HospitalInspections.org

Based on observation and interview, the facility failed to maintain a two hour fire barrier between the building and nonconforming buildings with which it shares the barrier. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/11/15 at 3:37 PM a tour was conducted of the fourth floor going from north to south, with Staff Q, R, S, and T. At 5:25 PM observation above the drop down ceiling of the two hour fire barrier between the facility and an extended care facility, as seen from the pulmonary rehabilitation room, revealed a one inch annular space over a heating, ventilation and cooling duct.

On 06/11/15 at 5:25 PM in an interview, Staff R confirmed the observation.

2. On 06/11/15 at 5:30 PM observation of the double doors between the facility and the extended care facility revealed, when tested, the double doors did not close and latch.

On 06/11/15 at 5:30 PM in an interview, Staff Q confirmed the observation.

3. On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 2:45 PM observation of the fire doors, separating new from existing construction, at m18, sk-6, revealed, when tested, they did not close and latch.

On 06/12/15 at 2:45 PM in an interview, Staff Q confirmed the observation.

4. On 06/12/15 at 2:56 PM observation above the drop down ceiling of the two hour rated fire barrier that separates new from existing construction, at L18, sk-6, revealed two copper lines with an annular space surrounding both and a conduit leading from the barrier to a junction with two missing knock-out.

On 06/12/15 at 2:56 PM in an interview, Staff R confirmed the observations.

5. On 06/12/15 at 3:00 PM observation above the drop down ceiling of the two hour rated fire barrier that separates new from existing construction at L18, sk-6, revealed a one inch conduit traveling from the barrier to an open junction box.

On 06/12/15 at 3:00 PM in an interview, Staff R confirmed the observation.

Based on record review and observation, the facility failed to provide construction of a type to accommodate not more than one story in a fully sprinklered building. Census at the time of survey was 6,879 cases performed in the last year.

Findings include

On 06/16/15 a review of the building ' s occupancy permit, dated 09/30/97, revealed it had a construction type of II(000).

Observation of the building on 06/10/15 revealed it had two stories with a radiology department and physician office spaces.

Based on observation and interview, the facility failed to ensure its corridor doors with gaps had astragals, rabbets or bevels covering the gaps and failed to ensure all latching hardware on corridor doors functioned. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/08/15 at 2:41 PM a tour was conducted of the tenth floor of the Renaissance building with Staff Q, R, and S. On 06/08/15 at 3:20 PM corridor doors to patient rooms 1006, 1008, 1003, and 1005 were observed to consist of two leafs. Observation of these doors at each of these rooms revealed there was a gap between the leaves of greater than 1/8 of an inch without an astragal, rabbet, or bevel protecting the opening.

On 06/08/15 at 2:41 PM in an interview Staff R and S confirmed the observation.

2. On 06/09/15 at 9:20 AM the tour of the 10th floor of the Renaissance building resumed with Staff Q, R, and S. On 06/09/15 at 9:30 AM observation of corridor doors to patient room 1015 revealed they consisted of two leafs. Observation of these doors revealed there was a gap between the leaves of greater than 1/8 of an inch without an astragal, rabbet, or bevel protecting the opening.

On 06/09/15 at 9:30 AM in an interview, Staff Q and R confirmed the observation.

3. On 06/09/15 at 9:30 AM observation of corridor doors to patient rooms 1013 and 1014 revealed they consisted of two leafs with latching hardware that, when tested, did not positively latch.

On 06/09/15 at 9:30 AM in an interview, Staff Q and R confirmed the observation.

4. On 06/09/15 at 9:41 AM observation of the corridor to the housekeeping closet by stair 01 revealed it did not close and positively latch.

On 06/09/15 at 9:41 AM in an interview, Staff Q and R confirmed the observation.

5. On 06/09/15 at 10:10 AM observation of the corridor door on the soiled utility room (two doors down from the aforementioned housekeeping closet) revealed it did not close and latch.

On 06/09/15 at 10:10 AM in an interview, Staff Q and R confirmed the observation.

6. On 06/09/15 at 10:41 AM observation of the corridor door to soiled utility room 1090 on the east side of Renaissance revealed the door did not close and latch when tested.

On 06/09/15 at 10:41 AM in an interview, Staff Q and R confirmed the observation.

7. On 06/15/15 at 1:36 PM a tour was taken of the seventh floor with Staff Q, R, and S. At 1:45 PM observation of the door to a clean utility room protecting the corridor at m22 revealed its latching hardware did not close and latch the door.

On 06/15/15 at 1:45 PM in an interview, Staff S confirmed the observation.

8. On 06/15/15 at 3:43 PM a tour was taken of the third floor with Staff Q, R, and S. At 4:05 PM observation of the doors to patient rooms 1321, 1329, and 1335, revealed they each had gaps of greater than one quarter of an inch.

On 06/15/15 at 4:05 PM in an interview, Staff S confirmed the observation.

9. On 06/15/15 at 4:41 PM a tour was taken of the second floor with Staff Q, R, and S. At 4:53 PM observation of corridor doors to patient room 1222 revealed they had latching hardware, which, when tested, did not completely close the doors.

On 06/15/15 at 4:53 PM in an interview, Staff R confirmed the observation.

10. On 06/15/15 at 5:01 PM observation of the corridor door to patient room 1207 revealed it was on a self closer that was held open with a wedge.

On 06/15/15 at 5:01 PM Staff W stated he/she places the wedge there to keep the door constantly open so that he/she can see her/his patient.

Based on observation and interview, the facility failed to ensure its corridor doors with gaps had astragals, rabbets or bevels covering the gaps. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/10/15 at 8:40 AM a tour was taken of the eighth floor of the Legacy building with Staff Q, R, S and T. On 06/10/15 at 8:48 AM patient room corridor doors to rooms 874 and 875 were observed to each have a gap of one-quarter of an inch.

On 06/10/15 at 8:48 AM in an interview, Staff T confirmed the observation.

2. On 06/10/15 at 12:00 PM a tour was conducted of the seventh floor going from north to south with Staff Q, R, S, and T. At 3:18 PM observation of the door protecting the corridor from the waiting room at h11, sk-2, revealed it had a self closer and latching hardware as means for keeping the door closed. However, when tested the latching hardware was observed to not completely work.

On 06/10/15 at 3:18 PM in an interview, Staff R confirmed the observation.

3. On 06/10/15 at 3:34 PM observation of the door protecting the corridor from a patient equipment room revealed it had latching hardware as a means for keeping the door closed. However, when tested, the door was observed to not completely work.

On 06/10/15 at 3:34 PM in an interview, Staff R confirmed the observation.

4. On 06/10/15 at 5:01 PM observation of the double doors protecting the corridor from the dumb waiter room revealed the door had latching hardware as means for keeping the doors closed. However, upon testing, the latching hardware did not completely work.

On 06/10/15 at 5:01 PM in an interview, Staff Q confirmed the observation.

5. On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 2:36 PM observation of the door protecting the corridor from the room at L16 revealed it had latching hardware used as means suitable for keeping it closed. When tested, the latching hardware did not completely close the door.

On 06/12/15 at 2:36 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to maintain a two hour fire rating on all shafts and chutes. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/09/15 at 9:20 AM a tour of the 10th floor of the Renaissance building was taken with Staff Q, R, and S. On 06/09/15 at 10:33 AM observation of the two hour protective construction around shaft 04 as seen from the northern hall, revealed a one foot by one foot square cut into the drywall, approximately one foot away where the words " 2HR RATING " are stenciled onto the wall.

On 06/09/15 at 10:33 AM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to maintain the rating of the barriers protecting its elevator shafts, chutes, and other vertical openings between floors. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/09/15 at 11:58 AM observation of the trash chute on the ninth in the north north (sic) building revealed the door ' s latching hardware did not function to either completely close or latch the door. Review of the drawing revealed it was protected with two hour fire rated construction.

On 06/09/15 at 11:58 AM in an interview, Staff Q confirmed the finding.

2. On 06/09/15 at 12:00 PM observation of the trash chute on the eighth floor of the north north building revealed its door had three signs affixed to it: " Do not Use, " " Please close chute door, " and " thanks. " Review of the drawing revealed the trash chute was protected with two hour fire rated construction. Observation of the closing of the chute door revealed its latching hardware did not function to either completely close or latch the door.

On 06/09/15 at 12:00 PM in an interview, Staff Q confirmed the observation.

3. On 06/09/15 at 12:05 PM observation of the trash chute on the seventh floor of the north north building revealed its door had a sign on it that said " do not use. " Review of the drawing revealed the trash chute was protected with two hour construction. Observation of the closing of the chute door revealed its latching hardware did not function to either completely close or latch the door.

On 06/09/15 at 12:05 PM in an interview, Staff Q confirmed the observation.

4. On 06/09/15 at 1:38 PM observation of the trash chute discharge in room 1961 revealed the door was bent so that, when tested, the door did not completely close off the chute.

On 06/09/15 at 1:38 PM in an interview, Staff Q explained staff will drop garbage down the chute when the chute door is closed. Then, when the trash hits the door, the door gets bent.

5. On 06/09/15 at 2:35 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft, as seen from the utility room at grid position H-13, revealed four smooth conduits going into the rated barrier surrounded by a six inch by six inch open square.

On 06/09/15 at 2:35 PM in an interview, Staff R confirmed the observation.

On 06/09/15 at 5:00 PM a tour was taken of the eighth floor of the Legacy building, starting with the north north building and traveling south to the south building. The tour was taken with Staff Q, R, and S.

6. On 06/09/15 at 5:24 PM observation above the drop down ceiling of the two hour rated construction protecting an unused elevator shaft, as seen from the men ' s bathroom, revealed two one inch wide penetrations.

On 06/09/15 at 5:24 PM in an interview, Staff R confirmed the observation.

7. On 06/10/15 at 8:40 AM a tour was taken of the eighth floor of the Legacy building with Staff Q, R, S and T. On 06/10/15 at 10:58 AM observation above the drop down ceiling of the two protective construction surrounding the southern bank of elevators in the south elevator lobby revealed a half inch open conduit running from the barrier.

On 06/10/15 at 10:58 AM in an interview, Staff R confirmed the observation.

8. On 06/10/15 at 11:06 AM observation of the doors protecting the dumb waiters in sk-1 did not reveal a fire/smoke rating on the doors.

On 06/10/15 at 11:06 AM in an interview, Staff Q confirmed the observation, and said each set of dumb waiter doors in the building (floors one through nine) would need to be evaluated.

9. On 06/10/15 at 1:23 PM observation above the drop down ceiling of the two hour rated barrier protecting a future elevator shaft as seen from the elevator lobby revealed a one inch wide hole in the concrete.

On 06/10/15 at 1:23 PM in an interview, Staff R confirmed the observation.

10. On 06/10/15 at 1:38 PM observation above the drop down ceiling of the two hour rated barrier protecting the future elevator bank as seen from the men ' s toilet revealed two one inch wide holes.

On 06/10/15 at 1:38 PM in an interview, Staff R confirmed the observation.

11. On 06/10/15 at 12:00 PM a tour was conducted of the seventh floor going from north to south with Staff Q, R, S, and T. At 2:15 PM observation above the drop down ceiling of the two hour barrier protecting the shaft at h13, sk-2, as seen from hazardous area room next to an office, revealed an annular space around a sprinkler line.

On 06/10/15 at 2:15 PM in an interview, Staff Q confirmed the observation.

12. On 06/10/15 at 2:55 PM observation of the floor at eastern nursing station of the medical intensive care unit revealed two open half inch conduits that communicated between the seventh and sixth floors thereby creating a vertical opening between the floors. The conduits had blue wires traveling through them.

On 06/10/15 at 2:55 PM Staff Q confirmed the observation.

13. On 06/10/15 at 3:00 PM observation of the floor at the western nursing station of the medical intensive care unit revealed a vertical opening between the seventh and sixth floors created by a half inch conduit.

On 06/10/15 at 3:00 PM in an interview, Staff Q confirmed the observation.

14. On 06/10/15 at 3:12 PM observation above the drop down ceiling of the two hour barrier protecting a shaft at h13, sk-2, as seen from the clean supply room, revealed a three inch open tube piercing the barrier and a half inch conduit traveling to an open junction box.

On 06/10/15 at 3:12 PM in an interview, Staff R confirmed the observations.

15. On 06/10/15 at 5:18 PM observation above the drop down ceiling of the two hour rated barrier surrounding a shaft, as seen from the impact coordinator ' s office, revealed a one inch wide penetration and a penetration created by two side-by-side one inch conduits.

On 06/10/15 at 5:18 PM in an interview, Staff R confirmed the observation.

