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Based on observation and interview, the facility failed to maintain 2 hour fire resistance separation between the clinic and the hospital. This deficient practice may allow for the spread of fire, smoke, and toxic gases between occupancies.
Findings are:
1. Observation on 07/08/2014 at 13:12pm revealed unsealed penetrations by pipes above the grid style ceiling over the 1.5 hour fire door. The penetrations were in a 2 hour fire resistance rated wall separating the clinic and the hospital.
During an interview conducted on 07/08/2014 at 13:12pm, Maintenance A confirmed this finding.
2. Observation on 07/08/2014 at 10:00am revealed the fire rated hardware on the 1.5 hour fire doors separating the clinic and the hospital as well as the 1.5 hour fire doors separating human resources/payroll and the hospital were modified so that they would not latch.
During an interview conducted on 07/08/2014 at 10:00am, Maintenance A confirmed these findings.

Based on observation and interview, the facility failed to maintain smoke barriers. This deficient practice may allow the communication of smoke from one smoke compartment to an adjacent compartment.

Findings are:

Observation on 07/08/2014 at 13:00pm revealed unsealed penetrations by cables in the above the ceiling wall over the 1 hour fire doors adjacent to the surgical department.

During an interview conducted on 07/08/2014 at 13:00pm, Maintenance A confirmed this finding.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice may allow for the communication of fire, smoke, and toxic gases between compartments.

Findings are:

1. Observation on 07/07/2014 at 14:20pm revealed the door to the IT storage room was not equipped with a self-closing device.

During an interview conducted on 07/07/2014 at 14:20pm, Maintenance A confirmed this finding.

2. Observation on 07/08/2014 at 10:10am revealed the door to the physical therapy storage room was not equipped with a self-closing device.

During an interview conducted on 07/08/2014 at 10:10am, Maintenance A confirmed this finding.

Based on observation and interview, the facility failed to prohibit the storage of combustible materials within stair enclosures. This deficient practice could potentially interfere with egress for all occupants in the basement.

Findings are:

Observation on 07/07/2014 at 14:30pm revealed the basement landing of the IT stair enclosure contained combustible material storage.

During an interview conducted on 07/07/2014 at 14:30pm, Maintenance A confirmed this finding.

Based on observation and interview, the facility failed to properly maintain means of egress reliability by allowing full length mirrors within an exit access corridor. This deficient practice could create confusion and potentially interfere with egress for all occupants in the basement.

Findings are:

Observation on 07/07/2014 at 14:17pm revealed full length mirrors on two perpendicular corridor walls in the basement near the IT offices.

During an interview conducted on 07/07/2014 at 14:17pm, Maintenance A confirmed this finding.

Based on record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice affects all occupants including staff, visitors and patients, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency.

Findings are:

Record review on 07/07/2014 at 13:50pm revealed the facility did not have documentation for the following drills: 1st shift- 2nd and 4th quarter, 2nd shift-3rd quarter, 3rd shift-all quarters.

During an interview conducted on 07/07/2014 at 13:50pm, Maintenance A confirmed this finding.

Based on observation and interview, the facility failed to provide an automatic fire sprinkler system in accordance with NFPA 13. This deficient practice may allow for fire growth and spread to uninvolved compartments. All occupants may be affected as several locations throughout the facility were found without automatic fire sprinkler protection.

Findings are:

1. Observation between 07/07/2014 at 14:35pm and 07/08/2014 at 11:40am revealed the following locations were not protected with automatic fire sprinklers: basement mechanical room offices, x-ray room, patient room B12, patient room B10, the maintenance shop, and the boiler room located adjacent to the maintenance shop.

During interviews conducted between 07/07/2014 at 14:35pm and 07/08/2014 at 11:40am, Maintenance A confirmed these findings.

2. Observation on 07/07/2014 at 15:20pm revealed ceiling mounted fire sprinklers could be obstructed by an open overhead door located in the materials management room adjacent to the kitchen. The overhead door was over 4 feet (1.2m) wide.

During an interview conducted on 07/07/2014 at 15:20pm, Maintenance A confirmed this finding.

