staff R confirmed the finding.

5. On 12/01/15 at 12:30 PM observation above the drop down ceiling of the two hour barrier in recovery room bay 11 and separating the building from an addition built in 2007 revealed an open one inch corrugated conduit holding a blue wire. On 12/01/15 at 12:30 PM in an interview, Staff R confirmed the finding.

On 12/01/15 at 4:05 PM a tour was taken of the first floor with Staff Q and R.

6. On 12/01/15 at 4:30 PM observation above the drop down ceiling of the two hour barrier in the chapel separating the building from an addition built in 2007 revealed over the cross a two inch by two inch square cut into the drywall holding a green corrugated conduit. On 12/01/15 at 4:30 PM in an interview, Staff R confirmed the finding.

7. On 12/01/15 at 4:35 PM observation above the drop down ceiling of the two hour barrier separating the building from an addition built in 2007 revealed in the southeast corner of the chapel a three inch conduit with a dorsal annular space. On 12/01/15 at 4:35 PM in an interview, Staff R confirmed the finding.

8. On 12/01/15 at 4:42 PM observation above the drop down ceiling of the two hour barrier separating the building from an addition built in 2007 revealed in stress laboratory one a one inch hole holding a blue wire. On 12/01/15 at 4:42 PM in an interview, Staff R confirmed the finding.

9. On 12/01/15 at 4:46 PM observation above the drop down ceiling of the two hour barrier separating the building from an addition built in 2007 revealed in the radiology office a two inch open conduit holding blue cables. On 12/01/15 at 4:46 PM in an interview, Staff R confirmed the finding.

On 12/02/15 at 4:47 PM a tour was taken of the ground floor with Staff Q and R.

10. On 12/02/15 at 5:31 PM observation over the door above the drop down ceiling of the two hour barrier that separated the building from a medical office building revealed an open two inch conduit holding blue wiring and one two inch conduit holding multiple lines and having fire stopping material off to the side. On the west side of the door, a one inch conduit was traveling through a two inch penetration. On 12/02/15 at 5:31 PM in an interview, Staff R confirmed the findings.

Based on observation and interview, the facility failed to ensure the corridor walls in a non-sprinklered area extended above the ceiling to the floor above. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 12/01/15 at 9:06 AM a tour of the third floor was conducted with Staff Q and R.

On 12/01/15 at 10:14 AM observation of the floor revealed it did not have sprinklers. Observation of the wall around the floor's nursing station revealed it was part of the floors corridor system. However, observation above the drop down ceiling revealed said wall did not extend above the drop down ceiling to the floor above. On 12/01/15 at 10:14 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure doors protecting corridor openings were free of penetrations and those with latching hardware closed and latched. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 12/01/15 at 4:05 PM a tour was taken of the first floor with Staff Q and R.

On 12/01/15 at 5:00 PM observation of emergency department corridor doors to trauma rooms one, two, and three revealed they had latching hardware that did not close and latch the doors. On 12/01/15 at 5:00 PM in an interview, Staff R confirmed the finding.

On 12/03/15 at 12:38 PM observation of the corridor door to the room of the main drain of the dry sprinkler system was observed to have four quarter inch holes at the top. On 12/03/15 at 12:38 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure doors protecting corridor openings were free of penetrations, were able to be closed and latched if they had latching hardware, and were undercut by no more than one inch. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 11/30/15 at 1:38 PM a tour was taken of the fifth floor with Staff Q and S.

1.On 11/30/15 at 2:07 PM observation of the corridor doors to the unisex, staff, and public bathrooms in the northern smoke compartment revealed each door to have two half inch holes in them. On 11/30/15 at 2:07 PM in an interview, Staff Q confirmed the finding.

On 11/30/15 at 3:34 PM a tour was taken of the fourth floor with Staff Q and S.

2. On 11/30/15 at 4:45 PM observation of the corridor door to room 422 revealed it was warped and could not be closed. On 11/30/15 at 4:45 PM in an interview, Staff Q confirmed the finding.

3. On 11/30/15 at 5:15 PM observation of a corridor door to room 411 revealed it had latching hardware that did not close and latch. On 11/30/15 at 5:15 PM in an interview, Staff Q confirmed the finding.

4. On 12/01/15 at 8:57 AM observation on the fifth floor of the "personnel only" room next to shower 1 room revealed the door to the "personnel only" room was located in a corridor and undercut by two inches. Observation within the "personnel only" room revealed it was being used to hold soiled linen. On 12/01/15 at 8:57 AM in an interview, Staff Q confirmed the finding.

5. On 12/01/15 at 9:03 AM observation of the fourth floor shower 1 room revealed its door was located in a corridor and was undercut by two inches. Observation within revealed it was being used for soiled linen. On 12/01/15 at 9:03 AM in an interview, Staff Q confirmed the finding.

On 12/01/15 at 9:06 AM a tour of the third floor was conducted with Staff Q and R.

6. On 12/01/15 at 10:22 AM observation of the door to the amalgamated food and allied workers room revealed it was in a corridor and was undercut by two inches. Observation within the room revealed it was being used for general storage (combustibles). On 12/01/15 at 10:22 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure vertical penetrations between floors in a type II (2,2,2) building were enclosed with construction having a fire resistive rating of at least one hour. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 11/30/15 at 1:36 PM a tour was taken of the penthouse with Staff Q and S.

1. On 11/30/15 at 1:36 PM observation within the electrical closet revealed an open two inch conduit that traveled through the floor and held blue wires. On 11/30/15 at 1:36 PM in an interview, Staff Q confirmed the finding.

On 11/30/15 at 1:38 PM a tour was taken of the fifth floor with Staff Q and S.

2. On 11/30/15 at 1:48 PM observation within the electrical closet revealed green and blue wiring running through a two inch opening in the floor with fire resistive foam lying off and to the side of the penetration. On 11/30/15 at 1:48 PM in an interview, Staff Q confirmed the finding.

3. On 11/30/15 at 2:36 PM observation within the electrical closet in the geriatric psychiatric unit revealed a open one foot by one foot panel exposing one open half inch vertical conduit that traveled between the floors, and another open half inch conduit traveling through the one hour barrier. On 11/30/15 at 2:36 PM in an interview, Staff Q confirmed the finding.

On 11/30/15 at 3:34 PM a tour was taken of the fourth floor with Staff Q and S.

4. On 11/30/15 at 3:53 PM observation of the electrical closet in the cardiac care waiting area revealed within a one inch open conduit traveling through the ceiling to the floor above. On 11/30/15 at 3:53 PM in an interview, Staff Q confirmed the finding.

5. On 11/30/15 at 4:35 PM observation within the electrical closet near the double doors that lead to the medical surgical units revealed an open cable TV junction box containing an open one inch conduit that traveled between the floor and ceiling. On 11/30/15 at 4:35 PM in an interview, Staff Q confirmed the finding.

On 12/01/15 at 9:06 AM a tour of the third floor was conducted with Staff Q and R.

