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Based on observation and interview the facility failed to provide exit access corridor walls that were at least 1/2 hour rated and resistant to the passage of smoke in accordance to NFPA 101 section 19.3.6.3.1, and was not in compliance as evidenced by the following items. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

Item 1: [Corrected 10/30/13-12:42pm] It was observed at 11:23 am on Monday, August 19th, 2013, that a transfer grille was installed in the wall of the corridor from the elevator equipment room.

Item 2: [Corrected 10/30/13-12:41pm] It was observed at 12:55 pm on Monday, August 19th, 2013, that a transfer grille was installed in the wall of the corridor from the telephone equipment room.

Item 3: It was observed at 8:05 am on Tuesday, August 20th, 2013, that a pass-through window into the Human resources office from the corridor was not smoke tight.

These deficient practices were confirmed by Staff C (Maintenance) at the time of discovery.

Based on observation and interview the facility failed to provide corridor doors that resisted the passage of smoke and no impediment to the closing of such doors in accordance to NFPA 101 ( 2000 edition) Section 19.3.6.3.1. and these doors are provided with a suitable means to keep them closed (roller latches are not allowed) as noted in 19.3.6.3.2 and was not in compliance as evidenced by the following items. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

Item 1: [Corrected 10/30/13 at 12:58pm] It was observed at 1:50 pm on Monday, August 19th, 2013, that a the door into the clean dish area was swollen and did not latch.

Item 2: It was observed at 2:33 pm on Monday, August 19th, 2013, that no astragal was provided at the meeting edge of the double doors into the Riverbend Conference room and the opening was not smoke tight.

Item 3: It was observed at 3:10 pm on Monday, August 19th, 2013, that no astragal was provided at that the meeting edge of the double doors into the Bone Density exam room and the opening was not smoke tight.

Item 4: It was observed at 3:27 pm on Monday, August 19th, 2013, that no astragal was provided at that the meeting edge of the double doors into the Radiology suite near the reception area and the opening was not smoke tight.

Item 5: It was observed at 9:37 am on Tuesday, August 20th, 2013, that a roller latch was provided at the door into Female Dressing room for Surgery

Item 6: It was observed at 10:00 am on Tuesday, August 20th, 2013, that the paired door into the Endoscopy procedure room was not equipped with an astragal to make this opening smoke tight. The small leaf was not kept in the closed position and not latched into place, this opening did not have any positive latching because of this condition.

Item 7: It was observed at 10:32 am on Tuesday, August 20th, 2013, that the door from the 'old Operating room' (in the 1957 building) was not equipped with a latching device. This room was within a suite before and no latching was acceptable. This passage is no longer in a suite configuration. This door is an opening into a corridor and positive latching mechanism is required.

Item 8: It was observed at 10:47 am on Tuesday, August 20th, 2013, that the astragal was provided at that the meeting edge of the double doors into the Operating room suite was not smoke tight, light was visible along this edge.

Item 9: It was observed at 11:17 am on Tuesday, August 20th, 2013, that the two doors into Clean Utility of the Medical Surgical unit are not equipped with positive latching at either door.

Item10: It was observed at 11:18 am on Tuesday, August 20th, 2013, that the west door into Soiled Utility of the Medical Surgical unit did not positively latch. The door appeared swollen in the frame.

These deficient practices were confirmed by Staff C (Maintenance) at the time of discovery.

Based on observation and interview the facility failed to provide a one-hour rated walls and 45-minute rated door into hazardous areas per NFPA 101 - 2000 edition, Section 19.3.2. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

Item 1: It was observed at 11:15 am on Monday, August 19th, 2013, that the Marketing storage was greater than 100 square feet and the door was not labeled to a 45-minute fire resistance rating.

Item 2: [Corrected 10/30/13 at 12:43pm] It was observed at 11:23 am on Monday, August 19th, 2013, that the Elevator Equipment room had two holes in the east wall that were not caulked to a two-hour fire resistance rating.

