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Based on observation and staff interview, one pair of automatic closing fire doors in the building separation wall did not latch in accordance with NFPA 101 (2012 edition), 8.3.3.1, and NFPA 80 (2010 edition) 6.1.4. This deficient practice affected an undetermined number of patients, staff and visitors.

Findings include:

On 12/05/16 between 1:00 pm and 3:46 pm, observation revealed that the 1-½ hour fire-rated double doors in the 2-hr fire-rated separation wall between the Legacy and Heritage buildings did not latch. The cross-corridor doors were located in the separation wall between corridors HM2899Q and HN2599. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff AJ, Staff AK and Staff AO.

NFPA 80 (2010 edition), 6.1.4 Operation of Doors. "All swinging doors shall be closed and latched at the time of fire."

Based on observation and interview, the facility failed to provide proper occupancy separation between the Legacy and Heritage buildings with a minimum of a two hour separation wall with properly rated doors on closer's that latch in accordance with NFPA 101 (2012 edition), sections 19.1.3.5 and 8.2.1.3. This deficient practice had the potential to affect all 247 patients and an undeterminable number of outpatients as well as staff and visitors.

Findings include:

1. On 12/05/16 at 2:40 pm, observation revealed that the double doors in the 3-hour rated separation wall between the Heritage and Legacy buildings did not close completely and latch.
2. On 12/05/16 at 4:00 pm, observation revealed door TU-21 was in a 3-hour rated separation wall and did not have an automatic closer.

These deficient practices were confirmed by staff AG, AH, and AI at the time of discovery.

Based on observation and staff interview, the facility did not maintain the fire rated roof assembly and structural members in accordance with NFPA 101 (2012 edition), 19.1.6.1. This deficient practice could affect 20 of 247 patients and an undeterminable number of staff and visitors

Findings include:

1. On 12/05/16 at 9:25 am, observation of a structural beam revealed in the corridor above the ceiling tile by door HNW-3211 a section of missing fire protection 2 feet by 1 foot. This deficient practice was confirmed by staff members AG, AH, and AI at the time of discovery.

2. On 12/05/16 at 2:20 pm, observation revealed within mechanical room (MR14A) that fire resistance rated fire proofing had been removed from structural members. Five instances were identified where utility hanger connections were achieved by removing required fire proofing. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AE and Staff AF.

Based on observation and interview, the facility failed to provide means of egress in accordance with the requirements of NFPA 101 (2012 edition). This deficient practice could affect an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 12/06/16 at 11:46 am, observation revealed exit stair (CSE1098) discharge lighting had a single bulb and fixture so the failure of any single lighting unit would result in illumination levels not in accordance with NFPA 101 (2012 edition), 7.8.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

2. On 12/06/16 at 3:00 pm, observation revealed the exit stair (CSE2098) door did not latch into the door frame in accordance with NFPA 101 (2012 edition), 7.8.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

Based on observation and staff interview, the facility did not ensure means of egress are continuously maintained free of all obstructions to full instant use in the case of emergency in accordance with NFPA 101 (2012 edition), 7.1.10.1. This deficient practice could affect 50 of 247 patients and an undeterminable number of staff and visitors.

Findings include:

1. On 12/06/16 at 9:20 am, observation revealed within Exit Stair E (HWL198) that the lowest landing contained a non-functional sprinkler valve placed on the floor. The sprinkler valve was a large outside yolk stem assembly weighing approximately 25 pounds and it was located within the path of egress on the bottom landing. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

2. On 12/06/16 at 10:00 am, observation revealed within the egress corridor (HWL199A) a construction cart obstruction. The cart was left for an extended period of time and was located in front of Exit Stair E. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

3. On 12/06/16 at 2:15 pm, observation revealed at the bottom of the stair shaft by door HNWLL-298A that the area was being used to store two pieces of plywood that were 4 feet by 4 feet. This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

Based on observation and staff interview, the facility did not install delayed egress locking mechanisms in accordance with NFPA 101 (2012 edition), 19.2.2.2.4. This deficient practice could affect 20 of 247 patients and an undeterminable number of staff and visitors.

Findings include:

1. On 12/05/16 at 2:50 pm, observation revealed exit door (HW5198E) has a delayed-egress locking device, yet did not have NFPA 101 (2012 edition), 7.2.1.6.1 instructions posted on the door leaf. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AE and Staff AF.

2. On 12/05/16 at 2:55 pm, observation revealed exit door (HW5198E) has a delayed-egress locking device, yet the instructions posted on the door leaf informed occupants the door is " locked and alarmed " which does not meet NFPA 101 (2012 edition), 7.2.1.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AE and Staff AF.

3. On 12/05/16 at 3:25 pm, observation revealed doors (HNW4299) had a de-activated delayed egress locking device with posted instructions. This non-required life safety feature shall either be maintained or removed in accordance with the requirements of NFPA 101 (2000 edition), 4.6.12.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AE and Staff AF.