16. On 06/11/15 at 8:30 AM a tour was taken of the sixth floor going from north to south with Staff Q, R, S and T. At 10:06 AM observation of the two hour rated barrier protecting a shaft, as seen from the family waiting area, revealed two half inch open conduits to an open junction box.

On 06/11/15 at 10:06 AM in an interview, Staff R confirmed the observation.

17. On 06/11/15 at 11:06 AM observation of the two hour barrier protecting a shaft, as seen from office space 654, revealed a one inch conduit with a broken coupling creating a penetration to the barrier.

On 06/11/15 at 11:06 AM in an interview, Staff R confirmed the observation.

18. On 06/11/15 at 11:17 AM a tour was conducted of the fifth floor going from north to south, with Staff Q, R, S, and T. At 1:08 PM observation above the drop down ceiling of the two hour barrier protecting a shaft, as seen in room 5409, revealed an annular space around a one inch smooth conduit.

On 06/11/15 at 1:08 PM in an interview, Staff Q confirmed the observation.

19. On 06/11/15 at 3:37 PM a tour was conducted of the fourth floor going from north to south with Staff Q, R, S, and T. At 3:45 PM observation above the drop down ceiling of the two hour barrier protecting a future elevator shaft as seen from the lobby revealed two one inch wide penetrations.

On 06/11/15 at 3:45 PM in an interview, Staff R confirmed the observation.

20. On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 3:08 PM observation above the drop down ceiling of the two hour barrier protecting a future elevator bank revealed two one inch wide holes into the barrier.

On 06/12/15 at 3:08 PM in an interview, Staff R confirmed the observation.

21. On 06/12/15 at 3:12 PM observation above the drop down ceiling of the two hour barrier protecting a shaft at j19 revealed a one inch PVC pipe with an annular space.

On 06/12/15 at 3:12 PM in an interview, Staff R confirmed the observation.

22. On 06/12/15 at 3:40 PM a tour was taken of the operating room suite on the second floor with Staff Q, R, and S. At 3:55 PM observation of the trash and soiled linen chute doors in a biohazard room next to an office revealed they were unrated and their latching hardware was not working.

On 06/12/15 at 3:55 PM in an interview, Staff Q confirmed the observation.

23. On 06/15/15 at 9:00 AM the tour of the second floor resumed with Staff Q, R, and S. At 9:37 AM observation of the chute located at j19, sk-4, revealed the latching hardware to the chute did not function, and the room containing the chute did not lock.

On 06/15/15 at 9:37 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure access to exits is marked by approved, readily visible signs. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/10/15 at 8:40 AM a tour was taken of the eighth floor of the Legacy building with Staff Q, R, S and T. On 06/10/15 at 9:30 AM observation of the southerly path of egress from the psychiatric unit to stair A revealed a set of double doors used for traffic control visually blocking the exit sign leading to stair A.

On 06/10/15 at 9:30 AM in an interview, Staff Q confirmed the observation.

On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 1:54 PM observation of exit stairwell D as seen from the public corridor revealed it did not have an exit sign.

On 06/12/15 at 1:54 PM in an interview, Staff Q confirmed the observation.

On 06/15/15 at 9:00 AM the tour of the second floor resumed with Staff Q, R, and S. At 9:45 AM a second path of egress from the endoscopy suites either out of the northwest doors or the northern doors were not marked.

On 06/15/15 at 9:45 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure access to exits is marked by approved, readily visible signs. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/16/15 at 11:28 AM a tour was taken of the unit with Staff Q and R. Observation of access to exits revealed a stairway which was not marked with a readily visible sign.

On 06/16/15 at 11:28 AM in an interview, Staff Q confirmed the observation.

Based on observation and staff interview it was determined that the facility failed to have a smoke barrier to form at least two smoke compartments on each floor used by inpatients for sleeping or treatment. This had a potential to affect all staff and patients within this facility. Census at the time of survey was 6,879 cases performed in the last year.

Findings:

During the tour, on 06/10/15 form 11:50 Am till 3:10 PM, of the facility, review of the life safety floor plans, and staff interview it was determined that the facility did not have the required smoke barrier to divide the floor into two smoke compartments. This was confirmed by Staff DD at the time of discovery.

Based on observation and interview, the facility failed to ensure the rating of its smoke barriers. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/08/15 at 2:41 PM a tour was conducted of the tenth floor of the Renaissance building with Staff Q, R, and S. Observation above the drop down ceiling over smoke barrier doors H building, Floor 10 East revealed two half-inch corrugated conduits open to air, and a cable tray with openings between it and the barrier.

On 06/08/15 at 2:41 PM in an interview, Staff R confirmed the finding.

On 06/09/15 at 9:20 AM the tour of the 10th floor of the Renaissance building resumed with Staff Q, R, and S.

2. On 06/09/15 at 9:25 AM observation above the drop down ceiling over smoke doors H building, Floor 10 West revealed a cable tray in the smoke barrier with gaps between it and the barrier.

On 06/09/15 at 9:25 AM in an interview, Staff R confirmed the finding.

3. On 06/15/15 at 2:33 PM a tour was taken of the fifth floor with Staff Q, R, and S. At 2:54 PM observation of the two hour rated barrier in the clean supply room across from patient room 1512 revealed at the corner where an automated medication dispenser is located a one inch open corrugated conduit traveling from the barrier and having red wires traveling out of it.

On 06/15/15 at2:54 PM in an interview, Staff R confirmed the observation.

4. On 06/15/15 at 3:15 PM observation above the drop down ceiling of the one hour rated barrier over the door to the soiled utility room across from patient room 1524 revealed three open one inch conduits.

On 06/15/15 at 3:15 PM in an interview, Staff R confirmed the observation.

5. On 06/15/15 at 3:18 PM observation above the drop down ceiling of the smoke barrier over the doors labeled H building, floor five east, revealed three open one inch conduits holding grey wiring.

On 06/15/15 at 3:18 PM in an interview, Staff R confirmed the observation.

6. On 06/15/15 at 3:22 PM observation above the drop down ceiling of the smoke barrier perpendicular to the doors labeled H building, floor five east revealed two open one inch conduits traveling from it, with one holding grey wires and the other holding a blue and grey wire.

On 06/15/15 at 3:22 PM in an interview, Staff R confirmed the observation.

7. On 06/15/15 at 3:25 PM observation above the drop down ceiling of the smoke barrier outside the consult room near doors labeled floor 5 east, revealed four open conduits with the annular space surrounding them taking the form of a rectangle.

On 06/15/15 at 3:25 PM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to maintain the rating of its smoke barriers. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/09/15 at 1:48 PM a tour was taken of the ninth floor of the Legacy building, starting with the north north building and traveling south to the south building. The tour was taken with Staff Q, R, and S.

1.On 06/09/15 at 2:24 PM observation above the drop down ceiling of the smoke barrier over smoke doors C building floor 9 north, revealed a two inch by two inch penetration.

On 06/09/15 at 2:24 PM, Staff R confirmed the observation.

2. On 06/09/15 at 2:28 PM observation above the drop down ceiling of the smoke barrier between rooms 968 and 969 revealed a two inch metal conduit with a left sided annular space.

On 06/09/15 at 2:28 PM in an interview, Staff R confirmed the observation.

3. On 06/09/15 3:37 PM observation above the drop down ceiling of the northern smoke barrier of the cart receiving room revealed a smooth conduit traveling from the barrier to an open junction box.

On 06/09/15 at 3:37 PM in an interview, Staff S confirmed the observation.

4. On 06/09/15 at 4:15 PM observation of the smoke barrier in room 981 revealed conduit traveling from the barrier to a junction box with a missing one inch knock-out.

On 06/09/15 at 4:15 PM in an interview, Staff S confirmed the observation.

5. On 06/10/15 at 8:40 AM a tour was taken of the eighth floor of the Legacy building with Staff Q, R, S and T. On 06/10/15 at 9:06 AM observation above the drop down ceiling of the smoke barrier running east/west along the northern wall of a staff room located at grid position H-13, sk-2, revealed a one inch flex duct with an annular space.

On 06/10/15 at 9:06 AM in an interview, Staff Q confirmed the observation.

6. On 06/10/15 at 9:45 AM a review of the facility ' s life safety code drawings revealed a smoke barrier that traveled from the northeast to the southwest, linking a staff room to a lounge (and the outside wall), and crossing a corridor in the process. The drawing shows the barrier to be located between grid positions a12 and a13. Observation above the drop down ceiling did not reveal this barrier, and one could not be located that crossed the corridor to the outside wall on the southwest side of the building.

On 06/10/15 at 9:45 AM in an interview, Staff Q confirmed the observation.

7. On 06/10/15 at 11:18 AM observation above the drop down ceiling of the smoke barrier over the double doors leading to the south wing of section sk-1 revealed an open junction box with a half inch open conduit that traveled through the smoke barrier.

On 06/10/15 at 11:18 AM in an interview, Staff R confirmed the observation.

8. On 06/10/15 at 12:00 PM a tour was conducted of the seventh floor going from north to south with Staff Q, R, S, and T. At 2:05 PM observation above the drop down ceiling of the smoke barrier between the two toilets in sk-3 revealed a one inch conduit traveling through the barrier to an open junction box. The conduit holds an orange wire.

On 06/10/15 at 2:05 PM in an interview, Staff R confirmed the observation.

9. On 06/10/15 at 3:25 PM observation above the drop down ceiling of the smoke barrier over the double doors near the south elevator lobby revealed a one inch open conduit on the east side.

On 06/10/15 at 3:25 PM in an interview, Staff R confirmed the observation.

10. On 06/11/15 at 8:30 AM a tour was taken of the sixth floor going from north to south with Staff Q, R, S and T. At 9:11 AM observation above the drop down ceiling of the smoke barrier over the double doors near patient room 668 revealed a three inch open conduit through the barrier.

On 06/11/15 at 9:11 AM in an interview, Staff R confirmed the observation.

11. On 06/11/15a t 9:42 AM observation above the drop down ceiling of the smoke barrier as seen from patient room 680 revealed a half inch smooth conduit traveling from the barrier to an open junction box.

On 06/11/15 at 9:42 AM in an interview, Staff R confirmed the observation.

12. On 06/11/15 at 10:21 AM double doors were observed in the smoke barrier perpendicular to the dumb waiter receiving area and staff lounge. The doors were observed to have a coordinator that, when tested, did not work.

On 06/11/15 at 10:21 AM in an interview, Staff S confirmed the observation.

13. On 06/11/15 at 10:31 AM double doors were observed in the smoke barrier between the dumb waiter receiving area and the corridor. The doors were observed to have a coordinator that, when tested, did not work.

On 06/11/15 at 10:31 am in an interview, Staff S confirmed the observation.

14. On 06/11/15 at 11:17 AM a tour was conducted of the fifth floor going from north to south, with Staff Q, R, S, and T. At 2:42 PM observation of the smoke barrier as seen from the family waiting area in the pediatric outpatient suite, revealed a one inch conduit piercing the barrier and traveling to an open junction box.

On 06/11/15 at 2:42 PM in an interview, Staff R confirmed the observation.

15.On 06/11/15 at 3:37 PM a tour was conducted of the fourth floor going from north to south, with Staff Q, R, S, and T. At 4:15 PM observation of the smoke barrier above the drop down ceiling over the double doors perpendicular to patient rooms 467 and 466 revealed blue wires pierced the barrier with an annular space.

On 06/11/15 at 4:15 PM in an interview, Staff R confirmed the observation.

16. On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 10:53 AM observation above the drop down ceiling of the smoke barrier over the door perpendicular to the nurse midwife area, located at g6, sk-2, revealed a conduit penetrating through the barrier and leading to an open junction box, and another unstopped conduit with a red wire traveling out of it.

On 06/12/15 at 10:53 AM in an interview, Staff R confirmed the observation.

17. On 06/12/15 at 12:00 PM observation above the drop down ceiling of the smoke barrier perpendicular to the electrical room door near n10, sk4, revealed a sprinkler line in a metal sleeve with an annular space between the sleeve and the sprinkler line.

On 06/12/15 at 12:00 PM in an interview, Staff R confirmed the observation.

18. On 06/12/15 at 1:29 PM observation above the drop down ceiling of the smoke barrier perpendicular to the vending machines at m10 revealed an open half inch corrugated conduit with red and grey wires traveling out of it.

On 06/12/15 at 1:29 PM in an interview, Staff R confirmed the observation.

19. On 06/12/15 at 2:00 PM observation of the smoke barrier in the informatics office at o13, sk-4, revealed a one inch opening with two blue wires traveling out of it.

On 06/12/15 at 2:00 PM in an interview, Staff R confirmed the observation.

20. On 06/12/15 at 3:40 PM a tour was taken of the operating room suite on the second floor with Staff Q, R, and S. At 4:18 PM observation of the double doors in the smoke barrier that runs along the perimeter of the dumb waiter room revealed the doors had latching hardware that when tested did not close and latch the doors.

