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Based on observation and interview, the facility failed to ensure each door in the three hour barrier between it and a building occupancy had a rating, and all open conduits were filled with fire stopping material. This had the potential to affect all patients receiving services from the facility. The patient census was 100 patients.

Findings include:

On 05/10/17 at 9:22 AM a tour was conducted of the first floor with Staff Q and R.

1. On 05/10/17 at 1:27 PM, observation of door 1e42 revealed it was in a three hour fire barrier between the building and a business occupancy. The observation did not reveal a rating for the door.

On 05/10/17 at 1:27 PM in an interview, Staff Q confirmed the finding.

2. On 05/10/17 at 1:30 PM, observation above the drop down ceiling of the same three hour fire barrier as seen at the corner 45 degrees and opposite from room 1e45 revealed three two inch open conduits with cables running from them.

On 05/10/17 at 1:30 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure penetrations in the fire barrier between floors were filled with firestopping material. This had the potential to affect all patients receiving services from the facility. The patient census was 100 patients. The patient census was 100 patients.

Findings include:

On 05/08/17 at 1:52 AM, a tour was taken of the sixth floor with Staff Q and R.

On 05/08/17 at 1:55 PM observation of the ceiling within the room next to elevator six revealed a one inch open conduit communicating between ceiling and the floor above.

On 05/08/17 at 1:55 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each of its exit discharges were free of all obstructions to full use. This had the potential to affect all patients receiving services from the facility. The patient census was 100 patients.

Findings include:

On 05/10/17 at 3:43 PM, observation of the exit discharge near area bm41 revealed multiple laundry carts parked in front of the discharge doors such that they would not open completely, and passage to the public way would have been difficult. A sign on the doors was observed to read, "Please do not block fire doors."

On 05/10/17 at 3:43 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure the three hour barrier between the 1959 building and the 1982 building had penetrations that were filled with firestopping material, and doors that were properly rated and closed and latched. This had the potential to affect all patients receiving services from the facility. The patient census was 100 patients. The patient census was 100 patients.

Findings include:

On 05/08/17 at 1:52 AM a tour was taken of the sixth floor with Staff Q and R.

1. On 05/08/17 at 2:22 PM, observation above the drop down ceiling (and over the double doors) of the three hour barrier between west wing and the 1982 structure revealed near room 621 a conduit that traveled through said barrier and had an open junction box.

On 05/08/17 at 2:22 PM in an interview, Staff Q confirmed the finding.

On 05/08/17 at 3:10 PM, a tour was conducted of the fifth floor with Staff Q and R.

2. On 05/08/17 at 3:14 PM, observation from the 1982 structure and above the drop down ceiling (and over the double doors) of the three hour barrier between west wing and said 1982 structure revealed, over the north door, an open one inch conduit with red lines running out of it. The double doors were also observed to be unrated.

On 05/08/17 at 3:14 PM in an interview, Staff Q confirmed the finding.

On 05/10/17 at 9:22 AM, a tour was conducted of the first floor with Staff Q and R.

3. On 05/10/17 at 9:49 AM, observation of the three hour door (1w14) to the west wing revealed it did not self close and latch.

On 05/10/17 at 9:49 AM in an interview, Staff Q confirmed the finding.

4. On 05/10/17 at 9:55 AM, observation of door 1w15 revealed it was in three hour fire rated construction with a 1.5 hours rating.

Observation above the drop down ceiling of the three hour barrier perpendicular to that door and above 1w14 (near the hinges) revealed an open one inch conduit with red wiring traveling out of it.

On 05/10/17 at 9:55 AM in an interview, Staff Q confirmed the findings.

5. On 05/10/17 at 10:02 AM, observation above the drop down ceiling of the three hour fire barrier as seen in room 1w01 revealed a one inch corrugated conduit traveling through a six inch by six inch penetration.

On 05/10/17 at 10:02 AM in an interview, Staff Q confirmed the finding.

6. On 05/10/17 at 10:05 AM, observation of the southern leaf of the double doors in the three hour fire barrier leading to corridor 1m25 revealed its rating was scratched away.

