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Based on facility observation, staff interview and staff verification the facility failed to ensure the stairwell doors latched securely to ensure that the vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour. The hospital was certified for 244 patient beds with a census of 79 patients at the time of the survey.

Findings include:

Tour of the main building's sixth floor took place on 06/16/10 from 8:30 AM to 9:15 AM, the fourth floor from 9:55 AM to 10:25 AM and the third floor from 11:00 AM to 11:40 AM with Staff Z, Y, X and W.
While touring the sixth floor, observation was made of the exit door of stairwell number six which failed to latch securely when released from the open position. While touring the fourth floor observation was made of the exit door of stairwell number four which failed to latch securely when released from the open position. While touring the third floor observation was made of the exit door of stairwell number seven which failed to latch securely when released from the open position

This was observed and verified during the tour by the accompanying staff.

Based on observation and staff verification it was determined this facility failed to ensure there were no penetrations in the smoke barriers that had been constructed to provide at least a half hour fire resistance rating in accordance with the National Fire Protection Association (NFPA) 101, Chapter 19. This had the potential to affect all those utilizing this facility. The total patient census at the beginning of the survey was 79.

Findings include:

Tour of the main building's second floor took place on 06/16/10 from 1:00 PM to 2:50 PM and tour of the main building's first floor took place on 06/17/10 from 8:00 AM to 11:00 AM with staff members Z, Y, X and W.
During tour, observation was made of several penetrations in the smoke barrier located above the ceiling tile in the following locations:

First floor:
* Within the corridor separating the outpatient suite number one from the nuclear med department and across from the outpatient waiting room, observation was made of two open end conduits located within the junction boxes which lacked a cover. The conduits leading from the junction boxes were observed to be penetrating the smoke barrier.
* Within the staff office located on the north side of the smoke barrier bordering the endo room number one, observation was made of one unsealed conduit penetrating the smoke barrier.
* Above the south double doors of the smoke barrier bordering the post anesthesia care unit, observation was made of one open end conduit.
* Within the corridor which borders the north end of the post anesthesia care unit room R-1, observation was made of a unsealed triangular opening beside a duct which penetrated the smoke barrier.
* Within the smoke barrier located in the southwest corner of the radio/cardio waiting room,
observation was made of two unsealed penetrations with wires passing through.

Second floor:
*Within the two hour fire barrier serving as a smoke compartment separation located between the cardio/rehab therapy room and the medical records room, observation was made of one unsealed conduit.
* Within the same two hour fire barrier noted above and located in the storage room north of the elevators, observation was made of five silver conduits passing through the wall which had what appeared to be insulation packed around them. This was verified by Staff X at 3:15 PM on 06/16/10, when Staff X stated this was regular insulation and not the required fire rated packing.
* From within the southeast corner of the serving area of the cafeteria, observation was made of an unsealed black drain line which penetrated the two hour fire rated wall.
* From within the southwest corner of the catering area of the dietary department, observation was made of two unsealed conduits passing through the two hour fire rated wall.
* Assessment was made of the two hour fire rated wall which separates the dietary department from the administration office area. From within the boardroom located in the administration offices area and facing the east wall, observation was made of two large sections of drywall which had been removed from this wall. These openings enabled this surveyor to identify this portion of the wall was not two hour fire rated construction. This section was approximately 12 feet in length and had only one layer of drywall.


This was observed and verified during the tour by the accompanying staff.

Based on observation and staff verification it was determined this facility failed to ensure there were no penetrations in the smoke barriers to ensure the smoke barriers were constructed to provide at least a one hour fire resistance rating in accordance with the National Fire Protection Association (NFPA) 101, Chapter 18. This had the potential to affect all those utilizing this facility. The total patient census at the beginning of the survey was 79.

Findings include:

Tour of the main building's emergency department took place on 06/17/10 from 8:00 AM to 11:00 AM, with staff members Z, Y, X and W.
During tour observation was made of several penetrations in the smoke barrier located above the ceiling tile in the following locations:

*Seven penetrations around conduits and wires were observed above the smoke barrier doors located in the southeast corner of the emergency department.
*Two unsealed flex conduits were observed in the southeast portion of the smoke barrier across from the cashiers' room.
*Multiple penetrations were observed around conduits, wires and one duct located in the southeast waiting area.
*One unsealed silver conduit and one grey wire were observed penetrating the smoke barrier above the doors located just outside of the clean supply room.
*One unsealed green wire and five unsealed silver conduits were observed above the clean supply room door.
*Within the clean supply room facing the west wall, observations were made of nine unsealed conduits
*Six unsealed conduits were observed above the northeast one hour smoke barrier doors.


