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Based on observations it was determined that the health care facility failed to maintain the integrity of the spray on fire proofing.

The findings include:

On 2/9-11/2016 it was identified by observation:
1. The spray on fire proofing on the ground floor structural steel was missing around beam clamps just outside Elevator 9 and above the camera located in the same area.
2. The spray on fire proofing in the main electrical room was missing from around beam clamps located above panel MBPBBL11X.
3. The spray on fire proofing in the corridor outside of the Imaging Staff Lounge just to the right of the fire damper was missing from around beam clamps and the beam.
4. There was missing/damaged spray on fire proofing in the 5th floor mechanical elevator room.
5. There was missing/damaged spray on fire proofing in the 5th floor mechanical room.
6. There was missing/damaged spray on fire proofing in the visitor elevator lobby on the 4th floor.
7. There was missing/damaged spray on fire proofing in the 4th floor cardiac soiled utility room.
8. There was missing/damaged spray on fire proofing in the 3rd floor storage and parts room
9. There was missing/damaged spray on fire proofing on the 2nd floor above the stair 1 door.
10. There was missing/damaged spray on fire proofing in the 2nd floor anesthesia work room.
11. There was missing/damaged spray on fire proofing by dressing room in radiology.
11. There was missing/damaged spray on fire proofing in the top of elevator 9 shaft.
12. There was missing/damaged spray on fire proofing throughout elevator 7 shaft.
13. There was missing/damaged spray on fire proofing throughout elevator 6 shaft.
14. There was missing/damaged spray on fire proofing throughout elevator 5 shaft.
15. There was missing/damaged spray on fire proofing in elevator 4 shaft.

Based on observations it was determined that the health care facility failed to maintain door hardware.

The findings include:
On 2/10/2016 at approximately 11:03 am, it was identified by observation the door to patient room 226 would not close and latch.

On 2/11/2016 at approximately 10:50 am, it was identified by observation the door to sleep room 1 would not close and latch.

Based on observations it was determined that the health care facility failed to mark a non exit.

The findings include:
On 2/10/2016 at approximately 2:50 PM, it was identified by observation the smoke barrier doors (FD49) could be confused as an exit when approached from the corridor side. The door swinging into the ED was not marked with a sign indicating "No Exit ".

Based on observations it was determined that the health care facility failed to maintain the integrity of rated separations.

The findings include:

On 2/9-11/2016 it was identified by observation:
1. There was an unsealed hole in and an improperly sealed deck edge in the 4th floor waiting area.
2. There were unsealed holes (x3) above FD137.
3. There was an unsealed penetration by FD137.
4. There was an open conduit above the double doors by room 327.
5. There were penetrations at the top of the smoke wall in room 306.
6. There was an open conduit by room 305.
7. There was an unsealed penetration on 3rd floor between restroom and dialysis storage.
8. There were unsealed penetrations(x2) in endo scope.
9. There was an unsealed penetration in the endo procedure room in the right corner.
10. There was an improperly sealed penetration in the women's OR locker room.
11. There was an improperly sealed penetration in women's locker room above locker 11.
12. There was an open conduit in the women's locker room above locker 1.
13. There was unapproved filler placed in cable sleeve above FD79.
14. There was an open conduit in the endo manager's office.
15. There was an open conduit and unsealed penetrations in the 2nd floor staff lounge.
16. There was inadequate fire caulking in SW corner of patient elevator lobby.
17. There were unsealed penetrations (x5) in the visitor elevator lobby.
18. There was inadequate fire caulking in the shell chase.
19. There was an unsealed penetration in room 201.
20. There was inadequate fire caulking above FD66.
21. There was inadequate fire caulking in RT soiled(x4).
22. There was an improperly sealed deck edge in RT workroom.
23. There were open conduit's (x3) in respiratory therapy workroom.
24. There was an unsealed hole and pipe penetration by central sterile dirty.
25. There was an open conduit and an unsealed penetration in central sterile dirty.
26. There was an improperly sealed pipe penetration in surgery receiving.
27. There was an improperly sealed pipe penetration in gas storage.
28. There was an open conduit in central sterile.
29. There was an unsealed penetration in central sterile clean and data central sterile.
30. There was an open conduit in anesthesia work room.
31. There was an unsealed hole, unsealed penetrations (x2) and an open conduit in the OR nurse chartroom.
32. There was an unsealed hole and an improperly sealed deck edge in the OR staff restroom.
33. There was an unsealed penetration and an open conduit above the doors to PACU.
34. There was an unsealed hole above the SDS doors.
35. There was an unsealed penetration above the on call room doors.
36. There was open MC and an unsealed penetration by soiled utility.
37. There was an excessive gap between panels of double doors to ICU at nurse's station.
38. There was an improperly sealed penetration on the 2nd floor by stair 1.
39. There was a penetration at the top of the smoke barrier in labor and delivery.
40. There was an improperly installed conduit through smoke barrier in labor and delivery family nourishment room.
41. There was an open conduit in the labor and delivery nurse manager office.
42. There were penetrations through patch in labor and delivery stair 5.
43. There was damage (charring) to rated walls in SDS4, SDS7 and SDS8.
44. There was an open conduit in SDS8.
45. There was an open conduit above double doors by sleep room 5.
46. There was an open conduit and an improperly sealed patch in scrub ex room.
47. There was an open conduit and an unsealed penetration in the men's OR locker room above the staff lounge door.
48. There was an open conduit in the laboratory by FD53.
49. There were unsealed penetrations in the laboratory above vent in back right corner and above entry door.
50. There was an open conduit in imaging lab waiting.
51. There was an open conduit, improperly sealed deck edge and a hole in fire caulk around duct in the ultra sound workroom.
52. There was an open conduit in ultra sound 1.
53. There was an open conduit above doors to radiology admin.
54. There was an unsealed sleeve by radiology admin door.
55. There was an improperly sealed sewer pipe penetrating rated wall corner in radiology.
56. There was open MC and an unsealed penetration by FD49.
57. There was an open conduit and unsealed penetrations (x3) above FD49.
58. There were unsealed water lines in CT.
59. The top of a duct picture frame was missing in CT.
60. There were unsealed water lines in nuclear medicine workroom (x2).
61. There was an open conduit and an unsealed penetration in 1st floor hallway by stair 4.
62. There was an improperly sealed smoke barrier on the ground floor above the smoke barrier doors (FD 156) outside of security. The barrier did not have taped and mudded joints and did not have mud covering the drywall screws.
63. There was an unsealed penetration above the patient registration desk on the first floor.
64. There was an improperly sealed penetration in the ED above smoke barrier doors.
65. There was an unsealed penetration in the gift shop above the cash register.
66. There was an improperly sealed penetration, 2 unsealed hole and no drywall mud covering drywall screws in the volunteer lounge above the door (FD38) in the one-hour barrier/smoke barrier.
67. There was an unsealed penetration on the first floor above the fire barrier/smoke barrier doors FD46 (from the eastern side).
68. The smoke barrier/fire barrier did not appear to be complete where it intersects the structural steel and shaft wall adjoin the elevator bank on the first floor above the fire barrier/smoke barrier doors FD46.
69. There were unsealed penetrations (x5) on the first floor in the smoke barrier located adjacent to Elevator #7.
70. There were improperly sealed sleeves in the 1st floor radiology reading room at the main desk.
71. There was an improperly sealed penetration in the first floor main lobby just west of the Radiology Administration door (FD61).
72. There was an unsealed hole above the first floor radiology administration door (FD61).
73. There were improperly sealed penetrations (x2) in the first floor lobby across from Stairwell 3.
74. There were improperly sealed penetrations (x2) in the first floor lobby just west of the imaging and lab waiting room.
75. There was an unsealed penetration above smoke/fire barrier doors FD59.
76. There was and unsealed penetration above the door to the imaging and lab waiting Room.
77. There was an improperly sealed penetration in Radiology Administration above the entry door (FD61).
78. There was an unsealed hole in the Radiology Administration Conference above the video display screen.
79. There was an unsealed hole in the Radiology Administration Conference Room.
80. There were multiple unsealed seams, holes, cracks, penetrations and joints throughout elevator shafts 3, 4, 5, 6, 7 and 9.
81. The top of elevator shaft 9 was not sealed properly.
82. There was an unsealed abandoned box in the top of elevator shaft 9.

Based on observations it was determined that the health care facility failed to maitain the integrity of rated separations.

The findings include:

On 2/9-11/2016 it was identified by observation:
1. There was an unsealed duct at the 4th floor electrical room.
2. There was an unsealed penetration in the 3rd floor mechanical room north side.
3. There were open conduits in the 3rd floor clean supply room along the west side.
4. There was an unsealed penetration in the 3rd floor equipment storage room along the corridor side.
5. There was an unsealed penetration in the 3rd floor dialysis storage room along the corridor side.
6. There was an unsealed duct outside the OR equipment storage room.
7. There were improperly sealed pipe penetrations in the west wall of the OR equipment storage room (x2).
8. The deck edge in the OR Clean linen was not properly sealed.
9. The deck edge in the OR soiled linen was not properly sealed.
10. There were unsealed penetrations in the 2nd floor clean supply room (x2).
11. There were unsealed penetrations in the 2nd floor equipment storage room along the right wall.
12. There were unsealed penetrations in the 2nd floor electrical room above the door.
13. There was an improperly sealed penetration across from room 219.
14. There was an open conduit in labor and delivery clean supply along the right wall.
15. There were open conduits in the labor and delivery soiled utility above the door.
16. There was an open conduit in same day surgery clean supply at the PACU end door.
17. There was a cable sleeve with no fire-stopping material in it in the 1 hour fire barrier located above the southern doors to Supply Chain Management.
18. There was a large hole in the Pharmacy a conduit penetrating the 2-hour fire barrier between the Pharmacy and the Main Electrical Room.
19. There was an unsealed round duct in the corridor outside the Engineering Shop that was penetrating the one hour fire barrier. The duct appeared to be the exhaust duct for the Engineering Shop bathroom.
20. There was an improperly sealed cable sleeve in the ED above the door (FD 42) to soiled utility that was penetrating the one-hour fire barrier.
21. There was an improperly sealed patch in the ED Decontamination Room in the one-hour fire barrier above the door.
22. There were gaps in the top of the 2hr wall seal in the EVS employee lounge.