7. Observation above the drop down ceiling over the middle of that door revealed an open, one inch conduit with a pull string traveling out of it.

8. Observation of the double doors together revealed the astragal prevented them from closing and latching.

On 05/10/17 at 10:05 AM in an interview, Staff Q confirmed the findings.

9. On 05/10/17 at 10:29 AM, observation above the drop down ceiling of the three hour fire barrier opposite elevator four revealed it did not extend all the way to the corner.

On 05/10/17 at 10:29 AM in an interview, Staff Q confirmed the finding.

10. On 05/10/17 at 10:36 PM, review of the drawing revealed a line showing a three hour fire barrier traveling through the middle of environmental services room 1mr22 and was therefore impossible to determine whether the door, which had a one and a half hour fire rating, was part of the three hour fire barrier.

On 05/10/17 at 10:36 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to have a directional indicator on its exit signage showing each path of egress on the third floor. This had the potential to affect all patients receiving services from the facility. The patient census was 100 patients.

Findings include:

On 05/09/17 at 4:07 PM, tour was taken of the third floor with Staff Q and R.

On 05/09/17 at 4:07 PM, a path of egress was observed traveling through the double doors and down the west wing; however the exit sign near room 3m18 (and just before the double doors) did not have a chevron showing this.

On 05/09/17 at 4:07 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure the protective construction surrounding its vertical openings had rated doors, and any penetrations were filled with fire stopping material. This had the potential to affect all patients receiving services from the facility. The patient census was 100 patients.

Findings include:

On 05/08/17 at 1:52 PM, a tour was taken of the sixth floor with Staff Q and R.

1. On 05/08/17 at 2:46 PM, observation above the drop down ceiling of the two hour fire rated construction protecting elevator 14 revealed a one inch conduit loosely packed with mineral wool and without any fire stopping substance at the end.

On 05/08/17 at 2:46 PM in an interview, Staff Q confirmed the finding.

On 05/08/17 at 3:10 PM, a tour was conducted of the fifth floor with Staff Q and R.

2. On 05/08/17 at 3:33 PM, observation above the drop down ceiling of the two hour fire rated construction protecting elevator 14 revealed at the north side a one inch open conduit loosely packed with mineral wool and without any fire stopping substance at the end.

On 05/08/17 at 3:33 PM in an interview, Staff Q confirmed the finding.

3. On 05/08/17 at 3:50 PM, observation revealed the rating to the soiled linen chute door was unable to be determined because the hinge was drilled into it.

On 05/08/17 at 3:50 PM in an interview, Staff Q confirmed the finding.

On 05/09/17 at 8:08 AM, a tour was taken of the fourth floor with Staff Q and R.

4. On 05/09/17 at 8:16 AM, observation revealed the rating to the soiled linen chute door was unable to be determined because the hinge was drilled into it.

On 05/09/17 at 8:16 AM in an interview, Staff Q confirmed the finding.

5. On 05/09/17 at 9:42 AM, stairway eight was observed to be protected with two hour fire rated construction, but the door was unrated.

On 05/09/17 at 9:42 AM in an interview, Staff Q confirmed the finding.

On 05/09/17 at 10:32 AM, a tour was taken of the third floor with Staff Q and R.

6. On 05/09/17 at 10:41 AM, observation revealed the rating to the soiled linen chute door was unable to be determined because the hinge was drilled into it.

On 05/09/17 at 10:41 AM in an interview, Staff Q confirmed the finding.

7. On 05/09/17 at 11:36 AM, observation above the drop down ceiling of the two hour fire rated construction protecting a equilateral triangle shaped vertical opening as seen above the intravenous fluid cabinet revealed a three inch by three inch square penetration with a half inch conduit traveling through it and an open junction box on its path of travel.

On 05/09/17 at 11:36 AM in an interview, Staff Q confirmed the finding.

8. On 05/09/17 at 11:45 AM, observation above the drop down ceiling of the equilateral triangle shaped vertical opening as seen from the electrical room revealed unknown rated foam was used to fill an annular space created by a two inch pipe.

