HospitalInspections.org

Based on record reviews, the facility failed to include all policies and procedures for the subsistence needs of patients and staff in the emergency preparedness program.

The findings included:

During the records review on 9/30/19 at 11:20 AM, the facility failed to provide policies and procedures for alternate sources of energy to maintain the following:
a. Temperatures to protect patient health and safety.
b. Emergency lighting
c. Fire detection, extinguishing, and alarm systems
d. Sewage and waste disposal

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19.

Based on observations, the facility failed to maintain the fire rated occupancy separation walls.

The findings included:

Observation on 10/02/2019 between 09:00 AM and 10:00 AM, revealed penetrations in the 1 hour fire rated occupancy separation wall not properly fire stopped in accordance with fire stop systems in the following locations:

Skyline endoscopy above back hall way door
a. 1- Cable wire.

Supply Storage
a. 1-1/4 inch metal sleeve.

Sterile Unit Wall
a. 1- 6inch in by 5 inch hole next to the hvac duct.

Wall by elevator BU-1
a. 1- 3 inch sprinkler pipe.
b. 1- Metal truss.
c. 1- ½ inch metal sleeve.

Wall next to Endoscopy 1st floor personnel door
a. 1- 8 inch by 1ft blow out patch.
b. 1- Metal Falange truss.

Wall across from the Director office
a. 1- Junction Box.
b. 1- Brown wire.

Wall across from Anesthesia office
a. 8 inch by 6 inch blow out patch

Wall above unisex bathroom
a. 6 inch by 6 inch blow out patch.
b. 2- metal bar joist

National Fire Protection Association, NFPA 101, 21.3.7.1 (1) (2012 Ed.), NFPA 101, 8.3.5 (2012 Ed.), NFPA 101, 8.3.5.1(2012 Ed.)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19. Firestopping citations were not individually covered per request of administration.

Based on observations, the facility failed to maintian the egress doors.

The finding inlcuded:

Observation on 10/02/2019 at 8:38 AM, revealed the egress door by the pre-admit office required the press of a button beside the door to release the lock. NFPA 101, 21.2.2 (2012 Edition) NFPA 101, 39.2.2.1 (2012 Edition) NFPA 101, 39.2.2.2.6 (2012 Edition) NFPA 101, 7.2.1.6.2* (2012 Edition).

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19.

Based on observations, the facility failed to maintain the means of egress.

The findings included:

Observation on 09/30/2019 at 1:58 PM, revealed the threshold at the D-1 stairwell door at the C-tower 4th floor stair discharge exit passageway was 6 inches of height. NFPA 101, 19.2.1 (2012 Edition) NFPA 101, 7.2.1.3.3 (2012 Edition)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19.

Based on observations, the facility failed to maintain the stairway enclosures.

The finding included:

Observation on 09/30/2019 at 2:00 PM, revealed 12 improper gypsum board patches (blow-out patches) on the 2 hour fire rated gypsum fur out of C-tower 4th floor stair discharge exit passageway. NFPA 101, 8.3.1.2 (2012 Edition) NFPA 101, 19.2.2.7 (2012 Edition) NFPA 101, 7.2.6.3 (2012 Edition)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19.

Based on observation the facility failed to maintain the protection requirements in accordance with chapter 21 of the life safety code

The findings included :

1. Document review on 10/02/2019 at 7:45 AM, revealed the facility failed to provide documentation for an annual sprinkler inspection for 2018. NFPA 101, 9.7.5 (2012 Edition) NFPA 25, 5.1.1.2 (2011 Edition)

2. Document review on 10/02/2019 at 7:47 AM, revealed the facility failed to provide documentation for a 5 year internal pipe inspection. NFPA 101, 9.7.5 (2012 Edition) NFPA 25, 14.2.1 (2011 Edition)

3. Observation on 10/02/2019 at 8:30 AM, revealed a blow- out patch in the 1 hour fire rated wall in the electrical room labeled BSx1xx1. NFPA 101, 8.3.1.2 (2012 Edition) NFPA 101, 8.3.5.1 (2012 Edition)

4. Observation on 10/02/2019 at 8:56 AM, revealed the door to the soiled cart holding room did not latch within the frame. NFPA 101, 21.3.2.1 (2012 Edition)

5. Observation on 10/02/2019 at 9:03 AM, revealed penetrations by electrical conduit, and sleeved communication wires not sealed properly, above the suspended ceiling, in the 1 hour fire rated wall in the corridor outside of electrical room BSx1xx1. NFPA 101, 8.3.1.2 (2012 Edition) NFPA 101, 8.3.5.1 (2012 Edition)

6. Observation on 10/02/2019 at 9:06 AM, revealed penetrations by steel pipes, and sleeved communication wires not sealed properly, above the suspended ceiling, in the 1 hour fire rated wall in the corridor outside of materials management. NFPA 101, 8.3.1.2 (2012 Edition) NFPA 101, 8.3.5.1 (2012 Edition)

7. Observation on 10/02/2019 at 9:14 AM, revealed penetrations by sleeved communication wires not sealed properly, above the suspended ceiling, in the 1 hour fire rated wall in the corridor outside of equipment room BSx1xx3. NFPA 101, 8.3.1.2 (2012 Edition) NFPA 101, 8.3.5.1 (2012 Edition)

8. Observation on 10/02/2019 at 9:18 AM, revealed penetrations by sleeved communication wires not sealed properly, above the suspended ceiling, in the 1 hour fire rated cross corridor smoke barrier wall in the corridor outside of pre-admit office. NFPA 101, 8.3.1.2 (2012 Edition) NFPA 101, 8.3.5.1 (2012 Edition)

9. Observation on 10/02/2019 at 9:28 AM, revealed penetrations by copper pipes, electrical conduits, and sleeved communication wires not sealed properly, above the suspended ceiling, in the 1 hour fire rated cross corridor smoke barrier wall in the corridor outside of the OR and Recovery hallway. NFPA 101, 8.3.1.2 (2012 Edition) NFPA 101, 8.3.5.1 (2012 Edition)

10. Observation on 10/02/2019 at 9:37 AM, revealed penetrations by electrical conduits, and sleeved communication wires not sealed properly, above the suspended ceiling, in the 1 hour fire rated wall in the clean carts storage room. NFPA 101, 8.3.1.2 (2012 Edition) NFPA 101, 8.3.5.1 (2012 Edition)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19. Firestopping citations were not individually covered per request of administration.

Based on observation the facility failed to maintain the protection requirements in accordance with chapter 21 of the life safety code

The findings included :

1. Observation on 10/2/19 between 8:30 AM and 9:30 AM, revealed penetrations through a one hour fire/smoke wall not sealed with approved firestop systems in the following locations:

Radiology
a. Computer room-(3) ¼ inch metal conduits, 1 inch metal conduit, ½ inch metal conduit, 2 inch metal conduit, black low voltage cable. NFPA 101, 8.3.1.2 (2012 Edition) NFPA 101, 8.3.5.1 (2012 Edition)


2. Observation on 10/2/19 between 8:30 AM and 9:30 AM, revealed penetrations through the one hour smoke wall not sealed with approved firestop systems in the following locations:

Radiology
a. Back wall of x-ray room- 4 ft x 2 ft drywall patch, 2 metallic flex conduits.
NFPA 101, 8.3.1.2 (2012 Edition) NFPA 101, 8.3.5.1 (2012 Edition)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19. Firestopping citations were not individually covered per request of administration.

Based on observation the facility failed to maintain the protection requirements in accordance with chapter 39 of the life safety code

The findings included :

1. Observation on 10/02/2019 between 10:00 AM and 11:45 AM, revealed penetrations in the 2 hour fire rated wall in the hazardous area (per drawings) not properly fire stopped in accordance with fire stop systems in the following locations:

West TN Imaging Center Electrical Room
a. 1- 1 inch metal conduit.
b. 3- Blue cable wires.
c. 1- 10inch by 10 inch blowout patch.
d. 1- 3 inch gray metal pipe.
e. 1- 1 ½ inch gray metal pipe.
f. 11- 2 inch metal conduits.
g. 22 -1 inch metal conduits.
h. 2- 1 inch metal hangers (green).
i. 1- 1 inch metal sleeve with a green wire.
j. 1- White cable bundle.
k. 1- 1 inch insulated pipe.
l. 1- 1ft by 1ft blow out patch.
m. 1- 8 inch by 10 inch blow out patch.