On 06/12/15 at 4:18 PM in an interview, Staff S confirmed the observation.

21. On 06/15/15 at 9:00 AM the tour of the second floor resumed with Staff Q, R, and S. At 9:18 AM observation above the drop down ceiling of the western smoke barrier in the endoscopy suite revealed an open half inch conduit and a sprinkler line with an annular space.

On 06/15/15 9:18 AM in an interview, Staff R confirmed the observation.

22. On 06/15/15 at 10:02 AM observation of the smoke barrier above the drop down ceiling in the office located at L19, sk6, revealed a half inch open conduit with a blue wire running from it, and a flex conduit with an annular space around it.

On 06/15/15 at 10:02 AM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to ensure all doors in its smoke barriers completely closed and shut and that gaps were covered by rabbets, bevels, or astragals. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/08/15 at 2:41 PM a tour was conducted of the tenth floor of the Renaissance building with Staff Q, R, and S. On 06/08/15 at 3:54 PM observation of smoke barrier doors H, Floor 10 East revealed they did not have rabbets, bevels, or astragals at their meeting edges, which had a gap of one quarter of an inch.

On 06/08/15 at 3:54 PM in an interview, Staff Q and R confirmed the observation.

2. On 06/15/15 at 1:36 PM a tour was taken of the seventh floor with Staff Q, R, and S. At 1:52 PM observation of smoke doors, H building, Floor 7 east, revealed, when tested, the doors did not close and shut.

On 06/15/15 at 1:52 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure each door in its smoke barrier closed completely. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 10:40 AM observation of the double doors in the smoke barrier perpendicular to the women ' s locker room at g8, sk-2, revealed they had a self closer and latching hardware. Upon testing, the latching hardware was observed not to completely close the doors.

On 06/12/15 at 10:40 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure each hazardous area had a self closing door. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/15/15 at 2:33 PM a tour was taken of the fifth floor with Staff Q, R, and S. At 2:51 PM observation of a pharmacist ' s office revealed it was packed with combustible items, specifically, texts and multiple boxes of paper such that the only avenue of travel was an alley from the door to the chair at the desk. Representing a hazard greater than that found in patient rooms, this room did not have a door with a self closer.

On 06/15/15 at 2:51 PM in an interview, Staff Q, R, and S confirmed the observation.

2. On 06/15/15 at 3:36 PM observation of the doors to a file room containing combustibles greater than that found in patient rooms revealed the door was not on a self closer.

On 06/15/15 at 3:36 PM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to ensure each hazardous area had a self closing door. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 9:18 AM observation of a utility room at f13, sk-2, revealed the room to hold over 40 boxes of paperwork and thus present a level of hazard greater than that of patient rooms. Observation of the door to this room revealed it was not on a self-closer.

On 06/12/15 at 9:18 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to maintain the rating of its barriers protecting stairways and other exit components. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/15/15 at 1:36 PM a tour was taken of the seventh floor with Staff Q, R, and S. At 2:01 PM observation above the drop down ceiling of the two hour barrier protecting stair 3 revealed a one inch penetration with a red wire traveling out of it.

On 06/15/15 at 2:01 PM in an interview, Staff R confirmed the observation.

2. On 06/15/15 at 2:33 PM a tour was taken of the fifth floor with Staff Q, R, and S. At 2:33 PM observation above the drop down ceiling of the two hour rating protecting stair 2 revealed three conduits open to air with grey wires traveling through them. The conduit was observed to come from the barrier.

On 06/15/15 at 2:33 PM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to maintain the rating of its barriers protecting stairways and other exit components. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/09/15 at 1:48 PM a tour was taken of the ninth floor of the Legacy building, starting with the north north building and traveling south to the south building. The tour was taken with Staff Q, R, and S.

1.On 06/09/15 at 1:56 PM observation above the drop down ceiling of the two hour rated construction near stair 2 and an elevator shaft revealed a one inch hole more than three inches deep.

On 06/09/15 at 1:56 PM in an interview, Staff R confirmed the observation.

2. On 06/09/15 at 2:00 PM observation above the drop down ceiling of the two hour rated construction protecting stair 2 revealed four one inch holes greater than three inches deep. The holes formed a constellation the shape of rectangle.

On 06/09/15 at 2:00 PM in an interview, Staff S confirmed the observation.

3. On 06/09/15 at 2:05 PM observation above the drop down ceiling of the two hour rated construction protecting a mechanical shaft next to stair 2 revealed another one inch hole and three one inch smooth conduits with annular spaces.

On 06/09/15 at 2:05 PM in an interview, Staff S confirmed the observation.

On 06/09/15 at 5:00 PM a tour was taken of the eighth floor of the Legacy building, starting with the north north building and traveling south to the south building. The tour was taken with Staff Q, R, and S.

4. On 06/09/15 at 5:10 PM observation above the drop down ceiling of the two hour rated construction protecting stair 2 revealed to the right of its door, two one inch holes.

On 06/09/15 at 5:10 PM in an interview, Staff R confirmed the observation.

5. On 06/09/15 at 5:15 PM observation above the drop down ceiling of the two hour rated construction protecting the elevator shaft next to stair 2 revealed two one inch holes, with one above the other.

On 06/09/15 at 5:15 PM in an interview, Staff R confirmed the observation.

6. On 06/10/15 at 8:40 AM the tour of the eighth floor of the Legacy building resumed with Staff Q, R, S and T. On 06/10/15 at 8:43 AM observation above the drop down ceiling of the two hour rated construction protecting the eight north stairway revealed a one inch conduit traveling from the stairway to an open junction box.

On 06/10/15 at 8:40 AM in an interview, Staff R confirmed the observation.

7. On 06/10/15 at 12:00 PM a tour of the seventh floor of the legacy building was conducted from north to south with Staff Q, R, S, and T. Observation of the two protective construction of stair number 2, as seen from the corridor, revealed a half inch conduit running into the barrier with an annular space.

On 06/10/15 at 12:00 PM in an interview, Staff Q confirmed the observation.

8. On 06/10/15 at 2:35 PM observation above the drop down ceiling of the two hour barrier surrounding the exit stairway in the medical intensive care unit revealed an annular space surrounding a one inch smooth conduit.

On 06/10/15 at 2:35 PM in an interview, Staff R confirmed the observation.

9. On 06/10/15 at 5:31 PM observation of the door protecting the stairway across from patient room 710 revealed it was not rated.

On 06/10/15 at 5:31 PM in an interview, Staff S confirmed the observation.

10. On 06/11/15 at 8:30 AM a tour was taken of the sixth floor going from north to south with Staff Q, R, S and T. On 06/11/15 at 8:48 AM observation of the communication room next to a trash chute room, located in the north north building, revealed two orange conduits piercing the floor to the ceiling below, creating a vertical opening between the sixth and fifth floors.

On 06/11/15 at 8:48 AM in an interview, Staff Q confirmed the observation.

11. On 06/11/15 at 10:57 AM observation above the drop down ceiling of the two hour barrier protecting the exit stairway across from patient room 606 revealed the barrier was pierced by a one inch open conduit.

On 06/11/15 at 10:57 AM in an interview, Staff R confirmed the observation.

12. On 06/11/15 at 11:17 AM a tour was conducted of the fifth floor going from north to south, with Staff Q, R, S, and T. At 11:24 AM observation above the drop down ceiling, as seen from the corridor, of exit stair 2, revealed a one inch open conduit traveling through the barrier.

On 06/11/15 at 11:24 AM in an interview, Staff R confirmed the observation.

13. On 06/11/15 at 2:22 PM observation above the drop down ceiling of the two hour rated barrier protecting the stairway at h8 revealed a two to three inch annular space around a one inch smooth conduit.

On 06/11/15 at 2:22 PM in an interview, Staff R confirmed the observation.


14. On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 10:30 AM observation above the drop down ceiling of the two hour rated fire barrier located outside stair A revealed one inch by a half-inch square penetration and a two inch by two inch square penetration with three small conduits running out of it.

On 06/12/15 at 10:30 AM in an interview, Staff R confirmed the observation.

15. On 06/15/15 at 11:00 AM a tour was taken of the first floor with Staff Q, R, and S. At 11:55 AM observation of the exit passageway protected with a two hour fire barrier revealed it contained a door across from elevator 12 in a room labeled west room. The door was observed to have a rating of 45 minutes.

On 06/15/15 at 11:55 AM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to comply with Chapter 7 of National Fire Protection Association 101, 2000 edition, and 7.2.1.6, special locking arrangements for locked doors in the psychiatric unit. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/10/15 at 8:40 AM a tour was taken of the eighth floor of the Legacy building with Staff Q, R, S and T. On 06/10/15 at 9:30 AM double doors leading to the psychiatric unit were observed to be locked on the egress side.

On 06/10/15 at 9:30 AM Staff Q explained the doors would automatically unlock when the fire alarm system becomes activated.

On 06/10/15 at 9:30 AM and again at 11:45 AM the fire alarm system was activated and at each time the doors were not observed to unlock from the egress side.
On 06/10/15 at 9:30 AM and again at 11:45 AM Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure emergency lighting was provided in accordance with National Fire Protection Association 101, 7.9. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/12/15 at 3:40 PM a tour was taken of the operating room suite on the second floor with Staff Q, R, and S. Observation of operating rooms 38, 39, and 40 revealed they did have battery powered emergency lighting. Observation of the battery powered emergency lighting in operating room 39 revealed they did not work.

On 06/12/15 at 3:40 PM in an interview, Staff Q confirmed the observation saying the battery operated lights had not been tested monthly or yearly.

Based on observation and staff interview it was determined that the facility failed to provide adequate Exit lights to show the path of egress. This had a potential to affect all staff and patients within the building.

Finding:

During the tour of the facility on 06/11/15 it was found that the facility failed to provided the required exit signs to provide direction of the path of egress from the first floor physical therapy rehab room 101. The tour revealed that when standing in the short corridor to the treatments rooms you could not see an Exit signs to either of the two exits. This was confirmed at the time of discovery by Staff CC.

During the tour of the Athletic club dressing rooms it was determined that there were only two exit lights and they were not visible from the locker room or shower stalls. Further, it was found that at the bottom of the stairs leading from the track there was no sign providing direction to the exits. Also, from the track lanes the signs of the exits could not be visualized from the corners of the track. This was confirmed at the time of discovery by Staff CC.

Based on document review and staff interview it was determined that the facility failed to include the physicians in the fire drill process. Based on document review and staff interview it was determined that the facility failed to include the physicians in the fire drill process.

Findings include:

On 06/16/15 a review of the facility ' s fire drill documentation was completed. A review of the drills revealed not one physician participated in the drills.

On 06/16/15 at 4:00 PM in an interview, Staff Q confirmed that of 850 physicians on staff, there wasn ' t evidence any had participated in any fire drills.

Based on document review and staff interview it was determined that the facility failed to include the physicians in the fire drill process. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/16/15 a review of the facility ' s fire drill documentation was completed. A review of the drills revealed not one physician participated in the drills.

On 06/16/15 at 4:00 PM in an interview, Staff Q confirmed that of 850 physicians on staff, there wasn ' t evidence any had participated in any fire drills.

Based on document review and staff interview it was determined that the facility failed to include the physicians in the fire drill process. This had a potential to affect all staff and patients within this facility. Census at the time of survey was 12,773 cases performed in the last year.

Findings:

The document review was done on 06/08/15 at 1:30 PM and failed to reveal that the physicians participated in the drill. 21.7.2.3 refers that ALL staff shall be instructed in the use of and response to fire alarms. During an interview with Staff CC, at 1:46 PM on 06/08/15, confirmed that the physicians did not participate in the drills. Staff CC, confirmed the find at the time of discover.

Based on document review and staff interview it was determined that the facility failed to include the physicians in the fire drill process. This had a potential to affect all staff and patients within this facility. Census at the time of survey was 6,879 cases performed in the last year.

Findings:

The document review was done on 06/15/15 at 11:30 AM and failed to reveal that the drills were performed at unexpected times and for all shifts and that the physicians did not participated in the drill. 21.7.2.3 refers that ALL staff shall be instructed in the use of and response to fire alarms. During an interview with Staff EE, at 11:35 PM on 06/09/15, confirmed that the physicians did not participate in the drills. Staff EE, confirmed the find at the time of discover.

Based on record review and interview, the facility failed to ensure its fire alarm system was maintained in accordance with National Fire Protection Association 72. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.


Findings include:

On 06/16/15 a review of the facility ' s fire alarm documentation was completed. The review revealed the system was tested on 10/31/14 and the test showed a battery in the basement failed. The review did not reveal where the battery was changed or otherwise rectified.