On 05/09/17 at 11:45 AM in an interview, Staff Q confirmed the finding.

9. On 05/09/17 at 12:03 PM, stairway eight was observed to be protected with two hour fire rated construction, but the door was unrated.

On 05/09/17 at 12:03 PM in an interview, Staff Q confirmed the finding.

On 05/09/17 at 2:35 PM, a tour was taken of the second floor with Staff Q and R.

10. On 05/09/17 at 2:49 PM, observation revealed the rating to the soiled linen chute door was unable to be determined because the hinge was drilled into it.

On 05/09/17 at 2:49 PM in an interview, Staff Q confirmed the finding.

11. On 05/09/17 at 4:15 PM, observation above the drop down ceiling of the two hour fire rated construction protecting an equilateral triangle shaped vertical opening as seen above the intravenous fluid cabinet revealed a two inch by two inch square penetration with a corrugated conduit and blue wire traveling through it.

On 05/09/17 at 4:15 PM in an interview, Staff Q confirmed the finding.

12. On 05/09/17 at 4:36 PM, stairway eight was observed to be protected with two hour fire rated construction, but the door was unrated.

On 05/09/17 at 4:36 PM in an interview, Staff Q confirmed the finding.

On 05/10/17 at 8:05 AM, the tour of the second floor resumed with Staff Q and R.

13. On 05/10/17 at 8:17 AM, the door to stair 13 was observed to have a one hour rating in a two hour fire barrier.

14. Above that door in the two hour fire barrier, a green corrugated conduit was observed to have an annular space.

On 05/10/17 at 8:17 AM in an interview, Staff Q confirmed the findings.

15. On 05/10/17 at 9:12 AM, the door to stair 14 was observed to have a one hour rating in a two hour fire barrier.

On 05/10/17 at 9:12 AM in an interview, Staff Q confirmed the finding.

16. On 05/10/17 at 9:15 AM, observation above the drop down ceiling and to the left of that door and above the pull station revealed a half inch penetration with two wires traveling through it.

On 05/10/17 at 9:15 AM in an interview, Staff Q confirmed the finding.

On 05/10/17 at 9:22 AM, a tour was conducted of the first floor with Staff Q and R.

17. On 05/10/17 at 9:28 AM, observation above the drop down ceiling of the two hour fire rated construction protecting the shaft for elevator four revealed two smooth conduits traveling from the barrier there to an open, six inch by six inch fiber junction box perpendicular to elevator six.

On 05/10/17 at 9:28 AM in an interview, Staff Q confirmed the finding.

18. On 05/10/17 at 9:38 AM, observation revealed the rating to the soiled linen chute door was unable to be determined because the hinge was drilled into it.

On 05/10/17 at 9:38 AM in an interview, Staff Q confirmed the finding.

19. On 05/10/17 at 10:21 AM, observation of the bottom of the soiled linen chute revealed the chute door there was unrated.

On 05/10/17 at 10:21 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to have its hazardous areas that were protected with one hour fire resistive construction have that construction extend all the way to the deck and have any penetrations filled with fire stopping material, and have doors in that construction be rated and self close and latch where doors are so equipped. This had the potential to affect all patients receiving services from the facility. The patient census was 100 patients.

Findings include:

On 05/08/17 at 1:52 PM, a tour was taken of the sixth floor with Staff Q and R.

1.On 05/08/17 at 2:34 PM observation of hazardous area 6w14 revealed it was unsprinklered and protected with one hour fire rated construction. The door to the area was observed to be unrated.

On 05/08/17 at 2:34 PM in an interview, Staff Q confirmed the finding.

2. On 05/08/17 at 2:40 PM, observation above the drop down ceiling of unsprinklered hazardous area 6w14 revealed the west and east wall did not extend all the way to the deck above.

On 05/08/17 at 2:40 PM in an interview, Staff Q confirmed the finding.

On 05/08/17 at 3:10 PM, a tour was conducted of the fifth floor with Staff Q and R.

3. On 05/08/17 at 3:39 PM, observation of room 5w17 revealed it was full of disaster preparedness materials including multiple boxes of dressings and body bags. The room was unsprinklered and was not surround by fire resistive construction.