National Fire Protection Association, NFPA 101, 39.3.2.1 (2012 Ed.), NFPA 101, 8.7.1.1(1)(2012 Ed.), NFPA 101, 8.3.5(2012 Ed.), NFPA 101, 8.3.5.1 (2012 Ed.)

2.Observation on 10/02/2019 at 10:55 AM, revealed 1 standard response sprinkler installed in exam room 1 mammogram The exam room had a total of 2 sprinklers 1 out of 2 of them were quick response sprinkler.

3. Observation on 10/02/2019 at 10:58 AM, revealed 1 standard response sprinkler installed in the Mammogram ultra sound hallway. The hallway had a total of 5 sprinklers and 4 out of the 5 sprinklers were quick response sprinklers.

National Fire Protection Association, NFPA 13, 8.3.3.2 (2010 Ed.)

4. Observation on 10/02/2019 between 10:30 AM and 11:45 AM, revealed corroded sprinklers in the following locations:

West TN Imaging Center
a. Pre-Register office (1 out of 3).

National Fire protection Association, NFPA 25, 5.2.1.1.1 (2) (2011 Ed.)

5. Observation on 10/ 02/2019 between 10:00 AM and 11:45 AM, revealed bent sprinklers in the following locations:

West TN Imaging center
a. Reading Room 10 (1 out of 1).

National Fire protection Association, NFPA 25, 5.2.1.1.1 (3) (2011 Ed.)

6. Observation on 10/02/2019 at 08:30 AM, revealed the facility failed to provide documentation for quarterly sprinkler inspections
for the West TN Imaging center.

National Fire Protection Association, NFPA 25 Table 5.1.1.2 (2011 Ed.)


These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19. Firestopping citations were not individually covered per request of administration.

Based on obervations, the facility failed to maintain the vertical openings.

The findings included.

1. Observation on 10/2/19 at 10:43 AM, revealed blue metal supports penetrating the 2 hour shaft wall for staff elevators on the 1st floor.

2. Observation on 10/2/19 at 10:52 AM, revaealed 3 blue metal support beams penetrating 2 hour rated public elevator shafts on the first floor.

3. Observation on 10/02/2019 at 1:30 PM, revealed a blow-out patch; penetrations by structural I-Beams, metal Z-channel, and steel pipes not sealed properly, above the suspended ceiling, in the 2 hour fire rated wall in the basement corridor outside of the North Stairway.

NFPA 101, 19.3.1 (2012 Edition) NFPA 101, 8.6.5 (2012 Edition) NFPA 101, 8.3.1.2 (2012 Edition) NFPA 101, 8.3.5.1 (2012 Edition)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19. Firestopping citations were not individually covered per request of administration.

Based on observations, the facility failed to maintain the vertical openings.

The findings included:

1. Observation on 09/30/2019 between 9:00 AM and 5:00 PM, revealed penetrations in the 2 hour fire rated shaft wall not properly fire stopped in accordance with fire stop systems in the following locations:

9th floor C tower Elevators C2 and C1
a. 10 -1/2 inch holes drilled into the concrete.

9th floor c tower (North Exit Stairwell)
a. 1- 1 inch sprinkler pipe.

9th floor tower a west stair well across from room 922
a. 1- ½ inch metal sleeve.
b. 1- 1/inch sprinkler pipe.

1st floor c tower GI exit stairwell
a. 2ft by 4ft blow out patch.
b. 3 inch by 3 inch hole.
c. 6 inch by 6 inch blow out patch.
d. 1- 1inch metal sleeve.
NFPA 101, 19.3.1 (2012 Ed.),NFPA 101, 8.6.4.1(2012 Ed.), NFPA 101, 8.6.5(2012 Ed.) NFPA 101, NFPA 101,8.3.5 (2012 Ed.), NFPA 101, 8.3.5.1(2012 Ed.)

2. Observation on 09/30/2019 at 1:30 PM, revealed a penetration by a steel pipe sealed with mixed fire stopping materials in the B-1 stairwell on the 4th floor of the B-tower. NFPA 101, 19.3.1 (2012 Ed.),NFPA 101, 8.6.4.1(2012 Ed.), NFPA 101, 8.6.5(2012 Ed.) NFPA 101, NFPA 101,8.3.5 (2012 Ed.), NFPA 101, 8.3.5.1(2012 Ed.)

3. Observation on 09/30/2019 at 2:02 PM, revealed a 1 hour door installed in the 2 hour fire rated shaft at the D-1 stairway elevator equipment room. NFPA 101, 19.3.1 (2012 Edition) NFPA 101, 8.6.5 (2012 Edition) NFPA 101, 7.1.3.2.1 (2012 Edition) NFPA 101, 8.3.4.2 (2012 Edition)

4. Observation on 09/30/2019 at 2:03 PM, revealed the 1 hour fire rated door of the elevator equipment room of the D-1 stairway did not self-close within the frame. NFPA 101, 19.3.1 (2012 Edition) NFPA 101, 8.6.5 (2012 Edition) NFPA 101, 7.1.3.2.1 (2012 Edition) NFPA 101, 8.3.4.2* (2012 Edition) NFPA 101, 8.3.3.3 (2012 Edition)

5. Observation on 09/30/2019 at 2:23 PM, revealed a hole (approximately 2'x6') in the 2 hour fire rated concrete shaft of the C-tower 4th floor linen chute covered with a non-framed gypsum wall. NFPA 101, 8.3.1.2 (2012 Edition)

6. Observation on 09/30/2019 at 2:54 PM, revealed a gap larger than 1/8 inch at the meeting edge of the double swinging stairway doors on the 4th floor of the D-4 stairway. NFPA 101, 19.3.1 (2012 Edition) NFPA 101, 8.6.5 (2012 Edition) NFPA 101, 7.1.3.2.1 (2012 Edition) NFPA 101, 8.3.4.2* (2012 Edition) NFPA 101, 8.3.3.1 (2012 Edition) NFPA 80, 6.3.1.7.1* (2010 Edition)

7. Observation on 09/30/2019 at 2:55 PM, revealed the double swinging stairway doors missing the bottom latching hardware on the 4th floor of the D-4 stairway. NFPA 101, 19.3.1 (2012 Edition) NFPA 101, 8.6.5 (2012 Edition) NFPA 101, 7.1.3.2.1 (2012 Edition) NFPA 101, 8.3.4.2* (2012 Edition) NFPA 101, 8.3.3.1 (2012 Edition) NFPA 80, 6.5.1* (2010 Edition)

8. Observation on 10/01/2019 at 8:41 AM, revealed an improper gypsum board patch (blow-out patch) in the 2 hour gypsum board shaft wall above the suspended ceiling in the corridor outside of the stairway by room C5101 on the 5th floor of C-tower. NFPA 101, 19.3.1 (2012 Edition) NFPA 101, 8.6.5 (2012 Edition) NFPA 101, 8.3.1.2 (2012 Edition)

9. Observation on 10/01/2019 at 9:18 AM, revealed penetrations in the 2 hour fire rated linen chute shaft not sealed properly above the suspended ceiling in the corridor by room C5120 on the 5th floor of C-tower. NFPA 101, 19.3.1 (2012 Edition) NFPA 101, 8.6.5 (2012 Edition) NFPA 101, 8.3.5.1 (2012 Edition)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19. Firestopping citations were not individually covered per request of administration.

Based on observations, the facility failed to maintain the hazardous areas.

The findings included:

1. Observation on 10/02/2019 at 1:49 PM, revealed penetrations by sleeved communication wires, and electrical conduits not sealed properly, above the suspended ceiling, in the 1 hour fire rated wall in the basement corridor outside of the decontamination room.

2. Observation on 10/02/2019 at 1:52 PM, revealed penetrations by copper pipes not sealed properly, above the suspended ceiling, in the 1 hour fire rated wall in the basement north corridor outside of the clean work room.

3. Observation on 10/02/2019 at 1:54 PM, revealed a blow-out patch; penetrations by communication wires, and insulated pipes not sealed properly, above the suspended ceiling, in the 1 hour fire rated wall in the basement north corridor outside of the material management room.

