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Based on an observation the facility failed to provide properly rated fire-resistance fire barrier doors. This deficient practice could affect an indeterminable number of patients, staff and visitors, if a fire was allowed to spread into the facility from an adjacent nonconforming building.

Findings include:

A. On 02/24/14 at 2:09 PM, while accompanied by the Director of Facilities Operations an observation determined that the designated fire barrier between the business occupancy and the Patient care portion of the hospital contained fire rated double egress doors installed with deficient door hardware. Each leaf in the double egress door contained a latch into the upper door frame but failed to include a second latch point per door leaf. This is not per NFPA 101, Section 8.2 and 19.1.2.3 and 7.2.1.7, NFPA 80 1999 Edition Fire Doors and Windows.

B. On 02/24/14 at 2:10 PM, while accompanied by the Director of Facilities Operations an observation determined that the designated fire barrier between the business occupancy and the Emergency Suite portion of the hospital contained fire rated double egress doors installed with deficient door hardware. Each leaf in the double egress door contained a latch into the upper door frame but failed to include a second latch point per door leaf. This is not per NFPA 101, Section 8.2 and 19.1.2.3 and 7.2.1.7, NFPA 80 1999 Edition Fire Doors and Windows.

Based on an observation it was determined that the facility failed to meet the minimum construction requirements based on construction type limitations. This deficient practice could affect an indeterminable number of patents, staff and visitors if fire were to compromise the structural integrity of the building.

Findings include:

A. On 2/24/14 at 10:30 AM, while accompanied by the Director of Facilities Operations an observation determined that in the Basement Mechanical room, ceiling contained a 4-foot section of a steel floor beam that was missing the spray on fire proofing. This does not comply with NFPA 101 section 19.1.6.2.

B. On 2/24/14 at 10:35 AM, while accompanied by the Director of Facilities Operations an observation determined that on the exterior of the building located adjacent to the generator and fuel tank a wood structure was built to enclose (2) fuel pumps that feed the partial basement boilers. This does not comply with NFPA 101 section 19.1.1.4.1.

C. On 2/24/14 at 11:18 AM, while accompanied by the Director of Facilities Operations an observation determined that a wood shed used for kitchen storage was located less then 1-foot from the existing outside wall of the hospital structure and less than 10-feet from patient room 1217 exterior window. This does not comply with NFPA 101 section 19.1.6.2. and NFPA 220 section 3-1.

Based on corridor wall observations, it was determined that the facility failed to provide properly constructed corridor walls. This deficient practice could affect an indeterminable number of patients, staff and visitors, if smoke or fire was allowed to pass into the egress corridor.

Findings include: On 02/24/14 at 11:22 AM, while accompanied by the Director of Facilities Operations it was determined by an observation that in the main egress corridor the facility has installed modular office partitions that for a 2-bay triage treatment unit. The installed modular partitions extend from the floor and terminate approximately 1-foot below the finished ceiling. Treatment rooms/areas are to be separated from the egress corridor per NFPA 101, section 19.3.6.1, exception no. 6.

Based on an observation the facility failed to provide exit access that is readily accessible to a public-way at all times. This deficient practice could affect an indeterminable number of patients, staff and visitors if the egress doors and exit paths prevented staff and residents from exiting the area in a timely manner during an emergency.

Findings include: On 02/24/14 at 1:04 PM, while accompanied by the Director of Facilities Operations an observation determined that in the Patient Care Area data/storage closet located in the egress corridor across from the nurse station contained a set of double doors. The inactive door leaf was installed with roller latches and the active door leaf latched into the inactive leaf. When the doors were tested the hardware installed did not allow for proper latching to the door frame. This is not per NFPA 101, Section 19.3.6.3.2.

Based on observations of a hazardous area and interviews, the facility failed to provide properly operating latching and self-closing door hardware that provides separation between hazardous areas and exit access corridors. This deficient practice could affect an indeterminable number patients, staff and visitors if a fire could spread without proper fire separation.

Findings include:

A. On 2/24/14 at 10:40 AM while accompanied by the Director of Facilities Operations an observation determined that in the Main Supply Storage Room the west door into the kitchen was being held open with a rope tied to a shelving unit. This is not per NFPA 101, section 19.3.2.1.