On 05/08/17 at 3:39 PM in an interview, Staff Q confirmed the finding.

4. On 05/08/17 at 3:50 PM, observation revealed the northern wall of the soiled linen chute room had a one hour fire resistive rating. Observation above the drop down ceiling of that wall as seen from the corridor revealed two four inch plumb lines with annular spaces on top.

On 05/08/17 at 3:50 PM in an interview, Staff Q confirmed the finding.

5. On 05/08/17 at 3:59 PM, observation revealed the west wall of the soiled linen chute room had a one hour fire resistive rating. Observation above the drop down ceiling of that wall as seen from the corridor revealed a six inch diameter duct traveling through an eight inch square creating an annular space.

On 05/08/17 at 3:59 PM in an interview, Staff Q confirmed the finding.

On 05/09/17 at 8:08 AM, a tour was taken of the fourth floor with Staff Q and R.

6. On 05/09/17 at 8:32 AM, observation of the double doors to the hazardous area (4m14) next to room 4m09 revealed they were in one hour fire rated construction with an astragal that would prevent both from closing if the one with the astragal closed first.

On 05/09/17 at 8:32 AM in an interview, Staff Q confirmed the finding.

7. On 05/09/17 at 8:47 AM, observation above the drop down ceiling of the one hour fire rated construction on the east wall of hazardous area room 4m14 revealed flexible conduit traveling through a three inch by one inch square.

On 05/09/17 at 8:47 AM in an interview, Staff Q confirmed the finding.

8. On 05/09/17 at 9:30 AM, observation above the drop down ceiling of the one hour fire rated construction protecting the hazardous space (soiled utility room) opposite room 424 revealed the west wall had a conduit traveling through it with a junction box with a missing knock out.

On 05/09/17 at 9:30 AM in an interview, Staff Q confirmed the finding.

9. On 05/09/17 at 9:54 AM, observation above the drop down ceiling of the one hour fire rated construction protecting the soiled utility room opposite room 412 revealed, as seen from within, to the right of the door an open half inch conduit with a white cord running through it, and between a heating, ventilation, and cooling duct and the ceiling, an open junction box with conduits traveling through the barrier.

On 05/09/17 at 9:54 AM in an interview, Staff Q confirmed the finding.

10. On 05/09/17 at 10:00 AM, observation of the hazardous area (clean utility room) opposite room 410 revealed it was protected with one hour fire rated construction, but the door was unrated.

On 05/09/17 at 10:00 AM in an interview, Staff Q confirmed the finding.

On 05/09/17 at 10:32 AM, a tour was taken of the third floor with Staff Q and R.

11. On 05/09/17 at 10:47 AM, observation of hazardous area room 3m27 (soiled utility) revealed it was protected with one hour fire rated construction, but the door was unrated.

On 05/09/17 at 10:47 AM in an interview, Staff Q confirmed the finding.

12. On 05/09/17 at 10:57 AM, observation of hazardous area 3m21 (clean utility room) revealed it was protected with one hour fire rated construction that did not extend to the deck above.

On 05/09/17 at 10:57 AM in an interview, Staff Q confirmed the finding.

13. On 05/09/17 at 11:03 AM, observation of hazardous area 3m08 (soiled utility room) revealed it was protected with one hour fire rated construction. Observation above the drop down ceiling, as seen from within, facing away from the door and above the shelving, a two inch copper line with an annular space on top.

On 05/09/17 at 11:03 AM in an interview, Staff Q confirmed the finding.

14. On 05/09/17 at 11:50 AM, observation of hazardous area 3m06 revealed it was protected with one hour fire rated construction. Observation above the drop down ceiling of that construction, as seen from within, revealed at the left corner (facing the door), a copper line was observed traveling through a two inch by two inch penetration.

On 05/09/17 at 11:50 AM in an interview, Staff Q confirmed the finding.

15. On 05/09/17 at 11:52 AM, observation of hazardous area 3m07 (clean utility room) revealed it was protected with one hour fire rated construction. Observation above the drop down ceiling of that construction, as seen from within, revealed at the left corner (facing the door), an open one inch conduit with two grey wires traveling from it.