This finding was verified by all staff present during tour on 06/17/10.

Based on observation during tour and staff verification it was determined this facility failed to ensure the swinging double doors located in the smoke barriers had less than a one eighth inch gap between the door leaves when in the closed position. Additionally,this facility failed to ensure all doors located in the smoke barrier were equipped with a self-closing or automatic closing device. This had the potential to affect all those utilizing this area of the facility. The patient census was 79 at the start of the survey.

Findings include:

Tour of the main building's first floor took place on 06/17/10 from 8:00 AM to 11:00 AM, with staff members Z, Y, X and W.
Observation was made of a gap greater than one eighth inch between the two leaves when in the closed position of the smoke barrier doors located near the isolation room of the post anesthesia care unit.
Observation was made of a gap greater than one eighth inch between the two leaves when in the closed position of the smoke barrier doors located near the southeast corner of the nuclear med department.
Observation was made of a smoke barrier door located in the respiratory storage area on the south side of the emergency department which lacked a self-closing or automatic closing device.

This was observed and verified during the tour by the accompanying staff.

Based on observation and staff verification, it was determined this facility failed to ensure the medical gas storage area was protected in accordance with NFPA 99, 1999 edition, 4-3.1.1.2 (a)(4), by mounting the light switch at least five feet or higher from the floor. This could potentially affect all patients, staff and visitors utilizing the services of the facility. The facility census was 79 at the beginning of the survey.

Findings include:

Tour of the sub-basement took place on 06/15/10 from 2:45 PM to 4:15 PM, with staff members Z, Y, X and W.
Observation was made, within the medical gas storage area located on the east side of lounge A-952, of a light switch mounted less than five feet from the floor just inside the door. Five "H" tanks of carbon dioxide was stored within this room.


This finding was verified by all staff present during tour on 06/15/10.

Based on observation during tour and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were located where airflow patterns would not prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all those utilizing this facility. The facility census at the time of the survey was 79.

Findings include:

Tour of the main building's second, fourth and fifth floors took place on 06/16/10 from 9:15 AM to 2:50 PM, and tour of the main building's first floor took place on 06/17/10 from 8:00 AM to 11:00 AM, with staff members Z, Y, X and W.

During tour, observation was made of several smoke detectors located in areas where air flow currents could inhibit the smoke detector's normal operation. These locations were identified as:

First Floor:
* Within the corridor of outpatient suite number two near ambulatory care unit (ACU) room numbers 5, 8 and 13. Within the soiled utility room across from ACU room number 13.
* Within the soiled utility room across from ACU room number 1 of outpatient suite number one.
*Within the waiting room of the outpatient surgery department, the reception desk area and the corridor just east of the reception desk.
* Within the storage room of the nuclear med department.
* Within the corridor of the changing rooms in the radiology department.
* Within the corridor separating the elevators and stair number seven between the emergency department and the cardiopulmonary department.
* Within the clean supply room located in the southwest corner of the intensive care unit.

Second floor:
* Within meeting room A.
* Within the corridor separating the elevators and stair number seven.

Fourth floor:
* Within the storage closet across from patient room number 4-453.
* Within equipment room number 4-417.

Fifth floor:
* Within patient room numbers 5-543, 5-544, 5-545 and 5-546.
* Within the closet across from patient room number 5-553.
* Within the galley across from patient room number 5-521.
* Within the galley across from patient room number 5-560.
* Within the closet across from patient room number 5-561.
* Within the consultation room next to the nurse station.

This this list may not be all inclusive of the smoke detectors located near air flow devices within this facility.

These findings were verified by all staff present during tour on 06/15/10.

Based on observation during tour and staff interview, the facility failed to ensure that smoke detectors located in spaces served by air-handling systems were located where airflow patterns would not prevent the normal operation of the smoke detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all those utilizing this facility. The facility census at the time of the survey was 79.

Findings include:

Tour of the main building's emergency department took place on 06/17/10 from 8:00 AM to 11:00 AM, with staff members Z, Y, X and W.
During tour, observation was made of two smoke detectors that were located near air flow devices in the following areas:
*In the corridor, just outside the restroom located in the southeast corner of the emergency department.
*Within the storage room located in the northwest corner of the emergency department.


These findings were verified by all staff present during tour.