Based on observation and interview, the facility failed to provide properly rated doors in a 2-hour stair shaft in accordance with NFPA 101 (2012 edition), 19.2.2.2.7 and 19.2.2.2.8. This deficient practice had the potential to affect 100 of 247 patients and an undeterminable number of outpatients as well as staff and visitors.

Findings include:

1. On 12/06/16 at 3:10 pm, observation of the door HNW-3298 that opened into the 2-hour rated stair shaft did not have a fire rating.

This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

Based upon observation and staff interview, the facility failed to provide a means to prevent stair shaft exiting down below the level of exit discharge in accordance with NFPA 101 (2012 edition), sections 19.2.2.3, 19.2.2.4, and 7.2. This deficient practice had the potential to affect 50 of 247 patients and an undeterminable number of outpatients as well as staff and visitors.

Findings include:

1. On 12/06/16 at 2:20 pm, observation revealed the stair shaft by door HNW-1298A did not have a means to prevent exiting past the level of exit discharge down into the lower level below grade. There were hinges on the bottom of the vertical handrail support at the bottom of the stairs and a gate that was leaning on the wall within the stair shaft. When asked why the gate was leaning on the wall and not installed to aid in proper exiting, staff AG stated the contractors removed the gate and forgot to reinstall it.

This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

Based on observation and interview, the facility failed to provide an exit discharge with a level walking surface and free of obstructions in accordance with NFPA 101 (2012 edition), 7.7. This deficient practice could affect approximately 50 of the 247 patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 12/06/16 at 9:40 am, observation revealed Stair E (HW1198) discharge had an exterior walking surface that changed in elevation approximately 6 inches due to a concrete curb. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

2. On 12/06/16 at 9:45 am, observation revealed Stair E (HW1198) discharge had an exterior area that was obstructed by construction equipment and materials. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB

Based on observation and interview, the facility failed to provide illumination of means of egress in accordance with the requirements of NFPA 101 (2012 edition), 7.8. This deficient practice could affect 50 of the 247 patients and an undetermined number of staff and visitors.

Findings include:

1. On 12/06/16 at 9:25 am, observation revealed Stair E (HW1198A) exit discharge lighting had a single bulb and fixture so the failure of any single lighting unit would result in illumination levels not in accordance with NFPA 101 (2012 edition), 7.8.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

2. On 12/06/16 at 9:30 am, observation revealed means of egress corridor (HW2199D) contained no illumination within the last 50 feet prior to entry of a required exit stair. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

3. On 12/06/16 at 10:25 am, observation revealed within the east elevator lobby (HC Level 2) an emergency light fixture powered by temporary wiring via an extension cord. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

4. On 12/05/16 at 2:50 pm, observation revealed within mechanical space (HW7198A), an emergency light fixture powered by temporary wiring via an extension cord. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AE and Staff AF.

5. On 12/06/16 at 10:20 am, observation revealed within space (HW7198), an emergency light fixture powered by temporary wiring via an extension cord. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

Based on observation and staff interview, the facility did not provide an exit sign above doors in one corridor to direct occupants to exits in accordance with NFPA 101 (2012 edition), 7.10.1.4. The deficiency affected an undetermined number of patients, staff and visitors in the facility.

Findings include:

1. On 12/06/16 between 9:00 am and 3:35 pm, observation revealed that there was no exit sign in the Corridor 1299A above the automatic closing, fire-rated cross-corridor doors, in a 3-hour rated fire barrier wall near the Legacy Staff Entrance. The next exit sign located further down was not visible from the Heritage side of corridor. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff AP, Staff AH and Staff AE.

Based on observation, record review and interview, the facility failed to provide protection in accordance with the requirements of NFPA 101 (2012 edition), 39.3. This deficient practice could affect an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 12/06/16 at 10:42 am, observation revealed that the electrical room (CWL008) contained combustible storage. The 2-hour non-sprinkler protected electrical room contained a 55 gallon drum of ethylene glycol and a sheet of wood which is not in accordance with NFPA 13 (2010 edition), 8.15.10. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

2. On 12/06/16 at 11:15 am, observation revealed that the electrical room (CWL008) had an accessible pipe chase closet that was not-sprinkler protected. The closet was accessible via a walk-in personnel door and contained approximately seven combustible snow removal shovels which is not in accordance with NFPA 13 (2010 edition), 8.15.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

3. On 12/06/12 at 12:15 pm, observation revealed that the stairways (CCL098, CSWL098, CWL098, CEL098, CNL098, and CCL008A) did not have sprinkler coverage at the bottom of the shaft or under the first accessible landing, which is not in accordance with NFPA 13 (2010 edition), 8.15.3.2. These conditions were confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

4. On 12/06/12 at 11:46 am, observation revealed that the space (CSE1098) contained an unsupervised outside stem and yoke sprinkler valve, which is not in accordance with NFPA 101 (2012 edition), 9.7.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

5. On 12/06/12 at 2:45 pm, observation revealed that the space (CSE2001) contained both quick and standard response sprinkler heads within the same compartment, which is not in accordance with NFPA 13 (2010 edition), 8.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