Item 3: It was observed at 11:29 am on Monday, August 19th, 2013, that Laundry/Paper storage was greater than 100 square feet. The door was not equipped with a door closer. And this door leave had been modified and thus was no longer a rated door due to the field modification.

Item 4: It was observed at 1:03 pm on Monday, August 19th, 2013, that the Gift shop storage was in a room greater than 100 square feet. The door was not equipped with a door closer. And the door was labeled at 20 minutes, a 45-minute label is required. There were approximately 6 or more penetrations in the west and north walls that were not fire caulked to a one-hour rating.

Item 5: [Corrected 10/30/13 at 1:00pm] It was observed at 2:01 pm on Monday, August 19th, 2013, that a sprinkler line above the freezer/refrigerator of the kitchen that penetrated the east wall was not fire caulked to a one-hour.

Item 6: [Corrected 10/30/13 at 1:09pm] It was observed at 2:11 pm on Monday, August 19th, 2013, that a 5 conduits in the east wall of the main electrical room of the 2006 addition were not fire caulked to a two-hour fire rating.

Item 7:[Corrected 10/30/13 at 1:10pm] It was observed at 2:19 pm on Monday, August 19th, 2013, that a 1" x 2" hole was present in the west wall of the materials management space. This wall is common to the main electrical room and a two-hour fire rating is required.

Item 8: [Corrected 10/30/13 at 1:02pm] It was observed at 2:34 pm on Monday, August 19th, 2013, that five holes in the north wall and 3 holes in the east wall of the Air handling room (across the hall from materials management) were not fire caulked to a one-hour fire rating.

Item 9: [Corrected 10/30/13 at 1:04pm] It was observed at 2:39 pm on Monday, August 19th, 2013, that a communication (Bx) cable in the north wall of the laundry room (across the hall from materials management) is not fire caulked to a one-hour fire rating.

Item 10: [Corrected 10/30/13 at 1:05pm] It was observed at 2:41 pm on Monday, August 19th, 2013, that one polyvinyl chloride (pvc) line in the east wall of the room west of the toilets (for the Riverbend conference room) was not fire caulked to a one-hour fire rating.

Item 11: [Corrected 10/30/13 at 1:25pm] It was observed at 3:04 pm on Monday, August 19th, 2013, that seven holes in the south wall of Imaging storage into the south clinic were not sealed to a 2-hour fire rating.

Item 12: It was observed at 9:26 am on Tuesday, August 20th, 2013, that the Clean utility in the OB suite is shown as a one-hour fire barrier. No 45-minute rated door is provided, and no walls are taped and mudded to a one-hour fire barrier and no penetrations were fire caulked to a one-hour on either side of this enclosure.

Item 13: It was observed at 10:14 am on Tuesday, August 20th, 2013, that the 'old OR' in the 1957 building is being used for combustible storage and greater than 100 square feet. The door into this space was not a 45-minute labeled door and no positive latching was provided for this room.

Item 14: It was observed at 10:57 am on Tuesday, August 20th, 2013, that a conduit in the south wall and a sprinkler line in the west wall of Ortho storage were not fire-caulked to a one-hour fire rating.

Item 15: [Corrected 10/30/13 at 1:31pm] It was observed at 11:15 am on Tuesday, August 20th, 2013, that holes in the ceiling of Soiled Utility room of Medical Surgical floor are not sealed to a one-hour fire rating.

Item 16: [Corrected 10/30/13 at 1:29pm] It was observed at 11:38 am on Tuesday, August 20th that the door into Pharmacy Storage is a 45-minute rated door and did not have a closer installed on the door.

These deficient practices were confirmed by Staff C (Maintenance) at the time of discovery.

Based on observation and interview the facility failed to provide exit access to exits at all times in accordance to NFPA 101, Section 7.1. This deficiency could affect all of the staff using the heliport and the patient being transported.

