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 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 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 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 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 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 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.