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Based on observation and interview, the facility did not provide corridor finishes with the appropriate rating. This deficiency occurred in 1 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/01/2016 at 3:20 PM, observation revealed on the Lobby level floor in the corridor near OR suite, that the facility could not confirm the corridor had an appropriate rating. Four 4'-0"x 3'-0" display boards with combustible papers were hung in corridor wall above 4 feet from finished floor. Staff A and B were unable to confirm the flame spread rating of the attached papers on the display board during survey. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W (Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

Based on observation and interview, the facility did not provide corridor separation doors with doors with positive-latching hardware. This deficiency occurred in 1 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/01/2016 at 2:15 PM, observation revealed on the 1st level floor in the Intensive care units, that the corridor door would not positively self-latch when pushed to a closed position. The life safety plan did not identify the intensive care units area as a suite and indicated exit route through the intensive care area from other parts of this floor. The pair of corridor doors in the intensive care rooms 1-6 did not latch because they were not equipped with positive latching hardware. At the same location, nurse server corridor doors in the intensive care rooms 1-6 did not latch either because they were also not equipped with positive latching hardware. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with compliant sized lettering on "no-exit" signs. The "no-exit" signs at that end may be confused as exits. This deficiency occurred in 1 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 12:30 PM, observation revealed on the 2nd level floor in the fire barrier door near the central stair, that the layout and lettering on the no exit sign did not meet the code requirements. The no exit sign was written as "NOT AN EXIT" with letter 3 inch high instead of code required, the word NO in letter 2 inch high with a stroke width of 3/8 inch and the word EXIT in letter 1 inch high, with the word EXIT below the word NO. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.8.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

2. On 02/01/2016 at 12:45 PM, observation revealed on the 2nd level floor in the Vestibule, that the path of travel was likely to be mistaken as an exit and a "NO Exit" sign was not provided. The door opening to the roof top garden permits viewing of the exterior and can be mistaken as an exit. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

3. On 02/01/2016 at 1:45 PM, observation revealed on the 2nd level floor in the Dining room, that the path of travel was likely to be mistaken as an exit and a "NO Exit" sign was not provided. Doors leading to the roof terrace permits viewing of the exterior and can be mistaken as exits. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.8.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with rated windows. This deficiency occurred in 2 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/02/2016 at 10:30 am, observation revealed on the Lower level floor in the cross corridor smoke barrier doors near suite C, that vision panels consisting of fire rated glazing or wired glass panels were not provided in each cross corridor swinging doors. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.7. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, rated wall construction, and rated doors. This deficiency occurred in 2 of the 13 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 2:35 PM, observation revealed on the 1st level floor in the Staff room 1329, that the door would not self-close because the door was not equipped with an automatic or self closing device. Eighteen cardboard boxes full of combustible materials were stored inside the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 and 18.3.6.3.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

2. On 02/01/2016 at 3:50 PM, observation revealed on the Lobby level floor in the Room 712 in the OR area, that the door in the hazard enclosure wall could not be verified as having at least a 45 minute rating. The room was used to store paper and plastic based combustible materials. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W (Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

3. On 02/01/2016 at 4:15 PM, observation revealed on the Lobby Level floor in the Prep & Pack room, that the door in the hazard enclosure wall could not be verified as having at least a 45 minute rating because seven combustible paper notice pages were taped on rated door. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W (Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 2 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 3:15 pm, observation revealed on the Lobby level floor in the corridor near OR suite, that a permanent writing desk with a chair was kept in the corridor that reduced corridor width to 7'-0". Corridors used by patients/residents are required to be at least 8'-0" vwide (6' in psychiatric units). This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff C (Facilities Engineer), and staff D (Director of Facilities & Operations Effectiveness).

2. On 02/01/2016 at 4:20 pm, observation revealed on the Lobby Level floor in the Surgery and Procedure center corridor, that the clear and unobstructed width of the corridor was 7 feet because sofas and chairs from waiting area were encroached to the corridor area also. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W (Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

Based on observation, interview and document review, the facility did not provide and maintain emergency illumination of the interior means of egress for at least 90 minutes after a power failure with adequate testing of emergency batteries. This deficiency occurred in 2 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 1:10 PM, observation revealed on the 2nd level floor in the C-Section operating room, that Staff B was unable to confirm the testing of 3 battery-powered emergency lights for 30 seconds each month and 90 minutes each year. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.9.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

2. On 02/02/2016 at 2:45 PM, during a review of facility documents, Staff B was unable to verify that the facility tested the battery-powered emergency lights for 30 seconds each month and 90 minutes each year located inside the operating rooms 1 to 6. This situation was not compliant with NFPA 101 (2000 ed.), 7.9.3. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on interview and record review, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency occurred in 13 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/02/2016 at 2:50 PM, during review of the facility fire drill record for the past 12 months it was revealed that fire drills were not conducted at varied times. Drills were conducted in the same shift within an hour of each other. The facility's fire drill records from March 2015 to December 2015 indicated that 1st, 2nd, 3rd & 4th Quarters of the (four) 2nd-shift drills were held between 7:30 PM and 7:45 PM, and 2nd, 3rd & 4th Quarters of the (four) 3rd-shift drills were held between 2:00 am and 3:00 am. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements with non-sprinkled rooms that meet permitted exceptions . This deficiency occurred in 1 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/02/2016 at 10:20 am, observation revealed on the Lower level floor in the Electrical room, that the room was not sprinkler protected, although the entire facility was required to be sprinkled. The facility did not meet all the requirements of the code to avoid sprinkling the space. The room was enclosed with 2-hour rated construction, but a 3' x 4' return air duct opening in the 2 hour rated wall was not protected with a fire damper. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.1 (exception) and NFPA 13 (1999 ed.), 5-3.11. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25, sprinklers free of lint, and weekly tests of the fire pump. This deficiency occurred in 13 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 2:00 PM, observation revealed on the 2nd level floor in the Chute room, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