4. Observation on 10/02/2019 at 1:56 PM, revealed a blow-out patch; penetrations by communication wires, and insulated pipes not sealed properly, above the suspended ceiling, in the 1 hour fire rated wall in the basement north corridor outside of the equipment room.

5. Observation on 10/02/2019 at 2:04 PM, revealed blow-out patches; penetrations by communication wires, and insulated pipes not sealed properly, above the suspended ceiling, in the 1 hour fire rated wall in the basement north corridor outside of the engineering room.

6. Observation on 10/02/2019 at 2:11 PM, revealed blow-out patches; penetrations by communication wires, and insulated pipes not sealed properly, above the suspended ceiling, in the 1 hour fire rated wall in the basement north corridor outside of the environmental services room.

7. Observation on 10/02/2019 at 2:18 PM, revealed penetrations by electrical conduits, steel pipes, and insulated pipes not sealed properly, above the suspended ceiling, in the 2 hour fire rated gypsum faced concrete block wall in the basement north corridor outside of the powerhouse.

National Fire Protection Association (NFPA) 101, 19.3.2.1 (2012 Ed.), NFPA 101, 8.7.1.1(1)(2012 Ed.) NFPA 101, 8.3.5. (2012 Ed.),NFPA 101, 8.3.5.1 (2012 Ed)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19. Firestopping citations were not individually covered per request of administration.

Based on observations, the facility failed to maintain the fire barrier walls protecting the hazardous areas in accordace with the building drawings provided by the facility.

The findings included:

1. Observations on 9/30/19 - 10/2/19 between 8:00 AM and 4:00 PM, revealed the 1 hour fire rated walls in the following hazardous areas contained penetratons and improper fire stopping not in accordance with fire stop systems:

Equipment room (BE) located in the basement
a. 3 ft x 2 ft blowout patch around a large duct
b. 18 in x 12 in blowout patch
c. 3 ft x 2.5 ft blowout patch around a large duct

Equipment room (BD) located in the basement
a. 1- 1 inch PVC pipe
b. 2 - 1/2 inch copper pipes
c. 3 - 3 inch metal conduits going into the stairway
d. 12 in x 12 in blowout patch in the wall
e. 12 in x 12 in blowout patch above BD room door

Electrical room (DCBAXB1) located in the basement
a. 2 ft x 3 ft blowout patch
b. 3 - 3 inch metal conduits
c. 2 - 12 inch insulated pipes (mixed caulk)
d. wall section damaged
e. 2 - unused holes (mixed caulk)
f. 4 - 2 inch conduits (mixed caulk)
g. 1 - 2 1/2 inch metal conduit (mixed caulk)
h. 2 - 2 inch metal conduit (mixed caulk)
i. 1 - 2 inch metal flex conduit (mixed caulk)
j. 1 - 1 1/2 inch metal conduit (mixed caulk)
k.1 - 1/2 inch metal conduit (mixed caulk)
l. 2 - 3 inch metal conduits (mixed caulk)

Mechaical room (DCBABBM) located in the basement
a. 1 - 3 inch metal conduit (mixed caulk)
b. 1 - 2 inch metal conduit
c. 18 in x 12 inch blowout patch
d. 18 in x 6 in blowout patch
e. 6 in x 12 in blowout patch
f. wall seams filled with fire caulk

Mechanical room (DNBABFQ) located in the basement
a. 2 - 1 inch insulated pipes (mixed caulk)
b. 3 - 3 inch insulated pipes (mixed caulk)

Mechanical room (BL) located in the basement
a. 2- 3 inch sleeves with cable bundles above the door (mixed caulk)
b. 1 - 2 inch steel pipe above door (mixed caulk)
c. 1 - 1 inch plastic flex (mixed caulk)
d. 2 - 3 inch metal conduits, 1- 2inch metal conduit, and a 12 in x 12 in duct. All going through a large hole in the concrete wall.

Fire pump room (CXBABBF) located in the basement
a. 1 - 2 inch metal conduit above the door

Electrical room (DSX1X1N) located on the first floor
a. 6 in x 12 in blowout patch

3rd floor C-tower outside soiled utlity room
a. blowout patch

3rd floor A tower Biomed/Telcom Room (Axx3x3h)
a. 3 - 1 inch metal sleeves.
b. 1 - 3 inch insulated line.
c. 3 - ½ inch metal conduits.
d. 3 - 3 inch metal sleeves.
e. Seams were not embedded with gypsum mud.

3rd floor A-tower infectious waste room
a. 1 inch orange metal sleeve.
b. 1 inch ¾ inch sleeve.
c. Seams were not embedded with gypsum mu

4th floor B tower Electrical room (Bxx4x4f)
a. 1 - 2 inch metal sleeve with low voltage cables.

8th floor A tower above electrical room next to doors 46-47
a. 2- 1 inch metal sleeves.

8th floor A tower wall next to class room across from the soiled utility (doors 34-35)
a. 2inch by 12 inch hole.

8th floor A tower wall outside 02 storage room across from the nurse's station
a. 1- ½ inch metal sleeve.
b. 1- yellow cable.

8th floor C tower electrical room (Bxx8x8d) next to envs closet
a. 1- 4inch metal sleeve.

8th floor C tower electrical room across from room C811
a. 2- 2inch metal sleeves.
b. 1- cable bundle.
c. 1- 6inch by 6 inch blow out patch.
d. 2- ½ inch metal sleeves.
e. 1- 3inch by 3 inch blow out patch.
f. 1- 8 inch by 10 inch blow out patch.
g. 1- 3 inch metal sleeve.

9th floor A tower above the Electrical room (Cxx9ben)
a. 1- 6 inch by 6 inch blow out patch.
b. 1- 9 inch by 9 inch blow out patch.
c. 1- Cable bundle.
d. 4- 2inch sleeves with cable bundle.
e. 3- 1 inch metal conduits.
f. 1- ¼ inch metal sleeve.

9th floor A tower 02 equipment room across from main nurse station
a. 2- ¼ inch metal sleeve.
b. 1- 1 inch metal sleeve.

A Tower
a. Telecom room Axx4x46- drywall seams.
b. 4th floor telecom room Axx3x36- drywall seams.
c. 2nd floor telecom room Axx2x2F- (7) ½ inch electrical conduits, ½ inch metal sleeve with low voltage cable.
d. Telecom room Axx2x29- drywall seams, ½ inch metallic flew conduit.
e. 1st floor telecom room Axx1x1F- 4 inch sleeve sealed with mixed caulk, drywall seams.
f. 4th floor Irrigation supply- (3) 4 inch metal sleeves, drywall seams.
g. Soiled utility- 1 inch sprinkler line, 1 inch sleeve with low voltage cable.
h. 4th floor telecom room Axx4x4D- in hallway above the door- 4 inch sleeve with low voltage cables sealed with mixed caulk, 3 inch x 3 inch drywall patch, drywall seams. Inside the room- 10 inch duct, drywall seams.
i. 1st floor Electrical room Axx1x1D- ½ metal conduit.
j. 1st floor inside pump room- wall not constructed to the deck

National Fire Protection Association (NFPA) 101, 19.3.2.1 (2012 Ed.), NFPA 101, 8.7.1.1(1)(2012 Ed.) NFPA 101, 8.3.5. (2012 Ed.),NFPA 101, 8.3.5.1 (2012 Ed)

2. Observation on 09/30/2019 at 12:49 PM, revealed the door to the storage room by the staff lounge did not self-close within the frame in B-tower 6th floor. NFPA 101, 19.3.2.1.3 (2012 Edition)

3. Observation on 09/30/2019 at 1:05 PM, revealed the door to the storage room by C6117 did not self-close within the frame on the 6th floor of C-tower. NFPA 101, 19.3.2.1.3 (2012 Edition)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19. Firestopping citations were not individually covered per request of administration.

Based on record review, the facility failed to maintain the fire alarm system.

The finding included:

Record review on 10/2/19 at 8:25 AM, revealed the facility could not provide documentation for the sensitvity testing of the smoke detectors. NFPA 72, 14.4.5.3.2 (2010 Ed)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19.

Based on observations, the facility failed to maintain the sprinkler system.