6. On 12/06/12 at 3:00 pm, observation revealed that the outside space (CSW3021) had a system smoke detector located within the air stream of a ventilation diffuser, which is not in accordance with NFPA 72 (2010 edition), 17.7.1.8 and 17.7.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

7. On 12/06/16 at 10:50 am, observation revealed that the file room (CCL008D) contained unrestrained cylinder storage. The room contained five (5) compressed cylinders of freon refrigerant free-standing on the floor which is not in accordance with NFPA 99 (2012 edition), 2.3.2, ASHRAE 170 (2010 edition), Chapter 9. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

8. On 12/06/16 at 10:52 am, observation revealed that the file room (CCL008D) contained a free-standing portable fire extinguisher located on the floor which is not in accordance with NFPA 10 (2010 edition), 6.1.3.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

9. On 12/06/16 at 2:40 pm, observation revealed that the shell space (CSW2011) contained a free-standing portable fire extinguisher located on the floor which is not in accordance with NFPA 10 (2010 edition), 6.1.3.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

10. On 12/06/16 at 11:50 am, observation revealed that the shaft access doors (CSE036, CN3012, and CE3009), are fire rated yet did not have self-closing or automatic-closing devices which is not in accordance with NFPA 80 (2010 edition), 4.6.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.


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11. On 12/06/16 at 1:56 pm, observation revealed that the shaft access doors (CSW098), are fire rated yet did not have operational self-closing and automatic-latching devices which is not in accordance with NFPA 80 (2010 edition), 4.6.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AA, AF and Staff AX.

12. On 12/06/16 at 2:03 pm observation revealed in electrical room (CSW5036), that there were penetrations through the ceiling and floor that were not fire stopped according to an approved method, in accordance with the requirements of NFPA 101 (2012 edition.), 39.3.1 and 8.6. The deficiency included two 4" diameter conduits and 2 1 ½ " conduits not sealed and plugged. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AA, AF and Staff AX.

13. On 12/06/2016 at 2:06 am, observation revealed on the 5th floor, that a pair of 2 hour rated doors (CSW5099) did not fully close and latch, because the door coordinator held the door open approximately 3 inches. This is not in accordance with the requirements of NFPA 101 (2012 edition.), 4.6.7.5, 4.6.12 & 8.5.4. The facility provided floor plan showed a 2 hour rated smoke barrier wall at this location, and the door was properly labeled. The deficiency included two 4" diameter conduits and 2 1 ½ " conduits not sealed and plugged. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AA, AF and Staff AX.

14. On 12/06/16 at 2:39 pm observation revealed in shaft (CE5011), there were penetrations through the shaft wall that were not fire stopped according to an approved method, in accordance with the requirements of NFPA 101 (2012 edition.), 39.3.1 and 8.6. The deficiency included a 5 " x3 " bundle of communication wires not sealed. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AA, AF and Staff AX.

15. On 12/06/16 at 2:56 pm observation revealed in shaft (CE5011), there were penetrations through the shaft wall that were not fire stopped according to an approved method, in accordance with the requirements of NFPA 101 (2012 edition.), 39.3.1 and 8.6. The deficiency included a bundle of 2 communication wires not sealed. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AA, AF and Staff AX.

16. On 12/06/16 at 15:23 pm observation revealed in electrical room (CW4056), there were penetrations through the ceiling and floor that were not fire stopped according to an approved method, in accordance with the requirements of NFPA 101 (2012 edition.), 39.3.1 and 8.6. The deficiency included two 2 1 ½ " conduits not sealed and plugged. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AA, AF and Staff AX.

17. On 12/07/16 at 8:29 am observation revealed in shaft (CE5012), there were penetrations through the shaft wall that were not fire stopped according to an approved method, in accordance with the requirements of NFPA 101 (2012 edition.), 39.3.1 and 8.6. The deficiency included a 3 " bundle of communication wires and 2 PVC pipes not properly sealed. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AP, AQ and Staff BG.


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18. On 12/5/2016 at 4:15 PM, during review of the facility fire alarm testing records it was discovered that none of the smoke detectors located in the facility were tested for sensitivity within the last two years. This condition is not in accordance with NFPA 101 (2012 edition), Sections 39.3.4.1 and 9.6, and NFPA 72 (2010 edition) Sections 14.4.5.3, 14.4.5.3.1 and 14.4.5.3.2. When asked, Staff AQ mentioned that they assumed smoke detectors sensitivity tests were not required as they had an addressable fire alarm control unit. This deficient practice was confirmed by Staff AQ (Security Supervisor) and Staff BF (Manager of Energy Management ) at the time of discovery.

19. On 12/5/2016 at 4:00 PM, during review of the facility monthly fire sprinkler system inspection records it was discovered that the facility only inspected the valves, not the gauges in every month within the last year. This condition is not in accordance with NFPA 101 (2012 edition), Sections 4.6.12 and 9.7, and NFPA 25 (2011 edition) Sections 5.2.4.1 and table 5.1.1.2. This deficient practice was confirmed by Staff AQ (Security Supervisor) and Staff BF (Manager of Energy Management ) at the time of discovery.