6. On 12/01/15 at 9:28 AM observation of the ceiling in the electrical closet across from the bathrooms revealed copper lines having annular spaces as they traveled through the ceiling. On 12/01/15 at 9:28 AM in an interview, Staff Q confirmed the finding.

On 12/02/15 at 4:47 PM a tour was taken of the ground floor with Staff Q and R.

7. On 12/02/15 at 4:50 PM observation in the electrical closet revealed an open communication box with two open one inch conduits traveling through the ceiling. On 12/02/15 at 4:50 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to maintain the rating of its smoke barriers. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 11/30/15 at 1:38 PM a tour was taken of the fifth floor with Staff Q and S.

1.On 11/30/15 at 2:29 PM observation above the drop down ceiling of the one hour smoke barrier over the east side of the double doors leading to the psychiatric unit revealed red, green, and white wires running through a one and a half inch penetration. On 11/30/15 at 2:29 PM in an interview, Staff Q confirmed the finding.

2. On 11/30/15 at 2:45 PM observation above the drop down ceiling between rooms 512 and 513 revealed a conduit traveling from the south one hour barrier to an open junction box and on to the north one hour barrier.

3. On the same date and time, observation above the drop down ceiling also revealed a green line traveling through a one inch penetration in the one hour barrier to the left of room 513. On 11/30/15 at 2:45 PM in an interview, Staff Q confirmed the findings.

4. On 11/30/15 at 2:53 PM observation above the drop down ceiling of the one hour barrier near room 512 revealed a blue line traveling through an open one inch barrier. On 11/30/15 at 2:53 PM in an interview, Staff Q confirmed the finding.

On 11/30/15 at 3:34 PM a tour was taken of the fourth floor with Staff Q and S.

5. On 11/30/15 at 4:32 PM observation above the drop down ceiling of the one hour barrier in the southeast portion of the elevator lobby and near the "floor 4" placard revealed a one and a half inch penetration. On 11/30/15 at 4:32 PM in an interview, Staff Q confirmed the finding.

6. On 11/30/15 at 4:39 PM observation above the drop down ceiling of the one hour barrier at room 413 revealed an open corrugated conduit traveling from room 413 and across the corridor above the drop down ceiling. On 11/30/15 at 4:39 PM in an interview, Staff Q confirmed the finding.

7. On 11/30/15 at 5:00 PM observation above the drop down ceiling of the one hour barrier in the locker room near the elevator/stair lobby revealed over the door green, blue, white, and orange wires traveling through a two inch hole, perpendicular to that an oval shaped penetration in the dry wall holding a one inch conduit, and near that an open penetration holding black wires and an orange flexi conduit. On 11/30/15 at 5:00 PM in an interview, Staff Q confirmed the finding.

On 12/01/15 at 9:06 AM a tour of the third floor was conducted with Staff Q and R.

8. On 12/01/15 at 9:37 AM observation above the drop down ceiling of the one hour barrier over the door to the obstetrical physician lounge and next to the service elevator revealed an open one inch metal sleeve holding blue wires. On 12/01/15 at 9:37 AM in an interview, Staff R confirmed the finding.

9. On 12/01/15 at 9:47 AM observation of the one hour barrier in the information technology closet in the physician lounge revealed a steel sleeve holding a copper line. Between the sleeve and the copper line an annular space was observed. On 12/01/15 at 9:47 AM in an interview, Staff Q confirmed the finding.


On 12/01/15 at 11:22 AM a tour was conducted of the second floor with Staff Q and R.

10. On 12/01/15 at 11:41 AM observation above the drop down ceiling of the one hour barrier near the operating room staff break room revealed a one inch conduit with an annular space. On 12/01/15 at 11:41 AM in an interview, Staff R confirmed the finding.

11. On 12/01/15 at 11:44 AM observation above the drop down ceiling of the one hour barrier by the service elevator and over the surgical office door revealed a one inch penetration. On 12/01/15 at 11:44 AM in an interview, Staff R confirmed the finding.

12. On 12/01/15 at 11:59 AM observation above the drop down ceiling of the one hour barrier to the left of the double doors to the recovery area revealed an open conduit holding a speaker wire. On 12/01/15 at 11:59 AM in an interview, Staff R confirmed the finding.

13. On 12/01/15 at 2:31 PM observation above the drop down ceiling of the two hour barrier over the double doors opposite operating room five revealed a one foot by six inch penetration with four copper lines running through it. On 12/01/15 at 2:31 PM in an interview, Staff R confirmed the finding.

14. On 12/01/15 at 2:32 PM observation of the doors to operating room six revealed they were in a two hour barrier and had a 7/16th inch gap between them. On 12/01/15 at 2:32 PM in an interview, Staff R confirmed the finding.

15. On 12/01/15 at 2:42 PM observation above the drop down ceiling of the two hour barrier over the double doors to the operating room area revealed two flex conduits traveling from the barrier to a junction box with a missing knock out. On 12/01/15 at 2:42 PM in an interview, Staff R confirmed the finding.

16. On 12/01/15 at 2:44 PM observation above the drop down ceiling of two one hour barriers perpendicular to the two hour barrier near the same set of double doors revealed a white tip open conduit holding a grey wire and communicating across the corridor to each other. On 12/01/15 at 2:44 PM in an interview, Staff R confirmed the finding.

17. On 12/01/15 at 2:55 PM observation above the drop down ceiling of the one hour barrier surrounding the room between operating rooms 7 and 8 revealed in the middle of the north, west, and east walls six inch penetrations holding blue wiring, and in the west and east walls an open one inch conduit holding a blue wire. On 12/01/15 at 2:55 PM in an interview, Staff R confirmed the finding.

18. On 12/01/15 at 3:16 PM observation of the two hour barrier in the electrical closet in the 2000 operating room addition revealed a one inch square cut into the drywall. On 12/01/15 at 3:16 PM in an interview, Staff R confirmed the finding.

19. On 12/01/15 at 5:41 PM observation above the drop down ceiling of the two hour barrier in back of the café storage area revealed six metal conduits traveling through an open six inch by one foot rectangle. On 12/01/15 at 5:41 PM in an interview, Staff R confirmed the finding.

20. On 12/01/15 at 5:45 PM observation above the drop down ceiling of the two hour barrier in the café over the silver wear revealed a corrugated conduit traveling through a two inch penetration and a half inch opening holding a black and white wire. On 12/01/15 at 5:45 PM in an interview, Staff R confirmed the finding.

Based on observation and interview, the facility failed to ensure doors in rated barriers were either rated or at least 1.75 inch thick solid bonded core wood, had self closing and latching hardware that closed and latched, or coordinated such that an astragal didn't prevent double doors from closing. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 11/30/15 at 1:38 PM a tour was taken of the fifth floor with Staff Q and S.