Based on record review and interview, the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 25 by not performing required quarterly inspections. This deficient practice could affect all occupants within the facility.

Findings are:

Record review on 07/07/2014 at 14:52pm revealed quarterly inspections had not been conducted on the automatic fire sprinkler system.

During an interview conducted on 07/07/2014 at14:52, Maintenance A confirmed this finding.

Based on observation and interview, the facility failed to maintain and test the exhaust hood and fire suppression system in compliance with NFPA 96. The deficient practice of improper inspection timelines may allow faults in fire protection equipment to go undetected. All occupants may affected by the lack of semiannual inspections

Findings are:

Record review on 07/07/2014 at15:05pm revealed the exhaust hood and fire suppression system had not received semi-annual inspection. Also, it was documented on the previous two inspection reports the electric receptacles beneath the hood did not disconnect upon activation of the system.

During an interview on 07/07/2014 at 15:05pm, Maintenance A confirmed this finding.

Based on observation and interview, the facility failed to properly limit the electrical items placed on the life safety branch of their Type 1 EES to those allowed in accordance with NFPA 99. This deficient practice would allow non-permissible items to receive power from the essential electrical system during potential emergencies and may affect all occupants.

Findings are:

Observation on 07/08/2014 at 12:05pm revealed non-permissible items on the schedule of life safety electrical panel XK. Items included circuits marked as receptacles for a refrigerator, a printer, and laboratory receptacles.

During an interview conducted on 07/08/2014 at 12:05pm, Maintenance A confirmed these findings.

Based on observation and interview, the facility did not prohibit the improper use of extension cords. This deficient practice creates the potential for an electrical fire in an unsprinklered portion of the facility. A fire in an unsprinklered portion of the facility may spread to other compartments and affect all occupants.

Findings are:

Observation on 07/08/2014 at 10:45 revealed an exhaust fan over an exterior door in the maintenance shop was connected to an extension cord substituted for permanent wiring.

During an interview conducted on 07/08/2014 at 10:45, Maintenance A confirmed this finding.

Based on observation and interview, the facility failed to maintain 2 hour fire resistance separation between the clinic and the hospital. This deficient practice may allow for the spread of fire, smoke, and toxic gases between occupancies.
Findings are:
1. Observation on 07/08/2014 at 13:12pm revealed unsealed penetrations by pipes above the grid style ceiling over the 1.5 hour fire door. The penetrations were in a 2 hour fire resistance rated wall separating the clinic and the hospital.
During an interview conducted on 07/08/2014 at 13:12pm, Maintenance A confirmed this finding.
2. Observation on 07/08/2014 at 10:00am revealed the fire rated hardware on the 1.5 hour fire doors separating the clinic and the hospital as well as the 1.5 hour fire doors separating human resources/payroll and the hospital were modified so that they would not latch.
During an interview conducted on 07/08/2014 at 10:00am, Maintenance A confirmed these findings.

Based on observation and interview, the facility failed to maintain smoke barriers. This deficient practice may allow the communication of smoke from one smoke compartment to an adjacent compartment.

Findings are:

Observation on 07/08/2014 at 13:00pm revealed unsealed penetrations by cables in the above the ceiling wall over the 1 hour fire doors adjacent to the surgical department.

During an interview conducted on 07/08/2014 at 13:00pm, Maintenance A confirmed this finding.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice may allow for the communication of fire, smoke, and toxic gases between compartments.

Findings are:

1. Observation on 07/07/2014 at 14:20pm revealed the door to the IT storage room was not equipped with a self-closing device.

During an interview conducted on 07/07/2014 at 14:20pm, Maintenance A confirmed this finding.

2. Observation on 07/08/2014 at 10:10am revealed the door to the physical therapy storage room was not equipped with a self-closing device.

During an interview conducted on 07/08/2014 at 10:10am, Maintenance A confirmed this finding.

Based on observation and interview, the facility failed to prohibit the storage of combustible materials within stair enclosures. This deficient practice could potentially interfere with egress for all occupants in the basement.