Based on observation and interview, the facility failed to provide a properly fire resistance rated exit enclosure in accordance with the requirements of NFPA 101 (2012 edition), 19.3.1. This deficient practice could affect 25 of the 247 patients and an undetermined number of staff and visitors.

Findings include:

1. On 12/05/16 at 2:05 pm, observation of the 2-hour rated stair shaft by door 3298A revealed there was no rating on the door. This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

2. On 12/05/16 at 2:05 pm, observation of the 2-hour rated stair shaft by door HNW-2998 revealed there was no rating on the door. This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

3. On 12/05/16 at 3:33 pm, observation revealed within exit stair (HW4198), the fire rated door had 4 unprotected or open holes that penetrated through the entire door leaf. These holes are not permitted in accordance with NFPA 80 (2010 edition), 5.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AE and Staff AF.

Based on observation and interview, the facility failed to protect hazardous areas in accordance with the requirements of NFPA 101 (2012 edition), 19.3.2, 8.3.3.1, 8.4.3.5. This deficient practice could affect 50 of the 247 patients and an undetermined number of staff and visitors.

Findings include:

1. On 12/06/16 at 11:55 am, observation revealed that the 1 ½-hr fire-rated corridor doors off the Loading dock Room HW1102 on the 1st Floor did not latch. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AP, Staff AH, and Staff AE.

2. On 12/06/16 at 2:42 pm observation revealed that the solid-bonded wood core corridor door (south door) of the Bed Repair Room HWL111 in the Lower Level did not have a self-closing device on the door. The room was considered a hazardous area due to combustibles stored in it. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AP, Staff AH, and Staff AE.


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3. On 12/05/16 at 2:27 pm, observation revealed that the mechanical ventilation room (MR14) was sharing one common space with maintenance refrigerant chemical storage. Heat transfer fluid of approximately 55 gallons of propylene glycol and 40 gallons of ethylene glycol was located and stored within the same room as the healthcare facility's ventilation equipment. Suppression protection of water fog, dry chemical, carbon dioxide, or foam was noted in the DOW Chemical safety data sheet for suitable extinguishing media, yet this type of suppression protection was not present within this space. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AE and Staff AF.

4. On 12/05/16 at 2:45 pm, observation revealed that mechanical ventilation room (MR14) was sharing one common space with maintenance repair equipment. Welding, band saw, and grinding wheel repair equipment where located within the same room as the healthcare facility's ventilation equipment. Suppression protection suitable for both the repair operations and the ventilation equipment could not be confirmed by the facility. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AE and Staff AF.

5. On 12/05/16 at 3:40 pm, observation revealed that hazardous room (HW4147) door did not have a door closer. The room is larger than 50 square feet in area and contained approximately 30 boxes of staff protective clothing. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AE and Staff AF.

6. On 12/05/16 at 1:55 pm, observation in the 148 square feet hazardous room NW-6284 revealed the door did not have a fire rating or a closer on it. This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

7. On 12/05/16 at 3:45 pm, observation in the mechanical room HNW-5216 revealed five 4 inch electrical conduit pipes penetrating the ceiling, each had 1 inch annular gaps around them that were not properly fire stopped, and the gaps were packed with fiberglass insulation. This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

8. On 12/05/16 at 3:48 pm, observation in the mechanical room HNW-4202 revealed five 4 inch electrical conduit pipes penetrating the ceiling,each had 1 inch annular gaps around them that were not properly fire stopped, and the gaps were packed with fiberglass insulation. This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

9. On 12/05/16 at 3:55 pm, observation in the hazardous lab room HNWFD-4204B revealed the coordinator on the double doors did not work and did not allow the doors to fully close and latch.This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

10. On 12/05/16 at 4:15 pm, observation in the hazardous lab room door NW-4299B revealed the doors did not fully close and latch. This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

Based on record review and interview, the facility failed to maintain and test emergency lights in anesthetizing locations in accordance with the requirements of NFPA 101 (2012 edition), Section 19.3.2.3 , NFPA 99 (2012 edition), Section 6.3.2.2.11.5 . This deficiency had the potential to affect 15 of 247 inpatients and an undeterminable number of staffs and visitors.

Findings include:

1. On 12/5/2016 at 1:38 PM, during review of the facility emergency light testing records it was discovered that tests were not conducted for the emergency lights located inside the fifteen second floor operating rooms for a minimum of 30 seconds each month and 30 minutes annually within the last year. This deficient practice was confirmed by Staff AQ (Security Supervisor) and Staff BF (Manager of Energy Management ) at the time of discovery.

Based on observation and interview, the facility did not provide a fire alarm panel marked to identify the power source, as per NFPA 101 (2012 ed.), 9.6.1.3 and NFPA 72 (2010 ed.), 10.5.5.2.1, 10.5.5.2.2 and 10.5.5.2.3. These deficiencies had the potential to affect an undeterminable number of outpatients, staffs and visitors.