Based on observations it was determined that the health care facility failed to maintain components of the fire alarm system.

The findings include:
On 2/9/2016 at approximately 2:30 PM, it was identified by observation the Main Fire Alarm Control Panel did not have the location of the circuit disconnecting means permanently identified.

On 2/9/2016 at approximately 2:35 PM, it was identified by observation the Fire Alarm Control Panel breaker was not identified with red marking nor did it have a device to prevent access by unauthorized personnel.

Based on observations it was determined the health care facility failed to install all required components, which would prevent upward movement of the sprinkler system piping, for systems with pressures exceeding 100 psi.

The findings include:
On 2/10/2016 at approximately 2:44 PM, it was identified by observation there was no uplift protection provided for sprinkler head in same day surgery by the soiled utility room.

On 2/11/2016 at approximately 9:30 AM, it was identified by observation there was no uplift protection provided for sprinkler in front of fume hood in the laboratory.

On 2/11/2016 at approximately 9:59 AM, it was identified by observation there was no uplift protection provided for the pendant sprinkler in the gift shop located closest to the wall separating the volunteer lounge.

Based on observations it was determined that the health care facility failed to maitain componants of the sprinkler system.

The findings include:

On 2/9-11/2016 it was identified by observation:
1. There was MC Cable touching sprinkler piping in room 427 rest room.
2. There was a ceiling grid wire touching sprinkler piping in the 4th floor waiting area.
3. There were wires resting on sprinkler piping in the 4th floor waiting area.
4. There was MC Cable touching sprinkler piping outside the 4th floor electrical room.
5. There was a ceiling grid wire touching sprinkler piping in room 401.
6. There were wires resting on sprinkler piping in room 401.
7. There was conduit touching sprinkler piping in the FD134 equipment storage room.
8. There was duct foil wrap insulation resting on sprinkler piping in the north equipment room.
9. There was flex duct piping touching sprinkler piping by room 417.
10. There were loaded sprinkler heads in room 424 and in the office across from room 430.
11. There was a pipe rack touching sprinkler piping on 4th floor by cardiac between elevators.
12. There was a loaded sprinkler head in the 3rd floor clean supply room.
13. There was a loaded sprinkler heads at the 3rd floor nurse's station.
14. There was conduit resting on sprinkler piping in the 3rd floor soiled utility room.
15. There were loaded sprinkler heads in rooms 306 and 316.
16. There were loaded sprinkler heads in the 3rd floor staff lounge.
17. There were wires resting on sprinkler piping on the 2nd floor by stair 2.
18. There was an escutcheon ring resting on a sprinkler head by the center beam detector in the atrium.
19. There were wires resting on sprinkler piping by the visitor elevators.
20. There was thread touching sprinkler piping in patient elevator lobby.
21. There were wires touching sprinkler piping in the shell space.
22. There was a loaded sprinkler head in the respiratory supervisor's office.
23. There was flex duct piping touching sprinkler piping in RT soiled.
24. There were wires resting on sprinkler piping in bio med supervisor's office.(Corrected on site)
25. There were loaded sprinkler heads in the 2nd floor staff lounge.
26. There were wires and conduit resting on sprinkler piping in room 226.
27. There were loaded sprinkler heads in room 201.
28. There were loaded sprinkler heads in ICU room 212 and restroom.
29. There were wires resting on sprinkler piping in corridor by central sterile.
30. There was a duct resting on sprinkler piping in OR equipment room(x2), outside east wall of OR equipment room and outside west wall of OR equipment room.
31. There was flex duct piping touching sprinkler piping by OR staff restroom.
32. There were wires resting on sprinkler piping by Or clean linen.
33. There was conduit resting on sprinkler piping at the OR nurse's station (x3).
34. There was a junction box resting on sprinkler piping by OR soiled utility.
35. There was a light fixture hanger wire wrapped around sprinkler piping in Or soiled linen. (Corrected on site)
36. There was a water pipe touching sprinkler piping in anesthesia work room.
37. There were loaded sprinkler heads in labor and delivery ante partum testing.
38. There was a loaded sprinkler head in sleep rooms 6 and 7.
39. There was a loaded sprinkler head in the CAIR lab prep recovery room 1.
40. There were wires resting on sprinkler piping in imaging lab waiting.
41. There was a light fixture hanger wire touching sprinkler piping in ultra sound 1.
42. There were wires resting on sprinkler piping in hall by radiology admin doors.
43. There was a light fixture hanger wire touching sprinkler piping in the nuclear medicine work room.
44. There were water pipes touching sprinkler piping in the nuclear medicine work room.
45. There was conduit resting on sprinkler piping in the corridor outside the Engineering Shop single door.
46. There was a wire resting on sprinkler piping above the ceiling by the overhead wayfinding sign outside of the Imaging and Lab Waiting Room.