Findings are:

Observation on 07/07/2014 at 14:30pm revealed the basement landing of the IT stair enclosure contained combustible material storage.

During an interview conducted on 07/07/2014 at 14:30pm, Maintenance A confirmed this finding.

Based on observation and interview, the facility failed to properly maintain means of egress reliability by allowing full length mirrors within an exit access corridor. This deficient practice could create confusion and potentially interfere with egress for all occupants in the basement.

Findings are:

Observation on 07/07/2014 at 14:17pm revealed full length mirrors on two perpendicular corridor walls in the basement near the IT offices.

During an interview conducted on 07/07/2014 at 14:17pm, Maintenance A confirmed this finding.

Based on record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice affects all occupants including staff, visitors and patients, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency.

Findings are:

Record review on 07/07/2014 at 13:50pm revealed the facility did not have documentation for the following drills: 1st shift- 2nd and 4th quarter, 2nd shift-3rd quarter, 3rd shift-all quarters.

During an interview conducted on 07/07/2014 at 13:50pm, Maintenance A confirmed this finding.

Based on observation and interview, the facility failed to provide an automatic fire sprinkler system in accordance with NFPA 13. This deficient practice may allow for fire growth and spread to uninvolved compartments. All occupants may be affected as several locations throughout the facility were found without automatic fire sprinkler protection.

Findings are:

1. Observation between 07/07/2014 at 14:35pm and 07/08/2014 at 11:40am revealed the following locations were not protected with automatic fire sprinklers: basement mechanical room offices, x-ray room, patient room B12, patient room B10, the maintenance shop, and the boiler room located adjacent to the maintenance shop.

During interviews conducted between 07/07/2014 at 14:35pm and 07/08/2014 at 11:40am, Maintenance A confirmed these findings.

2. Observation on 07/07/2014 at 15:20pm revealed ceiling mounted fire sprinklers could be obstructed by an open overhead door located in the materials management room adjacent to the kitchen. The overhead door was over 4 feet (1.2m) wide.

During an interview conducted on 07/07/2014 at 15:20pm, Maintenance A confirmed this finding.

Based on record review and interview, the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 25 by not performing required quarterly inspections. This deficient practice could affect all occupants within the facility.

Findings are:

Record review on 07/07/2014 at 14:52pm revealed quarterly inspections had not been conducted on the automatic fire sprinkler system.

During an interview conducted on 07/07/2014 at14:52, Maintenance A confirmed this finding.

Based on observation and interview, the facility failed to maintain and test the exhaust hood and fire suppression system in compliance with NFPA 96. The deficient practice of improper inspection timelines may allow faults in fire protection equipment to go undetected. All occupants may affected by the lack of semiannual inspections

Findings are:

Record review on 07/07/2014 at15:05pm revealed the exhaust hood and fire suppression system had not received semi-annual inspection. Also, it was documented on the previous two inspection reports the electric receptacles beneath the hood did not disconnect upon activation of the system.

During an interview on 07/07/2014 at 15:05pm, Maintenance A confirmed this finding.

Based on observation and interview, the facility failed to properly limit the electrical items placed on the life safety branch of their Type 1 EES to those allowed in accordance with NFPA 99. This deficient practice would allow non-permissible items to receive power from the essential electrical system during potential emergencies and may affect all occupants.

Findings are:

Observation on 07/08/2014 at 12:05pm revealed non-permissible items on the schedule of life safety electrical panel XK. Items included circuits marked as receptacles for a refrigerator, a printer, and laboratory receptacles.

During an interview conducted on 07/08/2014 at 12:05pm, Maintenance A confirmed these findings.

Based on observation and interview, the facility did not prohibit the improper use of extension cords. This deficient practice creates the potential for an electrical fire in an unsprinklered portion of the facility. A fire in an unsprinklered portion of the facility may spread to other compartments and affect all occupants.

Findings are:

Observation on 07/08/2014 at 10:45 revealed an exhaust fan over an exterior door in the maintenance shop was connected to an extension cord substituted for permanent wiring.

During an interview conducted on 07/08/2014 at 10:45, Maintenance A confirmed this finding.