On 06/16/15 at 4:00 PM in an interview, Staff X confirmed he/she could not show where the battery had been replaced.

Based on observation and interview, the facility failed to ensure its sprinklers were tested in accordance with National Fire Protection Association 25, 9-3.4.2, 1999 edition. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/16/15 a review of the building fire sprinkler system documentation was completed on 06/16/15. The review did not reveal where an annual main drain test at the riser was conducted.

On 06/16/15 at 4:00 PM in an interview, Staff X confirmed the main drain test had not been performed annually.

Based on observation and interview, the facility failed to have its automatic sprinkler system maintained in accordance with National Fire Protection Association 25, 1999 edition, and with National Fire Protection Association 13, 5-5.5.2.1, 1999 edition. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/09/15 at 11:15 AM a tour was taken of the elevator room in the northern expansion building with Staff Q, R, and S. A sprinkler head was observed so coated in dust that the struts could not be seen.

On 06/09/15 at 11:15 AM in an interview, Staff Q confirmed the observation.

2. On 06/09/15 at 11:38 AM a tour of the upper level penthouse in the south building with Staff Q, R, and S. A sprinkler head was observed with a layer of dust bridging the gap between the struts and the bulbs.

On 06/09/15 at 11:38 AM in an interview, Staff Q confirmed the observation.

On 06/09/15 at 1:48 PM a tour was taken of the ninth floor of the Legacy building, starting with the north north building and traveling south to the south building. The tour was taken with Staff Q, R, and S.

3. On 06/09/15 at 2:50 PM observation of the sprinkler head in the linen chute and the trash chute revealed each were packed with dust that could be removed in clumps.

On 06/09/15 at 2:50 PM in an interview, Staff Q, R and S confirmed the observation.

4. On 06/10/15 at 12:00 PM a tour was conducted of the seventh floor going from north to south with Staff Q, R, S, and T. At 1:59 PM observation of the sprinkler heads in the room at grid position h15 (sk-3) revealed the red bulbs were covered in dust.

On 06/10/15 at 1:59 PM in an interview, Staff Q confirmed the observation.

5. On 06/10/15 at 2:32 PM observation of the sprinkler heads in the trash and linen chutes in sk-2 revealed chunks of debris could be pulled from then.

On 06/10/15 at 2:32 PM in an interview, Staff Q confirmed the observation.

6. On 06/10/15 at 3:36 PM observation of the sprinkler head in the equipment room at g12, sk-1, revealed one so coated with dust the dust created a bridge between the bulb and the struts.

On 06/10/15 at 3:36 PM in an interview, Staff R confirmed the observation.

7. On 06/10/15 at 5:08 PM observation of the sprinklers in the women ' s locker room revealed two banks of lockers extending to the center of the room (and, hence, perpendicular to the wall). The lockers were observed to be 14.5 inches from the ceiling.

On 06/10/15 at 5:08 PM in an interview, Staff S confirmed the observation.

8. On 06/11/15 at 11:17 AM a tour was conducted of the fifth floor going from north to south, with Staff Q, R, S, and T. At 1:20 PM observation of the linen chute at h12, sk-2, revealed the sprinkler within was caked with dust.

On 06/11/15 at 1:20 PM in an interview, Staff Q confirmed the observation.

9. On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 9:37 AM observation of the sprinkler head in the trash chute room revealed the deflector of the sprinkler head was bent.

On 06/12/15 at 9:37 AM in an interview, Staff R confirmed the observation.

10. On 06/12/15 at 1:37 PM observation of the sprinkler heads at the women ' s locker room located at n12, sk-4, revealed two heads with dust cocooning both the bulb and the struts.

On 06/12/15 at 1:37 PM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to have its automatic sprinkler system maintained in accordance with National Fire Protection Association 25, 1999 edition. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/15/15 at 1:36 PM a tour was taken of the seventh floor with Staff Q, R, and S. At 2:23 PM observation of the sprinkler heads in the clean supply room revealed one was covered in dust.

On 06/15/15 at 2:23 PM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to ensure space heating devices were used appropriately. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/11/15 at 8:30 AM a tour was taken of the sixth floor going from north to south with Staff Q, R, S and T. At 10:41 AM a space heater was observed in a pharmacist office less than three feet from a chair and a rubbish container. Review of the tag on the heater revealed no combustibles or other furnishings were to be kept within three feet of the space heater.

On 06/11/15 at 8:30 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to keep space heaters out of patient care areas. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/15/15 at 3:43 PM a tour was taken of the third floor with Staff Q, R, and S. AT 3:50 PM observation of the office of the care coordinator, which is within the neonatal intensive care unit, revealed a running space heater under the desk.

On 06/15/15 at 3:50 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to comply with National Fire Protection Association 99, 1999 edition, at 4-3.1.2.3(d), for not having an intervening wall between a zone shut off valve and the outlets it serves and for not having zone shut off valves readily accessible at 4-3.2.2.6. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/11/15 at 11:17 AM a tour was conducted of the fifth floor going from north to south, with Staff Q, R, S, and T. At 1:35 PM two sets of oxygen shut off valves were found for pediatric intensive care unit (the north wing) rooms 1-15: one set found in the resource room, and another found in the corridor just outside the pediatric intensive care unit.

On 06/11/15 at 1:35 PM in an interview, Staff Q could not explain which shut off valves were downstream and which were upstream.

2. On 06/11/15 at 1:35 PM the vacuum shut off valves for the west and east wings (two different units) were found behind a computer work station.

On 06/11/15 at 1:30 PM Staff U couldn ' t find any medical gas shut off valves.

3. On 06/12/15 at 9:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 9:45 AM the oxygen shut off valves were observed behind a computer workstation ' s shelving at the nursing station.

On 06/12/15 at 9:45 AM in an interview Staff V said he/she was unable to find the shut off valves for the gases.

4. On 06/12/15 at 9:45 AM in an interview, neither Staff Q, R, nor S could say where the shut off valve for the vacuum system was.

On 06/12/15 at 10:02 AM in an interview, Staff R stated there were multiple vacuum shut off valves located up in the ceiling.

5. On 06/15/15 at 9:00 AM the tour of the second floor resumed with Staff Q, R, and S. At 10:30 AM the medical gas shut off valves for the post anesthesia care unit was located behind two computer carts. They were located across from the patient rooms that had the gas outlets the valves shut off, without any intervening wall in-between.

On 06/15/15 at 10:30 AM in an interview, Staff Q confirmed the observation.

6. On 06/15/15 at 11:00 AM a tour was taken of the first floor with Staff Q, R, and S. At 11:15 AM observation of the medical gas shut off valves for the interventional vascular unit revealed the shut off valves for rooms one through 34 were located across from rooms 30, 31, 32, 33, 34, and 8, without any intervening wall between them.

On 06/15/15 at 11:15 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to comply with National Fire Protection Association 99, 1999 edition, at 4-3.1.2.3(d), for not having an intervening wall between a zone shut off valve and the outlets it serves and for not having zone shut off valves readily accessible at 4-3.2.2.6. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/15/15 at 1:36 PM a tour was taken of the seventh floor with Staff Q, R, and S. At 1:56 PM observation within the supervisors office located within a patient care area revealed three power strips daisy chained together.

On 06/15/15 at 1:56 PM in an interview, Staff Q confirmed the observation.

2. On 06/15/15 at 2:00 PM observation of the conference room located within a patient care area revealed three power strips daisy chained together.

On 06/15/15 at 2:00 PM in an interview, Staff Q confirmed the observation.

3.On 06/15/15 at 2:20 PM observation west conference room revealed two power strips daisy chained together.

On 06/15/15 at 2:20 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to comply with National Fire Protection Association 99, 1999 edition, at 4-3.1.2.3(d), for not having an intervening wall between a zone shut off valve and the outlets it serves and for not having zone shut off valves readily accessible at 4-3.2.2.6. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/15/15 at 1:36 PM a tour was taken of the seventh floor with Staff Q, R, and S. At 1:56 PM observation within the supervisors office located within a patient care area revealed three power strips daisy chained together.

On 06/15/15 at 1:56 PM in an interview, Staff Q confirmed the observation.

2. On 06/15/15 at 2:00 PM observation of the conference room located within a patient care area revealed three power strips daisy chained together.

On 06/15/15 at 2:00 PM in an interview, Staff Q confirmed the observation.

3.On 06/15/15 at 2:20 PM observation west conference room revealed two power strips daisy chained together.

On 06/15/15 at 2:20 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure medical gas shut off valves were arranged so that shutting off one anesthetizing room or location would not affect others. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/12/15 at 3:40 PM a tour was taken of the operating room suite on the second floor with Staff Q, R, and S. At 4:22 PM observation revealed one set of medical gas shut off valves for oxygen, air, and vacuum to two operating rooms: 10 and 12.

On 06/12/15 at 4:22 PM in an interview, Staff Q confirmed the observation.

Based on observation and staff interview it was determined that the facility failed to maintain the smoke barriers from penetrations in accordance to NFPA 101 2000 edition 8.3.5. This had a potential to affect all staff and patients within this facility. Census at the time of survey was 6,879 cases performed in the last year.

Findings:

During the tour of the facility above the ceiling in the medical records office in the far left corner it was found that there were two openings in conduit and additionally in the corridor adjacent to the cyto room was found an additional open conduit. The findings were confirmed at the time of discovery by Staff DD.

Based on observation and interview, the facility failed to ensure compliance with National Fire Protection Association 99, 1999 edition, 3-3.2.1.2, by not having battery powered lighting in anesthetizing locations. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/12/15 at 3:40 PM a tour was taken of the operating room suite on the second floor with Staff Q, R, and S. Observation of the operating rooms revealed all anesthetizing locations except operating rooms 38, 39, and 40 revealed they did not have battery operated emergency lighting.

On 06/12/15 at 3:40 PM in an interview, Staff Q confirmed the observation.

Based on observation, plans review, and staff interview it was determined that the facility failed to maintain the one hour fire resistant rated wall between other tenant spaces. This had a potential to affect all staff and patients within this facility. Census at the time of survey was 12,773 cases performed in the last year.

Findings:

On 06/08/15 at 4:30 PM during the tour of the facility it was determined that the wall above the front entry area did not extend to the outer wall. The fire walls stopped just above the glassed-in enter. The area above the glassed-in door way was found to be open to the adjacent occupancy. Review of the drawings did confirm that the fire wall was to extend to the out wall. Staff AA and Staff BB confirmed the findings at the time of discovery.

On 06/08/15 at 4:50 PM in the mech/elec/telephone room it was noted that the fire wall had two ½ " conduit pipes with blue wire extending through them. The ends of the conduit were not filled with fire stop material, also it was noted that there were two white wires passing through the wall without a sleeve and failed to have fire stop around them. Further, there was a return steam pipe also passing through the wall that a gap was noted around the pipe without fire stop around the pipe. Staff AA and Staff BB confirmed the findings at the time of discovery.

19.2.7 Discharge from Exits.
Discharge from exits shall be arranged in accordance with Section 7.7.

7.7.3
The exit discharge shall be arranged and marked to make clear the direction of egress to a public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.

Based on observation and interview, the facility failed to ensure compliance with section 7.7 of National Fire Protection Association 101, 2000 edition. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/15/15 at 11:00 AM a tour was taken of the first floor with Staff Q, R, and S. At 11:15 AM observation of stair 1SE revealed the stairs continued more than half a story beyond the level of exit discharge without any effective means of interruption.

On 06/15/15 at 11:15 AM in an interview, Staff Q confirmed the observation.

2. On 06/15/15 at 11:30 AM observation of stair 1SW revealed the stairs continued more than half a story beyond the level of exit discharge without any effective means of interruption.

On 06/15/15 at 11:30 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure not more than 50 percent of the required number of exits discharged through areas on the level of exit discharge. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time discharge.

Findings include:

On 06/16/15 at 11:28 AM a tour was taken of the unit on the fifth floor with Staff Q and R. Observation of the unit revealed two exits in the form of stairwells. Following the exits to their terminus revealed neither discharged to the outside and both discharged to the elevator lobby.

On 06/16/15 at 11:28 am in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure power strips were used in accordance with National Fire Protection Association 70, 1999 edition. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/11/15 at 3:37 PM a tour was conducted of the fourth floor going from north to south, with Staff Q, R, S, and T. At 4:06 PM at the nursing station a daisy chain of three power strips was observed.

On 06/11/15 at 4:06 PM in an interview, Staff Q confirmed the observation.

2. On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 2:00 PM observation of the informatics office at o13, sk-4, revealed three power strips were daisy chained: one with five out of 6 outlets used, and another with four of four outlets used.