1.On 11/30/15 at 2:24 PM observation of the door in a one hour smoke barrier to the phone closet was observed to be unrated and made of steel. On 11/30/15 at 2:24 PM in an interview, Staff Q confirmed the finding.

2. On 11/30/15 at 2:38 PM observation of the doors to rooms 512 and 513 revealed each to be in a one hour barrier without self closers but with half to one quarter inch hole penetrations in each where a self closer or other apparatus may have been. On 11/30/15 at 2:38 PM in an interview, Staff Q confirmed the finding.

On 11/30/15 at 3:34 PM a tour was taken of the fourth floor with Staff Q and S.

3. On 11/30/15 at 4:23 PM observation of the door to the telephone closet, perpendicular to the double doors leading to the medical surgical units, and in a one hour barrier revealed it to be made of metal and unrated. On 11/30/15 at 4:23 PM in an interview, Staff Q confirmed the finding.

4. On 11/30/15 at 4:25 PM observation of the double doors perpendicular to the door to the electrical closet revealed they were in a one hour barrier and had self closing and latching hardware. However, when tested, the hardware did not self close and latch the doors. On 11/30/15 at 4:25 PM in an interview, Staff Q confirmed the finding.

5. On 11/30/15 at 4:38 PM observation of the door to room 413 revealed it was in a one hour barrier and had a self closer with latching hardware. When tested, the door did not self close and latch. On 11/30/15 at 4:38 PM in an interview, Staff Q confirmed the finding.

On 12/01/15 at 9:06 AM a tour of the third floor was conducted with Staff Q and R.

6. On 12/01/15 at 9:31 AM observation of the double doors leading to the obstetrical unit revealed they were in a one hour barrier, had latching hardware, and had a rubber astragal. When tested, the doors did not have a coordinator to prevent the astragal from preventing the doors to close and latch. On 12/01/15 at 9:31 AM in an interview, Staff Q confirmed the finding.

7. On 12/01/15 at 10:32 AM observation of the door to the phone closet revealed it was unrated, made of metal, and located within a one hour rated barrier. On 12/01/15 at 10:32 AM in an interview, Staff Q confirmed the finding.

On 12/01/15 at 11:22 AM a tour was conducted of the second floor with Staff Q and R.

8. On 12/01/15 at 2:49 PM observation of double doors in a one hour barrier across from operating room 8 revealed they had an astragal but not a means to prevent the astragal from stopping the double doors from closing and latching. On 12/01/15 at 2:49 PM in an interview, Staff Q confirmed the finding.

9. On 12/01/15 at 3:04 PM observation of the soiled utility room door in the one hour barrier in the operating room revealed it had latching hardware that did not close and latch the door. On 12/01/15 at 3:04 PM in an interview, Staff Q confirmed the finding.

10. On 12/01/15 at 3:06 PM observation above the drop down ceiling of the one hour barrier in the soiled utility room revealed a 1.5 inch by 1.5 inch square cut into the drywall above the hopper. On 12/01/15 at 3:06 PM in an interview, Staff R confirmed the finding.

11. On 12/01/15 at 3:12 PM observation above the drop down ceiling of the two hour barrier opposite the anesthesia office revealed a one inch penetration holding grey wires. On 12/01/15 at 3:12 PM in an interview, Staff R confirmed the finding.


12. On 12/01/15 at 3:53 PM observation of the door to room 213 and in a one hour barrier revealed it had a self closer with latching hardware that when tested did not self close and latch. On 12/01/15 at 3:53 PM in an interview, Staff Q confirmed the finding.

On 12/02/15 at 4:47 PM a tour was taken of the ground floor with Staff Q and R.

13. On 12/02/15 at 4:47 PM the door to the food and nutrition services office was observed to be metal and in a two hour barrier. It was not observed to have a rating. On 12/02/15 at 4:47 in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure doors to hazardous areas were self closing. This has the potential to affect all patients receiving services at the facility.

Findings include:

On 12/02/15 at 3:50 PM a tour was taken of the facility with Staff Q and R.

On 12/02/15 at 3:53 PM observation of the door to the soiled linen room revealed it had latching hardware that did not close and latch. On 12/02/15 at 3:53 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to maintain the stated rating of the barriers protecting its hazardous areas, failed to ensure doors protecting hazardous areas self closed, and failed to ensure astragals didn't stop double doors from closing. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 12/30/15 at 3:30 PM a tour was taken of the fourth floor with Staff Q and S.

1.On 11/30/15 at 3:56 PM observation of the double doors in a two hour rated barrier leading to the air handler mechanical space revealed the left (upon entering) door was on a self closer but the top of it would rub and stick to the heating, ventilation and cooling ducting above it. On 11/30/15 at 3:56 PM in an interview, Staff Q confirmed the finding.

2. On 11/30/15 at 3:58 PM observation of the two hour rated barrier protecting a mechanical space holding air handler units revealed in the barrier perpendicular to the entrance an oval/periscope shaped opening in the conduit that traveled through the barrier was without a cover. On 11/30/15 at 3:58 PM in an interview, Staff Q confirmed the finding.

3. On 11/30/15 at 4:01 PM observation of the two hour rated barrier protecting a mechanical space holding air handler units revealed in the most southerly west wall and located between two heating, ventilation and cooling ducts, a one inch conduit with an annular space. On 11/30/15 at 4:01 PM in an interview, Staff Q confirmed the finding.

4. On 11/30/15 at 4:07 PM observation of the two hour rated barrier that protects a mechanical space that holds air handler units and is perpendicular to the service elevator within, revealed traveling from the barrier and parallel to the elevator, a one inch conduit traveled to an open conduit. On 11/30/15 at 4:07 PM in an interview, Staff Q confirmed the finding.

On 12/02/15 at 4:47 PM a tour was conducted of the ground floor with Staff Q and R.

5. On 12/02/15 at 5:03 PM observation of the door to the soiled utility room revealed it was in a two hour barrier and had a self closer with latching hardware that when tested did not close and latch the door. On 12/02/15 at 5:03 PM in an interview, Staff Q confirmed the finding.

6. On 12/02/15 at 5:05 PM observation of the other door to the soiled utility room revealed it was metallic, unrated, in a two hour rated barrier, and had a self closer with latching hardware that when tested did not close and latch the door. On 12/02/15 at 5:05 PM in an interview, Staff Q confirmed the finding.

On 12/03/15 at 9:20 AM a tour was taken of the generator room with Staff Q and R.

7. On 12/03/15 at 9:20 AM observation of the room's double doors revealed they were in a two hour barrier but without a means of coordination, would not close together. On 12/03/15 at 9:20 AM in an interview, Staff Q confirmed the finding.

8. On 12/03/15 at 9:32 AM observation of the double doors to the magnetic resonance imaging suite revealed they were in a two hour barrier but without a means of coordination would not close together. On 12/03/15 at 9:32 AM in an interview, Staff Q confirmed the finding.