Findings include:

Item #1: It was observed at 11:48 am on Tuesday August 20th, 2013, that the second means of egress from the heliport across the roof deck had to cross a parapet wall. A change in elevation in a means of egress shall be accomplished with a ramp or stair per Section 7.1.7.

This deficient practice was confirmed by Staff E (Administration) and Staff C (Maintenance) at the time of discovery.

Based on observation and interview the facility failed to provide free exit access for all occupants and was not in compliance as evidenced by the following items. This deficiency could affect all of the patients and occupants of the OB unit that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

Item 1: It was observed at 9:36 am on Tuesday, August 20th, 2013, that egress from the OB suite was restricted at all times, unless the fire alarm system or sprinkler system was activated. Egress was only allowed only by card access or if the exit access doors were opened by staff from the nurse station. The public was not free egress out of this suite during normal conditions.

This deficient practice was confirmed by Staff E (Administration) and Staff C (Maintenance) at the time of discovery.

Based on observation and interview the facility failed to provide a sprinkler system that complied with the minimum requirements of NFPA 13 (1999 edition) and was not in compliance as evidenced by the following items. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

Item 1: [Corrected 10/30/13 at 12:47pm] It was observed at 9:36 am on Monday, August 19th, 2013, that no sprinkler head was installed within the elevator equipment room located in the Mechanical room on the lower level.

Item 2: It was observed at 2:08 pm on Monday, August 19th, 2013, that no sprinkler protection was provided for the loading dock canopy. This is a heavy timber (combustible) canopy greater than 4 feet in depth from the building face.

Item 3: [Corrected 10/30/13 at 1:22pm] It was observed at 3:24 pm on Monday, August 19th, 2013, that the sprinkler head within the closet of the doctors reading room #1 of the radiology department was obstructed by storage.

Item 4: [Corrected 10/30/13 at 1:28pm] It was observed at 3:42 pm on Monday, August 19th, 2013, that the ceiling tiles within housekeeping of the ED suite were removed, and the sprinkler head was greater than 22 inches from the deck above.

These deficient practices were confirmed by Staff C (Maintenance) at the time of discovery.

Based on observation and interview the facility failed to provide heating, ventilation in compliance with NFPA 101, Section 9.5, and was not in compliance as evidenced by the following items. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

Item 1: It was observed at 12:44 pm on Monday, August 19th, 2013, that the access door into the 60" x 20" duct for the fire damper into the Air handling mechanical room on the lower level was blocked by two electrical conduits. It was impossible to open this door to exercise the fusible link fire damper.

Item 2: It was observed at 12:49 pm on Monday, August 19th, 2013, that the mechanical plans indicated two fire dampers in the north wall of the same Air handling room in item #1. No access door could be seen.

Item 3: It was observed at 1:19 pm on Monday, August 19th, 2013, that a former storage room was now a Breakroom for Emergency Services (ES) staff. This room was not provided with any mechanical ventilation.

Item 4: It was observed at 1:22 pm on Monday, August 19th, 2013, that the 'old incinerator room' was now a locker room for kitchen staff. This room was not provided with any mechanical ventilation.

Item 5: It was observed at 2:08 pm on Monday, August 19th, 2013, that a new 12" x 20" duct was installed at the south wall of the 2-hour fire barrier for the Main electrical room in the 2006 addition. No fire damper was provided, and no metal angles were attached to this duct.

Item 6: [Corrected 10/30/13 at 1:07pm] It was observed at 2:33 pm on Monday, August 19th, 2013, that the Air handling room (lower level) on the far west end of the restricted corridor in the 2006 addition was being used for general storage of all sorts. Only air filter storage is allowed within an air handling room.