FINDINGS INCLUDE:

1. On 12/6/2016 at 10:10 am, observation revealed in the Lower Level in the Fire Security Room HC1319, that the fire alarm power circuit disconnecting information was not permanently identified at the clinic fire alarm panel.

2. On 12/6/2016 at 10:15 am, observation revealed in the Lower Level Room C1316A, that the fire alarm power circuit disconnecting breaker 23 inside the electrical panel was not identified as "FIRE ALARM CIRCUIT" and did not have red marking.

This deficient practice was confirmed by Staff AQ (Security Supervisor) and Staff BF (Manager of Energy Management ) at the time of discovery.

Based on record review and interview, the facility failed to test smoke detectors for sensitivity as required by NFPA 101 (2012 edition), Sections 19.3.4 and 9.6, and NFPA 72 (2010 edition) Sections 14.4.5.3, 14.4.5.3.1 and 14.4.5.3.2. This deficiency had the potential to affect 247 of 247 inpatients and an undeterminable number of outpatients, staffs and visitors.

Findings include:

1. On 12/5/2016 at 1:30 PM, during review of the facility fire alarm testing records it was discovered that none of the smoke detectors located in the facility were tested for sensitivity within the last two years. When asked, Staff AQ mentioned that they assumed smoke detectors sensitivity tests were not required as they had an addressable fire alarm control unit. This deficient practice was confirmed by Staff AQ (Security Supervisor) and Staff BF (Manager of Energy Management ) at the time of discovery.

Based on observations and staff interview, the facility did not provide a sprinkler system as required by the code; with all spaces sprinkler protected, unobstructed water distribution, and proper equipment protection. This deficient practice could affect 200 of 247 patients and an undeterminable number of staff and visitors.

Findings include:

1. On 12/06/16 at 9:17 am, observation revealed within mechanical room MR7 that the fire rated enclosure of the fire pump room was circumvented by a 6 inch diameter opening. This observed condition was not compliant with NFPA 20 (2010 edition), 4.12 and NFPA 20 (1999 edition), 2-7.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

2. On 12/05/16 at 9:00 am, observation revealed within mechanical room MR7 that the fire pump floor did not contain a floor drain. This observed condition was not compliant with NFPA 20 (2010 edition), 4.12 and NFPA 20 (1999 edition), 2-7.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AQ and Staff BF.

3. On 12/06/16 at 9:35 am, observation revealed that the operational loading dock (HW1103A) did not have sprinkler coverage for the entire room. This observed condition was not compliant with NFPA 13 (2010 edition), 8.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

4. On 12/06/16 at 9:40 am, observation revealed that the operational loading dock (HW1103A) had a canopy of greater than 2 feet in width, did not have sprinkler coverage. This observed condition was not compliant with NFPA 13 (2010 edition), 8.15.7.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

5. On 12/06/16 at 9:50 am, observation revealed the trash compactor area (HC1310) with three large operational units under a canopy greater than 2 feet in width, did not have sprinkler coverage. This observed condition was not compliant with NFPA 13 (2010 edition), 8.15.7.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

6. On 12/05/16 at 3:15 pm, observation revealed within room (HW5134) a sprinkler head was not properly installed within the suspended ceiling. The sprinkler deflector was not spaced properly below the ceiling plane and no escutcheon ring was mounted around the sprinkler head. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AE and Staff AF.

7. On 12/05/16 at 3:20 pm, observation revealed within room (HW5136) that a sprinkler head was not properly installed within the suspended ceiling. The sprinkler deflector was not spaced properly below the ceiling plane and no escutcheon ring was mounted around the sprinkler head. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AE and Staff AF.

8. On 12/05/16 at 1:14 pm, observation revealed within the egress corridor (HW3199B), that signage had not been removed from a de-activated fire hose cabinet, this condition is not in accordance with NFPA 101 (2012 edition), 19.1.1.1.3 and 4.6.12.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AE and Staff AF.

9. On 12/05/16 at 1:55 pm, observation revealed behind door (HC3300), that signage had not been removed from a de-activated fire hose cabinet, this condition is not in accordance with NFPA 101 (2012 edition), 19.1.1.1.3, and 4.6.12.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AE and Staff AF.

Based on record review and interview, the facility did not maintain the sprinkler system as required by NFPA 101 (2012 edition), 19.3.5, 9.7.2 and NFPA 72. This deficient practice could affect 50 of the 247 patients and an undetermined number of staff and visitors.

Findings include:

1. On 12/05/16 at 2:10 pm, review of records revealed the fire alarm system test documentation does not record special suppression system monitoring in accordance with NFPA 72 (2010 edition) 14.4.2.2. The elevator room (W7102) clean agent suppression system is not documented to verify receipt of the signal by the fire alarm control unit. The condition was confirmed by interview with Staff AQ.