9. On 12/03/15 at 9:35 AM the door to the magnetic resonance imaging waiting area was observed in a two hour barrier with self closing and latching hardware that did not close and latch the doors. On 12/03/15 at 9:35 AM in an interview, Staff R confirmed the finding.

Based on observation and interview, the facility failed to maintain the protective rating of each of its exit components. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 12/01/15 at 11:22 AM a tour was conducted of the second floor with Staff Q and R.

On 12/01/15 at 3:24 PM a one inch penetration was observed in the two hour barrier over the exit stair door near the pharmacy. On 12/01/15 at 3:24 PM in an interview, Staff R confirmed the finding.

Based on observation and interview, the facility failed to have its emergency lighting comply with National Fire Protection Association 101, Chapter 7.9.3. This has the potential to affect all patients at the sleep center.

Findings include:

On 12/03/15 at 7:45 AM a tour was taken of the sleep study building with Staff Q and R. During the tour emergency battery operated lighting was observed.

On 12/03/15 a review of the facility's life safety code documentation was completed. It did not reveal where, how often, and how long the emergency lighting had been tested.

On 12/03/15 at 3:02 PM in an interview, Staff R confirmed he/she did not have documentation for testing of the emergency lighting.

Based on record review and interview, the facility failed to ensure its fire drills were held at unexpected times under varying conditions. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 12/03/15 a review of the facility's life safety code documentation was completed.

A review of the fire drill documentation revealed fire drills were conducted on 03/11/15 at 12:30 AM, on 06/06/15 at 12:36 AM, and on 09/09/15 at 12:30 AM. On 12/03/15 at 3:02 PM in an interview, Staff Q and R confirmed the timing of the third shift fire drills.

Based on observation, interview, and record review, the facility failed to ensure its fire alarm system complied with National Fire Protection Association 72, 7-3, 1999edition. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 12/03/15 a review of the life safety code documentation was completed. The review revealed the facility's fire alarm was tested on 09/18/15. The review revealed smoke detector m4-46 at the second floor nursing station and pull station m2-93 at the fourth floor nurse's station were marked as "can't find".

On 12/03/15 at 12:27 PM the surveyor, Staff Q and R were able to find both devices.

On 12/03/15 at 12:27 PM in an interview, Staff Q said he/she didn't know why the inspector couldn't find the devices or why he/she did not ask for staff assistance to locate and test the devices.

Based on observation and interview, the facility failed to ensure its sprinklers were tested in accordance with National Fire Protection Association 25, 9-3.4.2, 1999 edition. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.
Findings include:

On 12/03/15 a review of the facility's life safety code documentation was completed. The review revealed the last time the facility's main drain test for its dry sprinkler system was completed on 06/27/14.

On 12/03/15 at 1:58 PM in an interview, Staff R was unable to find evidence of a more recent test of the facility's dry sprinkler system.

Based on observation and interview, the facility failed to maintain its sprinkler system in accordance with National Fire Protection Association 25, 1999 edition. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

1.On 12/03/15 at 8:45 AM a tour was taken of the facility's sprinkler pump room. During the tour spare sprinkler heads of the type used in the building could not be found.
On 12/03/15 at 9:03 AM Staff Q located some heads in a dark colored tin can in the pump room. The heads are observed to be coated in dust.

2. On 12/03/15 a review of the facility's life safety code documentation was completed. The review revealed the last time the sprinkler system was inspected, on 09/22/15, the report stated, "Main drain piping need replaced (leaking during inspection) ... "

On 12/03/15 at 1:33 PM Staff R said in an interview he/she thought the piping had been fixed, found an invoice dated 05/27/15 (four months prior to the inspection) for fixing piping, but could not explain why the inspection report still said the piping was leaking.

Based on observation and interview, the facility failed to ensure its fire extinguisher complied with National Fire Protection Association 10, Chapter 4-4, 1999 edition. This has the potential to affect all patients who use the sleep center.

Findings include:

On 12/03/15 at 7:45 AM a tour was taken of the sleep study building with Staff Q and R.

On 12/03/15 at 7:50 AM the fire extinguisher was observed to have last had its annual maintenance in June, 2014. On 12/03/15 at 7:50 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure its fire extinguishers complied with National Fire Protection Association 10, 1-6, 1999 edition. This has the potential to affect all patients receiving services at this facility.

Findings include:

On 12/02/15 at 3:50 PM a tour was taken of the facility with Staff Q and R.

On 12/02/15 at 4:07 PM observation of the waiting area revealed a large green plant (about the size of a person) obstructing the fire extinguisher. On 12/02/15 at 4:07 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to comply with National Fire Protection Association 99, 1999 edition, at 4-3.1.2.3(d), for not having an intervening wall between a zone shut off valve and the outlets it serves. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 12/01/15 at 11:22 AM a tour was conducted of the second floor with Staff Q and R.

On 12/01/15 at 1:37 PM observation of the same day surgical area revealed two areas containing two chairs each. Each chair was observed to be for patient use and had medical gas outlets at each chair. The shut off valves for these areas was observed across the corridors from the chairs and without any intervening wall between. On 12/01/15 at 1:37 PM in an interview, Staff Q confirmed the finding.

Based on record review and interview, the facility failed to ensure its Essential Electrical System complied with National Fire Protection Association 110, 6-4. This has the potential to affect all patients receiving services at the facility.

Findings include:

On 12/03/15 a review of the facility's life safety code documentation was completed. The review did not reveal where the generator had been inspected on a weekly basis.

On 12/03/15 at 12:00 PM in an interview, Staff R explained that the work order for the weekly inspections are created at the beginning of the month, and then closed at the end of the month. He/she said there is no way to determine if the work was actually done on a weekly basis.

Based on observation and interview, the facility failed to ensure lighting in its c-section room complied with National Fire Protection Association 99, 3-3.2.1.2. This has the potential to affect all patients receiving services at the facility.

Findings include:

On 12/01/15 at 9:06 AM a tour of the third floor was conducted with Staff Q and R.

On 12/01/15 at 10:43 AM observation of the emergency, battery-operated lighting in the c-section room revealed it did not illuminate when electricity was lost. On 12/01/15 at 10:43 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to maintain a two hour barrier between two non-conforming buildings: an existing structure and a new structure built in 2007. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 12/01/15 at 11:22 AM a tour was conducted of the second floor with Staff Q and R.

1. On 12/01/15 at 12:05 PM observation above the drop down ceiling of the two hour barrier separating the building from an addition built in 2007 revealed at the western most end of the recovery area and in the middle of bay five, an open white tip conduit holding a grey wire, and an open half inch conduit holding blue wires. Observation above the drop down ceiling of the two hour barrier near the border between bay four and five revealed an open one inch conduit holding two blue wires, and in bay four, an open white tip one inch conduit holding two blue wires. On 12/01/15 at 12:05 PM in an interview, Staff R confirmed the finding.

2. On 12/01/15 at 12:12 PM observation above the drop down ceiling of the two hour barrier separating the building from an addition built in 2007 revealed over bay one in the recovery area revealed an open white tip conduit holding two wires. On 12/01/15 at 12:12 PM in an interview, Staff R confirmed the finding.