On 06/12/15 at 2:00 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to maintain a two hour fire barrier between the building and nonconforming buildings with which it shares the barrier. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/11/15 at 3:37 PM a tour was conducted of the fourth floor going from north to south, with Staff Q, R, S, and T. At 5:25 PM observation above the drop down ceiling of the two hour fire barrier between the facility and an extended care facility, as seen from the pulmonary rehabilitation room, revealed a one inch annular space over a heating, ventilation and cooling duct.

On 06/11/15 at 5:25 PM in an interview, Staff R confirmed the observation.

2. On 06/11/15 at 5:30 PM observation of the double doors between the facility and the extended care facility revealed, when tested, the double doors did not close and latch.

On 06/11/15 at 5:30 PM in an interview, Staff Q confirmed the observation.

3. On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 2:45 PM observation of the fire doors, separating new from existing construction, at m18, sk-6, revealed, when tested, they did not close and latch.

On 06/12/15 at 2:45 PM in an interview, Staff Q confirmed the observation.

4. On 06/12/15 at 2:56 PM observation above the drop down ceiling of the two hour rated fire barrier that separates new from existing construction, at L18, sk-6, revealed two copper lines with an annular space surrounding both and a conduit leading from the barrier to a junction with two missing knock-out.

On 06/12/15 at 2:56 PM in an interview, Staff R confirmed the observations.

5. On 06/12/15 at 3:00 PM observation above the drop down ceiling of the two hour rated fire barrier that separates new from existing construction at L18, sk-6, revealed a one inch conduit traveling from the barrier to an open junction box.

On 06/12/15 at 3:00 PM in an interview, Staff R confirmed the observation.

Based on record review and observation, the facility failed to provide construction of a type to accommodate not more than one story in a fully sprinklered building. Census at the time of survey was 6,879 cases performed in the last year.

Findings include

On 06/16/15 a review of the building ' s occupancy permit, dated 09/30/97, revealed it had a construction type of II(000).

Observation of the building on 06/10/15 revealed it had two stories with a radiology department and physician office spaces.

Based on observation and interview, the facility failed to ensure its corridor doors with gaps had astragals, rabbets or bevels covering the gaps and failed to ensure all latching hardware on corridor doors functioned. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/08/15 at 2:41 PM a tour was conducted of the tenth floor of the Renaissance building with Staff Q, R, and S. On 06/08/15 at 3:20 PM corridor doors to patient rooms 1006, 1008, 1003, and 1005 were observed to consist of two leafs. Observation of these doors at each of these rooms revealed there was a gap between the leaves of greater than 1/8 of an inch without an astragal, rabbet, or bevel protecting the opening.

On 06/08/15 at 2:41 PM in an interview Staff R and S confirmed the observation.

2. On 06/09/15 at 9:20 AM the tour of the 10th floor of the Renaissance building resumed with Staff Q, R, and S. On 06/09/15 at 9:30 AM observation of corridor doors to patient room 1015 revealed they consisted of two leafs. Observation of these doors revealed there was a gap between the leaves of greater than 1/8 of an inch without an astragal, rabbet, or bevel protecting the opening.

On 06/09/15 at 9:30 AM in an interview, Staff Q and R confirmed the observation.

3. On 06/09/15 at 9:30 AM observation of corridor doors to patient rooms 1013 and 1014 revealed they consisted of two leafs with latching hardware that, when tested, did not positively latch.

On 06/09/15 at 9:30 AM in an interview, Staff Q and R confirmed the observation.

4. On 06/09/15 at 9:41 AM observation of the corridor to the housekeeping closet by stair 01 revealed it did not close and positively latch.

On 06/09/15 at 9:41 AM in an interview, Staff Q and R confirmed the observation.

5. On 06/09/15 at 10:10 AM observation of the corridor door on the soiled utility room (two doors down from the aforementioned housekeeping closet) revealed it did not close and latch.

On 06/09/15 at 10:10 AM in an interview, Staff Q and R confirmed the observation.

6. On 06/09/15 at 10:41 AM observation of the corridor door to soiled utility room 1090 on the east side of Renaissance revealed the door did not close and latch when tested.

On 06/09/15 at 10:41 AM in an interview, Staff Q and R confirmed the observation.

7. On 06/15/15 at 1:36 PM a tour was taken of the seventh floor with Staff Q, R, and S. At 1:45 PM observation of the door to a clean utility room protecting the corridor at m22 revealed its latching hardware did not close and latch the door.

On 06/15/15 at 1:45 PM in an interview, Staff S confirmed the observation.

8. On 06/15/15 at 3:43 PM a tour was taken of the third floor with Staff Q, R, and S. At 4:05 PM observation of the doors to patient rooms 1321, 1329, and 1335, revealed they each had gaps of greater than one quarter of an inch.

On 06/15/15 at 4:05 PM in an interview, Staff S confirmed the observation.

9. On 06/15/15 at 4:41 PM a tour was taken of the second floor with Staff Q, R, and S. At 4:53 PM observation of corridor doors to patient room 1222 revealed they had latching hardware, which, when tested, did not completely close the doors.

On 06/15/15 at 4:53 PM in an interview, Staff R confirmed the observation.

10. On 06/15/15 at 5:01 PM observation of the corridor door to patient room 1207 revealed it was on a self closer that was held open with a wedge.

On 06/15/15 at 5:01 PM Staff W stated he/she places the wedge there to keep the door constantly open so that he/she can see her/his patient.

Based on observation and interview, the facility failed to ensure its corridor doors with gaps had astragals, rabbets or bevels covering the gaps. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/10/15 at 8:40 AM a tour was taken of the eighth floor of the Legacy building with Staff Q, R, S and T. On 06/10/15 at 8:48 AM patient room corridor doors to rooms 874 and 875 were observed to each have a gap of one-quarter of an inch.

On 06/10/15 at 8:48 AM in an interview, Staff T confirmed the observation.

2. On 06/10/15 at 12:00 PM a tour was conducted of the seventh floor going from north to south with Staff Q, R, S, and T. At 3:18 PM observation of the door protecting the corridor from the waiting room at h11, sk-2, revealed it had a self closer and latching hardware as means for keeping the door closed. However, when tested the latching hardware was observed to not completely work.

On 06/10/15 at 3:18 PM in an interview, Staff R confirmed the observation.

3. On 06/10/15 at 3:34 PM observation of the door protecting the corridor from a patient equipment room revealed it had latching hardware as a means for keeping the door closed. However, when tested, the door was observed to not completely work.

On 06/10/15 at 3:34 PM in an interview, Staff R confirmed the observation.

4. On 06/10/15 at 5:01 PM observation of the double doors protecting the corridor from the dumb waiter room revealed the door had latching hardware as means for keeping the doors closed. However, upon testing, the latching hardware did not completely work.

On 06/10/15 at 5:01 PM in an interview, Staff Q confirmed the observation.

5. On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 2:36 PM observation of the door protecting the corridor from the room at L16 revealed it had latching hardware used as means suitable for keeping it closed. When tested, the latching hardware did not completely close the door.

On 06/12/15 at 2:36 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to maintain a two hour fire rating on all shafts and chutes. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/09/15 at 9:20 AM a tour of the 10th floor of the Renaissance building was taken with Staff Q, R, and S. On 06/09/15 at 10:33 AM observation of the two hour protective construction around shaft 04 as seen from the northern hall, revealed a one foot by one foot square cut into the drywall, approximately one foot away where the words " 2HR RATING " are stenciled onto the wall.

On 06/09/15 at 10:33 AM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to maintain the rating of the barriers protecting its elevator shafts, chutes, and other vertical openings between floors. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/09/15 at 11:58 AM observation of the trash chute on the ninth in the north north (sic) building revealed the door ' s latching hardware did not function to either completely close or latch the door. Review of the drawing revealed it was protected with two hour fire rated construction.

On 06/09/15 at 11:58 AM in an interview, Staff Q confirmed the finding.

2. On 06/09/15 at 12:00 PM observation of the trash chute on the eighth floor of the north north building revealed its door had three signs affixed to it: " Do not Use, " " Please close chute door, " and " thanks. " Review of the drawing revealed the trash chute was protected with two hour fire rated construction. Observation of the closing of the chute door revealed its latching hardware did not function to either completely close or latch the door.

On 06/09/15 at 12:00 PM in an interview, Staff Q confirmed the observation.

3. On 06/09/15 at 12:05 PM observation of the trash chute on the seventh floor of the north north building revealed its door had a sign on it that said " do not use. " Review of the drawing revealed the trash chute was protected with two hour construction. Observation of the closing of the chute door revealed its latching hardware did not function to either completely close or latch the door.

On 06/09/15 at 12:05 PM in an interview, Staff Q confirmed the observation.

4. On 06/09/15 at 1:38 PM observation of the trash chute discharge in room 1961 revealed the door was bent so that, when tested, the door did not completely close off the chute.

On 06/09/15 at 1:38 PM in an interview, Staff Q explained staff will drop garbage down the chute when the chute door is closed. Then, when the trash hits the door, the door gets bent.

5. On 06/09/15 at 2:35 PM observation above the drop down ceiling of the two hour rated construction protecting a shaft, as seen from the utility room at grid position H-13, revealed four smooth conduits going into the rated barrier surrounded by a six inch by six inch open square.

On 06/09/15 at 2:35 PM in an interview, Staff R confirmed the observation.

On 06/09/15 at 5:00 PM a tour was taken of the eighth floor of the Legacy building, starting with the north north building and traveling south to the south building. The tour was taken with Staff Q, R, and S.

6. On 06/09/15 at 5:24 PM observation above the drop down ceiling of the two hour rated construction protecting an unused elevator shaft, as seen from the men ' s bathroom, revealed two one inch wide penetrations.

On 06/09/15 at 5:24 PM in an interview, Staff R confirmed the observation.

7. On 06/10/15 at 8:40 AM a tour was taken of the eighth floor of the Legacy building with Staff Q, R, S and T. On 06/10/15 at 10:58 AM observation above the drop down ceiling of the two protective construction surrounding the southern bank of elevators in the south elevator lobby revealed a half inch open conduit running from the barrier.

On 06/10/15 at 10:58 AM in an interview, Staff R confirmed the observation.

8. On 06/10/15 at 11:06 AM observation of the doors protecting the dumb waiters in sk-1 did not reveal a fire/smoke rating on the doors.

On 06/10/15 at 11:06 AM in an interview, Staff Q confirmed the observation, and said each set of dumb waiter doors in the building (floors one through nine) would need to be evaluated.

9. On 06/10/15 at 1:23 PM observation above the drop down ceiling of the two hour rated barrier protecting a future elevator shaft as seen from the elevator lobby revealed a one inch wide hole in the concrete.

On 06/10/15 at 1:23 PM in an interview, Staff R confirmed the observation.

10. On 06/10/15 at 1:38 PM observation above the drop down ceiling of the two hour rated barrier protecting the future elevator bank as seen from the men ' s toilet revealed two one inch wide holes.

On 06/10/15 at 1:38 PM in an interview, Staff R confirmed the observation.

11. On 06/10/15 at 12:00 PM a tour was conducted of the seventh floor going from north to south with Staff Q, R, S, and T. At 2:15 PM observation above the drop down ceiling of the two hour barrier protecting the shaft at h13, sk-2, as seen from hazardous area room next to an office, revealed an annular space around a sprinkler line.

On 06/10/15 at 2:15 PM in an interview, Staff Q confirmed the observation.

12. On 06/10/15 at 2:55 PM observation of the floor at eastern nursing station of the medical intensive care unit revealed two open half inch conduits that communicated between the seventh and sixth floors thereby creating a vertical opening between the floors. The conduits had blue wires traveling through them.

On 06/10/15 at 2:55 PM Staff Q confirmed the observation.

13. On 06/10/15 at 3:00 PM observation of the floor at the western nursing station of the medical intensive care unit revealed a vertical opening between the seventh and sixth floors created by a half inch conduit.

On 06/10/15 at 3:00 PM in an interview, Staff Q confirmed the observation.

14. On 06/10/15 at 3:12 PM observation above the drop down ceiling of the two hour barrier protecting a shaft at h13, sk-2, as seen from the clean supply room, revealed a three inch open tube piercing the barrier and a half inch conduit traveling to an open junction box.

On 06/10/15 at 3:12 PM in an interview, Staff R confirmed the observations.

15. On 06/10/15 at 5:18 PM observation above the drop down ceiling of the two hour rated barrier surrounding a shaft, as seen from the impact coordinator ' s office, revealed a one inch wide penetration and a penetration created by two side-by-side one inch conduits.

On 06/10/15 at 5:18 PM in an interview, Staff R confirmed the observation.