On 05/09/17 at 11:52 AM in an interview, Staff Q confirmed the finding.

On 05/09/17 at 2:35 PM, a tour was taken of the second floor with Staff Q and R.

16. On 05/09/17 at 2:46 PM, observation in the rubbish chute of the one hour fire barrier as seen from within the access port revealed two turquois and one copper line traveling through a penetration and a two inch smooth steel conduit traveling through a four inch penetration.

On 05/09/17 at 2:46 PM in an interview, Staff Q confirmed the finding.

17. On 05/09/17 at 3:14 PM, observation above the drop down ceiling of the one hour fire barrier protecting a hazardous area, as seen from wheelchair alcove 2m14, revealed a one inch penetration with a flexible conduit traveling through it.

On 05/09/17 at 3:14 PM in an interview, Staff Q confirmed the finding.

18. On 05/09/17 at 3:21 PM, observation of the one hour fire barrier to a hazardous area, as seen from within the telemetry monitor room in the hemodialysis unit, revealed one penetration with a green corrugated conduit traveling through it and one with blue wiring traveling through it.

On 05/09/17 at 3:21 PM in an interview, Staff Q confirmed the finding.

19. On 05/09/17 at 5:10 PM, observation of hazardous area 2w05 revealed it was enclosed in one fire rated construction. The door in the western wall was observed to be unrated and without a self-closer.

On 05/09/17 at 5:10 PM in an interview, Staff Q confirmed the finding.

20. On 05/09/17 at 5:13 PM, observation above the drop down ceiling of the one hour fire barrier perpendicular to that door revealed it did not extend all the way to the deck above.

On 05/09/17 at 5:13 PM in an interview, Staff Q confirmed the finding.

On 05/10/17 at 8:05 AM, the tour of the second floor resumed with Staff Q and R.

21. On 05/10/17 at 8:48 AM, observation above the drop down ceiling of the one hour fire rated construction protecting the hazardous area opposite room 2n23 revealed in the southern wall a one inch open conduit with the word "t stat" written on it and a grey wire traveling out of it.

On 05/10/17 at 8:48 AM in an interview, Staff Q confirmed the finding.

22. On 05/10/17 at 8:58 AM, observation, from within and to the left of the door, above the drop down ceiling of the one hour fire rated construction protecting the hazardous area opposite room 2n24, revealed a one inch corrugated and half inch corrugated conduit traveling through a two inch by two inch square penetration.

On 05/10/17 at 8:58 AM in an interview, Staff Q confirmed the finding.

23. On 05/10/17 at 9:03 AM, observation above the drop down ceiling of the one hour fire rated construction protecting the hazardous area opposite room 2n26 revealed at the east wall a half inch open conduit with two grey wires traveling out of it.

On 05/10/17 at 9:22 AM, a tour was conducted of the first floor with Staff Q and R.

24. On 05/10/17 at 10:56 AM, observation above the drop down ceiling of the one hour barrier protecting hazardous area 1wed72 (soiled utility) revealed two half inch conduits open to air.

On 05/10/17 at 10:56 AM in an interview, Staff Q confirmed the finding.

25. On 05/10/17 at 1:55 PM, observation above the drop down ceiling of the one hour fire barrier protecting an arrow shaped hazardous area from the post anesthesia care unit, as seen from within the post anesthesia care unit, near the point 25 degrees from the right of the double doors, revealed the annular spaces around two heating, ventilation, and cooling ducts filled with unrated foam.

On 05/10/17 at 1:55 PM in an interview, Staff Q confirmed the finding.

26. On 05/10/17 at 2:03 PM, observation above the drop down ceiling of the one hour fire barrier protecting a hazardous area perpendicular to the entrance to the post anesthesia care unit, as seen from within the post anesthesia care unit, revealed two one inch conduits traveling over (and perpendicular to) a heating, ventilation, and cooling duct creating an annular space in the barrier.

On 05/10/17 at 2:03 PM in an interview, Staff Q confirmed the finding.