3. On 02/02/2016 at 2:30 PM, during a review of facility documents it was discovered, that the monthly wet sprinkler inspections were not performed as required by the code. There were no documents that showed valves were inspected monthly. This situation was not compliant with NFPA 25 (1998 ed.), 2-2, Table 2-1 and 9-4.1. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

4. On 02/02/2016 at 3:00 PM, during a review of the facility documents it could not verify the durations of the fire pump's 10 minute weekly churn test. This situation was not compliant with NFPA 25 (1998 ed.), 5-3.2. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide a kitchen extinguishing system as required by NFPA 96 with extinguisher operation instruction. This deficiency occurred in 1 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/01/2016 at 1:30 PM, observation revealed on the 2nd level floor in the Kitchen, that the placard to identify the use of the fire extinguisher as a secondary back up means to the automatic fire suppression system was not visible because it was covered with solid paper. This observed situation was not compliant with NFPA 96 (1998 ed.), Section 7-2.1.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash, and properly sized storage containers for soiled/trash. This deficiency occurred in 3 of the 13 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 1:40 PM, observation revealed on the 2nd level floor in the tray return area inside the dining room, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. Four trash and recycle receptacles of 28 gallon size each were kept in a close proximity within a 64 square feet area. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

2. On 02/01/2016 at 3:30 PM, observation revealed on the Lobby level floor in the OR number 1, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. Two 32 gallon size soiled linen hampers with full of soiled linen were kept side by side in a very close poximity. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff C (Facilities Engineer), and staff D (Director of Facilities & Operations Effectiveness).

3. On 02/01/2016 at 4:00 PM, observation revealed on the Lobby level floor in the Or number 6, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. Two 32 gallon size trash receptacles were kept side by side in a very close proximity. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff C (Facilities Engineer), and staff D (Director of Facilities & Operations Effectiveness).

4. On 02/02/2016 at 10:45 am, observation revealed on the Lower level floor in the Pharmacy room, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. A 64 gallon size trash receptacle was kept for trash collection. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.6. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide egress paths at all times with paths that are maintainable in all weather conditions, the sprinklers did not provide full coverage, and electrical extension cord were used instead of permanent wiring.

FINDINGS INCLUDE:

1. On 02/01/2016 at 8:30 AM, observation revealed on the 1st floor that the exit discharge path did not have a maintainable surface. The path was composed of gravel and grass. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.7.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

2. On 02/01/2016 at 8:45 AM, observation revealed on the 1st floor in the exterior of the building, that sprinkler protection was not provided at the overhand / canopy that extended more than 4 feet from the building and is made of combustible material. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-13.8.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

3. On 02/01/2016 at 8:45 AM, observation revealed on the 1st floor in the waiting room, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to fish tank. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

Based on observation and interview, the facility did not install the emergency electrical generator in accordance with the codes by having a generator with a remote stop and emergency battery powered lighting. This deficiency occurred in 1 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/02/2016 at 10:00 am, observation revealed in the exterior generator enclosure, that the emergency generators were provided with remote stop switches on the exterior of the generator enclosure wall near the enclosure door. Per code the remote stop switch shall be located elsewhere on the premises where the prime mover is located outside the building. This observed situation was not compliant with NFPA 110 (1999 ed.), 3-5.5.6. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

2. On 02/02/2016 at 10:15 am, observation revealed in the exterior generator enclosure, that the battery powered emergency lighting inside the generator enclosure was powered with the same prime mover starter batteries. The emergency lighting charging system shall be supplied from the load side of the transfer switch. This observed situation was not compliant with NFPA 110 (1999 ed.), 5.3.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with electrical panels having complete directories. This deficiency occurred in 3 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 1:20 PM, observation revealed on the 2nd level floor in the Electrical room, that electrical panel breakers were not labeled to identify the loads they fed. Circuit breakers 1-33 and 43-47 inside the panel B2/ Q2LA were not identified for the loads they were feeding. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

2. On 02/01/2016 at 2:45 PM, observation revealed on the 1st level floor in the Data Room 1538, that electrical panel breakers were not labeled to identify the loads they fed. Circuit breakers 1-16 inside the panel 1N/ UPSA were not identified for the loads they were feeding. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

3. On 02/02/2016 at 9:30 am, observation revealed on the Lower level floor in the room CUP 103, that electrical panel breakers were not labeled to identify the loads they fed. Circuit breakers inside the panel BILL/ INV were not identified for the loads they were feeding. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

4. On 02/02/2016 at 11:00 am, observation revealed on the Lower level floor in the Electrical Room LL224, that electrical panel breakers were not labeled to identify the loads they fed. Circuit breakers 1-12 inside the panel BLL/ Q2LB and circuit breakers 11, 14, 17, 31 inside the panel ALL/ CLC were not identified for the loads they were feeding. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).