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Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain the fire resistive rating of the roof assembly and walls to resist passage of smoke in accordance with NFPA 101 19.1.6.2.

Findings include:

The core measure nurse ' s office on the third floor was observed to have two 2 ' ' round holes in the ceiling that would not resist the passage of smoke or fire.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain smoke barriers constructed with at least ½ hour fire resistant rating in accordance with NFPA 101 19.3.7.3.

Findings include:

The smoke barrier wall on the second floor near the heliport was observed to have a 2 ' ' conduit penetrate the wall above the suspended ceiling that was left unsealed to the passage of smoke.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain 2 of approximately 30 corridor doors to resist the passage of smoke in accordance with NFPA 101 19.3.7.7.

Findings include:

The cross corridor doors at the Gero Psych unit did not close fully to resist the passage of smoke when tested.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1.

Findings include:

The kitchen storeroom, the old blood draw room, and the dialysis storeroom door were all observed not to be self closing. Storerooms over 50 square feet are required to be self closing or automatic closing in accordance with NFPA 101 19.3.2.1.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain exit access to be readily accessible at all times in accordance with NFPA 101 19.2.5.1.

Findings include:

The drs office on the fifth floor was observed to be behind a storeroom. All habitable spaces are required to have an exit access door leading directly to the exit access corridor.

Based on staff interview and observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not provide and maintain clear and unobstructed egress corridors in accordance with NFPA 101 19.2.3.3.

Findings:

The sterile egress corridor in the operating room suite was observed to contain storage items on two foot deep wire racks on wheels. The corridor had the storage racks on one side for the entire length of the corridor.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not provide an emergency lighting system in accordance with NFPA 101 7.9.3.

Findings Include:

1. The second floor transfer switch room had the emergency light with battery back up fail when tested.
2. The transfer switch in the receiving area was observed to not have an emergency light with battery back up capabilities.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain exit and directional signs with continuous illumination that is served by the emergency lighting system in accordance with NFPA 101 19.2.10.1 and 7.10.

Findings include:

The west end of the microbiology egress corridor was observed to contain no exit sign.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 72, and NFPA 101 9.6.5.2.

Findings include:

1. During the tour of the facility it was observed that several fire alarm pull stations were mounted higher than the maximum 54 ' ' . The areas include the third floor lobby, ground floor OR, first floor lab, respiratory therapy, cath lab corridor.
2. The x-ray server room housed a fire alarm slave panel and it was observed to be lacking a smoke detector.

Based upon record review and staff interview made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 72, and NFPA 101 9.6.1.4.

Findings include:

The facility failed to provide documentation that the annual amp hour load test was conducted on the fire alarm back up batteries.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain the fire sprinkler system in accordance with NFPA 25 and NFPA 101 9.7.5.

Findings include:

1. During the tour of the facility it was observed that several areas had missing acoustic ceiling tiles allowing any heat or smoke build up to escape the smoke barrier; this has the potential to delay the activation of the fire sprinkler system. The areas observed include the core measure nurse ' s office on the third floor, the lab corridor, the x-ray special room , and the ultrasound room.
2. The reception area for the physical therapy area on the ground floor was observed to have a fire sprinkler head less than four inches from the wall.
3. The fire sprinkler riser room in the far west wing was observed to have gauges that are past due for the five year recalibration period in accordance with NFPA 25 9-2.8.2.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain flame retardant treatment on combustible draperies, curtains and other loosely hanging fabrics in accordance with NFPA 101 10.3.1.

Findings include:

The facility failed to provide documentation that the white loosely hung fabric sun screen in the main lobby is flame resistant or treated to be flame resistant.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain medical gas storage in accordance with NFPA 101 19.3.2.4 and NFPA 99 4-3.1.1.2.

Findings include:

1. The ultra-sound and the cath lab recovery both were observed to have an unsecured medical gas E tank in the room. The tanks were removed during survey.
2. The facilities bulk oxygen storage room at the receiving area was observed to have the light switch lower that the five foot minimum height requirement.
3. The ICU store room was observed to be storing more than 300 cubic feet of oxygen in a room of mixed storage without any separation of the oxygen tanks and combustible storage.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain egress requirements for stairs in accordance with NFPA 7.7.3.

Findings include:

The stair tower near the chapel allowed people to egress past the level of discharge to a public way into the basement.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not provide warning signs in areas where oxygen is stored in accordance with NFPA 101 19.3.2.4 and NFPA 99 8-6.4.2.

Findings include:

The oxygen storage rooms in respiratory therapy and bulk oxygen storage near receiving were both observed to be lacking any warning sign that medical gasses were being stored.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

Findings include:

During the tour of the facility the following deficiencies were observed involving the inappropriate use of surge protected power strips and extension cords.

1. Surge protector plugged into surge protector creating a fire hazard observed in director of nursing office on the fourth floor, dr office in the lab, x-ray server room, and the respiratory therapy office.
2. Extension cords observed to be in use in physical therapy, central sterile, kitchen steam table, nursery, and director of woman ' s services office.
3. surge protected power strips supplying power to small appliances with motors in PBX room, central sterile, human resources, general lab, case manager next to the ICU, labor and delivery break room, and the admitting area.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain the fire resistive rating of the roof assembly and walls to resist passage of smoke in accordance with NFPA 101 19.1.6.2.

