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Based on observation the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On April 28, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety, observed penetrations in the corridor walls located in the Heli Pad Riser Room.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat will cause harm to the patients.

Based on observation the facility failed to protect a vertical opening for a service dumbwaiter and elevator.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.1.1 "Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating." Section 8.2.5.2 "Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

Findings Include:

On April 28, and 29th.2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety, observed the Clean Lift SPD door was removed.
Elevator # 7, the three hour rated door would not close.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Failing to provide enclosures between floors will cause harm to patients and staff.

Based on observation the facility failed to fill penetrations in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ? hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On April 28, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety, observed unsealed penetrations in the smoke barrier, located on the sixth floor by room 620.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which will cause harm to patients.

Based on observation the facility failed to maintain self closing doors in a smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Findings include:

On April 28, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety, observed the astragal was removed from the corridor smoke/fire doors between rooms 531 and 533 on five East. When closed the gap measured 1/8th inch and is not smoke tight.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

This installation will allow smoke to contaminate smoke zones not directly effected by the fire, which will cause harm to patients.

Base on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke.

NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On April 28; and 29th, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety, observed the following hazardous area doors:

1. Medical gas storage room by OR number four, no door closing device.
2. CV storage room, rated door impeded by equipment and will not close.
3. Lab, Door from waiting room, door closing device removed and held open with a kick down door impediment.
4. Lab Managers office, door closing device removed and held open with a kick down impediment.
5. Staff locker room contains soiled lab coats, and combustibles, door removed.
6. Kitchen, Dry food and alcohol storage, no door closing device and held open by an impediment.
7. Basement, Vendor storage room, door wedged open.
8. Basement, Medical storage, door removed.
9. Endoscope Decontaminating room, kick down door impediment, door will not close.
10. Health Medical Records, no door closing device.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on observation the facility failed to maintain the battery operated emergency lighting.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.9.1 " Emergency lighting shall be provided in accordance with Section 7.9."Section 7.9.2.4 "Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition."

Findings Include:

On April 28; and 29th, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety, tested the emergency lighting unit located in the Dry Food Storage area. The lighting unit would not light during the test.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Failure to maintain emergency lighting units in proper operating condition will cause harm to the employees/ patients during a power outage.

Based on record review, staff interview, and observation the facility failed to conduct the required fire drills and the facility failed to train the staff on life safety procedures and devices.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions." Chapter 19, Section 19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings include:

On April 24th; 28th; and 29th, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations Manager Life Safety, reviewed Fire Drill documentation, interviewed staff members and observed the following:

1. No Fire Drill reports for first quarter, second shift 2014, and second quarter, second shift 2013.
2. A seven year and a four year employee were interviewed on the second floor surgery work area, they stated never having an actual Fire Drill in the Surgery work area.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on documentation review and observation the facility did not inspect, test and maintain the automatic sprinkler system in accordance with the requirements of the Life Safety Code.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems."

NFPA 25, Water Based Extinguishment Systems, requires monthly, quarterly and annual testing of automatic sprinkler systems. NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material, paint, and physical damage and shall be installed in the proper orientation..."

NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings include:

On April 24th; 28th; and 29th, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations Manager Life Safety, reviewed the automatic sprinkler system documentation. The facility did not have documentation for the quarterly testing of the sprinkler system for second quarter and fourth quarter 2013. Of the four quarterly flow tests there was no documentation of time recorded, on the annual tests conducted by the contracted vendor.
The following observations were made:

1. By OR # 1 alcove, one of one sprinkler, escutcheon plate not smoke tight.
2. Fourth floor west, shower room, sprinkler covered with lint.
3. Door # 21017, Anesthesia Tech Room, gap around the escutcheon plate not smoke tight.
4. Kitchen, Wash tray area, two of two escutcheon plates missing.
5. Short order cook area, one of two sprinklers lint.
6. Lab. one of one sprinkler does not have 18 inches of clearance from book shelf at the BHB TCA station.
7. Health Medical Records, one of two sprinklers no escutcheon plate.
8. Kitchen, two sprinklers, lint.
9. IVS closet by visitors elevator, one of one sprinkler missing escutcheon plate.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients through the spread of smoke and fire.

Based on observation and staff interview the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.
The facility failed to provide fire protection for a deep fat fryer.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.6 "Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." , Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge".

" NFPA 96, Chapter 7, Section 7-1.2, "Cooking equipment that produces grease-laden vapors (such as but not limited to, deep fat fryers, ranges, griddles, and broilers, woks, tilting skillets, and braising pans) shall be protected by approved extinguishing equipment."

Findings include:

On April 28, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations Manager Life Safety, observed the kitchen exhaust system hood, filters and grease drip tray area have an excessive amount of grease buildup and the staff stated they are only cleaned one time a week. The extinguishing equipment nozzles were out of alignment.