3. On 12/01/15 at 12:20 PM observation above the drop down ceiling of the two hour barrier near the double doors to the recovery area and separating the building from an addition built in 2007 revealed an open conduit holding two blue wires. On 12/01/15 at 12:20 PM in an interview, Staff R confirmed the finding.

4. On 12/01/15 at 12:23 PM observation above the drop down ceiling of the two hour barrier in recovery room bay 10 and separating the building from an addition built in 2007 revealed an open one inch conduit holding two blue wires, and two open one inch conduits holding no wires. On 12/01/15 at 12:23 PM in an interview, Staff R confirmed the finding.

5. On 12/01/15 at 12:30 PM observation above the drop down ceiling of the two hour barrier in recovery room bay 11 and separating the building from an addition built in 2007 revealed an open one inch corrugated conduit holding a blue wire. On 12/01/15 at 12:30 PM in an interview, Staff R confirmed the finding.

On 12/01/15 at 4:05 PM a tour was taken of the first floor with Staff Q and R.

6. On 12/01/15 at 4:30 PM observation above the drop down ceiling of the two hour barrier in the chapel separating the building from an addition built in 2007 revealed over the cross a two inch by two inch square cut into the drywall holding a green corrugated conduit. On 12/01/15 at 4:30 PM in an interview, Staff R confirmed the finding.

7. On 12/01/15 at 4:35 PM observation above the drop down ceiling of the two hour barrier separating the building from an addition built in 2007 revealed in the southeast corner of the chapel a three inch conduit with a dorsal annular space. On 12/01/15 at 4:35 PM in an interview, Staff R confirmed the finding.

8. On 12/01/15 at 4:42 PM observation above the drop down ceiling of the two hour barrier separating the building from an addition built in 2007 revealed in stress laboratory one a one inch hole holding a blue wire. On 12/01/15 at 4:42 PM in an interview, Staff R confirmed the finding.

9. On 12/01/15 at 4:46 PM observation above the drop down ceiling of the two hour barrier separating the building from an addition built in 2007 revealed in the radiology office a two inch open conduit holding blue cables. On 12/01/15 at 4:46 PM in an interview, Staff R confirmed the finding.

On 12/02/15 at 4:47 PM a tour was taken of the ground floor with Staff Q and R.

10. On 12/02/15 at 5:31 PM observation over the door above the drop down ceiling of the two hour barrier that separated the building from a medical office building revealed an open two inch conduit holding blue wiring and one two inch conduit holding multiple lines and having fire stopping material off to the side. On the west side of the door, a one inch conduit was traveling through a two inch penetration. On 12/02/15 at 5:31 PM in an interview, Staff R confirmed the findings.

Based on observation and interview, the facility failed to ensure the corridor walls in a non-sprinklered area extended above the ceiling to the floor above. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 12/01/15 at 9:06 AM a tour of the third floor was conducted with Staff Q and R.

On 12/01/15 at 10:14 AM observation of the floor revealed it did not have sprinklers. Observation of the wall around the floor's nursing station revealed it was part of the floors corridor system. However, observation above the drop down ceiling revealed said wall did not extend above the drop down ceiling to the floor above. On 12/01/15 at 10:14 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure doors protecting corridor openings were free of penetrations and those with latching hardware closed and latched. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 12/01/15 at 4:05 PM a tour was taken of the first floor with Staff Q and R.

On 12/01/15 at 5:00 PM observation of emergency department corridor doors to trauma rooms one, two, and three revealed they had latching hardware that did not close and latch the doors. On 12/01/15 at 5:00 PM in an interview, Staff R confirmed the finding.

On 12/03/15 at 12:38 PM observation of the corridor door to the room of the main drain of the dry sprinkler system was observed to have four quarter inch holes at the top. On 12/03/15 at 12:38 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure doors protecting corridor openings were free of penetrations, were able to be closed and latched if they had latching hardware, and were undercut by no more than one inch. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 11/30/15 at 1:38 PM a tour was taken of the fifth floor with Staff Q and S.

1.On 11/30/15 at 2:07 PM observation of the corridor doors to the unisex, staff, and public bathrooms in the northern smoke compartment revealed each door to have two half inch holes in them. On 11/30/15 at 2:07 PM in an interview, Staff Q confirmed the finding.

On 11/30/15 at 3:34 PM a tour was taken of the fourth floor with Staff Q and S.

2. On 11/30/15 at 4:45 PM observation of the corridor door to room 422 revealed it was warped and could not be closed. On 11/30/15 at 4:45 PM in an interview, Staff Q confirmed the finding.

3. On 11/30/15 at 5:15 PM observation of a corridor door to room 411 revealed it had latching hardware that did not close and latch. On 11/30/15 at 5:15 PM in an interview, Staff Q confirmed the finding.

4. On 12/01/15 at 8:57 AM observation on the fifth floor of the "personnel only" room next to shower 1 room revealed the door to the "personnel only" room was located in a corridor and undercut by two inches. Observation within the "personnel only" room revealed it was being used to hold soiled linen. On 12/01/15 at 8:57 AM in an interview, Staff Q confirmed the finding.

5. On 12/01/15 at 9:03 AM observation of the fourth floor shower 1 room revealed its door was located in a corridor and was undercut by two inches. Observation within revealed it was being used for soiled linen. On 12/01/15 at 9:03 AM in an interview, Staff Q confirmed the finding.

On 12/01/15 at 9:06 AM a tour of the third floor was conducted with Staff Q and R.

6. On 12/01/15 at 10:22 AM observation of the door to the amalgamated food and allied workers room revealed it was in a corridor and was undercut by two inches. Observation within the room revealed it was being used for general storage (combustibles). On 12/01/15 at 10:22 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure vertical penetrations between floors in a type II (2,2,2) building were enclosed with construction having a fire resistive rating of at least one hour. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 11/30/15 at 1:36 PM a tour was taken of the penthouse with Staff Q and S.

1. On 11/30/15 at 1:36 PM observation within the electrical closet revealed an open two inch conduit that traveled through the floor and held blue wires. On 11/30/15 at 1:36 PM in an interview, Staff Q confirmed the finding.

On 11/30/15 at 1:38 PM a tour was taken of the fifth floor with Staff Q and S.

2. On 11/30/15 at 1:48 PM observation within the electrical closet revealed green and blue wiring running through a two inch opening in the floor with fire resistive foam lying off and to the side of the penetration. On 11/30/15 at 1:48 PM in an interview, Staff Q confirmed the finding.

3. On 11/30/15 at 2:36 PM observation within the electrical closet in the geriatric psychiatric unit revealed a open one foot by one foot panel exposing one open half inch vertical conduit that traveled between the floors, and another open half inch conduit traveling through the one hour barrier. On 11/30/15 at 2:36 PM in an interview, Staff Q confirmed the finding.