B. On 2/24/14 at 11:10 AM while accompanied by the Director of Facilities Operations an observation determined that in the kitchen, the west door into the serving line was installed with a deadbolt only and the door frame did not contain door stops. Then the door was released from the door hold open it did not latch to the frame. This is not per NFPA 101, section 19.3.6.3.2. and 8.4.1.1.

C. On 2/24/14 at 11:12 AM while accompanied by the Director of Facilities Operations an observation determined that in the kitchen, dishwashing area contained a 30-inch by 18-inch dish drop off opening that was open to the serving area and was not installed with a means to close the opening during a fire alarm. This is not per NFPA 101, section 19.3.6.3.2. and 19.3.6.3.4. and 8.4.1.1.

D. On 2/24/14 at 11:31 AM while accompanied by the Director of Facilities Operations an observation determined that in the Emergency Suite, Clean Utility Room door to the corridor did not latch to the door frame when tested with the door closer. This is not per NFPA 101, section 19.3.2.1.

Based on an observation, the facility failed to provide exit access that is readily accessible to a public-way at all times. This deficient practice could affect could affect an indeterminable number of patients, staff and visitors if the egress doors and exit paths did not terminate at a public way.

Findings include: On 02/24/14 at 11:20 AM, while accompanied by the Director of Facilities Operations an observation determined that the cafeteria, the labeled exit door to the exterior lead onto a concrete patio but did not contain additional paved sidewalks that lead to the public way. This was not in accordance with NFPA 101, section 19.2.7 and 7.7.1.

Based on fire alarm system inspection the facility failed to maintain and inspect the fire alarm system for deficiencies. This deficient practice could affect an indeterminable number of patients, staff and visitors if a fire were to occur and the fire alarm system devices failed to function properly during a fire emergency.

Findings include:

A. On 02/24/14 at 11:30 AM, while accompanied by the Director of Facilities Operations an observation determined that in the Emergency Room Suite contained a Sleep room (on-call) that was not installed with a visual notification device tied to the fire alarm system. This does not comply with NFPA 101, section 19.5.1 and 9.6.3.2, NFPA 72

B. On 02/24/14 at 2:09 AM, while accompanied by the Director of Facilities Operations an observation determined that in the Patient Care Area (2) Sleep room (on-call) rooms were not installed with visual notification devices tied to the fire alarm system. This does not comply with NFPA 101, section 19.5.1 and 9.6.3.2, NFPA 72.

Based on an interview, the facility failed to ensure that the kitchen staff was properly trained on the use of the range hood (ANSUL) fire extinguishing system and portable fire extinguishers. This deficient practice could affect an indeterminable number of patients, staff and visitors if fire in the kitchen was not contained properly due to lack of training.

Findings include: On 2/24/14 at 11:05 AM, while accompanied by the Director of Facilities Operations an Interview with the Kitchen cook determined that they have not been in-serviced regarding the proper sequence for activating the ANSUL hood extinguishing system and the use of the K-Type kitchen portable fire extinguisher if there was a fire at the cooking surface. Staff Training is not in accordance with NFPA 96, section 8-1.4.

The facility failed to provide a proper enclosure, generator equipment and inspections for the emergency generator set. This deficient practice could affect an indeterminable number of patients, staff and visitors if the generator failed to function properly or was unable to be shut down due to a malfunction.

Findings include: Based on direct observation the morning of 2/24/14 while in the company of the Director of Facilities Operations, the facility failed to provide:

Starting battery heater with auto shutoff for the emergency generator. (NFPA 110, 3-3.1)

Based on observations, the facility failed to properly install and maintain electrical wiring. This deficient practice could affect an indeterminable number of patients, staff and visitors if improperly installed or protected electrical wiring was to result in an electrical fire or was not available during an emergency.

Findings include: On 02/24/14 at 11:28 AM, while accompanied by the Director of Facilities Operations, an observation determined that in the Emergency Suite, Treatment room #7 did not contain an electrical outlet that was tied to the buildings normal power. All outlets identified were labeled as emergency power. This does not comply with NFPA 99 section 3-3.2.1.2 (a)1.