16. On 06/11/15 at 8:30 AM a tour was taken of the sixth floor going from north to south with Staff Q, R, S and T. At 10:06 AM observation of the two hour rated barrier protecting a shaft, as seen from the family waiting area, revealed two half inch open conduits to an open junction box.

On 06/11/15 at 10:06 AM in an interview, Staff R confirmed the observation.

17. On 06/11/15 at 11:06 AM observation of the two hour barrier protecting a shaft, as seen from office space 654, revealed a one inch conduit with a broken coupling creating a penetration to the barrier.

On 06/11/15 at 11:06 AM in an interview, Staff R confirmed the observation.

18. On 06/11/15 at 11:17 AM a tour was conducted of the fifth floor going from north to south, with Staff Q, R, S, and T. At 1:08 PM observation above the drop down ceiling of the two hour barrier protecting a shaft, as seen in room 5409, revealed an annular space around a one inch smooth conduit.

On 06/11/15 at 1:08 PM in an interview, Staff Q confirmed the observation.

19. On 06/11/15 at 3:37 PM a tour was conducted of the fourth floor going from north to south with Staff Q, R, S, and T. At 3:45 PM observation above the drop down ceiling of the two hour barrier protecting a future elevator shaft as seen from the lobby revealed two one inch wide penetrations.

On 06/11/15 at 3:45 PM in an interview, Staff R confirmed the observation.

20. On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 3:08 PM observation above the drop down ceiling of the two hour barrier protecting a future elevator bank revealed two one inch wide holes into the barrier.

On 06/12/15 at 3:08 PM in an interview, Staff R confirmed the observation.

21. On 06/12/15 at 3:12 PM observation above the drop down ceiling of the two hour barrier protecting a shaft at j19 revealed a one inch PVC pipe with an annular space.

On 06/12/15 at 3:12 PM in an interview, Staff R confirmed the observation.

22. On 06/12/15 at 3:40 PM a tour was taken of the operating room suite on the second floor with Staff Q, R, and S. At 3:55 PM observation of the trash and soiled linen chute doors in a biohazard room next to an office revealed they were unrated and their latching hardware was not working.

On 06/12/15 at 3:55 PM in an interview, Staff Q confirmed the observation.

23. On 06/15/15 at 9:00 AM the tour of the second floor resumed with Staff Q, R, and S. At 9:37 AM observation of the chute located at j19, sk-4, revealed the latching hardware to the chute did not function, and the room containing the chute did not lock.

On 06/15/15 at 9:37 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure access to exits is marked by approved, readily visible signs. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/10/15 at 8:40 AM a tour was taken of the eighth floor of the Legacy building with Staff Q, R, S and T. On 06/10/15 at 9:30 AM observation of the southerly path of egress from the psychiatric unit to stair A revealed a set of double doors used for traffic control visually blocking the exit sign leading to stair A.

On 06/10/15 at 9:30 AM in an interview, Staff Q confirmed the observation.

On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 1:54 PM observation of exit stairwell D as seen from the public corridor revealed it did not have an exit sign.

On 06/12/15 at 1:54 PM in an interview, Staff Q confirmed the observation.

On 06/15/15 at 9:00 AM the tour of the second floor resumed with Staff Q, R, and S. At 9:45 AM a second path of egress from the endoscopy suites either out of the northwest doors or the northern doors were not marked.

On 06/15/15 at 9:45 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure access to exits is marked by approved, readily visible signs. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/16/15 at 11:28 AM a tour was taken of the unit with Staff Q and R. Observation of access to exits revealed a stairway which was not marked with a readily visible sign.

On 06/16/15 at 11:28 AM in an interview, Staff Q confirmed the observation.

Based on observation and staff interview it was determined that the facility failed to have a smoke barrier to form at least two smoke compartments on each floor used by inpatients for sleeping or treatment. This had a potential to affect all staff and patients within this facility. Census at the time of survey was 6,879 cases performed in the last year.

Findings:

During the tour, on 06/10/15 form 11:50 Am till 3:10 PM, of the facility, review of the life safety floor plans, and staff interview it was determined that the facility did not have the required smoke barrier to divide the floor into two smoke compartments. This was confirmed by Staff DD at the time of discovery.

Based on observation and interview, the facility failed to ensure the rating of its smoke barriers. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/08/15 at 2:41 PM a tour was conducted of the tenth floor of the Renaissance building with Staff Q, R, and S. Observation above the drop down ceiling over smoke barrier doors H building, Floor 10 East revealed two half-inch corrugated conduits open to air, and a cable tray with openings between it and the barrier.

On 06/08/15 at 2:41 PM in an interview, Staff R confirmed the finding.

On 06/09/15 at 9:20 AM the tour of the 10th floor of the Renaissance building resumed with Staff Q, R, and S.

2. On 06/09/15 at 9:25 AM observation above the drop down ceiling over smoke doors H building, Floor 10 West revealed a cable tray in the smoke barrier with gaps between it and the barrier.

On 06/09/15 at 9:25 AM in an interview, Staff R confirmed the finding.

3. On 06/15/15 at 2:33 PM a tour was taken of the fifth floor with Staff Q, R, and S. At 2:54 PM observation of the two hour rated barrier in the clean supply room across from patient room 1512 revealed at the corner where an automated medication dispenser is located a one inch open corrugated conduit traveling from the barrier and having red wires traveling out of it.

On 06/15/15 at2:54 PM in an interview, Staff R confirmed the observation.

4. On 06/15/15 at 3:15 PM observation above the drop down ceiling of the one hour rated barrier over the door to the soiled utility room across from patient room 1524 revealed three open one inch conduits.

On 06/15/15 at 3:15 PM in an interview, Staff R confirmed the observation.

5. On 06/15/15 at 3:18 PM observation above the drop down ceiling of the smoke barrier over the doors labeled H building, floor five east, revealed three open one inch conduits holding grey wiring.

On 06/15/15 at 3:18 PM in an interview, Staff R confirmed the observation.

6. On 06/15/15 at 3:22 PM observation above the drop down ceiling of the smoke barrier perpendicular to the doors labeled H building, floor five east revealed two open one inch conduits traveling from it, with one holding grey wires and the other holding a blue and grey wire.

On 06/15/15 at 3:22 PM in an interview, Staff R confirmed the observation.

7. On 06/15/15 at 3:25 PM observation above the drop down ceiling of the smoke barrier outside the consult room near doors labeled floor 5 east, revealed four open conduits with the annular space surrounding them taking the form of a rectangle.

On 06/15/15 at 3:25 PM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to maintain the rating of its smoke barriers. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/09/15 at 1:48 PM a tour was taken of the ninth floor of the Legacy building, starting with the north north building and traveling south to the south building. The tour was taken with Staff Q, R, and S.

1.On 06/09/15 at 2:24 PM observation above the drop down ceiling of the smoke barrier over smoke doors C building floor 9 north, revealed a two inch by two inch penetration.

On 06/09/15 at 2:24 PM, Staff R confirmed the observation.

2. On 06/09/15 at 2:28 PM observation above the drop down ceiling of the smoke barrier between rooms 968 and 969 revealed a two inch metal conduit with a left sided annular space.

On 06/09/15 at 2:28 PM in an interview, Staff R confirmed the observation.

3. On 06/09/15 3:37 PM observation above the drop down ceiling of the northern smoke barrier of the cart receiving room revealed a smooth conduit traveling from the barrier to an open junction box.

On 06/09/15 at 3:37 PM in an interview, Staff S confirmed the observation.

4. On 06/09/15 at 4:15 PM observation of the smoke barrier in room 981 revealed conduit traveling from the barrier to a junction box with a missing one inch knock-out.

On 06/09/15 at 4:15 PM in an interview, Staff S confirmed the observation.

5. On 06/10/15 at 8:40 AM a tour was taken of the eighth floor of the Legacy building with Staff Q, R, S and T. On 06/10/15 at 9:06 AM observation above the drop down ceiling of the smoke barrier running east/west along the northern wall of a staff room located at grid position H-13, sk-2, revealed a one inch flex duct with an annular space.

On 06/10/15 at 9:06 AM in an interview, Staff Q confirmed the observation.

6. On 06/10/15 at 9:45 AM a review of the facility ' s life safety code drawings revealed a smoke barrier that traveled from the northeast to the southwest, linking a staff room to a lounge (and the outside wall), and crossing a corridor in the process. The drawing shows the barrier to be located between grid positions a12 and a13. Observation above the drop down ceiling did not reveal this barrier, and one could not be located that crossed the corridor to the outside wall on the southwest side of the building.

On 06/10/15 at 9:45 AM in an interview, Staff Q confirmed the observation.

7. On 06/10/15 at 11:18 AM observation above the drop down ceiling of the smoke barrier over the double doors leading to the south wing of section sk-1 revealed an open junction box with a half inch open conduit that traveled through the smoke barrier.

On 06/10/15 at 11:18 AM in an interview, Staff R confirmed the observation.

8. On 06/10/15 at 12:00 PM a tour was conducted of the seventh floor going from north to south with Staff Q, R, S, and T. At 2:05 PM observation above the drop down ceiling of the smoke barrier between the two toilets in sk-3 revealed a one inch conduit traveling through the barrier to an open junction box. The conduit holds an orange wire.

On 06/10/15 at 2:05 PM in an interview, Staff R confirmed the observation.

9. On 06/10/15 at 3:25 PM observation above the drop down ceiling of the smoke barrier over the double doors near the south elevator lobby revealed a one inch open conduit on the east side.

On 06/10/15 at 3:25 PM in an interview, Staff R confirmed the observation.

10. On 06/11/15 at 8:30 AM a tour was taken of the sixth floor going from north to south with Staff Q, R, S and T. At 9:11 AM observation above the drop down ceiling of the smoke barrier over the double doors near patient room 668 revealed a three inch open conduit through the barrier.

On 06/11/15 at 9:11 AM in an interview, Staff R confirmed the observation.

11. On 06/11/15a t 9:42 AM observation above the drop down ceiling of the smoke barrier as seen from patient room 680 revealed a half inch smooth conduit traveling from the barrier to an open junction box.

On 06/11/15 at 9:42 AM in an interview, Staff R confirmed the observation.

12. On 06/11/15 at 10:21 AM double doors were observed in the smoke barrier perpendicular to the dumb waiter receiving area and staff lounge. The doors were observed to have a coordinator that, when tested, did not work.

On 06/11/15 at 10:21 AM in an interview, Staff S confirmed the observation.

13. On 06/11/15 at 10:31 AM double doors were observed in the smoke barrier between the dumb waiter receiving area and the corridor. The doors were observed to have a coordinator that, when tested, did not work.

On 06/11/15 at 10:31 am in an interview, Staff S confirmed the observation.

14. On 06/11/15 at 11:17 AM a tour was conducted of the fifth floor going from north to south, with Staff Q, R, S, and T. At 2:42 PM observation of the smoke barrier as seen from the family waiting area in the pediatric outpatient suite, revealed a one inch conduit piercing the barrier and traveling to an open junction box.

On 06/11/15 at 2:42 PM in an interview, Staff R confirmed the observation.

15.On 06/11/15 at 3:37 PM a tour was conducted of the fourth floor going from north to south, with Staff Q, R, S, and T. At 4:15 PM observation of the smoke barrier above the drop down ceiling over the double doors perpendicular to patient rooms 467 and 466 revealed blue wires pierced the barrier with an annular space.

On 06/11/15 at 4:15 PM in an interview, Staff R confirmed the observation.

16. On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 10:53 AM observation above the drop down ceiling of the smoke barrier over the door perpendicular to the nurse midwife area, located at g6, sk-2, revealed a conduit penetrating through the barrier and leading to an open junction box, and another unstopped conduit with a red wire traveling out of it.

On 06/12/15 at 10:53 AM in an interview, Staff R confirmed the observation.

17. On 06/12/15 at 12:00 PM observation above the drop down ceiling of the smoke barrier perpendicular to the electrical room door near n10, sk4, revealed a sprinkler line in a metal sleeve with an annular space between the sleeve and the sprinkler line.

On 06/12/15 at 12:00 PM in an interview, Staff R confirmed the observation.

18. On 06/12/15 at 1:29 PM observation above the drop down ceiling of the smoke barrier perpendicular to the vending machines at m10 revealed an open half inch corrugated conduit with red and grey wires traveling out of it.

On 06/12/15 at 1:29 PM in an interview, Staff R confirmed the observation.

19. On 06/12/15 at 2:00 PM observation of the smoke barrier in the informatics office at o13, sk-4, revealed a one inch opening with two blue wires traveling out of it.

On 06/12/15 at 2:00 PM in an interview, Staff R confirmed the observation.

20. On 06/12/15 at 3:40 PM a tour was taken of the operating room suite on the second floor with Staff Q, R, and S. At 4:18 PM observation of the double doors in the smoke barrier that runs along the perimeter of the dumb waiter room revealed the doors had latching hardware that when tested did not close and latch the doors.