Based on facility observation, staff interview and staff verification the facility failed to ensure the stairwell doors latched securely to ensure that the vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour. The hospital was certified for 244 patient beds with a census of 79 patients at the time of the survey.

Findings include:

Tour of the main building's sixth floor took place on 06/16/10 from 8:30 AM to 9:15 AM, the fourth floor from 9:55 AM to 10:25 AM and the third floor from 11:00 AM to 11:40 AM with Staff Z, Y, X and W.
While touring the sixth floor, observation was made of the exit door of stairwell number six which failed to latch securely when released from the open position. While touring the fourth floor observation was made of the exit door of stairwell number four which failed to latch securely when released from the open position. While touring the third floor observation was made of the exit door of stairwell number seven which failed to latch securely when released from the open position

This was observed and verified during the tour by the accompanying staff.

Based on observation and staff verification it was determined this facility failed to ensure there were no penetrations in the smoke barriers that had been constructed to provide at least a half hour fire resistance rating in accordance with the National Fire Protection Association (NFPA) 101, Chapter 19. This had the potential to affect all those utilizing this facility. The total patient census at the beginning of the survey was 79.

Findings include:

Tour of the main building's second floor took place on 06/16/10 from 1:00 PM to 2:50 PM and tour of the main building's first floor took place on 06/17/10 from 8:00 AM to 11:00 AM with staff members Z, Y, X and W.
During tour, observation was made of several penetrations in the smoke barrier located above the ceiling tile in the following locations:

First floor:
* Within the corridor separating the outpatient suite number one from the nuclear med department and across from the outpatient waiting room, observation was made of two open end conduits located within the junction boxes which lacked a cover. The conduits leading from the junction boxes were observed to be penetrating the smoke barrier.
* Within the staff office located on the north side of the smoke barrier bordering the endo room number one, observation was made of one unsealed conduit penetrating the smoke barrier.
* Above the south double doors of the smoke barrier bordering the post anesthesia care unit, observation was made of one open end conduit.
* Within the corridor which borders the north end of the post anesthesia care unit room R-1, observation was made of a unsealed triangular opening beside a duct which penetrated the smoke barrier.
* Within the smoke barrier located in the southwest corner of the radio/cardio waiting room,
observation was made of two unsealed penetrations with wires passing through.

Second floor:
*Within the two hour fire barrier serving as a smoke compartment separation located between the cardio/rehab therapy room and the medical records room, observation was made of one unsealed conduit.
* Within the same two hour fire barrier noted above and located in the storage room north of the elevators, observation was made of five silver conduits passing through the wall which had what appeared to be insulation packed around them. This was verified by Staff X at 3:15 PM on 06/16/10, when Staff X stated this was regular insulation and not the required fire rated packing.
* From within the southeast corner of the serving area of the cafeteria, observation was made of an unsealed black drain line which penetrated the two hour fire rated wall.
* From within the southwest corner of the catering area of the dietary department, observation was made of two unsealed conduits passing through the two hour fire rated wall.
* Assessment was made of the two hour fire rated wall which separates the dietary department from the administration office area. From within the boardroom located in the administration offices area and facing the east wall, observation was made of two large sections of drywall which had been removed from this wall. These openings enabled this surveyor to identify this portion of the wall was not two hour fire rated construction. This section was approximately 12 feet in length and had only one layer of drywall.


This was observed and verified during the tour by the accompanying staff.

Based on observation and staff verification it was determined this facility failed to ensure there were no penetrations in the smoke barriers to ensure the smoke barriers were constructed to provide at least a one hour fire resistance rating in accordance with the National Fire Protection Association (NFPA) 101, Chapter 18. This had the potential to affect all those utilizing this facility. The total patient census at the beginning of the survey was 79.

Findings include:

Tour of the main building's emergency department took place on 06/17/10 from 8:00 AM to 11:00 AM, with staff members Z, Y, X and W.
During tour observation was made of several penetrations in the smoke barrier located above the ceiling tile in the following locations:

*Seven penetrations around conduits and wires were observed above the smoke barrier doors located in the southeast corner of the emergency department.
*Two unsealed flex conduits were observed in the southeast portion of the smoke barrier across from the cashiers' room.
*Multiple penetrations were observed around conduits, wires and one duct located in the southeast waiting area.
*One unsealed silver conduit and one grey wire were observed penetrating the smoke barrier above the doors located just outside of the clean supply room.
*One unsealed green wire and five unsealed silver conduits were observed above the clean supply room door.
*Within the clean supply room facing the west wall, observations were made of nine unsealed conduits
*Six unsealed conduits were observed above the northeast one hour smoke barrier doors.