The findings included:

1. Observation on 09/30/2019 at 10:08 AM, revealed an escutcheon plate missing from the sprinkler in the 9th floor B-tower EVS closet by electrical room Bxx9x9C. NFPA 101, 19.3.5.1 (2012 Edition) NFPA 101, 9.7.5 (2012 Edition) NFPA 25, 5.2.1.1.4 (2011 Edition)

2. Observation on 09/30/2019 at 10:15 AM, revealed an escutcheon plate missing from the sprinkler in the 9th floor B-tower EVS closet by electrical room Bxx9x98. NFPA 101, 19.3.5.1 (2012 Edition) NFPA 101, 9.7.5 (2012 Edition) NFPA 25, 5.2.1.1.4 (2011 Edition)

3. Observation on 09/30/2019 at 1:24 PM, revealed ceiling tiles missing from the ceiling in the C-tower 6th floor communications room. NFPA 101, 19.3.5.1 (2012 Edition) NFPA 101, 9.7.5 (2012 Edition) NFPA 25, 4.1.5* (2011 Edition)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19.

Based on observations, the facility failed to maintian the sprinkler system.

The finding included:

1. Observation on 10/2/19 at 8:26 AM, revealed that (2 of 12) sprinklers in the conference room was recessed into the ceiling grid creating an obstruction to the spray pattern. NFPA 25, 5.2.1.1.1 (2011 Ed)

2. Observation on 10/2/19 at 8:26 AM, revealed that (1 of 12) sprinklers in the conference room was not in the correct orientation.
NFPA 25, 5.2.1.1.1 (2011 Ed)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19.

Based on observations, the facility failed to maintain corridor openings.

The finding included:

Observation on 09/30/2019 at 1:11 PM, revealed 2 louvers installed on the door to the storage room across from the Resource Center on the 6th floor of C-tower. NFPA 101, 19.3.6.4.1 (2012 Edition)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19.

Based on obervations, the facility failed to maintain the smoke barriers.

The findings included:

1. Observation on 10/2/19 between 8:00 AM and 3:00 PM, revealed penetrations and improper firestopping in the following 1 hour fire/smoke barriers not in accordance with fire stop systems:

Basement above Business office B-025
a. 1- 6 inch by 6 inch blow out patch.
b. 1- Blue cable wire.

Basement wall above Specimen desk in the lab
a. 1- blue cable bundle

Basement wall above lab south end entrance
a. 1- ½ inch metal sleeve.
b. 1- 2 inch metal sleeve.
c. 1- 8inch by 8 inch blow out patch.
d. 1- 6ft by 1 ½ ft blow out patch.

Basement wall next to the lab vitros machines
a. 3- Steel I beam.

Basement wall above the north Counter top in the lab (Blood bank counter top)
a. 1- 6 inch by 6 inch blow out patch.

Basement
a. Above soiled utility- ½ inch electrical conduit.
b. Above clean utility- (2) 2 ½ inch metal conduits, (2) 2 inch insulated water lines not sealed, 1 inch sprinkler line.
c. Between decontamination room and material management- (2) 3 inch x 9 inch drywall patches.
d. In material management room- 1 inch copper line, ½ inch metal conduit, (2) ½ inch metal sleeves, (2) 2 inch sleeves.

Basement above breakroom in material management
a. 2 penetration holes not sealed,
b. ½ inch flex conduit.

Basement above equipment storage
a. 8 inch x 16 inch drywall patch.

1st floor above cross corridor doors and womans imaging center entrance
a. 18 in x 18 in blowout patch

1st floor wall by radiologist billing office
a. 2 - 2 inch insulated pipes

1st floor wall above cross corridor doors next to short elevator
a. 2 - 4 inch insulated pipes
b. 1 - 2 inch insulated pipe

1st floor walls between corridors 1-013 and 1-270
a. 4 - 2 inch insulated pipes
b. 1 - 6 inch insulated pipes
c. 1 - 1 inch insulated pipe

1st floor wall above kitchen door in corridor 1-270
a. 1- cable bundle

1st floor wall above storage room door 1-239 in corridor 1-039
a. 1 - 1/2 inch med gas copper pipe

1st floor wall above cross corridor doors 0827
a. 2 - 6 inch insulated pipes
b. 1 - 10 inch insulated pipe

1st Floor inside dining room
a. 1 inch black cable over door from Lobby.
b. A ½ inch metal sleeve above the television.
c. An 8 inch insulated line by the roll-up gate.
d. 1 - ½ black cable.
e. 2 - ¾ inch metal flexible conduits.

1st floor back hall of dining room
a. The wall was not sealed to the deck.
b. 1 - ¾ inch metal conduit.
c. A 1 ¼ inch metal sleeve by rear dining room entrance door.

1st floor wall at Health Information Management
a. 3 - 1 inch sleeves.
b. 2 - 1 inch metal conduits.
c. A 2 inch metal sleeve.
d. 2 - 1 inch metal sleeves above the medical records shelves.
e. 2 - ½ inch metal conduits above the medical records shelves.

1st floor mamogram changing room
a.1- metal conduit
b.1 - sprinkler pipe

1st floor air handler 6 meachical room
a. 1 -spinkler pipe
b. 2 - large metal conduits

1st floor class room A
a. 4 - metal conduits

1st floor doctors lounge
a. insulated hot water pipes
b. 8- data cables

1st floor storage room for OR6 & OR7
a. 4 metal conduits with mixed caulk

1st floor staff work room
a. 4 - insulated pipes
b. 1 - sprinkler pipe

1st floor soiled utility by staff work room
a. 1 - metal conduit
b. 1 - sprinkler pipe
c. 1 - open hole

1st floor soild utility room
a. multiple blowout patches
b. 2 - metal conduits

2nd floor rear wall of the soiled utility room on nurses station side
a. 2 blowout patches.
b. 2 blue ½ inch metal sleeves.
c. the wall is not sealed to the iron beam.
d. 2 - ½ metal conduits recessed in wall.

2nd floor communications equipment room
a. Drywall seam sealed with fire stop material.
b. A metal strut.
c. 1 - ½ metal sleeve.
d.1 - ¾ inch metal conduit.
e. 2 - 2 ½ water lines.

2nd floor inside clean utility room
a. Blowout patch.
b.Seams not sealed.

2nd Floor wall at MICU Unit Soiled Utility
a. 2 inch metal sleeve.
b. 2 - ½ metal sleeves.
c. 1 - 1 ½ inch metal sleeve.
d. 2 - 1 inch insulated lines.

2nd Floor Family Birth Center Entrance doors
a. 3 blowout patches
b. 1 - 2 inch metal sleeve

2nd floor Soiled Utility Room
a. 3 - 2 ½ inch insulated water lines.

2nd floor back Hallway of the Family Birth Center
a. 2 - 2 ½ inch insulated lines above the door of the clean utility across from
Room #4.

2nd floor above cross corridor doors by anesthesia directors office
a. 1 black cable
b. 1 cable bundle
c. 1 - 2 inch sleeve with cable bundle
d. wall not sealed at the deck

3rd Floor Wall at EXIT sign #130.
a. The drywall to the deck was not sealed.
b. 1 ½ inch sprinkler line.
c. An unused penetration.
d. 1 inch metal sleeve on the opposite side of the smoke barrier wall.

3rd Floor Wall at the Soiled utility room.
a. Blowout patch.
b. 1 - 1 ½ inch insulated line.
c. An 8 inch cut in drywall not sealed.
d. 2 inch sprinkler line in the drywall over the communications door in the soiled utility room.