Based on document review and interview, the facility failed to ensure its fire alarm system was tested and documented in accordance with NFPA 72, 2010 edition, 14.6.2.4. This had the potential to affect all patients receiving services from the facility. The patient census was 100 patients.

Findings include:

On 05/11/17 a review of the facility's life safety code documentation was completed. The documents revealed the facility's alarm system was tested in December 2016. The review did not reveal each device at each location had been tested.

On 05/11/17 at 10:00 AM in an interview, Staff T confirmed the finding.

Based on observation and interview, the facility failed to ensure areas that were open to corridors had smoke detection systems. This had the potential to affect all patients receiving services from the facility. The patient census was 100 patients.

Findings include:

On 05/08/17 at 3:10 PM, a tour was conducted of the fifth floor with Staff Q and R.

1. On 05/08/17 at 4:39 PM, observation of waiting area 5m08 revealed the door to it was open and without a self closer and the area was without a smoke detector.

On 05/08/17 at 4:39 PM in an interview, Staff Q confirmed the finding.

On 05/09/17 at 8:08 AM, a tour was taken of the fourth floor with Staff Q and R.

2. On 05/09/17 at 9:20 AM, observation of the waiting area next to room 4m01 revealed the door to it was open and without a self-closer and the area was without a smoke detector.

On 05/09/17 at 9:20 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure its sprinkler heads were clean and where installed in drop down ceilings, said drop down ceilings had tiles in place. This had the potential to affect all patients receiving services from the facility. The patient census was 100 patients.

Findings include:

On 05/08/17 at 3:10 PM, a tour was conducted of the fifth floor with Staff Q and R.

1. On 05/08/17 at 4:08 PM, observation above the drop down ceiling of room 5m14 revealed it had a down pendant sprinkler head, but the drop down ceiling was not there to make it effective.

On 05/08/17 at 4:08 PM in an interview, Staff Q confirmed the finding.

On 05/09/17 at 8:08 AM, a tour was taken of the fourth floor with Staff Q and R.

2. On 05/09/17 at 8:55 AM, observation of the soiled utility room opposite room 445 revealed a sprinkler head next to a missing tile in the drop down ceiling thereby reducing its effectiveness.

On 05/09/17 at 8:55 AM in an interview, Staff Q confirmed the finding.

3. On 05/09/17 at 9:30 AM, observation of the soiled utility room opposite room 424 revealed a sprinkler head next to an open tile in the drop down ceiling thereby reducing its effectiveness.

On 05/09/17 at 9:30 AM in an interview, Staff Q confirmed the finding.

On 05/09/17 at 10:32 AM, a tour was taken of the third floor with Staff Q and R.

4. On 05/09/17 at 11:52 AM, observation of hazardous area 3m07 (clean utility room) revealed it had a sprinkler head coated with dust and debris so that the struts were not discernable.

On 05/09/17 at 11:52 AM in an interview, Staff Q confirmed the finding.

5. On 05/09/17 at 2:16 PM, in room 3w23 a sprinkler head was observed to be covered with dust.

On 05/09/17 at 2:16 PM in an interview, Staff Q confirmed the finding.

On 05/09/17 at 2:35 PM, a tour was taken of the second floor with Staff Q and R.

6. On 05/09/17 at 2:59 PM, observation of room 2m26 (an information technology closet) revealed sprinkler heads in a drop down ceiling that no longer had any tiles in it, thereby reducing the sensitivity of the sprinkler heads.

On 05/09/17 at 2:59 PM in an interview, Staff Q confirmed the finding.

7. On 05/09/17 at 4:15 PM, the sprinkler head near the automated medication dispensing machine was observed covered with dust.

On 05/09/17 at 4:15 PM in an interview, Staff Q confirmed the finding.

On 05/10/17 at 9:22 AM, a tour was conducted of the first floor with Staff Q and R.

8. On 05/10/17 at11:18 AM, observation of the sprinkler head in room wed33 revealed it did not have an escutcheon.

On 05/10/17 at 11:18 AM in an interview, Staff Q confirmed the finding.