Based on observation, record review and interview, the facility failed to inspect the sprinkler system as required by NFPA 101 (2012 edition), Sections 19.3.5 and 9.7, and NFPA 25 (2011 edition) Sections 5.2.4.1 and table 5.1.1.2. This deficiency had the potential to affect 247 of 247 inpatients and an undeterminable number of outpatients, staffs and visitors.

Findings include:

1. On 12/6/2016 at 8:20 am, during review of the facility monthly fire sprinkler system inspection records it was discovered that the facility only inspected the valves, not the gauges, in every month within the last year. This deficient practice was confirmed by Staff AQ (Security Supervisor) and Staff BF (Manager of Energy Management ) at the time of discovery.

2. On 12/05/2016 at 9:15 am, observation by door NW-3214 revealed 3 holes that were 12 inches by 4 inches in the ceiling tile. This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

3. On 12/05/16 at 9:16 am, observation by room HNW-3216C revealed the sprinkler diffuser was ½ inch from the escutcheon ring. This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

4. On 12/05/16 at 1:40 pm, observation by room NW-6260 revealed the sprinkler diffuser was ½ inch from the escutcheon ring. This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

5. On 12/05/2016 at 1:45 pm, observation in the 6th floor Cath Lab revealed a missing section of ceiling tile that was 1 foot by 1 foot. This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

6. On 12/05/16 at 2:26 pm, observation by room NW-6202 revealed the sprinkler diffuser was ½ inch from the escutcheon ring. This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

7. On 12/05/2016 at 3:05 pm, observation on the 4th floor by door HNW-4298 revealed 3 holes in the ceiling tile that were 3 inches in diameter. This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

Based on observation and interview, the facility failed to maintain portable fire extinguishers as required by NFPA 101 (2012 edition) 19.3.5.12 and 9.7.4.1, and NFPA 10 (2010 edition) 7.2.1, 7.2.1.2, 7.2.4.4 and 7.2.4.5 with monthly inspections. This deficiency had the potential to affect 27 of 27 patients and an undeterminable number of, staffs and visitors.
FINDINGS INCLUDE:
1. On 12/5/2016 at 1:51 pm, observation revealed that the fire extinguisher located by dining room (BH2009) was missing the November 2016 monthly inspection. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AR, Staff BC, Staff BD and Staff BE.
2. On 12/5/2016 at 1:55 pm, observation revealed that the fire extinguisher located by room (BH2019) was missing the November 2016 monthly inspection. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AR, Staff BC, Staff BD and Staff BE.
3. On 12/5/2016 at 2:30 pm, observation revealed that the fire extinguisher located by room (BH2059) was missing the November 2016 monthly inspection. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AR, Staff BC, Staff BD and Staff BE.
4. On 12/5/2016 at 2:34 pm, observation revealed that the fire extinguisher located by room (BH2075) was missing the November 2016 monthly inspection. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AR, Staff BC, Staff BD and Staff BE.
5. On 12/5/2016 at 2:50 pm, observation revealed that the fire extinguisher located in the Behavioral Health Penthouse was missing the November 2016 monthly inspection. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AR, Staff BC, Staff BD and Staff BE.
6. On 12/5/2016 at 2:55 pm, observation revealed that the fire extinguisher located by room (BH2001) was missing the November 2016 monthly inspection. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AR, Staff BC, Staff BD and Staff BE.
7. On 12/5/2016 at 3:00 pm, observation revealed that the fire extinguisher located in elevator equipment room (BH1080) was missing the November 2016 monthly inspection. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AR, Staff BC, Staff BD and Staff BE.
8. On 12/5/2016 at 3:20 pm, observation revealed that the fire extinguisher located by room (BH1050) was missing the November 2016 monthly inspection. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AR, Staff BC, Staff BD and Staff BE.
9. On 12/5/2016 at 3:32 pm, observation revealed that the fire extinguisher located in elevator equipment room (BHLL01A) was missing the November 2016 monthly inspection. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AR, Staff BC, Staff BD and Staff BE.
10. On 12/5/2016 at 3:36 pm, observation revealed that the fire extinguisher located by door (BHLL099B) was missing the November 2016 monthly inspection. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AR, Staff BC, Staff BD and Staff BE.

Based on observation and staff interview, the corridor wall in one location on the 2nd Floor surgery area was not smoke-tight in accordance with NFPA 101 (2012 edition), 19.3.6.2.3, 19.3.6.1(1)(c). This deficient practice affected an undetermined number of patients, staff and visitors.

Findings include:

On 12/05/16 between 1:00 pm and 3:46 pm, observation revealed that the corridor wall of the Surgery Scheduling Office HM2816 on the 2nd Floor, Legacy building did not limit the transfer of smoke due to sliding glass windows in the wall, nor did the office space have a smoke detector supervised by the the building fire alarm system. The condition was confirmed at the time of discovery by a concurrent observation and interview Staff AJ, Staff AK, Staff AO, and Staff AN.