Based on an observation the facility failed to provide properly rated fire-resistance fire barrier doors. This deficient practice could affect an indeterminable number of patients, staff and visitors, if a fire was allowed to spread into the facility from an adjacent nonconforming building.

Findings include:

A. On 02/24/14 at 2:09 PM, while accompanied by the Director of Facilities Operations an observation determined that the designated fire barrier between the business occupancy and the Patient care portion of the hospital contained fire rated double egress doors installed with deficient door hardware. Each leaf in the double egress door contained a latch into the upper door frame but failed to include a second latch point per door leaf. This is not per NFPA 101, Section 8.2 and 19.1.2.3 and 7.2.1.7, NFPA 80 1999 Edition Fire Doors and Windows.

B. On 02/24/14 at 2:10 PM, while accompanied by the Director of Facilities Operations an observation determined that the designated fire barrier between the business occupancy and the Emergency Suite portion of the hospital contained fire rated double egress doors installed with deficient door hardware. Each leaf in the double egress door contained a latch into the upper door frame but failed to include a second latch point per door leaf. This is not per NFPA 101, Section 8.2 and 19.1.2.3 and 7.2.1.7, NFPA 80 1999 Edition Fire Doors and Windows.

Based on an observation it was determined that the facility failed to meet the minimum construction requirements based on construction type limitations. This deficient practice could affect an indeterminable number of patents, staff and visitors if fire were to compromise the structural integrity of the building.

Findings include:

A. On 2/24/14 at 10:30 AM, while accompanied by the Director of Facilities Operations an observation determined that in the Basement Mechanical room, ceiling contained a 4-foot section of a steel floor beam that was missing the spray on fire proofing. This does not comply with NFPA 101 section 19.1.6.2.

B. On 2/24/14 at 10:35 AM, while accompanied by the Director of Facilities Operations an observation determined that on the exterior of the building located adjacent to the generator and fuel tank a wood structure was built to enclose (2) fuel pumps that feed the partial basement boilers. This does not comply with NFPA 101 section 19.1.1.4.1.

C. On 2/24/14 at 11:18 AM, while accompanied by the Director of Facilities Operations an observation determined that a wood shed used for kitchen storage was located less then 1-foot from the existing outside wall of the hospital structure and less than 10-feet from patient room 1217 exterior window. This does not comply with NFPA 101 section 19.1.6.2. and NFPA 220 section 3-1.

Based on corridor wall observations, it was determined that the facility failed to provide properly constructed corridor walls. This deficient practice could affect an indeterminable number of patients, staff and visitors, if smoke or fire was allowed to pass into the egress corridor.

Findings include: On 02/24/14 at 11:22 AM, while accompanied by the Director of Facilities Operations it was determined by an observation that in the main egress corridor the facility has installed modular office partitions that for a 2-bay triage treatment unit. The installed modular partitions extend from the floor and terminate approximately 1-foot below the finished ceiling. Treatment rooms/areas are to be separated from the egress corridor per NFPA 101, section 19.3.6.1, exception no. 6.

Based on an observation the facility failed to provide exit access that is readily accessible to a public-way at all times. This deficient practice could affect an indeterminable number of patients, staff and visitors if the egress doors and exit paths prevented staff and residents from exiting the area in a timely manner during an emergency.

Findings include: On 02/24/14 at 1:04 PM, while accompanied by the Director of Facilities Operations an observation determined that in the Patient Care Area data/storage closet located in the egress corridor across from the nurse station contained a set of double doors. The inactive door leaf was installed with roller latches and the active door leaf latched into the inactive leaf. When the doors were tested the hardware installed did not allow for proper latching to the door frame. This is not per NFPA 101, Section 19.3.6.3.2.

Based on observations of a hazardous area and interviews, the facility failed to provide properly operating latching and self-closing door hardware that provides separation between hazardous areas and exit access corridors. This deficient practice could affect an indeterminable number patients, staff and visitors if a fire could spread without proper fire separation.

Findings include:

A. On 2/24/14 at 10:40 AM while accompanied by the Director of Facilities Operations an observation determined that in the Main Supply Storage Room the west door into the kitchen was being held open with a rope tied to a shelving unit. This is not per NFPA 101, section 19.3.2.1.