1. Main cook line, three of five filter doors, heavily contaminated with grease, drip trays full.
2. Short order cook line, five of five filters heavily contaminated with grease, drip trays full.
3. Main cook line deep fat fryer, three of six extinguishing equipment nozzles were out of alignment.
4. Short order line deep fat fryer, one of two extinguishing equipment nozzles were out of alignment.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Failing to keep the entire kitchen exhaust hood system clean from grease will cause a fire, which could cause damage to the kitchen and will cause harm to the patients.

Based on Observation the facility failed to separate empty and full medical gas cylinders and provide a sign for medical gas cylinder and keep the oxygen bottles free of combustible materials.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.4. "Medical gas storage and administration areas shall be protected in Accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99, Chapter 4, Section 4-3.5.2.2 (a) (2) "If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

NFPA 101 Life Safety Code 2000, or Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities"NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet..." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

Findings Include:

On April 28th, and 29th, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations Manager Life Safety, observed the following oxygen storage:

1. OR corridor, twenty six EO2 bottles stored in the corridor (twelve E O2 bottle limit), four full and eight empty in the FULL rack. Three full and eleven empty in the Empty rack. All within sixty inches of combustibles.
2. Sixth floor, Private Office, 1 EO2 bottle stored by combustibles.
3. Six east storage room, 12 EO2 bottles stored forty three inches from combustibles.
4. Forth floor, door 40010 by room 441, 6 EO2 bottles stored within sixty inches of combustibles.
5. Second floor, 15 E O2 bottles stored in the corridor. (twelve Limit)
6. Basement, Respiratory Therapy, 7 E O2 bottles stored next to combustibles.
7. Basement, 6 EO2 bottles stored in Medical equipment clean room within sixty inches of combustibles.
8. First floor. 1 EO2 bottle not secure, not stored in a rack.
9. Trauma Cart Room, 1 E O2 empty bottle in the full rack, within 60 inches of combustibles.
10. Sixth floor 5 EO2 bottles room 601 within sixty inches of combustibles.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations Manager Life Safety.

Leaking oxygen could penetrate combustible materials and create an extreme fire hazard, which could cause harm to the patients. In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on record review and Staff interview the facility failed to document the required testing of the emergency generator.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.6 " Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction."

NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 6-4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly.

NFPA 110, Chapter 6, Section 6-4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...."

Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

Findings Include:

On April 24, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations Manager Life Safety, reviewed the generator test records. No documentation of weekly inspections or monthly tests were seen for the following generators dated:

Generator Number One, no load transfer for October 2013.

Generator Number Two, no load transfer for January thru December 2013. Missed four weekly checks, and the seven day interval check was incomplete from October 15, 2013 to October 27, 2013.

Generator Number Three, No documented load transfer times for 2014, no load transfer time documented for; January; June; July; August; September; October; November; and December 2013. Weekly battery check not to exceed seven days were missed or spaced on the following dates; September 23, 2013 to October 8, 2012, October 8, 2012 to October 18, 2012 and September 11, 2012 to September 23, 2012.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Failure to test the emergency generator under load, inspect weekly, and document time from normal power to emergency power could result in harm to patients during emergency system failures.

Based on observation the facility failed to allow access to the electrical equipment/panels, and the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

( NO STORAGE ALLOWED IN THE WORKING SPACE)

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

On April 28th, and 29th, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations Manager Life Safety, observed storage in front of the electrical panel (s) located in the following areas, to include microwaves plugged into power strips:

1. Dirty lift room, storage #4, combustibles within 36 inches of panel MCC 2LAM.
2. Soiled linen six east front of panel 6A.
3. Medical Staff Services, eleven boxes blocking panel 1LK.
4. Admitting Supervisor office, Microwave plugged into power strip.
5. Material Management, microwave plugged into power strip.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Mangaer Life Safety.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients will be harmed if a fire should start because of a delay.
The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

Based on document review the facility failed to test the fire fighter service, monthly, on the elevators.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.3, "Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4. Section 9.4.6 "Elevator Testing." "Elevators shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators."

Findings include:

On April 29, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations Manager Life Safety, reviewed the monthly elevator fire fighter service test documentation. The facility did not test the fire fighter service on a monthly schedule and no documentation of testing was completed for the following:

1. Elevators One and Two, no monthly documentation for June thru December 2013, and March 2014.
2. Elevators Three and Four, no monthly documentation for June thru December 2013, and March 2014.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Fire fighter service is critical during an emergency and failing to test the elevators may cause harm to patients, staff and visitors.

Based on observation the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On April 28, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety, observed penetrations in the corridor walls located in the Heli Pad Riser Room.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat will cause harm to the patients.