47. There was a loaded sprinkler head in the walk in cooler.
48. There was rust staining on the seat and deflector of a sprinkler head in the walk in cooler.
49. There was a foreign material on a sprinkler head in the kitchen cart wash area.

Based on observations it was determined that the health care facility failed to maintain portable fire extinguishers.

The findings include:
On 2/10/2016 at approximately 3:30 PM, it was identified by observation the portable fire extinguisher in OR1 was obstructed and inaccessible.

On 2/10/2016 at approximately 3:32 PM, it was identified by observation the portable fire extinguisher in OR3 was obstructed and inaccessible.

On 2/10/2016 at approximately 3:34 PM, it was identified by observation the portable fire extinguisher in OR4 was obstructed and inaccessible.

Based on observations it was determined that the health care facility failed to control dust accumulation.

The findings include:

On 2/9/2016 at approximately 10:15 AM, it was identified by observation there was an excessive accumulation of dust on the restroom vent in room 427.

Based on observations it was determined that the health care facility failed to maintain an exit door.

The findings include:
On 2/9/2016 at approximately 2:20 PM, it was identified by observation the delayed egress lock on the smoke barrier doors on the second floor by the equipment storage room exceeds the allotted time to release.

Based on observation the facility failed to ensure that openings in its fire barriers are adequately protected.
NFPA 101-2000
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
NFPA 80-1999
2-5.1 General. The installation of all components of a fire door assembly shall be in accordance with the specific listing of each component.
2-5.2 Manufacturers' Instructions. All components shall be installed in accordance with the manufacturers ' installation instructions and shall be adjusted to function as described in the listing.
From 2/9/16 through 2/11/16 fire doors of 45 minute and 90 minute ratings installed in pairs with concealed vertical rod fire exit devices were observed in multiple locations on the ground level, 1st floor and 2nd floor. These doors did not have bottom rods installed. Upon review of the manufacturer's documentation for the fire exit hardware it was noted that this hardware requires the use of a thermal latch pin if the bottom rod assembly is omitted. These doors did not have thermal latch pins installed.
On 2/9/16 at approximately 1:40 PM it was observed that the fire door located on the ground floor by receiving (FD14) was missing 2 screws from one of its hinges.
Based on observation and interview the facility failed to ensure that its employees are adequately trained in response to a cooking fire.
NFPA 96-1998
8-1.4 Instructions for manually operating the fire-extinguishing system shall be posted conspicuously in the kitchen and shall be reviewed periodically with employees by the management.
On 2/9/2016 at approximately 2:10 PM during the building tour of the kitchen 2 of 2 employees interviewed were not able to accurately identify and/or describe the procedures to follow upon discovery of a deep fryer fire.

Based on observations it was determined the health care facility failed control chemical storage.

The findings include:
On 2/11/2016 at approximately 11:30 AM, it was identified by observation the chemical fume hood work space was being used as chemical storage.

Based on observations it was determined that the health care facility failed to control oxygen storage.

The findings include:
On 2/9/2016 at approximately 11:00 AM, it was identified by observation there were oxygen tanks being stored without appropriate signage in the 3rd floor equipment room.

On 2/9/2016 at approximately 2:30 PM, it was identified by observation there were oxygen tanks being stored without appropriate signage in the 2nd floor equipment room.

Based on observations it was determined that the health care facility failed to prevent various electrical hazards.

The findings include:

On 2/9-11/2016 it was identified by observation:
1. There was dead end wiring in the 3rd floor IT closet at the back wall.
2. There was an open junction box above the ceiling in the 2nd floor staff lounge.
3. There was an extension cord being used as permanent wiring in the 2nd floor IT closet.
4. There was an open junction box above the ceiling by room 210 at the double doors.
5. There was an open junction box above the double doors by the conference and consultation room.
6. There was an open junction box above the ceiling in the bio med supervisor's office.
7. There was an extension cord being used as permanent wiring in central sterile dirty.
8. There were two open junction boxes in the smoke barrier above FD49.
9. There was an open junction box in the ceiling above the southern supply chain management doors.
10. There was an open box in the elevator pit for elevator 7.

Based on observations it was determined that the health care facility failed to control placement of alcohol based hand sanitizer.

The findings include:
On 2/9/2016 at approximately 2:32 PM, it was identified by observation there was an alcohol based hand sanitizer dispenser mounted within the allowable distance from a light switch in biomed.