9. On 05/10/17 at 1:35 PM, observation of the closet in corridor 1e54 and near stair six revealed it had sprinklers but the tiles for the drop down ceiling were absent decreasing the sensitivity of the sprinkler head.

On 05/10/17 at 1:35 PM in an interview, Staff Q confirmed the finding.

10. On 05/10/17 at 1:45 PM, observation of the drop down ceiling in break room 1ms08 revealed a missing tile next to a sprinkler head, thereby decreasing the sensitivity of the sprinkler head.

On 05/10/17 at 1:45 PM in an interview, Staff Q confirmed the finding.

11. On 05/10/17 at 3:17 PM, observation of a sprinkler head near the kitchen sinks revealed it to be green and corroded.

On 05/10/17 at 3:17 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure all corridor doors closed, and where so equipped, latched. This had the potential to affect all patients receiving services from the facility. The patient census was 100 patients.

Findings include:

On 05/09/17 at 8:08 AM, a tour was taken of the fourth floor with Staff Q and R.

1. On 05/09/17 at 10:14 AM, observation of patient room 404 revealed it had latching hardware that did not latch the door closed.

On 05/09/17 at 10:14 AM in an interview, Staff Q confirmed the finding.

On 05/10/17 at 8:05 AM, the tour of the second floor resumed with Staff Q and R.

2. On 05/10/17 at 8:35 AM, the door to patient room 277 in the intensive care unit did not easily close and latch.

On 05/10/17 at 8:35 AM in an interview, Staff Q confirmed the finding.

On 05/10/17 at 9:22 AM, a tour was conducted of the first floor with Staff Q and R.

3. On 05/10/17 at 10:51 AM, observation of the corridor door to patient room 15 in the emergency department was observed to not close and latch because the hole for the latch was too small.

On 05/10/17 at 10:51 AM in an interview, Staff Q confirmed the finding.

4. On 05/10/17 at 10:53 AM, observation of double doors in the corridor to areas six and seven in the emergency department revealed the self closing and latching hardware did not self close and latch the doors.

On 05/10/17 at 10:53 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure penetrations into its smoke barriers were filled with material capable of restricting the transfer of smoke. This had the potential to affect all patients receiving services from the facility. The patient census was 100 patients.

Findings include:

On 05/09/17 at 10:32 AM, a tour was taken of the third floor with Staff Q and R.

1. On 05/09/17 at 11:29 AM, observation above the drop down ceiling of the one hour rated smoke barrier between room 3m32 and the corridor, revealed at the most eastern part of the barrier (just before it turned into protective construction for a hazardous area), and seen from the corridor, revealed a four inch open conduit with multiple colored cables traveling from it. Below the conduit, written on the drywall, were the words "reseal pipe" with an arrow pointing to said conduit.

On 05/09/17 at 11:29 AM in an interview, Staff Q confirmed the finding.

2. On 05/09/17 at 11:50 AM, observation above the drop down ceiling of the one hour smoke barrier as seen from within room 3w24 and to the left of the bathroom revealed a one inch open conduit with two grey wires traveling out of it.

On 05/09/17 at 11:50 AM in an interview, Staff Q confirmed the finding.

On 05/09/17 at 2:35 PM, a tour was taken of the second floor with Staff Q and R.

3. On 05/09/17 at 2:59 PM, observation of the one hour smoke barrier on the east side of room 2m26 revealed a fist sized penetration.

On 05/09/17 at 2:59 PM in an interview, Staff Q confirmed the finding.

4. On 05/09/17 at 3:08 PM, observation of the double doors to the hemodialysis unit revealed them to be in a one hour smoke barrier. Observation above the drop down ceiling of that smoke barrier over the right door (as seen from without) revealed two red wires traveling out from an open one inch conduit.

On 05/09/17 at 3:08 PM in an interview, Staff Q confirmed the finding.

On 05/10/17 at 8:05 AM, the tour of the second floor resumed with Staff Q and R.

5. On 05/10/17 at 8:05 AM, observation above the drop down ceiling of the one hour smoke barrier near stair 13 revealed writing that said to reseal after running wire and near that was a one inch open conduit with a green guidewire traveling out of it.