On 11/30/15 at 3:34 PM a tour was taken of the fourth floor with Staff Q and S.

4. On 11/30/15 at 3:53 PM observation of the electrical closet in the cardiac care waiting area revealed within a one inch open conduit traveling through the ceiling to the floor above. On 11/30/15 at 3:53 PM in an interview, Staff Q confirmed the finding.

5. On 11/30/15 at 4:35 PM observation within the electrical closet near the double doors that lead to the medical surgical units revealed an open cable TV junction box containing an open one inch conduit that traveled between the floor and ceiling. On 11/30/15 at 4:35 PM in an interview, Staff Q confirmed the finding.

On 12/01/15 at 9:06 AM a tour of the third floor was conducted with Staff Q and R.

6. On 12/01/15 at 9:28 AM observation of the ceiling in the electrical closet across from the bathrooms revealed copper lines having annular spaces as they traveled through the ceiling. On 12/01/15 at 9:28 AM in an interview, Staff Q confirmed the finding.

On 12/02/15 at 4:47 PM a tour was taken of the ground floor with Staff Q and R.

7. On 12/02/15 at 4:50 PM observation in the electrical closet revealed an open communication box with two open one inch conduits traveling through the ceiling. On 12/02/15 at 4:50 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to maintain the rating of its smoke barriers. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 11/30/15 at 1:38 PM a tour was taken of the fifth floor with Staff Q and S.

1.On 11/30/15 at 2:29 PM observation above the drop down ceiling of the one hour smoke barrier over the east side of the double doors leading to the psychiatric unit revealed red, green, and white wires running through a one and a half inch penetration. On 11/30/15 at 2:29 PM in an interview, Staff Q confirmed the finding.

2. On 11/30/15 at 2:45 PM observation above the drop down ceiling between rooms 512 and 513 revealed a conduit traveling from the south one hour barrier to an open junction box and on to the north one hour barrier.

3. On the same date and time, observation above the drop down ceiling also revealed a green line traveling through a one inch penetration in the one hour barrier to the left of room 513. On 11/30/15 at 2:45 PM in an interview, Staff Q confirmed the findings.

4. On 11/30/15 at 2:53 PM observation above the drop down ceiling of the one hour barrier near room 512 revealed a blue line traveling through an open one inch barrier. On 11/30/15 at 2:53 PM in an interview, Staff Q confirmed the finding.

On 11/30/15 at 3:34 PM a tour was taken of the fourth floor with Staff Q and S.

5. On 11/30/15 at 4:32 PM observation above the drop down ceiling of the one hour barrier in the southeast portion of the elevator lobby and near the "floor 4" placard revealed a one and a half inch penetration. On 11/30/15 at 4:32 PM in an interview, Staff Q confirmed the finding.

6. On 11/30/15 at 4:39 PM observation above the drop down ceiling of the one hour barrier at room 413 revealed an open corrugated conduit traveling from room 413 and across the corridor above the drop down ceiling. On 11/30/15 at 4:39 PM in an interview, Staff Q confirmed the finding.

7. On 11/30/15 at 5:00 PM observation above the drop down ceiling of the one hour barrier in the locker room near the elevator/stair lobby revealed over the door green, blue, white, and orange wires traveling through a two inch hole, perpendicular to that an oval shaped penetration in the dry wall holding a one inch conduit, and near that an open penetration holding black wires and an orange flexi conduit. On 11/30/15 at 5:00 PM in an interview, Staff Q confirmed the finding.

On 12/01/15 at 9:06 AM a tour of the third floor was conducted with Staff Q and R.

8. On 12/01/15 at 9:37 AM observation above the drop down ceiling of the one hour barrier over the door to the obstetrical physician lounge and next to the service elevator revealed an open one inch metal sleeve holding blue wires. On 12/01/15 at 9:37 AM in an interview, Staff R confirmed the finding.

9. On 12/01/15 at 9:47 AM observation of the one hour barrier in the information technology closet in the physician lounge revealed a steel sleeve holding a copper line. Between the sleeve and the copper line an annular space was observed. On 12/01/15 at 9:47 AM in an interview, Staff Q confirmed the finding.


On 12/01/15 at 11:22 AM a tour was conducted of the second floor with Staff Q and R.

10. On 12/01/15 at 11:41 AM observation above the drop down ceiling of the one hour barrier near the operating room staff break room revealed a one inch conduit with an annular space. On 12/01/15 at 11:41 AM in an interview, Staff R confirmed the finding.

11. On 12/01/15 at 11:44 AM observation above the drop down ceiling of the one hour barrier by the service elevator and over the surgical office door revealed a one inch penetration. On 12/01/15 at 11:44 AM in an interview, Staff R confirmed the finding.

12. On 12/01/15 at 11:59 AM observation above the drop down ceiling of the one hour barrier to the left of the double doors to the recovery area revealed an open conduit holding a speaker wire. On 12/01/15 at 11:59 AM in an interview, Staff R confirmed the finding.

13. On 12/01/15 at 2:31 PM observation above the drop down ceiling of the two hour barrier over the double doors opposite operating room five revealed a one foot by six inch penetration with four copper lines running through it. On 12/01/15 at 2:31 PM in an interview, Staff R confirmed the finding.

14. On 12/01/15 at 2:32 PM observation of the doors to operating room six revealed they were in a two hour barrier and had a 7/16th inch gap between them. On 12/01/15 at 2:32 PM in an interview, Staff R confirmed the finding.

15. On 12/01/15 at 2:42 PM observation above the drop down ceiling of the two hour barrier over the double doors to the operating room area revealed two flex conduits traveling from the barrier to a junction box with a missing knock out. On 12/01/15 at 2:42 PM in an interview, Staff R confirmed the finding.

16. On 12/01/15 at 2:44 PM observation above the drop down ceiling of two one hour barriers perpendicular to the two hour barrier near the same set of double doors revealed a white tip open conduit holding a grey wire and communicating across the corridor to each other. On 12/01/15 at 2:44 PM in an interview, Staff R confirmed the finding.

17. On 12/01/15 at 2:55 PM observation above the drop down ceiling of the one hour barrier surrounding the room between operating rooms 7 and 8 revealed in the middle of the north, west, and east walls six inch penetrations holding blue wiring, and in the west and east walls an open one inch conduit holding a blue wire. On 12/01/15 at 2:55 PM in an interview, Staff R confirmed the finding.

18. On 12/01/15 at 3:16 PM observation of the two hour barrier in the electrical closet in the 2000 operating room addition revealed a one inch square cut into the drywall. On 12/01/15 at 3:16 PM in an interview, Staff R confirmed the finding.

19. On 12/01/15 at 5:41 PM observation above the drop down ceiling of the two hour barrier in back of the café storage area revealed six metal conduits traveling through an open six inch by one foot rectangle. On 12/01/15 at 5:41 PM in an interview, Staff R confirmed the finding.