Based on observation and staff interview, the facility failed to provide doors in accordance with NFPA 101(2012 ed) 19.3.6.3. This deficient practice affected an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 12/05/16 between 1:00 pm and 3:46 pm, observation revealed that the corridor door to Aisle HNW2205 in the Cath Lab, IR and OR area in the 2nd Floor Heritage building did not latch to keep the door suitably closed in accordance with NFPA 101 (2012 ed)19.3.6.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AN, Staff AJ, Staff AK and Staff AO.

2. On 12/06/16 at 1:55 pm, observation revealed that the double corridor doors S1413 of the Kitchen on the 1st Floor did not have positive latching hardware to keep the doors suitably closed in accordance with NFPA 101 (2012 ed) 19.3.6.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AP, Staff AH, and Staff AE.

3. On 12/06/16 at 2:00 pm, observation revealed that the fully glazed double doors of the Chapel on the 1st Floor did not have positive latching hardware to keep the doors suitably closed in accordance with NFPA 101 (2012 ed) 19.3.6.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AP, Staff AH, and Staff AE.

4. On 12/05/16 at 3:00 pm, observation by room HNW-5251A revealed the room did not have smoke detection, like the corridor and the door was being help open with a wood wedge. When tested without the wood wedge in the way, the door would not latch. This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed penetrations as required by NFPA 101 (2012 edition), 19.3.7.3, and 8.5. This deficient practice could affect 25 of the 247 patients and an undetermined number of staff and visitors.

Findings include:

1. On 12/05/16 at 2:05 pm, observation revealed that the smoke barrier past conference room (HC3300), above the ceiling, had a penetration that was not sealed according to an approved method. The deficiency included broken and partially removed block. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AE and Staff AF.

2. On 12/05/16 at 3:52 pm, observation revealed in the smoke barrier wall above the ceiling tile by door NW-4298 that a 2 inch electrical conduit pipe was passing through the wall and there was a half inch annular gap around the pipe that was not properly fire caulked. This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

Based on observation and staff interview, the facility failed to ensure safety to patients due to failure to maintain two pairs of smoke doors in smoke barriers in accordance with NFPA 101 (2012 edition), 19.3.7.8, 8.5.4.1. The deficiency affected an undetermined number of patients, staff and visitors in the facility.


Findings include:

1. On 12/05/16 between 1:00 pm and 3:46 pm, observation revealed that the cross-corridor smoke doors in the 1-hr smoke barrier wall between the Waiting HM2803 space and Corridor HM2899P in the 2nd Floor Legacy building did not fully close and left a gap of 1 inch at the meeting edge, which is more than the minimum required for operation of doors. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff AO, Staff AJ and Staff AK.

2. On 12/05/15 at 1:50 pm, observation revealed that the cross corridor smoke doors HM689D in the 1-hr smoke barrier wall did not fully close and left a gap of 1 inch at the meeting edge, which is more than the minimum required for operation of doors. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AA, AB and AC.

3. On 12/06/16 at 11:27 am, observation revealed that the smoke doors HM1799M at the Legacy staff entrance had a 3/16 " wide gap at the meeting edge, which exceeded the minimum clearance required for operation of smoke doors. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff AP, Staff AH, and Staff AE.

Based on observations and interview, the facility did not maintain the electrical equipment in accordance with NFPA 101 - 2012 edition sections 39.3, 21.7, 21.3 and 9.1.2, and NFPA 70 - 2011 edition. This deficient practice could affect an undeterminable number of outpatients as well as staff and visitors.


Findings include:
1. On 12/06/16 at 10:15 am, observation revealed an electrical circuit breaker panel by room 11 did not have the breaker switches labeled for what they were providing power to.
2. On 12/06/16 at 11:25 am, observation revealed in room EB-3020 a refrigerator and a microwave oven were plugged into a power strip.

These deficient practices were confirmed by staff AA, AF, and AV at the time of discovery.

Based on observations and interview, the facility did not maintain electrical equipment in accordance with NFPA 101 (2012 edition), sections 19.5.1.1 and 9.1.2, and NFPA 70 - 2011 edition. This deficient practice could affect 20 of 247 patients and an undeterminable number of outpatients as well as staff and visitors.

Findings include:

1. On 12/05/16 at 4:30 pm, observation in room 4223 on the 4th floor revealed a power strip daisy chain condition where one power strip was plugged into another that was plugged into the wall outlet. This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

2. On 12/05/16 at 2:38 pm, observation revealed in room NW-6247 that a refrigerator, microwave oven, and a toaster were plugged into a single power strip. This deficient practice was confirmed by staff AG, AH, and AI at the time of discovery.

Based on observation and staff interview, the facility failed to maintain a laundry chute door in accordance with NFPA 101 (2012 edition), 19.5.4.1, 9.5.1.2 and 8.3.4.2. This deficient practice affected an undetermined number of patients and staff.

Findings include

1. On 12/05/16 between 1:00 pm and 3:46 pm, observation revealed that the Laundry Chute door did not latch due to damaged latching hardware. The laundry chute was located in the Soiled Utility Room HNW2203 in the IR/Cath Lab area on the 2nd Floor Heritage building.