3rd Floor Wall at the Soiled utility room
a. 2 inch sprinkler line above in the clean supply corridor side of the drywall

4th floor wall inside the soiled utility room
a. blowout patch

National Fire Protection Association (NFPA) 101, 19.3.7.3 (2012 Ed.), NFPA 101, 8.5.6.2 (2012 Ed.)
NFPA 101, 8.5.6.3 (2012 Ed.), NFPA 101, 8.3.5. (2012 Ed.), NFPA 101, 8.3.5.1 (2012 Ed)

2. Observation on 10/02/2019 at 1:25 PM, revealed a blow-out patch; penetrations by structural I-Beams, and sleeved communication wires not sealed properly, above the suspended ceiling, in the 1 hour fire rated wall in the basement corridor outside of the laboratory. NFPA 101, 8.3.1.2 (2012 Edition) NFPA 101, 8.3.5.1 (2012 Edition)

3. Observation on 10/02/2019 at 1:35 PM, revealed improper gypsum board patches (blow-out patches and fire caulked gypsum board patch); penetrations by sleeved communication wires not sealed properly, above the suspended ceiling, in the 1 hour fire rated wall in the basement corridor outside of the north laboratory door. NFPA 101, 8.3.1.2 (2012 Edition) NFPA 101, 8.3.5.1 (2012 Edition)

4. Observation on 10/02/2019 at 1:43 PM, revealed a blow-out patch; penetrations by structural I-Beams, and communication wires not sealed properly, above the suspended ceiling, in the 1 hour fire rated cross corridor smoke barrier wall in the basement north corridor outside of the laboratory. NFPA 101, 8.3.1.2 (2012 Edition) NFPA 101, 8.3.5.1 (2012 Edition)

5. Observation on 10/02/2019 at 1:53 PM, revealed a blow-out patch, above the suspended ceiling, in the 1 hour fire rated barrier wall in the basement north corridor outside of the male restroom. NFPA 101, 8.3.1.2 (2012 Edition)

6. Observation on 10/2/19 between 8:00 AM and 3:00 PM, revealed the following 1 hour rated fire/smoke barriers were not firestopped at the deck and around the structual I-beams.
a. 2nd floor wall in office 2-187
b 2nd floor wall in lounge 2-233 and med room 2-234
c. 2nd floor wall in room Ex/Tr 2-229
d. 2nd floor above cross corridor doors by room Ex/Tr 2-229
e. 2nd floor anesthesia directors office
f. 1st floor above cross corridor doors and womans imaging center entrance
g. 1st floor wall by radiologist billing office
h. 1st floor wall above cross corridor doors next to short elevator
i. 1st floor wall above pre-admission consultation office and short elevator
j. 1st floor wall behind electrical room 1-243
k. 1st floor wall between electrical room 1-243 and cross corridor doors 0822.
l. 1st floor walls between corridors 1-013 and 1-270
m. 1st floor wall above kitchen door in corridor 1-270
n. 1st floor wall above storage room door 1-239 in corridor 1-039
o. 1st floor wall above cross corridor doors 0827
p. 4th floor corridor wall side of the soiled utility room
q. 4th floor wall inside the soiled utility room
r. 4th foor corridor wall side of the Environmental Services closet
t. 3rd Floor Wall at EXIT sign #130
w. Basement bove the business office B-025.
x. Basement wall above the Specimen desk in the lab.
y. Basement wall above the north counter top (Blood Bank Counter top in the basement lab).
z. Basement wall above the lab refrigerators (B-016).
aa. Basement wall above the North West counter top in the lab.
bb. Basement wall in the Bacterial room.
cc. Basment wall above the north entrance to lab.
dd. Basemnt wall above the south entrance to the lab.
ee. Basement wall above the vitros machine in the lab.
ff. Basement wall in lab managers office B-018
gg. Basement wall in lab storge room.

National Fire Protection Association (NFPA) 101, 19.3.7.3 (2012 Ed.), NFPA 101, 8.5.6.2 (2012 Ed.)
NFPA 101, 8.5.6.3 (2012 Ed.), NFPA 101, 8.3.5. (2012 Ed.), NFPA 101, 8.3.5.1 (2012 Ed)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19. Firestopping citations were not individually covered per request of administration.

Based on obervations, the facility failed to maintain the smoke barriers.

The findings included:

1. Observations on 9/30/19 - 10/2/19 between 8:00 AM and 4:00 PM, revealed the 1 hour fire/smoke barrrier walls in the following areas contained penetratons and improper fire stopping not in accordance with fire stop systems:

C- Tower 10th floor next to room 1017
a. 1- red cable.
b. 1- ½ inch medical gas pipe.
c. 1- 1 inch metal sleeve.

C-Tower 10th floor across from room 1017/1015
a. 1- 1 inch sprinkler pipe.
b. 1- 4 inch by 4 inch blow out patch.
c. 2- 1/2inch copper pipe.
d. 1 -1/2 inch metal conduit.

9th floor A tower above doors next to class room
a. 1- 4 inch metal sleeve.

Wall next to Clean room above the door behind the main nurse's station
a. 2 - 1inch metal conduits.
b. 1- 6inch by 6 inch blow out patch.
c. 1- 4 inch by 4 inch blow out patch.
d. 1-3 inch by 3 inch blow out patch.
e.1- ½ inch metal sleeve.

9th floor C tower clean room behind the main nurse's station
a. sections of the wall not fully constructed

Wall next to Room C 1020
a. 1- 5 inch by 5 inch blow out patch.

Wall above doors next to C1019
a. 1-1 inch metal sleeve.
b. 1 -1 inch metal conduit.

9th floor C Tower above fire door 29 by C9117
a. 1 -3 inch by 4inch blow out patch.
b. 1-1inch metal sleeve.
c. 1-1/4 inch metal sleeve.
d. 1- 1ft by 1ft blow out patch.
e. 2- ½ inch metal conduits.
f. 1- 1inch hole next to the metal conduits.
g.1- 2 inch metal sleeve.

9th floor C tower above doors 29 by clean supply
a. 1- 10 inch by 10 inch blow out patch.
b. 1- Red cable.
c. 1- 4 inch by 5 inch blow out patch.
d. 1- 3 inch copper pipe.
e. 1- 2inch metal sleeve.
f. 4-1/4 inch metal conduit.
g. 1- ¼ flex conduit.
h. 1- gray cable.

9th floor C Tower clean supply room near fire door 24
a. 1 -1 inch metal conduit.

9th floor C tower above fire doors 31 next to C9122
a. 1- 3ft by 2ft blow out patch.
b. 1- cable wire.

9th floor C tower above ceiling in room C9120
a. 1-1 inch metal sleeve.

9th floor B tower in bathroom of conference room.
a. 1- 2inch by 10 inch blow out patch.
b. 2- 6 inch by 2ft bow out patch.

9th floor B tower conference room across from clinical manager's office
a. 3- 1 inch med gas lines.
b. 8- ½ inch metal conduits.

9th floor B tower by room 967
a. 2- 2 inch hot water lines.
b. 1- 2 inch chilled water line.
c. 1-5 inch insulated pipe.
d. 2- 2 inch metal sleeves.

9th floor B tower near fire door 24-25
a. 1- 2 inch metal sleeve.
b. 1- Brown wire.
c. 1- 1inch sprinkler pipe.
d. 2- 6inch ventilation duct.
e. 3- 6inch by 12 inch blow out patches.
f. 1- 6 inch insulated pipe.

9th floor B tower next to room 975
a.1- 3 inch by 4 inch blow out patch.
b. 1- 3 inch insulated pipe.

9th floor B tower in room 975a
a 2- 1 inch metal conduits.
b. 3- 1 inch copper pipes.
c. 1- 8 inch by 8 inch blow out patch.
d . 1- 6 inch by 8 inch blow out patch.

9th floor B tower nutrition in the room
a.2 inch by 10 inch blow out patch.

9th floor B tower above the nutrition room door
a. 1- 2inch by 8 inch blowout patch.

9th floor B tower above fire doors near nutrition room
a.1- 4 inch blow out patch.
b. 2- 3 inch insulated pipes.
c. 1- 6 inch insulated pipe.

9th floor B tower in resident room 967
a. 1- 6 inch by 12 inch blow out patch.

9th floor B tower in front of room 967
a. 6ft by 3ft blow out patch.

8th floor C tower above door 38
a. 2- 3 inch by 3 inch blow out patch.
b. 1- yellow cable wire.

8th floor C tower in clean room behind main nurse's station
a. 1-2 inch metal sleeve.
b. 1- 6ft by 5ft blow out patch.

8th floor A tower above doors 39-40
a. 1-1/4 inch flex conduit (green).

8th floor A tower above the clean supply room (2)
a. 1- 1inch metal sleeve.

8th floor A tower above doors 46-47 (next to class room)
a. 2- 3 inch insulated pipes

8th floor A tower above doors 52-53
a. 1- 1inch metal conduit.

8th floor C tower above doors 44-45
a. 2- 6 inch duct work.

8th floor C tower door 37-38
a. 1- 8inch by 10 inch blow out patch.
b. 1- 1inch metal conduit.
c. 1- cable bundle.
d. 2- 1inch insulated pipe.