This finding was verified by all staff present during tour on 06/17/10.

Based on observation during tour and staff verification it was determined this facility failed to ensure the swinging double doors located in the smoke barriers had less than a one eighth inch gap between the door leaves when in the closed position. Additionally,this facility failed to ensure all doors located in the smoke barrier were equipped with a self-closing or automatic closing device. This had the potential to affect all those utilizing this area of the facility. The patient census was 79 at the start of the survey.

Findings include:

Tour of the main building's first floor took place on 06/17/10 from 8:00 AM to 11:00 AM, with staff members Z, Y, X and W.
Observation was made of a gap greater than one eighth inch between the two leaves when in the closed position of the smoke barrier doors located near the isolation room of the post anesthesia care unit.
Observation was made of a gap greater than one eighth inch between the two leaves when in the closed position of the smoke barrier doors located near the southeast corner of the nuclear med department.
Observation was made of a smoke barrier door located in the respiratory storage area on the south side of the emergency department which lacked a self-closing or automatic closing device.

This was observed and verified during the tour by the accompanying staff.

Based on observation and staff verification, it was determined this facility failed to ensure the medical gas storage area was protected in accordance with NFPA 99, 1999 edition, 4-3.1.1.2 (a)(4), by mounting the light switch at least five feet or higher from the floor. This could potentially affect all patients, staff and visitors utilizing the services of the facility. The facility census was 79 at the beginning of the survey.

Findings include:

Tour of the sub-basement took place on 06/15/10 from 2:45 PM to 4:15 PM, with staff members Z, Y, X and W.
Observation was made, within the medical gas storage area located on the east side of lounge A-952, of a light switch mounted less than five feet from the floor just inside the door. Five "H" tanks of carbon dioxide was stored within this room.


This finding was verified by all staff present during tour on 06/15/10.

Based on observation during tour and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were located where airflow patterns would not prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all those utilizing this facility. The facility census at the time of the survey was 79.

Findings include:

Tour of the main building's second, fourth and fifth floors took place on 06/16/10 from 9:15 AM to 2:50 PM, and tour of the main building's first floor took place on 06/17/10 from 8:00 AM to 11:00 AM, with staff members Z, Y, X and W.

During tour, observation was made of several smoke detectors located in areas where air flow currents could inhibit the smoke detector's normal operation. These locations were identified as:

First Floor:
* Within the corridor of outpatient suite number two near ambulatory care unit (ACU) room numbers 5, 8 and 13. Within the soiled utility room across from ACU room number 13.
* Within the soiled utility room across from ACU room number 1 of outpatient suite number one.
*Within the waiting room of the outpatient surgery department, the reception desk area and the corridor just east of the reception desk.
* Within the storage room of the nuclear med department.
* Within the corridor of the changing rooms in the radiology department.
* Within the corridor separating the elevators and stair number seven between the emergency department and the cardiopulmonary department.
* Within the clean supply room located in the southwest corner of the intensive care unit.

Second floor:
* Within meeting room A.
* Within the corridor separating the elevators and stair number seven.

Fourth floor:
* Within the storage closet across from patient room number 4-453.
* Within equipment room number 4-417.

Fifth floor:
* Within patient room numbers 5-543, 5-544, 5-545 and 5-546.
* Within the closet across from patient room number 5-553.
* Within the galley across from patient room number 5-521.
* Within the galley across from patient room number 5-560.
* Within the closet across from patient room number 5-561.
* Within the consultation room next to the nurse station.

This this list may not be all inclusive of the smoke detectors located near air flow devices within this facility.

These findings were verified by all staff present during tour on 06/15/10.

Based on observation during tour and staff interview, the facility failed to ensure that smoke detectors located in spaces served by air-handling systems were located where airflow patterns would not prevent the normal operation of the smoke detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all those utilizing this facility. The facility census at the time of the survey was 79.

Findings include:

Tour of the main building's emergency department took place on 06/17/10 from 8:00 AM to 11:00 AM, with staff members Z, Y, X and W.
During tour, observation was made of two smoke detectors that were located near air flow devices in the following areas:
*In the corridor, just outside the restroom located in the southeast corner of the emergency department.
*Within the storage room located in the northwest corner of the emergency department.


These findings were verified by all staff present during tour.