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It was determined through observation during the survey that the facility failed to maintain the corridor doors in accordance with the Life Safety Code. This was evidenced by:

The corridor door for patient room #405 had warped, creating a gap larger than one half inch (1/2") between the door and the door stop, on the latch-side of the door at the top.

The corridor door deficiency item was discussed during the survey and again during the exit conference on October 13, 2011.

It was determined through observation during the survey that the facility failed to maintain the fire rated smoke barrier walls in accordance with the Life Safety Code. This was evidenced by:

The smoke barrier on the fourth floor was found to have an approximately 4-inch conduit penetration that had been sealed with fire stop at one point; however, at the time of the survey the fire stop material had been removed from the conduit and had not been re-installed.

The smoke barrier wall deficiency item was discussed during the survey and again during the exit conference on October 13, 2011.

It was determined through observation during the survey that the facility failed to maintain the fire rated smoke barrier doors in accordance with the Life Safety Code. This was evidenced by:

One of two smoke barrier doors, located outside the PACU, failed to latch into the frame when closed.

The smoke barrier door deficiency items were discussed during the survey and again during the exit conference on October 13, 2011.

It was determined through observation during the survey that the facility failed to maintain and protect sprinkler protected hazardous areas in accordance with the Life Safety Code. This was evidenced by:

The second floor house linen room, which is greater than 55-square feet in size and contained a large amount of combustible material, failed to have the required self-closure device on the corridor door.

The hazardous area deficiency item was discussed during the survey and again during the exit conference on October 13, 2011.

It was determined through observation and document review during the survey, that the facility failed to perform fire drills in accordance with the Life Safety Code. This was evidenced by:

Documentation was not provided at the time of the survey to show the following drills had been completed:

a. One (1) during the second shift in the first quarter of 2011.
b. One (1) during the first shift in the first quarter of 2011.
(Note: The facility provided documentation at the time of the survey to reflect that drills had taken place on January 1, 2011, February 4, 2001, and March 18, 2011; however, these drills were documented during a false alarm of the fire and smoke detection system. Fire drills must be pre-planned events and the facility may not utilize false alarms of the fire and smoke detection system or real events in lieu of these pre-planned events.)

The fire drill deficiency items were discussed during the survey.

It was determined through observation and record review during the survey, that the facility failed to inspect and maintain the Fire Alarm System in accordance with the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by:

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) At the time of the survey the smoke detectors in the following locations were detached from the ceiling and were hanging by their associated electrical wires:
a) in the dialysis room on the third floor, and
b) in the nurses' station on the third floor.
Note: this items were corrected during the survey.

The Fire Alarm System deficiency items were discussed during the survey and again during the exit conference on October 13, 2011.

It was determined through observation during the survey that the facility failed to install the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13. This was evidenced by:

1) Two (2) domestic water lines were found to be strapped to and supported by the automatic fire sprinkler branch line located outside the old emergency generator room in the basement.

2) A refrigeration line was found to be strapped to and supported by the automatic fire sprinkler branch line located inside the old emergency generator room in the basement.

3) the sprinkler heads in the following locations were found to be installed less than four inches from a wall:
a) in the staff breakroom on the third floor, and
b) in the staff bathroom on the third floor.

4) The kitchen contained Quick Response (QR) sprinkler heads and standard response (SR) sprinkler heads in the same smoke compartment.
Note:Per NFPA 13 1999 Edition, section 5-4.5.3 "Where residential sprinklers are installed in a compartment as defined in 1-4.2, all sprinklers within the compartment shall be of the fast-response type that meets the criteria of 1-4.5.1(a)1."

5) The IT room, located in the basement of the facility, had an opening that was approximately one foot by twelve feet located behind the server rack that was open to the concealed space above the ceiling. This opening would allow for heat and products of combustion to accumulate above the ceiling, bypassing the sprinkler protection in the room.

6) The x-ray room on the second floor had x-ray equipment attached to the ceiling that potentially obstructs the discharge pattern of the fire sprinkler system.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference on October 13, 2011.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

1) The required escutcheon plates were missing in the following locations:
a) in the basement walk-in cooler,
b) in the first floor conference room preparation area,
c) in the first floor conference room closet, and
d) in the bathroom of patient room #407.

2) The gauge on the main system riser located in the seventh floor kitchen elevator motor room was more than five years old and the facility failed to provide documentation that this gauge had been re-calibrated at any time. Note: The date on the gauge was 2001.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference on October 13, 2011.

It was determined through observation during the survey that the facility failed to inspect and maintain the fire extinguishers in accordance with the Life Safety Code and NFPA 10. This was evidenced by:

1) The fire extinguisher cabinet at the generator installation site was empty at the time of the survey.

2) The fire extinguisher, located in the kitchen storeroom in the basement, was not documented as having had a monthly visual inspection during the month of September, as required.
Note: The last date noted on the extinguisher maintenance tag was August 17, 2011.

The Fire Extinguisher deficiency items were discussed during the survey and again during the exit conference on October 13, 2011.

It was determined through observation during the survey that the facility failed to maintain the bulk oxygen storage site in accordance with the Life Safety Code, NFPA 99, Healthcare Facilities, and NFPA 50, Bulk Oxygen Systems at Consumer Sites. This was evidenced by:

The uninsulated portions of the bulk oxygen storage site on the South side of the building failed to meet the distance requirements from combustibles, as set forth in NFPA 50. This was evidenced by:

a) The bulk storage location was within approximately 10 feet of one tree and 15 feet of another, both considered fuels that would burn slowly,
b) The bulk storage location was within approximately 8 feet of a wood fence, considered fuels that would burn rapidly, and
c) The bulk storage location was surrounded by vegetation, including bushes and vines, also considered fuels that would burn rapidly.

The bulk oxygen storage site deficiency items were discussed during the survey and again during the exit conference on October 13, 2011.

It was determined through observation during the survey that the facility failed to maintain the generator and related equipment in accordance with the Life Safety Code, NFPA 99, Healthcare Facilities, and NFPA 110, Standard for Emergency and Standby Power Equipment. This was evidenced by:

1) The facility failed to provide battery backed up lighting in the ATS room adjacent to the generator installation site, as required.

2) The facility failed to provide documentation at the time of the survey to reflect that the generator was being visually inspected weekly, as required.

The generator deficiency items were discussed during the survey and again during the exit conference on October 13, 2011.

It was determined by observation during the course of the survey that the facility failed to provide electrical power to equipment in accordance with NFPA 70, National Electric Code and the Life Safety Code. This was evidenced by the following:

1) A surge protected power strip was found to be plugged into a second surge protected power strip in the IT room in the basement.

2) The facility was using extension cords in place of permanent wiring in the basement IT room to provide power to a surge protected power strip.

The electrical deficiency item was discussed during a tour of the facility and again during the exit conference.