Item 7: It was observed at 9:47 am on Tuesday, August 20th, 2013, that the old preop area was now locker rooms, breakrooms, toilets, and an office for Surgery staff. The following violations were found: Toilet (mens) no air movement at exhaust grille. Office (mens) no supply or return grilles present, Breakroom (mens) no return grille present. Toilet (womens) minimal exhaust air movement, Breakroom (womens) no return grille present, Shower (womens) no exhaust grille, only two exhaust grilles were provided for each of these areas outside of the toilets and showers. Both grilles were located within the locker rooms and very little air movement was detected at either grille.

These deficient practices were confirmed by Staff C (Maintenance) at the time of discovery.

Based on observation and interview the facility failed to provide interior walls in Type II construction type of non-combustible or limited combustible materials, and was not in compliance as evidenced by the following items. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

Item 1: It was observed at 1:52 pm on Monday, August 19th, 2013, that the newly constructed common wall between dishwashing and the 'retro' dining room in the 1957 building is constructed of wood framing. This hospital facility is a Type II (2,2,2) class of construction building.

This deficient practice was confirmed by Staff E (Administration) and Staff C (Maintenance) at the time of discovery.

Based on observation and interview the facility failed to provide electrical wiring and equipment in accordance to NFPA 70, and was not in compliance as evidenced by the following items. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

Item 1:[Corrected 10/30/13 at 1:27pm] It was observed at 11:32 am on Monday, August 19th, 2013, that a power strip within the Employee Fitness gym had 6 outlets within 6 feet of the edge of the sink that were not provided with ground fault circuit interrupter (GFCI) protection.

Item 2: [Corrected 10/30/13 at 12:48pm] It was observed at 1:07 pm on Monday, August 19th, 2013, that a junction box in the air handling mechanical room (lower level) at 6 feet above the finished floor was found without the coverplate in place.

Item 3: It was observed at 1:11 pm on Monday, August 19th, 2013, that the 'old transformer room' is being used concurrently as a storage room for painting supplies (some combustible). Electrical rooms with this level of power should be dedicated spaces. The other Main Electrical equipment room (adjoining this room) was also being used for miscellaneous storage of combustible materials.

Item 4: [Corrected 10/30/13 at 12:52pm] It was observed at 1:11 pm on Monday, August 19th, 2013, that the 'old transformer room' and the Main Electrical room (next door) both were two-hour fire barriers per NFPA 70. Several holes were found in the south wall of the Transformer room, a 2 - 1/2 inch polyvinyl chloride (pvc) pipe penetrated the floor deck/ceiling without a fire collar or fire caulking, and duct and pipe penetrations into this space were not fire caulked to a two-hour fire rating. These penetrations degrade a two-hour fire barrier integrity.

Item 5: [Corrected 10/30/13 at 1:00pm] It was observed at 1:27 pm on Monday, August 19th, 2013, that a junction box within the air handling mechanical room (lower level) of the 1957 building located near the ceiling was open.

Item 6: [Corrected 10/30/13 at 1:08pm] It was observed at 2:02 pm on Monday, August 19th, 2013, that a junction box within the loading dock room was found open.

Item 7: [Corrected 10/30/13 at 1:23pm] It was observed at 3:02 pm on Monday, August 19th, 2013, that a junction box within the housekeeping room on the first floor near the south clinic was found open.

Item 8: [Corrected 10/30/13 at 1:21pm] It was observed at 3:40 pm on Monday, August 19th, 2013, that a junction box within the air shaft (east side of corridor) on the first floor near was found open.

Item 9: [Corrected 10/30/13 at 1:14pm] It was observed at 8:10 am on Tuesday, August 20th, 2013, that a junction box within the mechanical room for OB on the first floor near was found open.

Item 10: [Corrected 10/30/13 at 1:16pm] It was observed at 9:33 am on Tuesday, August 20th that a power strip within the Obstetrics (OB) workroom had outlets within 6 feet of the edge of the sink that were not provided with GFCI protection.

These deficient practices were confirmed by Staff C (Maintenance) at the time of discovery.