Based on observation the facility failed to protect a vertical opening for a service dumbwaiter and elevator.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.1.1 "Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating." Section 8.2.5.2 "Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

Findings Include:

On April 28, and 29th.2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety, observed the Clean Lift SPD door was removed.
Elevator # 7, the three hour rated door would not close.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Failing to provide enclosures between floors will cause harm to patients and staff.

Based on observation the facility failed to fill penetrations in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ? hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On April 28, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety, observed unsealed penetrations in the smoke barrier, located on the sixth floor by room 620.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which will cause harm to patients.

Based on observation the facility failed to maintain self closing doors in a smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Findings include:

On April 28, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety, observed the astragal was removed from the corridor smoke/fire doors between rooms 531 and 533 on five East. When closed the gap measured 1/8th inch and is not smoke tight.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

This installation will allow smoke to contaminate smoke zones not directly effected by the fire, which will cause harm to patients.

Base on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke.

NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On April 28; and 29th, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety, observed the following hazardous area doors:

1. Medical gas storage room by OR number four, no door closing device.
2. CV storage room, rated door impeded by equipment and will not close.
3. Lab, Door from waiting room, door closing device removed and held open with a kick down door impediment.
4. Lab Managers office, door closing device removed and held open with a kick down impediment.
5. Staff locker room contains soiled lab coats, and combustibles, door removed.
6. Kitchen, Dry food and alcohol storage, no door closing device and held open by an impediment.
7. Basement, Vendor storage room, door wedged open.
8. Basement, Medical storage, door removed.
9. Endoscope Decontaminating room, kick down door impediment, door will not close.
10. Health Medical Records, no door closing device.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on observation the facility failed to maintain the battery operated emergency lighting.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.9.1 " Emergency lighting shall be provided in accordance with Section 7.9."Section 7.9.2.4 "Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition."

Findings Include:

On April 28; and 29th, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety, tested the emergency lighting unit located in the Dry Food Storage area. The lighting unit would not light during the test.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Failure to maintain emergency lighting units in proper operating condition will cause harm to the employees/ patients during a power outage.

Based on record review, staff interview, and observation the facility failed to conduct the required fire drills and the facility failed to train the staff on life safety procedures and devices.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions." Chapter 19, Section 19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings include:

On April 24th; 28th; and 29th, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations Manager Life Safety, reviewed Fire Drill documentation, interviewed staff members and observed the following:

1. No Fire Drill reports for first quarter, second shift 2014, and second quarter, second shift 2013.
2. A seven year and a four year employee were interviewed on the second floor surgery work area, they stated never having an actual Fire Drill in the Surgery work area.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on documentation review and observation the facility did not inspect, test and maintain the automatic sprinkler system in accordance with the requirements of the Life Safety Code.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems."

NFPA 25, Water Based Extinguishment Systems, requires monthly, quarterly and annual testing of automatic sprinkler systems. NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material, paint, and physical damage and shall be installed in the proper orientation..."

NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings include:

On April 24th; 28th; and 29th, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations Manager Life Safety, reviewed the automatic sprinkler system documentation. The facility did not have documentation for the quarterly testing of the sprinkler system for second quarter and fourth quarter 2013. Of the four quarterly flow tests there was no documentation of time recorded, on the annual tests conducted by the contracted vendor.
The following observations were made:

1. By OR # 1 alcove, one of one sprinkler, escutcheon plate not smoke tight.
2. Fourth floor west, shower room, sprinkler covered with lint.
3. Door # 21017, Anesthesia Tech Room, gap around the escutcheon plate not smoke tight.
4. Kitchen, Wash tray area, two of two escutcheon plates missing.
5. Short order cook area, one of two sprinklers lint.
6. Lab. one of one sprinkler does not have 18 inches of clearance from book shelf at the BHB TCA station.
7. Health Medical Records, one of two sprinklers no escutcheon plate.
8. Kitchen, two sprinklers, lint.
9. IVS closet by visitors elevator, one of one sprinkler missing escutcheon plate.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients through the spread of smoke and fire.

Based on observation and staff interview the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.
The facility failed to provide fire protection for a deep fat fryer.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.6 "Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." , Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge".

" NFPA 96, Chapter 7, Section 7-1.2, "Cooking equipment that produces grease-laden vapors (such as but not limited to, deep fat fryers, ranges, griddles, and broilers, woks, tilting skillets, and braising pans) shall be protected by approved extinguishing equipment."

Findings include:

On April 28, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations Manager Life Safety, observed the kitchen exhaust system hood, filters and grease drip tray area have an excessive amount of grease buildup and the staff stated they are only cleaned one time a week. The extinguishing equipment nozzles were out of alignment.