Findings include:

The core measure nurse ' s office on the third floor was observed to have two 2 ' ' round holes in the ceiling that would not resist the passage of smoke or fire.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain smoke barriers constructed with at least ½ hour fire resistant rating in accordance with NFPA 101 19.3.7.3.

Findings include:

The smoke barrier wall on the second floor near the heliport was observed to have a 2 ' ' conduit penetrate the wall above the suspended ceiling that was left unsealed to the passage of smoke.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain 2 of approximately 30 corridor doors to resist the passage of smoke in accordance with NFPA 101 19.3.7.7.

Findings include:

The cross corridor doors at the Gero Psych unit did not close fully to resist the passage of smoke when tested.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1.

Findings include:

The kitchen storeroom, the old blood draw room, and the dialysis storeroom door were all observed not to be self closing. Storerooms over 50 square feet are required to be self closing or automatic closing in accordance with NFPA 101 19.3.2.1.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain exit access to be readily accessible at all times in accordance with NFPA 101 19.2.5.1.

Findings include:

The drs office on the fifth floor was observed to be behind a storeroom. All habitable spaces are required to have an exit access door leading directly to the exit access corridor.

Based on staff interview and observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not provide and maintain clear and unobstructed egress corridors in accordance with NFPA 101 19.2.3.3.

Findings:

The sterile egress corridor in the operating room suite was observed to contain storage items on two foot deep wire racks on wheels. The corridor had the storage racks on one side for the entire length of the corridor.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not provide an emergency lighting system in accordance with NFPA 101 7.9.3.

Findings Include:

1. The second floor transfer switch room had the emergency light with battery back up fail when tested.
2. The transfer switch in the receiving area was observed to not have an emergency light with battery back up capabilities.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain exit and directional signs with continuous illumination that is served by the emergency lighting system in accordance with NFPA 101 19.2.10.1 and 7.10.

Findings include:

The west end of the microbiology egress corridor was observed to contain no exit sign.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 72, and NFPA 101 9.6.5.2.

Findings include:

1. During the tour of the facility it was observed that several fire alarm pull stations were mounted higher than the maximum 54 ' ' . The areas include the third floor lobby, ground floor OR, first floor lab, respiratory therapy, cath lab corridor.
2. The x-ray server room housed a fire alarm slave panel and it was observed to be lacking a smoke detector.

Based upon record review and staff interview made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 72, and NFPA 101 9.6.1.4.

Findings include:

The facility failed to provide documentation that the annual amp hour load test was conducted on the fire alarm back up batteries.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain the fire sprinkler system in accordance with NFPA 25 and NFPA 101 9.7.5.

Findings include:

1. During the tour of the facility it was observed that several areas had missing acoustic ceiling tiles allowing any heat or smoke build up to escape the smoke barrier; this has the potential to delay the activation of the fire sprinkler system. The areas observed include the core measure nurse ' s office on the third floor, the lab corridor, the x-ray special room , and the ultrasound room.
2. The reception area for the physical therapy area on the ground floor was observed to have a fire sprinkler head less than four inches from the wall.
3. The fire sprinkler riser room in the far west wing was observed to have gauges that are past due for the five year recalibration period in accordance with NFPA 25 9-2.8.2.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain flame retardant treatment on combustible draperies, curtains and other loosely hanging fabrics in accordance with NFPA 101 10.3.1.

Findings include:

The facility failed to provide documentation that the white loosely hung fabric sun screen in the main lobby is flame resistant or treated to be flame resistant.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain medical gas storage in accordance with NFPA 101 19.3.2.4 and NFPA 99 4-3.1.1.2.

Findings include:

1. The ultra-sound and the cath lab recovery both were observed to have an unsecured medical gas E tank in the room. The tanks were removed during survey.
2. The facilities bulk oxygen storage room at the receiving area was observed to have the light switch lower that the five foot minimum height requirement.
3. The ICU store room was observed to be storing more than 300 cubic feet of oxygen in a room of mixed storage without any separation of the oxygen tanks and combustible storage.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain egress requirements for stairs in accordance with NFPA 7.7.3.

Findings include:

The stair tower near the chapel allowed people to egress past the level of discharge to a public way into the basement.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not provide warning signs in areas where oxygen is stored in accordance with NFPA 101 19.3.2.4 and NFPA 99 8-6.4.2.

Findings include:

The oxygen storage rooms in respiratory therapy and bulk oxygen storage near receiving were both observed to be lacking any warning sign that medical gasses were being stored.

Based upon observations made in the presence of the administrator, plant manager, and the head of security on 9/27/12, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

Findings include:

During the tour of the facility the following deficiencies were observed involving the inappropriate use of surge protected power strips and extension cords.

1. Surge protector plugged into surge protector creating a fire hazard observed in director of nursing office on the fourth floor, dr office in the lab, x-ray server room, and the respiratory therapy office.
2. Extension cords observed to be in use in physical therapy, central sterile, kitchen steam table, nursery, and director of woman ' s services office.
3. surge protected power strips supplying power to small appliances with motors in PBX room, central sterile, human resources, general lab, case manager next to the ICU, labor and delivery break room, and the admitting area.