B. On 2/24/14 at 11:10 AM while accompanied by the Director of Facilities Operations an observation determined that in the kitchen, the west door into the serving line was installed with a deadbolt only and the door frame did not contain door stops. Then the door was released from the door hold open it did not latch to the frame. This is not per NFPA 101, section 19.3.6.3.2. and 8.4.1.1.

C. On 2/24/14 at 11:12 AM while accompanied by the Director of Facilities Operations an observation determined that in the kitchen, dishwashing area contained a 30-inch by 18-inch dish drop off opening that was open to the serving area and was not installed with a means to close the opening during a fire alarm. This is not per NFPA 101, section 19.3.6.3.2. and 19.3.6.3.4. and 8.4.1.1.

D. On 2/24/14 at 11:31 AM while accompanied by the Director of Facilities Operations an observation determined that in the Emergency Suite, Clean Utility Room door to the corridor did not latch to the door frame when tested with the door closer. This is not per NFPA 101, section 19.3.2.1.

Based on an observation, the facility failed to provide exit access that is readily accessible to a public-way at all times. This deficient practice could affect could affect an indeterminable number of patients, staff and visitors if the egress doors and exit paths did not terminate at a public way.

Findings include: On 02/24/14 at 11:20 AM, while accompanied by the Director of Facilities Operations an observation determined that the cafeteria, the labeled exit door to the exterior lead onto a concrete patio but did not contain additional paved sidewalks that lead to the public way. This was not in accordance with NFPA 101, section 19.2.7 and 7.7.1.

Based on fire alarm system inspection the facility failed to maintain and inspect the fire alarm system for deficiencies. This deficient practice could affect an indeterminable number of patients, staff and visitors if a fire were to occur and the fire alarm system devices failed to function properly during a fire emergency.

Findings include:

A. On 02/24/14 at 11:30 AM, while accompanied by the Director of Facilities Operations an observation determined that in the Emergency Room Suite contained a Sleep room (on-call) that was not installed with a visual notification device tied to the fire alarm system. This does not comply with NFPA 101, section 19.5.1 and 9.6.3.2, NFPA 72

B. On 02/24/14 at 2:09 AM, while accompanied by the Director of Facilities Operations an observation determined that in the Patient Care Area (2) Sleep room (on-call) rooms were not installed with visual notification devices tied to the fire alarm system. This does not comply with NFPA 101, section 19.5.1 and 9.6.3.2, NFPA 72.

Based on an interview, the facility failed to ensure that the kitchen staff was properly trained on the use of the range hood (ANSUL) fire extinguishing system and portable fire extinguishers. This deficient practice could affect an indeterminable number of patients, staff and visitors if fire in the kitchen was not contained properly due to lack of training.

Findings include: On 2/24/14 at 11:05 AM, while accompanied by the Director of Facilities Operations an Interview with the Kitchen cook determined that they have not been in-serviced regarding the proper sequence for activating the ANSUL hood extinguishing system and the use of the K-Type kitchen portable fire extinguisher if there was a fire at the cooking surface. Staff Training is not in accordance with NFPA 96, section 8-1.4.

The facility failed to provide a proper enclosure, generator equipment and inspections for the emergency generator set. This deficient practice could affect an indeterminable number of patients, staff and visitors if the generator failed to function properly or was unable to be shut down due to a malfunction.

Findings include: Based on direct observation the morning of 2/24/14 while in the company of the Director of Facilities Operations, the facility failed to provide:

Starting battery heater with auto shutoff for the emergency generator. (NFPA 110, 3-3.1)

Based on observations, the facility failed to properly install and maintain electrical wiring. This deficient practice could affect an indeterminable number of patients, staff and visitors if improperly installed or protected electrical wiring was to result in an electrical fire or was not available during an emergency.

Findings include: On 02/24/14 at 11:28 AM, while accompanied by the Director of Facilities Operations, an observation determined that in the Emergency Suite, Treatment room #7 did not contain an electrical outlet that was tied to the buildings normal power. All outlets identified were labeled as emergency power. This does not comply with NFPA 99 section 3-3.2.1.2 (a)1.