1. Main cook line, three of five filter doors, heavily contaminated with grease, drip trays full.
2. Short order cook line, five of five filters heavily contaminated with grease, drip trays full.
3. Main cook line deep fat fryer, three of six extinguishing equipment nozzles were out of alignment.
4. Short order line deep fat fryer, one of two extinguishing equipment nozzles were out of alignment.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Failing to keep the entire kitchen exhaust hood system clean from grease will cause a fire, which could cause damage to the kitchen and will cause harm to the patients.

Based on Observation the facility failed to separate empty and full medical gas cylinders and provide a sign for medical gas cylinder and keep the oxygen bottles free of combustible materials.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.4. "Medical gas storage and administration areas shall be protected in Accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99, Chapter 4, Section 4-3.5.2.2 (a) (2) "If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

NFPA 101 Life Safety Code 2000, or Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities"NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet..." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

Findings Include:

On April 28th, and 29th, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations Manager Life Safety, observed the following oxygen storage:

1. OR corridor, twenty six EO2 bottles stored in the corridor (twelve E O2 bottle limit), four full and eight empty in the FULL rack. Three full and eleven empty in the Empty rack. All within sixty inches of combustibles.
2. Sixth floor, Private Office, 1 EO2 bottle stored by combustibles.
3. Six east storage room, 12 EO2 bottles stored forty three inches from combustibles.
4. Forth floor, door 40010 by room 441, 6 EO2 bottles stored within sixty inches of combustibles.
5. Second floor, 15 E O2 bottles stored in the corridor. (twelve Limit)
6. Basement, Respiratory Therapy, 7 E O2 bottles stored next to combustibles.
7. Basement, 6 EO2 bottles stored in Medical equipment clean room within sixty inches of combustibles.
8. First floor. 1 EO2 bottle not secure, not stored in a rack.
9. Trauma Cart Room, 1 E O2 empty bottle in the full rack, within 60 inches of combustibles.
10. Sixth floor 5 EO2 bottles room 601 within sixty inches of combustibles.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations Manager Life Safety.

Leaking oxygen could penetrate combustible materials and create an extreme fire hazard, which could cause harm to the patients. In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on record review and Staff interview the facility failed to document the required testing of the emergency generator.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.6 " Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction."

NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 6-4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly.

NFPA 110, Chapter 6, Section 6-4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...."

Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

Findings Include:

On April 24, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations Manager Life Safety, reviewed the generator test records. No documentation of weekly inspections or monthly tests were seen for the following generators dated:

Generator Number One, no load transfer for October 2013.

Generator Number Two, no load transfer for January thru December 2013. Missed four weekly checks, and the seven day interval check was incomplete from October 15, 2013 to October 27, 2013.

Generator Number Three, No documented load transfer times for 2014, no load transfer time documented for; January; June; July; August; September; October; November; and December 2013. Weekly battery check not to exceed seven days were missed or spaced on the following dates; September 23, 2013 to October 8, 2012, October 8, 2012 to October 18, 2012 and September 11, 2012 to September 23, 2012.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Failure to test the emergency generator under load, inspect weekly, and document time from normal power to emergency power could result in harm to patients during emergency system failures.

Based on observation the facility failed to allow access to the electrical equipment/panels, and the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

( NO STORAGE ALLOWED IN THE WORKING SPACE)

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

On April 28th, and 29th, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations Manager Life Safety, observed storage in front of the electrical panel (s) located in the following areas, to include microwaves plugged into power strips:

1. Dirty lift room, storage #4, combustibles within 36 inches of panel MCC 2LAM.
2. Soiled linen six east front of panel 6A.
3. Medical Staff Services, eleven boxes blocking panel 1LK.
4. Admitting Supervisor office, Microwave plugged into power strip.
5. Material Management, microwave plugged into power strip.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Mangaer Life Safety.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients will be harmed if a fire should start because of a delay.
The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

Based on document review the facility failed to test the fire fighter service, monthly, on the elevators.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.3, "Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4. Section 9.4.6 "Elevator Testing." "Elevators shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators."

Findings include:

On April 29, 2014, the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Power Plant Operations Manager Life Safety, reviewed the monthly elevator fire fighter service test documentation. The facility did not test the fire fighter service on a monthly schedule and no documentation of testing was completed for the following:

1. Elevators One and Two, no monthly documentation for June thru December 2013, and March 2014.
2. Elevators Three and Four, no monthly documentation for June thru December 2013, and March 2014.

During the exit conference on April 29, 2014, the above findings were again acknowledged by the Director Network Facilities Engineering and the Manager Power Plant Operations, Manager Life Safety.

Fire fighter service is critical during an emergency and failing to test the elevators may cause harm to patients, staff and visitors.