8th floor C tower in A855
a. 4- ¼ inch metal conduits.
b. 3- 1 inch sprinkler pipe.
c. 1- 2 inch pvc pipe.

8th floor C tower pod 1 nurses station
a. 1- 2 ft. by 2 ft. blow out patches.

8th floor C tower above door 39
a. 1- 5 inch by 5inch blow out patch.
b. 1- 1inch metal sleeve.
c. 1- cable.

8th floor C tower across from b865
a. 1- 8ft by 8ft blow out patch.

8th floor C tower in room 867
a. 1- 1 inch sprinkler pipe.
b. 1- 1inch metal conduit.
c. 2 -1/4 inch copper pipe.

8th floor C tower above doors 47-48
a. 1- ¼ inch copper pipe.

8th floor C tower next to room A 875
a. 1- 4 inch by 4 inch blow out patch.

8th floor C tower in room A 875
a. 7- ½ inch metal conduits.
b. 1- 3 inch insulated pipe.
c. 6-1/2 inch copper pipe.
d. 1- 1 inch sprinkler pipe.
e. 2- ¼ inch metal sleeves.

8th floor C tower main nurses station
a. 1- 4inch by 6 inch blow out patch.

8th floor C tower clean room behind nurses station
a. sections of wall not constructed

8th floor C tower above door 43
a. sections of wall not constucted

8th floor C tower in room A 889
a. 1- ¼ inch copper pipe.
b. 1- 1inch sprinkler.

7th floor cardiology nurse pracitoners office
a. 3 ft x 3 ft blowout patch

7th floor CCU entrance doors
a. 2 - 3 inch insulated pipes (fire caulk mixed with drywall mud)
b. 1 - 2 inch insulated pipe (fire caulk mixed with drywall mud)
c. 1 - 2 inch steel pipe (fire caulk mixed with drywall mud)
d. 7 - 1 inch metal conduits (fire caulk mixed with drywall mud)
e. 3 - 1/2 inch metal conduits (fire caulk mixed with drywall mud)

7th floor above door DH-357 by the directors office
a. 4 - 3 inch metal conduits (fire caulk mixed with drywall mud)
b. 1 - 1 inch steel pipe (fire caulk mixed with drywall mud)
c. 1 - 1/2 inch metal conduit (fire caulk mixed with drywall mud)
d. 2 - 1 inch metal conduits (fire caulk mixed with drywall mud)

7th floor clinical managers office
a. 6 in x 15 in blowout patch

7th floor stat lab
a. 6 in x 15 in blowout patch
b. 6 in x 8 in blowout patch
c. 4 in x 4 in blowout patch

7th floor above door DH-360
a. 4 - 1 inch metal conduits (fire caulk mixed with drywall mud)
b. 1 - 12 inch duct (fire caulk mixed with drywall mud)
c. 1 - 3 inch insulated pipe (fire caulk mixed with drywall mud)

7th floor behind CCU nurses station
a. 2 - 6 in x 18 in blowout patches

7th floor in CCU above cross corridor doors DH-358
a. 2 - 4 in x 4 in blowout patches
b. 2 - 6 inch insulated pipes (fire caulk mixed with drywall mud)
c. 2 - 3 inch insulated pipes (fire caulk mixed with drywall mud)
d. 1 - 2 1/2 inch steel pipe (fire caulk mixed with drywall mud)
e. 2 - 2 inch steel pipes (fire caulk mixed with drywall mud)
f. 4 - 1 1/2 inch metal conduits (fire caulk mixed with drywall mud)
g. 2 - 1 inch metal conduits (fire caulk mixed with drywall mud)
h. 1 - 1/4 copper pipe (fire caulk mixed with drywall mud)

7th floor staff lounge
a. 4 in x 4 in blowout patch
b. multiple blowout patches around duct

7th floor nourishment room
a. 1 - 2 inch insulated pipe (fire caulk mixed with drywall mud)
b. 1 - 1 inch insulated pipe (fire caulk mixed with drywall mud)
c. 1 - 3 inch steel pipe (fire caulk mixed with drywall mud)

7th floor above CCU cross corridor doors DH-361
a. 4 - 3 in x 8 in blowout patched around a pipe bundle

7th floor dialysis equipment room
a. 4 - 2 in x 6 in blowout patches around the duct

6th foor above cross corridor door by room B654
a. 1- blowout patch

6th floor above starwell door across from room B661
a. 1 - data cable
b. 1- metal conduit

6th floor above cross corridor doors by room C6114
a. 1 - blowout patch

5th floor above the suspended ceiling in the bathroom of room C5117
a. multiple insulated pipes not sealed

5th floor above the suspended ceiling in the corridor outside of room C5117
a. 5 - blowout patches
b. multiple penetrations

5th floor above the suspended ceiling in concrete block wall of electrical room Cxx5BER
a. multiple penetrations

5th floor corridor wall outside of room C5117
a. multiple blowout patches
b. insulated pipes
c. communication wires

A Tower 4th floor
a. Above door by staff lounge- 3 inch insulated water line, 2 inch insulated water lines.
b. Above door by room A432- drywall seams, 5 inch sleeve not sealed.
c. Above doors by staff elevators- 1 inch sprinkler line.

B Tower 4th floor
a.Wall above the door on the right side of the nurses station- (2) ½ inch metal sleeves, 3 drywall patches.
b. Above the nurses station- ½ inch metal conduit, 4 inch x 4 inch drywall patch.
c. Behind nurses station in charting room- ½ inch metal conduit, drywall seams.
d. Above doors by charting- 2 drywall patches, (2) 1 ½ metal sleeves with low voltage cable bundles.

C Tower 4th floor
a. By room C4117- (2) ½ inch metal conduits, 2 cable bundles.
b. Soiled utility- 4 inch by 4inch drywall patch.
c. Above door to clean supply- 4 inch x 4 inch drywall patch, (2) ¼ inch metal conduits, 1 inch sleeve.

3rd floor cross corridor wall at room C3101
a. sleeved communication wires
b. pass through device not installed correctly

3rd floor in the corridor outside Mid-South Perinatal clinic
a. multiple penetrations not sealed

3rd floor cross corridor wall by elevators at the OB Emergency Triage
a. multiple sleeved communication wires
b. multiple conduits

3rd floor above the suspended ceiling in the OB Emergency Triage medical storage room
a. 2 blowout patches
b. metal clad wires

3rd floor above the suspended ceiling Clinic mangers office and NICU office
a. multiple blowout patches

3rd floor A tower -Outside equipment room wall in front of Women and Children Center nurses station
a. 4 inch metal conduit.
b. 3 - ¾ inch flexible metal conduit.
c. bundle of 3 - 1 inch metal conduits.
d. seams were not embedded with gypsum mud.

3rd floor A tower above entrance doors to the Women and Children's Center between the nurses station and equipment room.
a. The 1 hour fire rated wall was not constructed properly.The wall did not extend to the deck above the ductwork.

3rd floor A tower hallway outside the Women and Children's Center above the reception desk and exit doors in front of the illuminated signage and fire extinguisher.
a. The wall was not sealed to the deck above the damper.
b. 2 ½ sprinkler line.
c. 3 cable bundles.
d. recessed all thread.
e. recessed pipe brace for the sprinkler line.
f. Seams were not embedded with gypsum mud.
g. recessed metal strut supporting medical gas lines.
h. 1 -1/2 green flexible cable.
i. blowout patch.
j. 1 - ½ inch blue cable.
k.2 inch medical vacuum line.
l. pipe hangar recessed into the wall.
m.1 - ¾ inch metal sleeve.
n. 1 - ½ metal conduit.
o. 1 - ¼ inch green flexible conduit.
p. 2 - ½ inch metal sleeves.
q. 2 separate white cables.

3rd floor A-tower- wall between the corridors inside the Women and Children's Center.
a. 4 - 3 inch metal sleeves.
b. 1 - 5/8 inch metal sleeve.
c. Seams were not embedded with gypsum mud.

3rd floor A tower-wall above the Certificate Specialist office.
a. Wall was not constructed per an approved assembly. The wall did not extend to the deck above the duct work.