On 2/10/2016 at approximately 2:59 PM, it was identified by observation there was an alcohol based hand sanitizer dispenser mounted above an electrical outlet in PACU bay 1.

Based on observations it was determined that the health care facility failed to maintain the integrity of the spray on fire proofing.

The findings include:

On 2/9-11/2016 it was identified by observation:
1. The spray on fire proofing on the ground floor structural steel was missing around beam clamps just outside Elevator 9 and above the camera located in the same area.
2. The spray on fire proofing in the main electrical room was missing from around beam clamps located above panel MBPBBL11X.
3. The spray on fire proofing in the corridor outside of the Imaging Staff Lounge just to the right of the fire damper was missing from around beam clamps and the beam.
4. There was missing/damaged spray on fire proofing in the 5th floor mechanical elevator room.
5. There was missing/damaged spray on fire proofing in the 5th floor mechanical room.
6. There was missing/damaged spray on fire proofing in the visitor elevator lobby on the 4th floor.
7. There was missing/damaged spray on fire proofing in the 4th floor cardiac soiled utility room.
8. There was missing/damaged spray on fire proofing in the 3rd floor storage and parts room
9. There was missing/damaged spray on fire proofing on the 2nd floor above the stair 1 door.
10. There was missing/damaged spray on fire proofing in the 2nd floor anesthesia work room.
11. There was missing/damaged spray on fire proofing by dressing room in radiology.
11. There was missing/damaged spray on fire proofing in the top of elevator 9 shaft.
12. There was missing/damaged spray on fire proofing throughout elevator 7 shaft.
13. There was missing/damaged spray on fire proofing throughout elevator 6 shaft.
14. There was missing/damaged spray on fire proofing throughout elevator 5 shaft.
15. There was missing/damaged spray on fire proofing in elevator 4 shaft.

Based on observations it was determined that the health care facility failed to maintain door hardware.

The findings include:
On 2/10/2016 at approximately 11:03 am, it was identified by observation the door to patient room 226 would not close and latch.

On 2/11/2016 at approximately 10:50 am, it was identified by observation the door to sleep room 1 would not close and latch.

Based on observations it was determined that the health care facility failed to mark a non exit.

The findings include:
On 2/10/2016 at approximately 2:50 PM, it was identified by observation the smoke barrier doors (FD49) could be confused as an exit when approached from the corridor side. The door swinging into the ED was not marked with a sign indicating "No Exit ".

Based on observations it was determined that the health care facility failed to maintain the integrity of rated separations.

The findings include:

On 2/9-11/2016 it was identified by observation:
1. There was an unsealed hole in and an improperly sealed deck edge in the 4th floor waiting area.
2. There were unsealed holes (x3) above FD137.
3. There was an unsealed penetration by FD137.
4. There was an open conduit above the double doors by room 327.
5. There were penetrations at the top of the smoke wall in room 306.
6. There was an open conduit by room 305.
7. There was an unsealed penetration on 3rd floor between restroom and dialysis storage.
8. There were unsealed penetrations(x2) in endo scope.
9. There was an unsealed penetration in the endo procedure room in the right corner.
10. There was an improperly sealed penetration in the women's OR locker room.
11. There was an improperly sealed penetration in women's locker room above locker 11.
12. There was an open conduit in the women's locker room above locker 1.
13. There was unapproved filler placed in cable sleeve above FD79.
14. There was an open conduit in the endo manager's office.
15. There was an open conduit and unsealed penetrations in the 2nd floor staff lounge.
16. There was inadequate fire caulking in SW corner of patient elevator lobby.
17. There were unsealed penetrations (x5) in the visitor elevator lobby.
18. There was inadequate fire caulking in the shell chase.
19. There was an unsealed penetration in room 201.
20. There was inadequate fire caulking above FD66.
21. There was inadequate fire caulking in RT soiled(x4).
22. There was an improperly sealed deck edge in RT workroom.
23. There were open conduit's (x3) in respiratory therapy workroom.
24. There was an unsealed hole and pipe penetration by central sterile dirty.
25. There was an open conduit and an unsealed penetration in central sterile dirty.
26. There was an improperly sealed pipe penetration in surgery receiving.
27. There was an improperly sealed pipe penetration in gas storage.
28. There was an open conduit in central sterile.
29. There was an unsealed penetration in central sterile clean and data central sterile.
30. There was an open conduit in anesthesia work room.
31. There was an unsealed hole, unsealed penetrations (x2) and an open conduit in the OR nurse chartroom.
32. There was an unsealed hole and an improperly sealed deck edge in the OR staff restroom.
33. There was an unsealed penetration and an open conduit above the doors to PACU.
34. There was an unsealed hole above the SDS doors.
35. There was an unsealed penetration above the on call room doors.
36. There was open MC and an unsealed penetration by soiled utility.
37. There was an excessive gap between panels of double doors to ICU at nurse's station.
38. There was an improperly sealed penetration on the 2nd floor by stair 1.
39. There was a penetration at the top of the smoke barrier in labor and delivery.
40. There was an improperly installed conduit through smoke barrier in labor and delivery family nourishment room.
41. There was an open conduit in the labor and delivery nurse manager office.
42. There were penetrations through patch in labor and delivery stair 5.
43. There was damage (charring) to rated walls in SDS4, SDS7 and SDS8.
44. There was an open conduit in SDS8.
45. There was an open conduit above double doors by sleep room 5.
46. There was an open conduit and an improperly sealed patch in scrub ex room.
47. There was an open conduit and an unsealed penetration in the men's OR locker room above the staff lounge door.
48. There was an open conduit in the laboratory by FD53.
49. There were unsealed penetrations in the laboratory above vent in back right corner and above entry door.
50. There was an open conduit in imaging lab waiting.
51. There was an open conduit, improperly sealed deck edge and a hole in fire caulk around duct in the ultra sound workroom.
52. There was an open conduit in ultra sound 1.
53. There was an open conduit above doors to radiology admin.
54. There was an unsealed sleeve by radiology admin door.
55. There was an improperly sealed sewer pipe penetrating rated wall corner in radiology.
56. There was open MC and an unsealed penetration by FD49.
57. There was an open conduit and unsealed penetrations (x3) above FD49.
58. There were unsealed water lines in CT.
59. The top of a duct picture frame was missing in CT.
60. There were unsealed water lines in nuclear medicine workroom (x2).
61. There was an open conduit and an unsealed penetration in 1st floor hallway by stair 4.
62. There was an improperly sealed smoke barrier on the ground floor above the smoke barrier doors (FD 156) outside of security. The barrier did not have taped and mudded joints and did not have mud covering the drywall screws.
63. There was an unsealed penetration above the patient registration desk on the first floor.
64. There was an improperly sealed penetration in the ED above smoke barrier doors.
65. There was an unsealed penetration in the gift shop above the cash register.
66. There was an improperly sealed penetration, 2 unsealed hole and no drywall mud covering drywall screws in the volunteer lounge above the door (FD38) in the one-hour barrier/smoke barrier.
67. There was an unsealed penetration on the first floor above the fire barrier/smoke barrier doors FD46 (from the eastern side).
68. The smoke barrier/fire barrier did not appear to be complete where it intersects the structural steel and shaft wall adjoin the elevator bank on the first floor above the fire barrier/smoke barrier doors FD46.
69. There were unsealed penetrations (x5) on the first floor in the smoke barrier located adjacent to Elevator #7.
70. There were improperly sealed sleeves in the 1st floor radiology reading room at the main desk.
71. There was an improperly sealed penetration in the first floor main lobby just west of the Radiology Administration door (FD61).
72. There was an unsealed hole above the first floor radiology administration door (FD61).
73. There were improperly sealed penetrations (x2) in the first floor lobby across from Stairwell 3.
74. There were improperly sealed penetrations (x2) in the first floor lobby just west of the imaging and lab waiting room.
75. There was an unsealed penetration above smoke/fire barrier doors FD59.
76. There was and unsealed penetration above the door to the imaging and lab waiting Room.
77. There was an improperly sealed penetration in Radiology Administration above the entry door (FD61).
78. There was an unsealed hole in the Radiology Administration Conference above the video display screen.
79. There was an unsealed hole in the Radiology Administration Conference Room.
80. There were multiple unsealed seams, holes, cracks, penetrations and joints throughout elevator shafts 3, 4, 5, 6, 7 and 9.
81. The top of elevator shaft 9 was not sealed properly.
82. There was an unsealed abandoned box in the top of elevator shaft 9.

Based on observations it was determined that the health care facility failed to maitain the integrity of rated separations.

The findings include:

On 2/9-11/2016 it was identified by observation:
1. There was an unsealed duct at the 4th floor electrical room.
2. There was an unsealed penetration in the 3rd floor mechanical room north side.
3. There were open conduits in the 3rd floor clean supply room along the west side.
4. There was an unsealed penetration in the 3rd floor equipment storage room along the corridor side.
5. There was an unsealed penetration in the 3rd floor dialysis storage room along the corridor side.
6. There was an unsealed duct outside the OR equipment storage room.
7. There were improperly sealed pipe penetrations in the west wall of the OR equipment storage room (x2).
8. The deck edge in the OR Clean linen was not properly sealed.
9. The deck edge in the OR soiled linen was not properly sealed.
10. There were unsealed penetrations in the 2nd floor clean supply room (x2).
11. There were unsealed penetrations in the 2nd floor equipment storage room along the right wall.
12. There were unsealed penetrations in the 2nd floor electrical room above the door.
13. There was an improperly sealed penetration across from room 219.
14. There was an open conduit in labor and delivery clean supply along the right wall.
15. There were open conduits in the labor and delivery soiled utility above the door.
16. There was an open conduit in same day surgery clean supply at the PACU end door.
17. There was a cable sleeve with no fire-stopping material in it in the 1 hour fire barrier located above the southern doors to Supply Chain Management.
18. There was a large hole in the Pharmacy a conduit penetrating the 2-hour fire barrier between the Pharmacy and the Main Electrical Room.
19. There was an unsealed round duct in the corridor outside the Engineering Shop that was penetrating the one hour fire barrier. The duct appeared to be the exhaust duct for the Engineering Shop bathroom.
20. There was an improperly sealed cable sleeve in the ED above the door (FD 42) to soiled utility that was penetrating the one-hour fire barrier.
21. There was an improperly sealed patch in the ED Decontamination Room in the one-hour fire barrier above the door.
22. There were gaps in the top of the 2hr wall seal in the EVS employee lounge.