On 06/12/15 at 4:18 PM in an interview, Staff S confirmed the observation.

21. On 06/15/15 at 9:00 AM the tour of the second floor resumed with Staff Q, R, and S. At 9:18 AM observation above the drop down ceiling of the western smoke barrier in the endoscopy suite revealed an open half inch conduit and a sprinkler line with an annular space.

On 06/15/15 9:18 AM in an interview, Staff R confirmed the observation.

22. On 06/15/15 at 10:02 AM observation of the smoke barrier above the drop down ceiling in the office located at L19, sk6, revealed a half inch open conduit with a blue wire running from it, and a flex conduit with an annular space around it.

On 06/15/15 at 10:02 AM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to ensure all doors in its smoke barriers completely closed and shut and that gaps were covered by rabbets, bevels, or astragals. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/08/15 at 2:41 PM a tour was conducted of the tenth floor of the Renaissance building with Staff Q, R, and S. On 06/08/15 at 3:54 PM observation of smoke barrier doors H, Floor 10 East revealed they did not have rabbets, bevels, or astragals at their meeting edges, which had a gap of one quarter of an inch.

On 06/08/15 at 3:54 PM in an interview, Staff Q and R confirmed the observation.

2. On 06/15/15 at 1:36 PM a tour was taken of the seventh floor with Staff Q, R, and S. At 1:52 PM observation of smoke doors, H building, Floor 7 east, revealed, when tested, the doors did not close and shut.

On 06/15/15 at 1:52 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure each door in its smoke barrier closed completely. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 10:40 AM observation of the double doors in the smoke barrier perpendicular to the women ' s locker room at g8, sk-2, revealed they had a self closer and latching hardware. Upon testing, the latching hardware was observed not to completely close the doors.

On 06/12/15 at 10:40 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure each hazardous area had a self closing door. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/15/15 at 2:33 PM a tour was taken of the fifth floor with Staff Q, R, and S. At 2:51 PM observation of a pharmacist ' s office revealed it was packed with combustible items, specifically, texts and multiple boxes of paper such that the only avenue of travel was an alley from the door to the chair at the desk. Representing a hazard greater than that found in patient rooms, this room did not have a door with a self closer.

On 06/15/15 at 2:51 PM in an interview, Staff Q, R, and S confirmed the observation.

2. On 06/15/15 at 3:36 PM observation of the doors to a file room containing combustibles greater than that found in patient rooms revealed the door was not on a self closer.

On 06/15/15 at 3:36 PM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to ensure each hazardous area had a self closing door. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 9:18 AM observation of a utility room at f13, sk-2, revealed the room to hold over 40 boxes of paperwork and thus present a level of hazard greater than that of patient rooms. Observation of the door to this room revealed it was not on a self-closer.

On 06/12/15 at 9:18 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to maintain the rating of its barriers protecting stairways and other exit components. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/15/15 at 1:36 PM a tour was taken of the seventh floor with Staff Q, R, and S. At 2:01 PM observation above the drop down ceiling of the two hour barrier protecting stair 3 revealed a one inch penetration with a red wire traveling out of it.

On 06/15/15 at 2:01 PM in an interview, Staff R confirmed the observation.

2. On 06/15/15 at 2:33 PM a tour was taken of the fifth floor with Staff Q, R, and S. At 2:33 PM observation above the drop down ceiling of the two hour rating protecting stair 2 revealed three conduits open to air with grey wires traveling through them. The conduit was observed to come from the barrier.

On 06/15/15 at 2:33 PM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to maintain the rating of its barriers protecting stairways and other exit components. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/09/15 at 1:48 PM a tour was taken of the ninth floor of the Legacy building, starting with the north north building and traveling south to the south building. The tour was taken with Staff Q, R, and S.

1.On 06/09/15 at 1:56 PM observation above the drop down ceiling of the two hour rated construction near stair 2 and an elevator shaft revealed a one inch hole more than three inches deep.

On 06/09/15 at 1:56 PM in an interview, Staff R confirmed the observation.

2. On 06/09/15 at 2:00 PM observation above the drop down ceiling of the two hour rated construction protecting stair 2 revealed four one inch holes greater than three inches deep. The holes formed a constellation the shape of rectangle.

On 06/09/15 at 2:00 PM in an interview, Staff S confirmed the observation.

3. On 06/09/15 at 2:05 PM observation above the drop down ceiling of the two hour rated construction protecting a mechanical shaft next to stair 2 revealed another one inch hole and three one inch smooth conduits with annular spaces.

On 06/09/15 at 2:05 PM in an interview, Staff S confirmed the observation.

On 06/09/15 at 5:00 PM a tour was taken of the eighth floor of the Legacy building, starting with the north north building and traveling south to the south building. The tour was taken with Staff Q, R, and S.

4. On 06/09/15 at 5:10 PM observation above the drop down ceiling of the two hour rated construction protecting stair 2 revealed to the right of its door, two one inch holes.

On 06/09/15 at 5:10 PM in an interview, Staff R confirmed the observation.

5. On 06/09/15 at 5:15 PM observation above the drop down ceiling of the two hour rated construction protecting the elevator shaft next to stair 2 revealed two one inch holes, with one above the other.

On 06/09/15 at 5:15 PM in an interview, Staff R confirmed the observation.

6. On 06/10/15 at 8:40 AM the tour of the eighth floor of the Legacy building resumed with Staff Q, R, S and T. On 06/10/15 at 8:43 AM observation above the drop down ceiling of the two hour rated construction protecting the eight north stairway revealed a one inch conduit traveling from the stairway to an open junction box.

On 06/10/15 at 8:40 AM in an interview, Staff R confirmed the observation.

7. On 06/10/15 at 12:00 PM a tour of the seventh floor of the legacy building was conducted from north to south with Staff Q, R, S, and T. Observation of the two protective construction of stair number 2, as seen from the corridor, revealed a half inch conduit running into the barrier with an annular space.

On 06/10/15 at 12:00 PM in an interview, Staff Q confirmed the observation.

8. On 06/10/15 at 2:35 PM observation above the drop down ceiling of the two hour barrier surrounding the exit stairway in the medical intensive care unit revealed an annular space surrounding a one inch smooth conduit.

On 06/10/15 at 2:35 PM in an interview, Staff R confirmed the observation.

9. On 06/10/15 at 5:31 PM observation of the door protecting the stairway across from patient room 710 revealed it was not rated.

On 06/10/15 at 5:31 PM in an interview, Staff S confirmed the observation.

10. On 06/11/15 at 8:30 AM a tour was taken of the sixth floor going from north to south with Staff Q, R, S and T. On 06/11/15 at 8:48 AM observation of the communication room next to a trash chute room, located in the north north building, revealed two orange conduits piercing the floor to the ceiling below, creating a vertical opening between the sixth and fifth floors.

On 06/11/15 at 8:48 AM in an interview, Staff Q confirmed the observation.

11. On 06/11/15 at 10:57 AM observation above the drop down ceiling of the two hour barrier protecting the exit stairway across from patient room 606 revealed the barrier was pierced by a one inch open conduit.

On 06/11/15 at 10:57 AM in an interview, Staff R confirmed the observation.

12. On 06/11/15 at 11:17 AM a tour was conducted of the fifth floor going from north to south, with Staff Q, R, S, and T. At 11:24 AM observation above the drop down ceiling, as seen from the corridor, of exit stair 2, revealed a one inch open conduit traveling through the barrier.

On 06/11/15 at 11:24 AM in an interview, Staff R confirmed the observation.

13. On 06/11/15 at 2:22 PM observation above the drop down ceiling of the two hour rated barrier protecting the stairway at h8 revealed a two to three inch annular space around a one inch smooth conduit.

On 06/11/15 at 2:22 PM in an interview, Staff R confirmed the observation.


14. On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 10:30 AM observation above the drop down ceiling of the two hour rated fire barrier located outside stair A revealed one inch by a half-inch square penetration and a two inch by two inch square penetration with three small conduits running out of it.

On 06/12/15 at 10:30 AM in an interview, Staff R confirmed the observation.

15. On 06/15/15 at 11:00 AM a tour was taken of the first floor with Staff Q, R, and S. At 11:55 AM observation of the exit passageway protected with a two hour fire barrier revealed it contained a door across from elevator 12 in a room labeled west room. The door was observed to have a rating of 45 minutes.

On 06/15/15 at 11:55 AM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to comply with Chapter 7 of National Fire Protection Association 101, 2000 edition, and 7.2.1.6, special locking arrangements for locked doors in the psychiatric unit. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/10/15 at 8:40 AM a tour was taken of the eighth floor of the Legacy building with Staff Q, R, S and T. On 06/10/15 at 9:30 AM double doors leading to the psychiatric unit were observed to be locked on the egress side.

On 06/10/15 at 9:30 AM Staff Q explained the doors would automatically unlock when the fire alarm system becomes activated.

On 06/10/15 at 9:30 AM and again at 11:45 AM the fire alarm system was activated and at each time the doors were not observed to unlock from the egress side.
On 06/10/15 at 9:30 AM and again at 11:45 AM Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure emergency lighting was provided in accordance with National Fire Protection Association 101, 7.9. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/12/15 at 3:40 PM a tour was taken of the operating room suite on the second floor with Staff Q, R, and S. Observation of operating rooms 38, 39, and 40 revealed they did have battery powered emergency lighting. Observation of the battery powered emergency lighting in operating room 39 revealed they did not work.

On 06/12/15 at 3:40 PM in an interview, Staff Q confirmed the observation saying the battery operated lights had not been tested monthly or yearly.

Based on observation and staff interview it was determined that the facility failed to provide adequate Exit lights to show the path of egress. This had a potential to affect all staff and patients within the building.

Finding:

During the tour of the facility on 06/11/15 it was found that the facility failed to provided the required exit signs to provide direction of the path of egress from the first floor physical therapy rehab room 101. The tour revealed that when standing in the short corridor to the treatments rooms you could not see an Exit signs to either of the two exits. This was confirmed at the time of discovery by Staff CC.

During the tour of the Athletic club dressing rooms it was determined that there were only two exit lights and they were not visible from the locker room or shower stalls. Further, it was found that at the bottom of the stairs leading from the track there was no sign providing direction to the exits. Also, from the track lanes the signs of the exits could not be visualized from the corners of the track. This was confirmed at the time of discovery by Staff CC.

Based on document review and staff interview it was determined that the facility failed to include the physicians in the fire drill process. Based on document review and staff interview it was determined that the facility failed to include the physicians in the fire drill process.

Findings include:

On 06/16/15 a review of the facility ' s fire drill documentation was completed. A review of the drills revealed not one physician participated in the drills.

On 06/16/15 at 4:00 PM in an interview, Staff Q confirmed that of 850 physicians on staff, there wasn ' t evidence any had participated in any fire drills.

Based on document review and staff interview it was determined that the facility failed to include the physicians in the fire drill process. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/16/15 a review of the facility ' s fire drill documentation was completed. A review of the drills revealed not one physician participated in the drills.

On 06/16/15 at 4:00 PM in an interview, Staff Q confirmed that of 850 physicians on staff, there wasn ' t evidence any had participated in any fire drills.

Based on document review and staff interview it was determined that the facility failed to include the physicians in the fire drill process. This had a potential to affect all staff and patients within this facility. Census at the time of survey was 12,773 cases performed in the last year.

Findings:

The document review was done on 06/08/15 at 1:30 PM and failed to reveal that the physicians participated in the drill. 21.7.2.3 refers that ALL staff shall be instructed in the use of and response to fire alarms. During an interview with Staff CC, at 1:46 PM on 06/08/15, confirmed that the physicians did not participate in the drills. Staff CC, confirmed the find at the time of discover.

Based on document review and staff interview it was determined that the facility failed to include the physicians in the fire drill process. This had a potential to affect all staff and patients within this facility. Census at the time of survey was 6,879 cases performed in the last year.

Findings:

The document review was done on 06/15/15 at 11:30 AM and failed to reveal that the drills were performed at unexpected times and for all shifts and that the physicians did not participated in the drill. 21.7.2.3 refers that ALL staff shall be instructed in the use of and response to fire alarms. During an interview with Staff EE, at 11:35 PM on 06/09/15, confirmed that the physicians did not participate in the drills. Staff EE, confirmed the find at the time of discover.

Based on record review and interview, the facility failed to ensure its fire alarm system was maintained in accordance with National Fire Protection Association 72. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.


Findings include:

On 06/16/15 a review of the facility ' s fire alarm documentation was completed. The review revealed the system was tested on 10/31/14 and the test showed a battery in the basement failed. The review did not reveal where the battery was changed or otherwise rectified.

