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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:

2. On 05/27/2016 at 3:50 PM, observation revealed on the Lobby level floor in Room 712 in the OR area, that the window 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).

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 05/27/2016 at 12:15 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'-6". Corridors used by patients/residents are required to be at least 8'-0" wide. 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), and staff W (Facilities Engineer).

Based on 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 05/27/2016 at 1:10 PM, during a record review of facility documents and interview, Staff A was unable to verify that on the 2nd level floor in the C-Section operating room, that testing of 3 battery-powered emergency lights for 30 seconds each month and 90 minutes each year occured. 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 observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

2. On 05/27/2016 at 1:10 PM, during a record review of facility documents and interview, Staff A was unable to verify that the operating rooms 1-6 had testing of the battery-powered emergency lights for 30 seconds each month and 90 minutes each year. 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).

Surveyor: Wallace, Lynn
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 5/27/2016 at 1:45 PM, during record review, only one fire drill was conducted since the survey of 2/2/2016. Per interview with staff A, the facility was wondering if the 3 fire drills on the different shifts could be done on one day in the quarter. In conjuction with the previous findings, the fire drills are not being conducted at various times. 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 W (Facility Engineer).

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 05/27/2016 at 2:20 pm, observation of the storage room in the Operating room area, had items being stored within 18 inches below the sprinkler heads. This 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 W (Facility Engineer).





29942

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 05/27/2016 at 12:50 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. A trash and recycle receptacle of 16 gallon size each were kept in a close proximity within a 64 square feet area. In addition, another 16 gallon plastic garabage bag full of combusible trash was stored on the floor. 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 05/27/2016 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), and staff W (Facilities Engineer). CHANGE

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), and staff W (Facilities Engineer). CHANGE

Based on observation and interview, the facility did not provide proper exiting in accordance with NFPA 101, 39.2.4.

FINDINGS INCLUDE:

1. On 06/3/2016 at 2:35 PM, observation revealed on the basement floor that there is only one exit out of the basement. The common path of travel is 90 out of the basement and the distance to an exit is 106 feet, up a stairs and out through a break room, onto an unsprinkler 1st floor. The basement is fully sprinklered. The plan of correction is to abandon the basement. On tour of the basement, there was full trash cans in the bathroom and adjacent space indicating that the area is not abandon. In addition, staff indicated that this is their tornado shelter. This situation was not compliant with NFPA 101 (2000 ed.), 39.2.4.2. The situation did not meet any of the exceptions for one exit. There is a storage room, a shower, bath and a workout room for staff. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer).

Based on observation and interview, the facility did not provide proper exiting in accordance with NFPA 101, 39.2.4. Hazardous areas were not enclosed with one hour fire rated construction, no sprinklers in hazardous area and there was exiting through a hazardous area.

FINDINGS INCLUDE:

1. On 06/3/2016 at 3:10 PM, observation revealed on the basement floor that there is only one exit out of the basement. The common path of travel is more than 100 feet out of the basement and, up a stairs and out through a back corridor. The building is not sprinklered. A second 'exit' did exist which is into a hazardous space occupied by a different tenant. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.2.4.2. The situation did not meet any of the exceptions for one exit. There is a storage room, a break room and a furnace room. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer).

2. On 06/3/2016 at 3:13 PM, observation revealed on the basement floor that the exit from the staff lounge (a non hazardous room) is through the furnace room, a hazardous location. This situation was not compliant with NFPA 101 (2000 ed.) 7.5.1.7 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer).

3. On 6/3/2016 at 3:15 PM, observation revealed on the basement floor that the furnace and hot water heaters were not enclosed in 1 hour rated walls and ceiling and the area that contained the furnaces and hot water heater were not sprinklered. This is considered a hazardous area. This situation was not compliant with NFPA 101 (2000 ed.) 39.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer).

Based on observation and interview, the facility did not provide proper sprinkler coverage.

FINDINGS INCLUDE:

6. On 06/03/2016 at 1:45 PM, observation revealed on the 1st floor in the Ortho supply room, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This situation was not compliant with NFPA 13 (1999 ed.), 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer).

9 On 06/03/2016 at 1:42 PM, observation revealed on the 1st floor in the ev1 utility room, that the discharge of sprinkler water was obstructed from reaching an unprotected area on the other side of a surface mounted light fixture. This situation was not compliant with NFPA 13 (1999 ed.), 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer).

{K20}
Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with rated doors and rated wall construction.

FINDINGS INCLUDE:

1. Previously, on 02/01/2016 at 1:15 PM, observation revealed on the 1st, 2nd & 3rd floor in the Atrium that the fire shutters on the 2nd and 3rd floors did not close and the Won door on the first floor does not close in the fire barrier wall. On 6/3/2016 at 10:44 AM staff W indicated that the Won doors worked, they closed on local smoke detectors but the Won doors did not close on the general fire alarm. This reported situation was not compliant with NFPA 101 (2000 ed.), 38.3.3.1, 8.2.5.4, 8.2.5.5 and 8.2.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer).

2. Previously, on 02/01/2016 at 1:55 PM, observation revealed on the 1st floor in the Atrium door to exit passage way, that the door in the fire barrier wall could not be verified of having the required rating. On 6/3/2016 at 10:45 AM staff W indicated that the Won doors worked, they closed on local smoke detectors but the Won doors did not close on the general fire alarm. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.1.1, and 8.2.5.4, 8.2.5.5 and 8.2.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer).

3. Previously, on 02/01/2016 at 2:00 PM, observation revealed on the 1st floor in the Stair to the north by the main entrance which has it's own exit passageway that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because above the ceiling is not rated nor the wall to the back side of the Won door at the bottom of the stairs. On 6/3/2016, at 10:50 AM, it could not be verified that the shaft wall ceiling could bare the weight of the pipes above or that the hangers for the pipes were not 1 hour rated. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer).

5. Previously, on 02/01/2016 at 2:15 PM, observation revealed on the lower level floor in the electrical closet by stair 2, that the duct passing through the ceiling/floor assembly could not be verified of having a fire damper. On 6/3/2016 at 11:45 AM, it was observed that 2 layers of drywall and been put across the opening. This is not a 2 hour rated assembly. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer).


29942

{K38} now {29}
Based on observation and interview, previously, the facility did not provide egress paths at all times with door hardware that operated with a single release motion and now the hazardous storage space does not have 3/4 hour rated doors.

FINDINGS INCLUDE:

Previously on 02/03/2016 at 2:45 PM, observation revealed on the Lobby level floor in the Kitchen room, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a dead bolt installed 1 foot above the door handle. On 6/3/2016 at 10:30 AM, the dead bolt had been removed, but now the door is not a 3/4 hour fire rated door. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.2.1 & 7.2.1.5.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer).

Based on observation and interview, the facility did not provide sprinkler protection inside the elevator equipment room.

FINDINGS INCLUDE:

7. On 06/03/2016 at 10:15 AM, observation revealed on the lower level floor in the elevator equipment room, that the room was not sprinkled. Some portion of this building was remodeled in 2015. Access to exit through corridors in this building did not have a 1 hour fire resistance rating so all areas in this building shall be protected with sprinklers. This situation was not compliant with NFPA 101 (2000 ed.), 38.3.6.1. 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).