3rd floor A tower hallway outside the Women and Children's Center above the reception desk and exit doors in front of the illuminated signage and fire extinguisher.
a. The wall was not sealed to the deck above the damper.
b. 2 ½ sprinkler line.
c. 3 cable bundles.
d. recessed all thread.
e. recessed pipe brace for the sprinkler line.
f. Seams were not embedded with gypsum mud.
g. recessed metal strut supporting medical gas lines.
h. 1 -1/2 green flexible cable.
i. Blowout patch.
j. 1 - ½ inch blue cable.
k. 2 inch medical vacuum line.

3rd floor A tower- wall by classroom.
a. 3 inch metal sleeve left of classroom door.
b. 1 red cable left of classroom door.
c. The wall to the deck had blue caulking and a beige caulking on top of the blue.
d. Seams were not embedded with gypsum mud.

3rd floor A tower - wall across from conference room.
a. 1 ¾ inch metal sleeve.
b. 1 - ¾ inch metal sleeve.
c. Green flexible conduit.
d. ½ metal conduit.
e. 2 inch sprinkler line.
f. Seams were not embedded with gypsum mud.

3rd floor A tower -wall by room A330.
a. 4 - 4 inch metal sleeves.
b. Seams were not embedded with gypsum mud.

3rd floor A-tower equipment room
a. 1 inch metal sleeve.
b. 1 ½ metal sleeve.
c. 2 low voltage bundles.
d. ½ inch metal sleeve.
e. 1 inch flexible metal conduit.
f. 2 - ½ metal sleeves.
g. Seams were not embedded with gypsum mud.

2nd floor ICU cross corridor doors by room A232
a. 1 - 1/2 inch metal flex conduit
b. 1 - 6 inch insulated pipe

2nd floor corridor wall at A2 soiled utility
a. 1 - 3 inch metal conduit
b. 1 - 6 inch metal conduit
c. 1 - 1/4 inch metal flex conduit

2nd floor A2 access door by directors office
a. 1 - 1 inch metal conduit

2nd floor above A2 CVICU access doors
a. 2 - 6 inch metal sleeves with cable bundles

2nd floor above cross corridor doors by room C2119
a. deck sealed with mixed fire caulk

2nd floor equipment room across from room C2118
a. 1 - 3 inch insulated pipe (mixed caulk)
b. deck sealed with mixed fire caulk

2nd floor 2C surgery entrance at cross corridor doors (labeled 2 hour fire smoke barrier)
a. 1 - 1 inch metal flex conduit

2nd floor surgery department ( labeled 2 hour fire smoke barrier)
a. entire fire smoke barrier surrounding the surgery area had penetrations sealed with unknown cream colored caulk

2nd floor above cross corridor doors next to anesthesiology room
a. 1 - blowout patch

2nd floor above cross corridor door next to scope processing area
a. multiple penetrations with mixed caulk

2nd floor to the right of the respiratory care room door above ceiling
a. deck not sealed

2nd floor back of blood gas storage
a. 1- cable bundle
b. multiple blowout patches

2nd floor above cross corridor doors next to family room
a. 1- blowout patch

2nd floor back side of room B273
a. not constructed properly (heavy drywall mud used for the top 12 to 18" of wall

2nd floor back side of room B269
a. multiple blowout patches
b. multiple penetrations sealed with draywall mud.

1st floor above TV at the flower delivery desk
a. 1 - 2 inch metal conduit

1st floor- wall above radiology waiting room
a. 12ft x 14ft section of drywall missing
b. wall not constructed to the deck

1st floor radiology waitng room
a. door/window assemby not fire rated

1st floor above cross corridor doors at radiology
a. 6 - 6 in x 6 in blowout patches

1st floor cross corridor doors DH-104 by radiology entrance
a. 1 - 6 in x 18 in blowout patch around pipe bundle

1st floor above cross corridor doors DH-106 in radiology
a. 2 in x 2 in unused hole

1st floor above door DH-110 in radiology
a. 8 - 2 inch metal conduits (fire caulk mixed with drywall mud)
b. 6 - 1 inch metal conduits (fire caulk mixed with drywall mud)
c. 1 - 6 inch insulated pipe (fire caulk mixed with drywall mud)
d. 1 - 3 inch steel pipe (fire caulk mixed with drywall mud)
e. 1 - 6 inch metal sleeve with cable bundle (fire caulk mixed with drywall mud)
f. 1 - 3 inch copper pipe (fire caulk mixed with drywall mud)
g. 1 - 2 inch copper pipe (fire caulk mixed with drywall mud)
h. 1 - 3/4 inch copper pipe (fire caulk mixed with drywall mud)
i. 1 - 1 inch copper pipe (fire caulk mixed with drywall mud)

1st floor above supply area #3 in radiology by dictation room
a. 5 - 1 inch metal conduits
b. 1 - 6 inch metal conduits
c. 1 - 12 inch duct
d. 1 - 3 inch insulated pipe
e. 2 - cable bundles

1st floor radiology- wall above door DH-115 that continues behind storage cabinets and into nuclear med room O to the exterior wall
a. Multiple penetrations of metal conduits, cable bundles, insulated pipes, and copper pipes. (fire caulk mixed with drywall mud)

1st floor above the cross corridor by the telecom room ExxlclM
a. multiple penetrations sealed with mixed fire caulk

1st floor above the electrical room by donor service
a. 2 metal conduits not sealed

1st floor above ceiling by the fire alarm strobe next to the cath lab
a. hole around the damper

1st floor between sane waiting room and womens locker room
a. 1- blowout patch
b. 1- metal conduit

1st floor in the fast track supply room
a. 18"X6" hole and multiple penetrations not sealed

1st floor ER waiting room
a. 1-blowout patch
b. multiple penetrations

1st floor cross corridor wall by the Quality Plus Coordinator office
a. multiple blowout patches
b. sleeved bundle of communication wires

GI 1st floor D tower med room
a.1ft by 2ft blow out patch.
b.1- 3 inch by 3 inch blow out patch.
c.1- 2 inch metal sleeve.

GI 1st floor D tower clean scope room
a. 1- 5 inch by 6 inch hole.
b. 1- 4 inch by 3 inch hole.
c. 2- 2 inch insulated pipes.

GI 1st floor D tower telecom room
a. 1- ¼ inch metal sleeve

1st floor A tower - elevator lobby in the 1 hour fire smoke barrier
a. 2 - 1 inch metal sleeves above television monitor by double doors.
b. Seams were not embedded with gypsum mud.

1st floor -wall by main door to city county room
a. 6 - ½ metal flexible conduits.
b. ½ inch metal sleeve.
c. 1 inch metal sleeve.
d. 2 inch metal sleeve.
e. 2 inch steel line.
f. Seams were not embedded with gypsum mud.

A Tower 1st floor
a. Above entrance to conference center- 1 inch sprinkler line.
b. In hall of conference room- ½ inch metal conduit, 1 inch metal conduit, 1 ½ inch metal conduit, 2 inch metal conduit.
c. By Carter waiting entrance- ½ inch metal sleeve.
d. In front of chapel doors- 3 inch metal sleeve, 4 inch metal sleeve.
e. By P elevators- 3 inch sleeve.
f. Cardiac cath lab 2- (2) ½ inch metal conduits, 4 inch metal sleeve, ¼ copper line.

In basement across from critical care waiting room door
a. 2 - metal conduits not sealed

In basement to the left of ENVS closet by the cross corridor wall
a. 2 - metal conduits not sealed

In basement over cross corridor wall by the ENVS closet
a. 2 - metal conduits not sealed

In basement over the cardiac rehab storage room door
a. 1 - metal flex conduit not sealed

In basement in the 2nd clinical manager office of cardiac rehab
a. 1 - 2 inch sprinkler pipe

In basement over the cross corridor doors by equipment room/escalators
a. 4 - large metal conduits with low voltage wires

In basement in the dish wash alcove above ceiling
a. 1 - 2 inch sprinker pipe

In basement inside the meeting room by P1 elevators
a. 1 - large insulated pipe

In basement above cross corridor door by the pantry and medical records room
a. 1 - metal conduit

In basement in the corridor wall by medical records
a. 2 - 6 inch holes filled with fire caulk

In basement above corridor across from the mechanical room CxBAxBK
a. multiple penetrations not sealed

In basement above electrical panel PAA by equipment room DCBABBH
a. multiple penetrations not sealed

In basement on the CMU wall by the cross corridor wall next to equipment room DCBABBH
a. multiple blowout patches

In basement above ceiling at the back dock entrance
a. multiple penetrations
b. wall not completely constructed

In basement between staff elevators and pharmacy learning room
a. multiple penetrations
b. multiple blowout patches

In basement thoughout the CSR area
a. deck not sealed

National Fire Protection Association (NFPA) 101, 19.3.7.3 (2012 Ed.), NFPA 101, 8.5.6.2 (2012 Ed.)
NFPA 101, 8.5.6.3 (2012 Ed.), NFPA 101, 8.3.5. (2012 Ed.), NFPA 101, 8.3.5.1 (2012 Ed)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19. Firestopping citations were not individually covered per request of administration.