20. On 12/01/15 at 5:45 PM observation above the drop down ceiling of the two hour barrier in the café over the silver wear revealed a corrugated conduit traveling through a two inch penetration and a half inch opening holding a black and white wire. On 12/01/15 at 5:45 PM in an interview, Staff R confirmed the finding.

Based on observation and interview, the facility failed to ensure doors in rated barriers were either rated or at least 1.75 inch thick solid bonded core wood, had self closing and latching hardware that closed and latched, or coordinated such that an astragal didn't prevent double doors from closing. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 11/30/15 at 1:38 PM a tour was taken of the fifth floor with Staff Q and S.

1.On 11/30/15 at 2:24 PM observation of the door in a one hour smoke barrier to the phone closet was observed to be unrated and made of steel. On 11/30/15 at 2:24 PM in an interview, Staff Q confirmed the finding.

2. On 11/30/15 at 2:38 PM observation of the doors to rooms 512 and 513 revealed each to be in a one hour barrier without self closers but with half to one quarter inch hole penetrations in each where a self closer or other apparatus may have been. On 11/30/15 at 2:38 PM in an interview, Staff Q confirmed the finding.

On 11/30/15 at 3:34 PM a tour was taken of the fourth floor with Staff Q and S.

3. On 11/30/15 at 4:23 PM observation of the door to the telephone closet, perpendicular to the double doors leading to the medical surgical units, and in a one hour barrier revealed it to be made of metal and unrated. On 11/30/15 at 4:23 PM in an interview, Staff Q confirmed the finding.

4. On 11/30/15 at 4:25 PM observation of the double doors perpendicular to the door to the electrical closet revealed they were in a one hour barrier and had self closing and latching hardware. However, when tested, the hardware did not self close and latch the doors. On 11/30/15 at 4:25 PM in an interview, Staff Q confirmed the finding.

5. On 11/30/15 at 4:38 PM observation of the door to room 413 revealed it was in a one hour barrier and had a self closer with latching hardware. When tested, the door did not self close and latch. On 11/30/15 at 4:38 PM in an interview, Staff Q confirmed the finding.

On 12/01/15 at 9:06 AM a tour of the third floor was conducted with Staff Q and R.

6. On 12/01/15 at 9:31 AM observation of the double doors leading to the obstetrical unit revealed they were in a one hour barrier, had latching hardware, and had a rubber astragal. When tested, the doors did not have a coordinator to prevent the astragal from preventing the doors to close and latch. On 12/01/15 at 9:31 AM in an interview, Staff Q confirmed the finding.

7. On 12/01/15 at 10:32 AM observation of the door to the phone closet revealed it was unrated, made of metal, and located within a one hour rated barrier. On 12/01/15 at 10:32 AM in an interview, Staff Q confirmed the finding.

On 12/01/15 at 11:22 AM a tour was conducted of the second floor with Staff Q and R.

8. On 12/01/15 at 2:49 PM observation of double doors in a one hour barrier across from operating room 8 revealed they had an astragal but not a means to prevent the astragal from stopping the double doors from closing and latching. On 12/01/15 at 2:49 PM in an interview, Staff Q confirmed the finding.

9. On 12/01/15 at 3:04 PM observation of the soiled utility room door in the one hour barrier in the operating room revealed it had latching hardware that did not close and latch the door. On 12/01/15 at 3:04 PM in an interview, Staff Q confirmed the finding.

10. On 12/01/15 at 3:06 PM observation above the drop down ceiling of the one hour barrier in the soiled utility room revealed a 1.5 inch by 1.5 inch square cut into the drywall above the hopper. On 12/01/15 at 3:06 PM in an interview, Staff R confirmed the finding.

11. On 12/01/15 at 3:12 PM observation above the drop down ceiling of the two hour barrier opposite the anesthesia office revealed a one inch penetration holding grey wires. On 12/01/15 at 3:12 PM in an interview, Staff R confirmed the finding.


12. On 12/01/15 at 3:53 PM observation of the door to room 213 and in a one hour barrier revealed it had a self closer with latching hardware that when tested did not self close and latch. On 12/01/15 at 3:53 PM in an interview, Staff Q confirmed the finding.

On 12/02/15 at 4:47 PM a tour was taken of the ground floor with Staff Q and R.

13. On 12/02/15 at 4:47 PM the door to the food and nutrition services office was observed to be metal and in a two hour barrier. It was not observed to have a rating. On 12/02/15 at 4:47 in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure doors to hazardous areas were self closing. This has the potential to affect all patients receiving services at the facility.

Findings include:

On 12/02/15 at 3:50 PM a tour was taken of the facility with Staff Q and R.

On 12/02/15 at 3:53 PM observation of the door to the soiled linen room revealed it had latching hardware that did not close and latch. On 12/02/15 at 3:53 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to maintain the stated rating of the barriers protecting its hazardous areas, failed to ensure doors protecting hazardous areas self closed, and failed to ensure astragals didn't stop double doors from closing. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 12/30/15 at 3:30 PM a tour was taken of the fourth floor with Staff Q and S.

1.On 11/30/15 at 3:56 PM observation of the double doors in a two hour rated barrier leading to the air handler mechanical space revealed the left (upon entering) door was on a self closer but the top of it would rub and stick to the heating, ventilation and cooling ducting above it. On 11/30/15 at 3:56 PM in an interview, Staff Q confirmed the finding.

2. On 11/30/15 at 3:58 PM observation of the two hour rated barrier protecting a mechanical space holding air handler units revealed in the barrier perpendicular to the entrance an oval/periscope shaped opening in the conduit that traveled through the barrier was without a cover. On 11/30/15 at 3:58 PM in an interview, Staff Q confirmed the finding.

3. On 11/30/15 at 4:01 PM observation of the two hour rated barrier protecting a mechanical space holding air handler units revealed in the most southerly west wall and located between two heating, ventilation and cooling ducts, a one inch conduit with an annular space. On 11/30/15 at 4:01 PM in an interview, Staff Q confirmed the finding.

4. On 11/30/15 at 4:07 PM observation of the two hour rated barrier that protects a mechanical space that holds air handler units and is perpendicular to the service elevator within, revealed traveling from the barrier and parallel to the elevator, a one inch conduit traveled to an open conduit. On 11/30/15 at 4:07 PM in an interview, Staff Q confirmed the finding.

On 12/02/15 at 4:47 PM a tour was conducted of the ground floor with Staff Q and R.

5. On 12/02/15 at 5:03 PM observation of the door to the soiled utility room revealed it was in a two hour barrier and had a self closer with latching hardware that when tested did not close and latch the door. On 12/02/15 at 5:03 PM in an interview, Staff Q confirmed the finding.

6. On 12/02/15 at 5:05 PM observation of the other door to the soiled utility room revealed it was metallic, unrated, in a two hour rated barrier, and had a self closer with latching hardware that when tested did not close and latch the door. On 12/02/15 at 5:05 PM in an interview, Staff Q confirmed the finding.