On 06/16/15 at 4:00 PM in an interview, Staff X confirmed he/she could not show where the battery had been replaced.

Based on observation and interview, the facility failed to ensure its sprinklers were tested in accordance with National Fire Protection Association 25, 9-3.4.2, 1999 edition. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/16/15 a review of the building fire sprinkler system documentation was completed on 06/16/15. The review did not reveal where an annual main drain test at the riser was conducted.

On 06/16/15 at 4:00 PM in an interview, Staff X confirmed the main drain test had not been performed annually.

Based on observation and interview, the facility failed to have its automatic sprinkler system maintained in accordance with National Fire Protection Association 25, 1999 edition, and with National Fire Protection Association 13, 5-5.5.2.1, 1999 edition. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/09/15 at 11:15 AM a tour was taken of the elevator room in the northern expansion building with Staff Q, R, and S. A sprinkler head was observed so coated in dust that the struts could not be seen.

On 06/09/15 at 11:15 AM in an interview, Staff Q confirmed the observation.

2. On 06/09/15 at 11:38 AM a tour of the upper level penthouse in the south building with Staff Q, R, and S. A sprinkler head was observed with a layer of dust bridging the gap between the struts and the bulbs.

On 06/09/15 at 11:38 AM in an interview, Staff Q confirmed the observation.

On 06/09/15 at 1:48 PM a tour was taken of the ninth floor of the Legacy building, starting with the north north building and traveling south to the south building. The tour was taken with Staff Q, R, and S.

3. On 06/09/15 at 2:50 PM observation of the sprinkler head in the linen chute and the trash chute revealed each were packed with dust that could be removed in clumps.

On 06/09/15 at 2:50 PM in an interview, Staff Q, R and S confirmed the observation.

4. On 06/10/15 at 12:00 PM a tour was conducted of the seventh floor going from north to south with Staff Q, R, S, and T. At 1:59 PM observation of the sprinkler heads in the room at grid position h15 (sk-3) revealed the red bulbs were covered in dust.

On 06/10/15 at 1:59 PM in an interview, Staff Q confirmed the observation.

5. On 06/10/15 at 2:32 PM observation of the sprinkler heads in the trash and linen chutes in sk-2 revealed chunks of debris could be pulled from then.

On 06/10/15 at 2:32 PM in an interview, Staff Q confirmed the observation.

6. On 06/10/15 at 3:36 PM observation of the sprinkler head in the equipment room at g12, sk-1, revealed one so coated with dust the dust created a bridge between the bulb and the struts.

On 06/10/15 at 3:36 PM in an interview, Staff R confirmed the observation.

7. On 06/10/15 at 5:08 PM observation of the sprinklers in the women ' s locker room revealed two banks of lockers extending to the center of the room (and, hence, perpendicular to the wall). The lockers were observed to be 14.5 inches from the ceiling.

On 06/10/15 at 5:08 PM in an interview, Staff S confirmed the observation.

8. On 06/11/15 at 11:17 AM a tour was conducted of the fifth floor going from north to south, with Staff Q, R, S, and T. At 1:20 PM observation of the linen chute at h12, sk-2, revealed the sprinkler within was caked with dust.

On 06/11/15 at 1:20 PM in an interview, Staff Q confirmed the observation.

9. On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 9:37 AM observation of the sprinkler head in the trash chute room revealed the deflector of the sprinkler head was bent.

On 06/12/15 at 9:37 AM in an interview, Staff R confirmed the observation.

10. On 06/12/15 at 1:37 PM observation of the sprinkler heads at the women ' s locker room located at n12, sk-4, revealed two heads with dust cocooning both the bulb and the struts.

On 06/12/15 at 1:37 PM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to have its automatic sprinkler system maintained in accordance with National Fire Protection Association 25, 1999 edition. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/15/15 at 1:36 PM a tour was taken of the seventh floor with Staff Q, R, and S. At 2:23 PM observation of the sprinkler heads in the clean supply room revealed one was covered in dust.

On 06/15/15 at 2:23 PM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to ensure space heating devices were used appropriately. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/11/15 at 8:30 AM a tour was taken of the sixth floor going from north to south with Staff Q, R, S and T. At 10:41 AM a space heater was observed in a pharmacist office less than three feet from a chair and a rubbish container. Review of the tag on the heater revealed no combustibles or other furnishings were to be kept within three feet of the space heater.

On 06/11/15 at 8:30 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to keep space heaters out of patient care areas. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/15/15 at 3:43 PM a tour was taken of the third floor with Staff Q, R, and S. AT 3:50 PM observation of the office of the care coordinator, which is within the neonatal intensive care unit, revealed a running space heater under the desk.

On 06/15/15 at 3:50 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to comply with National Fire Protection Association 99, 1999 edition, at 4-3.1.2.3(d), for not having an intervening wall between a zone shut off valve and the outlets it serves and for not having zone shut off valves readily accessible at 4-3.2.2.6. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/11/15 at 11:17 AM a tour was conducted of the fifth floor going from north to south, with Staff Q, R, S, and T. At 1:35 PM two sets of oxygen shut off valves were found for pediatric intensive care unit (the north wing) rooms 1-15: one set found in the resource room, and another found in the corridor just outside the pediatric intensive care unit.

On 06/11/15 at 1:35 PM in an interview, Staff Q could not explain which shut off valves were downstream and which were upstream.

2. On 06/11/15 at 1:35 PM the vacuum shut off valves for the west and east wings (two different units) were found behind a computer work station.

On 06/11/15 at 1:30 PM Staff U couldn ' t find any medical gas shut off valves.

3. On 06/12/15 at 9:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 9:45 AM the oxygen shut off valves were observed behind a computer workstation ' s shelving at the nursing station.

On 06/12/15 at 9:45 AM in an interview Staff V said he/she was unable to find the shut off valves for the gases.

4. On 06/12/15 at 9:45 AM in an interview, neither Staff Q, R, nor S could say where the shut off valve for the vacuum system was.

On 06/12/15 at 10:02 AM in an interview, Staff R stated there were multiple vacuum shut off valves located up in the ceiling.

5. On 06/15/15 at 9:00 AM the tour of the second floor resumed with Staff Q, R, and S. At 10:30 AM the medical gas shut off valves for the post anesthesia care unit was located behind two computer carts. They were located across from the patient rooms that had the gas outlets the valves shut off, without any intervening wall in-between.

On 06/15/15 at 10:30 AM in an interview, Staff Q confirmed the observation.

6. On 06/15/15 at 11:00 AM a tour was taken of the first floor with Staff Q, R, and S. At 11:15 AM observation of the medical gas shut off valves for the interventional vascular unit revealed the shut off valves for rooms one through 34 were located across from rooms 30, 31, 32, 33, 34, and 8, without any intervening wall between them.

On 06/15/15 at 11:15 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to comply with National Fire Protection Association 99, 1999 edition, at 4-3.1.2.3(d), for not having an intervening wall between a zone shut off valve and the outlets it serves and for not having zone shut off valves readily accessible at 4-3.2.2.6. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/15/15 at 1:36 PM a tour was taken of the seventh floor with Staff Q, R, and S. At 1:56 PM observation within the supervisors office located within a patient care area revealed three power strips daisy chained together.

On 06/15/15 at 1:56 PM in an interview, Staff Q confirmed the observation.

2. On 06/15/15 at 2:00 PM observation of the conference room located within a patient care area revealed three power strips daisy chained together.

On 06/15/15 at 2:00 PM in an interview, Staff Q confirmed the observation.

3.On 06/15/15 at 2:20 PM observation west conference room revealed two power strips daisy chained together.

On 06/15/15 at 2:20 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to comply with National Fire Protection Association 99, 1999 edition, at 4-3.1.2.3(d), for not having an intervening wall between a zone shut off valve and the outlets it serves and for not having zone shut off valves readily accessible at 4-3.2.2.6. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/15/15 at 1:36 PM a tour was taken of the seventh floor with Staff Q, R, and S. At 1:56 PM observation within the supervisors office located within a patient care area revealed three power strips daisy chained together.

On 06/15/15 at 1:56 PM in an interview, Staff Q confirmed the observation.

2. On 06/15/15 at 2:00 PM observation of the conference room located within a patient care area revealed three power strips daisy chained together.

On 06/15/15 at 2:00 PM in an interview, Staff Q confirmed the observation.

3.On 06/15/15 at 2:20 PM observation west conference room revealed two power strips daisy chained together.

On 06/15/15 at 2:20 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure medical gas shut off valves were arranged so that shutting off one anesthetizing room or location would not affect others. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/12/15 at 3:40 PM a tour was taken of the operating room suite on the second floor with Staff Q, R, and S. At 4:22 PM observation revealed one set of medical gas shut off valves for oxygen, air, and vacuum to two operating rooms: 10 and 12.

On 06/12/15 at 4:22 PM in an interview, Staff Q confirmed the observation.

Based on observation and staff interview it was determined that the facility failed to maintain the smoke barriers from penetrations in accordance to NFPA 101 2000 edition 8.3.5. This had a potential to affect all staff and patients within this facility. Census at the time of survey was 6,879 cases performed in the last year.

Findings:

During the tour of the facility above the ceiling in the medical records office in the far left corner it was found that there were two openings in conduit and additionally in the corridor adjacent to the cyto room was found an additional open conduit. The findings were confirmed at the time of discovery by Staff DD.

Based on observation and interview, the facility failed to ensure compliance with National Fire Protection Association 99, 1999 edition, 3-3.2.1.2, by not having battery powered lighting in anesthetizing locations. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/12/15 at 3:40 PM a tour was taken of the operating room suite on the second floor with Staff Q, R, and S. Observation of the operating rooms revealed all anesthetizing locations except operating rooms 38, 39, and 40 revealed they did not have battery operated emergency lighting.

On 06/12/15 at 3:40 PM in an interview, Staff Q confirmed the observation.

Based on observation, plans review, and staff interview it was determined that the facility failed to maintain the one hour fire resistant rated wall between other tenant spaces. This had a potential to affect all staff and patients within this facility. Census at the time of survey was 12,773 cases performed in the last year.

Findings:

On 06/08/15 at 4:30 PM during the tour of the facility it was determined that the wall above the front entry area did not extend to the outer wall. The fire walls stopped just above the glassed-in enter. The area above the glassed-in door way was found to be open to the adjacent occupancy. Review of the drawings did confirm that the fire wall was to extend to the out wall. Staff AA and Staff BB confirmed the findings at the time of discovery.

On 06/08/15 at 4:50 PM in the mech/elec/telephone room it was noted that the fire wall had two ½ " conduit pipes with blue wire extending through them. The ends of the conduit were not filled with fire stop material, also it was noted that there were two white wires passing through the wall without a sleeve and failed to have fire stop around them. Further, there was a return steam pipe also passing through the wall that a gap was noted around the pipe without fire stop around the pipe. Staff AA and Staff BB confirmed the findings at the time of discovery.

19.2.7 Discharge from Exits.
Discharge from exits shall be arranged in accordance with Section 7.7.

7.7.3
The exit discharge shall be arranged and marked to make clear the direction of egress to a public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.

Based on observation and interview, the facility failed to ensure compliance with section 7.7 of National Fire Protection Association 101, 2000 edition. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/15/15 at 11:00 AM a tour was taken of the first floor with Staff Q, R, and S. At 11:15 AM observation of stair 1SE revealed the stairs continued more than half a story beyond the level of exit discharge without any effective means of interruption.

On 06/15/15 at 11:15 AM in an interview, Staff Q confirmed the observation.

2. On 06/15/15 at 11:30 AM observation of stair 1SW revealed the stairs continued more than half a story beyond the level of exit discharge without any effective means of interruption.

On 06/15/15 at 11:30 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure not more than 50 percent of the required number of exits discharged through areas on the level of exit discharge. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time discharge.

Findings include:

On 06/16/15 at 11:28 AM a tour was taken of the unit on the fifth floor with Staff Q and R. Observation of the unit revealed two exits in the form of stairwells. Following the exits to their terminus revealed neither discharged to the outside and both discharged to the elevator lobby.

On 06/16/15 at 11:28 am in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure power strips were used in accordance with National Fire Protection Association 70, 1999 edition. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/11/15 at 3:37 PM a tour was conducted of the fourth floor going from north to south, with Staff Q, R, S, and T. At 4:06 PM at the nursing station a daisy chain of three power strips was observed.

On 06/11/15 at 4:06 PM in an interview, Staff Q confirmed the observation.

2. On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 2:00 PM observation of the informatics office at o13, sk-4, revealed three power strips were daisy chained: one with five out of 6 outlets used, and another with four of four outlets used.

On 06/12/15 at 2:00 PM in an interview, Staff Q confirmed the observation.