Based on observations it was determined that the health care facility failed to maintain components of the fire alarm system.

The findings include:
On 2/9/2016 at approximately 2:30 PM, it was identified by observation the Main Fire Alarm Control Panel did not have the location of the circuit disconnecting means permanently identified.

On 2/9/2016 at approximately 2:35 PM, it was identified by observation the Fire Alarm Control Panel breaker was not identified with red marking nor did it have a device to prevent access by unauthorized personnel.

Based on observations it was determined the health care facility failed to install all required components, which would prevent upward movement of the sprinkler system piping, for systems with pressures exceeding 100 psi.

The findings include:
On 2/10/2016 at approximately 2:44 PM, it was identified by observation there was no uplift protection provided for sprinkler head in same day surgery by the soiled utility room.

On 2/11/2016 at approximately 9:30 AM, it was identified by observation there was no uplift protection provided for sprinkler in front of fume hood in the laboratory.

On 2/11/2016 at approximately 9:59 AM, it was identified by observation there was no uplift protection provided for the pendant sprinkler in the gift shop located closest to the wall separating the volunteer lounge.

Based on observations it was determined that the health care facility failed to maitain componants of the sprinkler system.

The findings include:

On 2/9-11/2016 it was identified by observation:
1. There was MC Cable touching sprinkler piping in room 427 rest room.
2. There was a ceiling grid wire touching sprinkler piping in the 4th floor waiting area.
3. There were wires resting on sprinkler piping in the 4th floor waiting area.
4. There was MC Cable touching sprinkler piping outside the 4th floor electrical room.
5. There was a ceiling grid wire touching sprinkler piping in room 401.
6. There were wires resting on sprinkler piping in room 401.
7. There was conduit touching sprinkler piping in the FD134 equipment storage room.
8. There was duct foil wrap insulation resting on sprinkler piping in the north equipment room.
9. There was flex duct piping touching sprinkler piping by room 417.
10. There were loaded sprinkler heads in room 424 and in the office across from room 430.
11. There was a pipe rack touching sprinkler piping on 4th floor by cardiac between elevators.
12. There was a loaded sprinkler head in the 3rd floor clean supply room.
13. There was a loaded sprinkler heads at the 3rd floor nurse's station.
14. There was conduit resting on sprinkler piping in the 3rd floor soiled utility room.
15. There were loaded sprinkler heads in rooms 306 and 316.
16. There were loaded sprinkler heads in the 3rd floor staff lounge.
17. There were wires resting on sprinkler piping on the 2nd floor by stair 2.
18. There was an escutcheon ring resting on a sprinkler head by the center beam detector in the atrium.
19. There were wires resting on sprinkler piping by the visitor elevators.
20. There was thread touching sprinkler piping in patient elevator lobby.
21. There were wires touching sprinkler piping in the shell space.
22. There was a loaded sprinkler head in the respiratory supervisor's office.
23. There was flex duct piping touching sprinkler piping in RT soiled.
24. There were wires resting on sprinkler piping in bio med supervisor's office.(Corrected on site)
25. There were loaded sprinkler heads in the 2nd floor staff lounge.
26. There were wires and conduit resting on sprinkler piping in room 226.
27. There were loaded sprinkler heads in room 201.
28. There were loaded sprinkler heads in ICU room 212 and restroom.
29. There were wires resting on sprinkler piping in corridor by central sterile.
30. There was a duct resting on sprinkler piping in OR equipment room(x2), outside east wall of OR equipment room and outside west wall of OR equipment room.
31. There was flex duct piping touching sprinkler piping by OR staff restroom.
32. There were wires resting on sprinkler piping by Or clean linen.
33. There was conduit resting on sprinkler piping at the OR nurse's station (x3).
34. There was a junction box resting on sprinkler piping by OR soiled utility.
35. There was a light fixture hanger wire wrapped around sprinkler piping in Or soiled linen. (Corrected on site)
36. There was a water pipe touching sprinkler piping in anesthesia work room.
37. There were loaded sprinkler heads in labor and delivery ante partum testing.
38. There was a loaded sprinkler head in sleep rooms 6 and 7.
39. There was a loaded sprinkler head in the CAIR lab prep recovery room 1.
40. There were wires resting on sprinkler piping in imaging lab waiting.
41. There was a light fixture hanger wire touching sprinkler piping in ultra sound 1.
42. There were wires resting on sprinkler piping in hall by radiology admin doors.
43. There was a light fixture hanger wire touching sprinkler piping in the nuclear medicine work room.
44. There were water pipes touching sprinkler piping in the nuclear medicine work room.
45. There was conduit resting on sprinkler piping in the corridor outside the Engineering Shop single door.
46. There was a wire resting on sprinkler piping above the ceiling by the overhead wayfinding sign outside of the Imaging and Lab Waiting Room.