On 12/03/15 at 9:20 AM a tour was taken of the generator room with Staff Q and R.

7. On 12/03/15 at 9:20 AM observation of the room's double doors revealed they were in a two hour barrier but without a means of coordination, would not close together. On 12/03/15 at 9:20 AM in an interview, Staff Q confirmed the finding.

8. On 12/03/15 at 9:32 AM observation of the double doors to the magnetic resonance imaging suite revealed they were in a two hour barrier but without a means of coordination would not close together. On 12/03/15 at 9:32 AM in an interview, Staff Q confirmed the finding.

9. On 12/03/15 at 9:35 AM the door to the magnetic resonance imaging waiting area was observed in a two hour barrier with self closing and latching hardware that did not close and latch the doors. On 12/03/15 at 9:35 AM in an interview, Staff R confirmed the finding.

Based on observation and interview, the facility failed to maintain the protective rating of each of its exit components. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 12/01/15 at 11:22 AM a tour was conducted of the second floor with Staff Q and R.

On 12/01/15 at 3:24 PM a one inch penetration was observed in the two hour barrier over the exit stair door near the pharmacy. On 12/01/15 at 3:24 PM in an interview, Staff R confirmed the finding.

Based on observation and interview, the facility failed to have its emergency lighting comply with National Fire Protection Association 101, Chapter 7.9.3. This has the potential to affect all patients at the sleep center.

Findings include:

On 12/03/15 at 7:45 AM a tour was taken of the sleep study building with Staff Q and R. During the tour emergency battery operated lighting was observed.

On 12/03/15 a review of the facility's life safety code documentation was completed. It did not reveal where, how often, and how long the emergency lighting had been tested.

On 12/03/15 at 3:02 PM in an interview, Staff R confirmed he/she did not have documentation for testing of the emergency lighting.

Based on record review and interview, the facility failed to ensure its fire drills were held at unexpected times under varying conditions. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 12/03/15 a review of the facility's life safety code documentation was completed.

A review of the fire drill documentation revealed fire drills were conducted on 03/11/15 at 12:30 AM, on 06/06/15 at 12:36 AM, and on 09/09/15 at 12:30 AM. On 12/03/15 at 3:02 PM in an interview, Staff Q and R confirmed the timing of the third shift fire drills.

Based on observation, interview, and record review, the facility failed to ensure its fire alarm system complied with National Fire Protection Association 72, 7-3, 1999edition. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 12/03/15 a review of the life safety code documentation was completed. The review revealed the facility's fire alarm was tested on 09/18/15. The review revealed smoke detector m4-46 at the second floor nursing station and pull station m2-93 at the fourth floor nurse's station were marked as "can't find".

On 12/03/15 at 12:27 PM the surveyor, Staff Q and R were able to find both devices.

On 12/03/15 at 12:27 PM in an interview, Staff Q said he/she didn't know why the inspector couldn't find the devices or why he/she did not ask for staff assistance to locate and test the devices.

Based on observation and interview, the facility failed to ensure its sprinklers were tested in accordance with National Fire Protection Association 25, 9-3.4.2, 1999 edition. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.
Findings include:

On 12/03/15 a review of the facility's life safety code documentation was completed. The review revealed the last time the facility's main drain test for its dry sprinkler system was completed on 06/27/14.

On 12/03/15 at 1:58 PM in an interview, Staff R was unable to find evidence of a more recent test of the facility's dry sprinkler system.

Based on observation and interview, the facility failed to maintain its sprinkler system in accordance with National Fire Protection Association 25, 1999 edition. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

1.On 12/03/15 at 8:45 AM a tour was taken of the facility's sprinkler pump room. During the tour spare sprinkler heads of the type used in the building could not be found.
On 12/03/15 at 9:03 AM Staff Q located some heads in a dark colored tin can in the pump room. The heads are observed to be coated in dust.

2. On 12/03/15 a review of the facility's life safety code documentation was completed. The review revealed the last time the sprinkler system was inspected, on 09/22/15, the report stated, "Main drain piping need replaced (leaking during inspection) ... "

On 12/03/15 at 1:33 PM Staff R said in an interview he/she thought the piping had been fixed, found an invoice dated 05/27/15 (four months prior to the inspection) for fixing piping, but could not explain why the inspection report still said the piping was leaking.

Based on observation and interview, the facility failed to ensure its fire extinguisher complied with National Fire Protection Association 10, Chapter 4-4, 1999 edition. This has the potential to affect all patients who use the sleep center.

Findings include:

On 12/03/15 at 7:45 AM a tour was taken of the sleep study building with Staff Q and R.

On 12/03/15 at 7:50 AM the fire extinguisher was observed to have last had its annual maintenance in June, 2014. On 12/03/15 at 7:50 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure its fire extinguishers complied with National Fire Protection Association 10, 1-6, 1999 edition. This has the potential to affect all patients receiving services at this facility.

Findings include:

On 12/02/15 at 3:50 PM a tour was taken of the facility with Staff Q and R.

On 12/02/15 at 4:07 PM observation of the waiting area revealed a large green plant (about the size of a person) obstructing the fire extinguisher. On 12/02/15 at 4:07 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to comply with National Fire Protection Association 99, 1999 edition, at 4-3.1.2.3(d), for not having an intervening wall between a zone shut off valve and the outlets it serves. This has the potential to affect all patients receiving services at the facility. The facility had a census of six patients at the time of the survey.

Findings include:

On 12/01/15 at 11:22 AM a tour was conducted of the second floor with Staff Q and R.

On 12/01/15 at 1:37 PM observation of the same day surgical area revealed two areas containing two chairs each. Each chair was observed to be for patient use and had medical gas outlets at each chair. The shut off valves for these areas was observed across the corridors from the chairs and without any intervening wall between. On 12/01/15 at 1:37 PM in an interview, Staff Q confirmed the finding.

Based on record review and interview, the facility failed to ensure its Essential Electrical System complied with National Fire Protection Association 110, 6-4. This has the potential to affect all patients receiving services at the facility.

Findings include:

On 12/03/15 a review of the facility's life safety code documentation was completed. The review did not reveal where the generator had been inspected on a weekly basis.

On 12/03/15 at 12:00 PM in an interview, Staff R explained that the work order for the weekly inspections are created at the beginning of the month, and then closed at the end of the month. He/she said there is no way to determine if the work was actually done on a weekly basis.

Based on observation and interview, the facility failed to ensure lighting in its c-section room complied with National Fire Protection Association 99, 3-3.2.1.2. This has the potential to affect all patients receiving services at the facility.

Findings include:

On 12/01/15 at 9:06 AM a tour of the third floor was conducted with Staff Q and R.

On 12/01/15 at 10:43 AM observation of the emergency, battery-operated lighting in the c-section room revealed it did not illuminate when electricity was lost. On 12/01/15 at 10:43 AM in an interview, Staff Q confirmed the finding.