On 05/10/17 at 8:05 AM in an interview, Staff Q confirmed the finding.

On 05/10/17 at 9:22 AM, a tour was conducted of the first floor with Staff Q and R.

6. On 05/10/17 at 11:03 AM, observation above the drop down ceiling and on the east side of the one hour smoke barrier over door 1wed87 revealed a one and a half inch open conduit with two red and one green guidewire traveling through it, and one grey wire traveling through a penetration.

On 05/10/17 at 11:03 AM in an interview, Staff Q confirmed the finding.

7. On 05/10/17 at 11:54 AM, observation above the drop down ceiling of the one hour smoke barrier as seen to the left of the double doors leading to the catheterization laboratory and ultrasound area, as seen from within, revealed a one inch conduit traveling through an unstopped three inch penetration creating an annular space in the barrier.

On 05/10/17 at 11:54 AM in an interview, Staff Q confirmed the finding.

8. On 05/10/17 at 11:59 AM, observation above the drop down ceiling of the one hour smoke barrier above the western door 1ms01b revealed an open one inch conduit with one grey wire traveling through it.

On 05/10/17 at 11:59 AM in an interview, Staff Q confirmed the finding.

9. On 05/10/17 at 12:05 PM, observation above the drop down ceiling of the one hour smoke barrier as seen from corridor 1ms01 and over the east leaf of door 1ms01b revealed a four inch open conduit with a bundle of blue wiring traveling through it.

On 05/10/17 at 12:05 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each door in a smoke barrier self closed and double doors did not have a gap of greater than one eighth of an inch. This had the potential to affect all patients receiving services from the facility. The patient census was 100 patients.

Findings include:

On 05/10/17 at 9:22 AM, a tour was conducted of the first floor with Staff Q and R.

1. On 05/10/17 at 11:05 AM, observation of door 1wed54 revealed it was in a one hour smoke barrier and did not have a self-closer.

On 05/10/17 at 11:05 AM in an interview, Staff Q confirmed the finding.

2. On 05/10/17 at 11:59 AM, observation of double doors 1ms01b revealed between the leaves was gap of three eighths of an inch.

On 05/10/17 at 11:59 AM in an interview, Staff Q confirmed the finding.

Based on record review and interview, the facility failed to conduct fire drills under varied conditions and failed to include participation of any physicians. This had the potential to affect all patients receiving services from the facility. The patient census was 100 patients.

Findings include:

A review of the facility's life safety code documentation was completed on 05/11/17. The review did not reveal where any fire drills had been conducted between midnight and 10:00 AM for the past 15 months.

Additionally, there was no evidence of any physician participation in the drills.

A review of the facility's fire prevention procedure was completed on 05/11/17. The review revealed surgeons participated in the fire plan and were to assist in extinguishing a fire and assist in evacuation of the patient if necessary.

On 05/10/17 at 4:55 PM in an interview, Staff S confirmed the findings.

Based on observation and interview, the facility failed to ensure its medical gas shut off valves located immediately outside each vital life-support area, critical care area, and anesthetizing location were readily accessible in accordance with NFPA 99, 5.1.4.8.7, 2012 edition. This had the potential to affect all patients receiving services from the facility. The patient census was 100 patients.

Findings include:

On 05/09/17 at 10:32 AM, a tour was taken of the third floor with Staff Q and R.

On 05/09/17 at 2:28 PM the gas shut off valves for cesarean section room one was revealed to have the crash cart and a bassinette parked in front of them.

On 05/09/17 at 2:28 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure all areas wherein there was deep sedation or general anesthesia had one or more battery powered emergency lighting, in accordance with NFPA 99 6.3.2.2.11, 2012 edition. This had the potential to affect all patients receiving services from the facility. The patient census was 100 patients.

Findings include:

On 05/09/17 at 10:32 AM, a tour was taken of the third floor with Staff Q and R.

On 05/09/17 at 2:28 PM, observation of the cesarean section rooms revealed they did not have battery powered emergency lighting.

On 05/09/17 at 2:28 PM in an interview, Staff Q confirmed the finding.