The above deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff AJ, Staff AK, Staff AO and Staff AN.

Based on record review and interview, the facility failed to conduct fire drills in accordance with the requirements of NFPA 101 (2012 edition), section 21.7.1.6. This deficiency had the potential to affect an undeterminable number of outpatients, staffs and visitors.

Findings included:

1. On 12/6/2016 at 10:55 am, review of the facility fire drill documents for the last 12 months revealed that there was no fire drill conducted on the first shift during the first and second quarters of 2016 located in the fifth floor out patient surgery center. This deficient practice was confirmed by Staff AQ (Security Supervisor) and Staff BF (Manager of Energy Management ) at the time of discovery.

Based on record review and interview, the facility failed to conduct fire drills at varied times in accordance with the requirements of NFPA 101 (2012 edition), Section 19.7.1.4, 19.7.1.5, 19.7.1.6 and 19.7.1.7. This deficiency had the potential to affect 247 of 247 inpatients and an undeterminable number of outpatients, staffs and visitors.

Findings include:

1. On 12/5/2016 at 1:46 PM, review of the facility fire drill documents for the last 12 months revealed that fire drills on the third shift were not conducted at varied times. Three of four fire drills were conducted between 2:32 am and 3.03 am. This deficient practice was confirmed by Staff AQ (Security Supervisor) and Staff BF (Manager of Energy
Management ) at the time of discovery.

Based on interview and observation, the facility did not maintain the emergency electrical generator in accordance with the requirements of NFPA 101 (2012 edition), Section 4.6.12 and NFPA 110 (2012 edition), Sections 5.6.5.6. and 5.6.5.6.1. This deficiency had the potential to affect an undeterminable number of outpatients, staffs and visitors.

Findings include:

1. On 12/6/2016 at 3:15 PM, observation revealed that emergency generators located in the Lower level Room CONL079D were not provided with a remote stop switch. This deficient practice was confirmed by Staff AQ (Security Supervisor) and Staff BF (Manager of Energy Management ) at the time of discovery.

Based on observations and staff interview, the facility did not provide electrical receptacles in accordance with NFPA 99 (2012 edition). Findings include:This deficient practice could affect 30 of 2600 outpatients and an undeterminable number of staff and visitors.



1. On 12/06/16 at 3:45 pm, observation revealed within patient examination rooms (CE3003-CE3019) that healthcare grade medical devices were plugged into a non-medical grade receptacles. This non-medical grade receptacle is not listed for this healthcare purpose and is not compliant with NFPA 99 (2012 edition), 10.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

2. On 12/06/16 at 3:50 pm, observation revealed within patient examination rooms (CN3001-CN3020) that healthcare grade medical devices were plugged into a non-medical grade receptacles. This non-medical grade receptacle is not listed for this healthcare purpose and is not compliant with NFPA 99 (2012 edition), 10.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

Based on interview and observation, the facility did not maintain the emergency electrical generator in accordance with the requirements of NFPA 101 (2012 edition), Section 9.1.3.1, and NFPA 110 (2012 edition), Sections 5.6.5.6. and 5.6.5.6.1. This deficiency had the potential to affect 247 of 247 inpatients and an undeterminable number of staffs and visitors.

FINDINGS INCLUDE:

1. On 12/5/2016 at 1:48 PM, observation revealed that none of the three 2 mega watt capacity emergency generators located inside the power plant building were not provided with a remote stop switch. This deficient practice was confirmed by Staff AQ (Security Supervisor) and Staff BF (Manager of Energy Management ) at the time of discovery.

Based on observations and staff interview, the facility did not provide fixed electrical wiring in accordance with NFPA 99 (2012 edition) and NFPA 70 (2011 edition). This deficient practice could affect 100 of 2600 outpatients and an undeterminable number of staff and visitors.

Findings include:

1. On 12/06/16 at 10:45 am, observation revealed within file room (CCL008D) that two trouble lights where wired with temporary wiring to an open junction box. The temporary wiring was not contained within conduit and was open to the room. This observed condition was not compliant with NFPA 70 (2011 edition), 400.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

2. On 12/06/16 at 2:04 pm, observation revealed within room (CE2036) that a healthcare grade thermal bath device was plugged into a non-medical grade timer. The timer is not listed for this healthcare purpose and is not compliant with NFPA 99 (2012 edition), 10.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

3. On 12/06/16 at 3:30 pm, observation revealed within room (CW3021) that two (2) plug strip multiple outlet devices were used to power three high voltage appliances: a microwave oven, a coffee pot, and a toaster. These multiple outlet connection devices are not listed for this purpose and are not in accordance with NFPA 70 (2011 edition), 400.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.

4. On 12/06/16 at 3:40 pm, observation revealed within room (CN3008) that one (1) plug strip multiple outlet device was used to power a high voltage microwave appliance. This multiple outlet connection device is not listed for this purpose and is not in accordance with NFPA 70 (2011 edition), 400.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff AG and Staff AB.