47. There was a loaded sprinkler head in the walk in cooler.
48. There was rust staining on the seat and deflector of a sprinkler head in the walk in cooler.
49. There was a foreign material on a sprinkler head in the kitchen cart wash area.

Based on observations it was determined that the health care facility failed to maintain portable fire extinguishers.

The findings include:
On 2/10/2016 at approximately 3:30 PM, it was identified by observation the portable fire extinguisher in OR1 was obstructed and inaccessible.

On 2/10/2016 at approximately 3:32 PM, it was identified by observation the portable fire extinguisher in OR3 was obstructed and inaccessible.

On 2/10/2016 at approximately 3:34 PM, it was identified by observation the portable fire extinguisher in OR4 was obstructed and inaccessible.

Based on observations it was determined that the health care facility failed to control dust accumulation.

The findings include:

On 2/9/2016 at approximately 10:15 AM, it was identified by observation there was an excessive accumulation of dust on the restroom vent in room 427.

Based on observations it was determined that the health care facility failed to maintain an exit door.

The findings include:
On 2/9/2016 at approximately 2:20 PM, it was identified by observation the delayed egress lock on the smoke barrier doors on the second floor by the equipment storage room exceeds the allotted time to release.

Based on observation the facility failed to ensure that openings in its fire barriers are adequately protected.
NFPA 101-2000
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
NFPA 80-1999
2-5.1 General. The installation of all components of a fire door assembly shall be in accordance with the specific listing of each component.
2-5.2 Manufacturers' Instructions. All components shall be installed in accordance with the manufacturers ' installation instructions and shall be adjusted to function as described in the listing.
From 2/9/16 through 2/11/16 fire doors of 45 minute and 90 minute ratings installed in pairs with concealed vertical rod fire exit devices were observed in multiple locations on the ground level, 1st floor and 2nd floor. These doors did not have bottom rods installed. Upon review of the manufacturer's documentation for the fire exit hardware it was noted that this hardware requires the use of a thermal latch pin if the bottom rod assembly is omitted. These doors did not have thermal latch pins installed.
On 2/9/16 at approximately 1:40 PM it was observed that the fire door located on the ground floor by receiving (FD14) was missing 2 screws from one of its hinges.
Based on observation and interview the facility failed to ensure that its employees are adequately trained in response to a cooking fire.
NFPA 96-1998
8-1.4 Instructions for manually operating the fire-extinguishing system shall be posted conspicuously in the kitchen and shall be reviewed periodically with employees by the management.
On 2/9/2016 at approximately 2:10 PM during the building tour of the kitchen 2 of 2 employees interviewed were not able to accurately identify and/or describe the procedures to follow upon discovery of a deep fryer fire.

Based on observations it was determined the health care facility failed control chemical storage.

The findings include:
On 2/11/2016 at approximately 11:30 AM, it was identified by observation the chemical fume hood work space was being used as chemical storage.

Based on observations it was determined that the health care facility failed to control oxygen storage.

The findings include:
On 2/9/2016 at approximately 11:00 AM, it was identified by observation there were oxygen tanks being stored without appropriate signage in the 3rd floor equipment room.

On 2/9/2016 at approximately 2:30 PM, it was identified by observation there were oxygen tanks being stored without appropriate signage in the 2nd floor equipment room.

Based on observations it was determined that the health care facility failed to prevent various electrical hazards.

The findings include:

On 2/9-11/2016 it was identified by observation:
1. There was dead end wiring in the 3rd floor IT closet at the back wall.
2. There was an open junction box above the ceiling in the 2nd floor staff lounge.
3. There was an extension cord being used as permanent wiring in the 2nd floor IT closet.
4. There was an open junction box above the ceiling by room 210 at the double doors.
5. There was an open junction box above the double doors by the conference and consultation room.
6. There was an open junction box above the ceiling in the bio med supervisor's office.
7. There was an extension cord being used as permanent wiring in central sterile dirty.
8. There were two open junction boxes in the smoke barrier above FD49.
9. There was an open junction box in the ceiling above the southern supply chain management doors.
10. There was an open box in the elevator pit for elevator 7.