Based on records review, the facility failed to maintain heating, ventilation and air conditioning systems.

The findings included:

Document review on 10/02/2019 at 7:49 AM, revealed the facility failed to provide documentation for a 4 year fire damper inspection. National Fire Protection Association, NFPA 101, 21.5.2.1 (2012 Ed.), NFPA 101, 9.2.1 (2012 Ed.), NFPA 5.4.8.1 (2012 Ed.), NFPA 80, 19.4.1.1 (2010 Ed.)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19.

Based on records review, the facility failed to maintain heating, ventilation and air conditioning systems.

The findings included:

Records review on 10/02/2019 at 08:10 AM, revealed the facility failed to provide the 4 year fire damper inspection documentation.

National Fire Protection Association, NFPA 101, 21.5.2.1 (2012 Ed.), NFPA 101, 9.2.1 (2012 Ed.), NFPA 5.4.8.1 (2012 Ed.), NFPA 80, 19.4.1.1 (2010 Ed.)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19.

Based on observations, the facilty failed to maintain the linen chutes.

The findings included:

1. Observation on 09/30/2019 at 9:46 AM, revealed a non-listed latch on the A-tower 9th floor linen chute door. NFPA 101, 4.6.12.2 (2012 Edition) NFPA 101, 9.5.2 (2012 Edition) NFPA 82, 5.3.2.1.2 (2009 Edition) NFPA 101, 9.5.1.2 (2012 Edition) NFPA 101, 8.3.4.2* (2012 Edition) NFPA 101, 8.3.3.1 (2012 Edition) NFPA 80, 15.1.3 (2010 Edition)

2. Observation on 09/30/2019 at 9:47 AM, revealed the A-tower 9th floor linen chute shaft access door did not self-close. NFPA 101, 9.5.1.1 (2012 Edition) NFPA 101, 8.3.4.2* (2012 Edition) NFPA 101, 8.3.3.1 (2012 Edition) NFPA 101, 8.3.3.3 (2012 Edition)

3. Observation on 09/30/2019 at 10:40 AM, revealed a non-listed latch on the C-tower 8th floor linen chute door. NFPA 101, 4.6.12.2 (2012 Edition) NFPA 101, 9.5.2 (2012 Edition) NFPA 82, 5.3.2.1.2 (2009 Edition) NFPA 101, 9.5.1.2 (2012 Edition) NFPA 101, 8.3.4.2* (2012 Edition) NFPA 101, 8.3.3.1 (2012 Edition) NFPA 80, 15.1.3 (2010 Edition)

4. Observation on 09/30/2019 at 11:43 AM, revealed a non-listed latch on the C-tower 7th floor linen chute door. NFPA 101, 4.6.12.2 (2012 Edition) NFPA 101, 9.5.2 (2012 Edition) NFPA 82, 5.3.2.1.2 (2009 Edition) NFPA 101, 9.5.1.2 (2012 Edition) NFPA 101, 8.3.4.2* (2012 Edition) NFPA 101, 8.3.3.1 (2012 Edition) NFPA 80, 15.1.3 (2010 Edition)

5. Observation on 09/30/2019 at 12:58 PM, revealed a non-listed latch on the B-tower 6th floor linen chute door. NFPA 101, 4.6.12.2 (2012 Edition) NFPA 101, 9.5.2 (2012 Edition) NFPA 82, 5.3.2.1.2 (2009 Edition) NFPA 101, 9.5.1.2 (2012 Edition) NFPA 101, 8.3.4.2* (2012 Edition) NFPA 101, 8.3.3.1 (2012 Edition) NFPA 80, 15.1.3 (2010 Edition)

6. Observation on 09/30/2019 at 1:09 PM, revealed a non-listed latch on the C-tower 6th floor linen chute door. NFPA 101, 4.6.12.2 (2012 Edition) NFPA 101, 9.5.2 (2012 Edition) NFPA 82, 5.3.2.1.2 (2009 Edition) NFPA 101, 9.5.1.2 (2012 Edition) NFPA 101, 8.3.4.2* (2012 Edition) NFPA 101, 8.3.3.1 (2012 Edition) NFPA 80, 15.1.3 (2010 Edition)

7. Observation on 09/30/2019 at 3:00 PM, revealed a non-listed latch on the D-tower 3rd floor linen chute door. NFPA 101, 4.6.12.2 (2012 Edition) NFPA 101, 9.5.2 (2012 Edition) NFPA 82, 5.3.2.1.2 (2009 Edition) NFPA 101, 9.5.1.2 (2012 Edition) NFPA 101, 8.3.4.2* (2012 Edition) NFPA 101, 8.3.3.1 (2012 Edition) NFPA 80, 15.1.3 (2010 Edition)

8. Observation on 09/30/2019 at 3:28 PM, revealed a non-listed latch on the D-tower 2nd floor linen chute door. NFPA 101, 4.6.12.2 (2012 Edition) NFPA 101, 9.5.2 (2012 Edition) NFPA 82, 5.3.2.1.2 (2009 Edition) NFPA 101, 9.5.1.2 (2012 Edition) NFPA 101, 8.3.4.2* (2012 Edition) NFPA 101, 8.3.3.1 (2012 Edition) NFPA 80, 15.1.3 (2010 Edition)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19.

Based on record review, the failed to maintain the fire doors.

The finding included:

Document review on 10/02/2019 at 7:45 AM, revealed the facility failed to provide documentation for an annual fire door inspection for 2018. NFPA 101, 4.6.12 (2012 Edition) NFPA 101, 4.6.12.4 (2012 Edition) NFPA 101, 8.3.3.1 (2012 Edition) NFPA 80, 5.2.3 (2010 Edition)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19.

Based on observations, the facility failed to maintain the fire doors.

The findings included:

1. Observation on 09/30/2019 at 1:00 PM, revealed latches not labeled fire exit hardware on the 1 ½ hour cross corridor double swinging fire doors at the 6B and 6C connector hall. NFPA 101, 8.3.4.2 (2012 Edition) NFPA 101, 8.3.3.1 (2012 Edition) NFPA 80, 6.4.4.2.2 (2010 Edition)

2. Observation on 09/30/2019 at 1:01 PM, revealed multiple holes filled with an unknown material in the fire-rated steel door frame at the 6B and 6C connector hallway. NFPA 101, 8.3.4.2* (2012 Edition) NFPA 101, 8.3.3.1 (2012 Edition) NFPA 80, 5.2.15.4 (2010 Edition)

3. Observation on 09/30/2019 at 3:35 PM, revealed the latches not labeled fire exit hardware on the 1 ½ hour cross corridor double swinging fire doors at the Pain Clinic and parking garage connector on 2nd floor of D-tower. NFPA 101, 8.3.4.2* (2012 Edition) NFPA 101, 8.3.3.1 (2012 Edition) NFPA 80, 6.4.4.2.2 (2010 Edition)

4. Observation on 09/30/2019 at 3:36 PM, revealed a latch not latching on the 1 ½ hour cross corridor double swinging fire doors at the Pain Clinic and parking garage connector on 2nd floor of D-tower. NFPA 101, 8.3.4.2* (2012 Edition) NFPA 101, 8.3.3.1 (2012 Edition) NFPA 80, 5.2.15.3 (2010 Edition)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19.

Based on records review, the facility failed to maintain medical gas outlets.

These findings included:

Records review on 10/02/2019 at 09:45 AM, revealed the facility failed to provide documentation of the annual medical gas certification for the oxygen outlets.

NFPA 99, 5.1.14.4.4 (3) (2012 Ed.)

These findings were verified by maintenance staff during the survey and was acknowledged by the Chief Executive Officer and his team during the exit conference on 10/2/19.