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Based on observation and interview the facility failed to maintain the fire-resistance rating of the structure by having areas of the structure where unidentified yellow foam was on beams and not removed, the facility failed to maintain building construction type. This deficient practice affected all patients, staff, and visitors of the facility. The facility census was 206 patients.

Findings are:

Observations on 11-1-10 at 1:43 pm in the revealed:

1. Visible structural beam members above ceiling tiles near 6th floor west nurse station E where yellow foam was partly removed and some remained.

2. Visible structural beam members above ceiling tiles near the north corner of 6th floor west nurse station E where yellow foam remained and was partially covered with hand packed fire safing, which exposed the yellow foam underneath.

During an interview on 11-1-10 at 11:43 pm, Construction Superintendent confirmed the yellow foam remained on the structural beams.

Based on observation and interview the facility failed to maintain the doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas such that they are substantial doors, such as those constructed of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes and are provided with a positive latching means for keeping the door closed. They shall also resist the passage of smoke. The facility census was 206 patients.

Findings are:

1. Observations on 11-1-10 at 4:36 pm revealed a Gait Belt tied to a cabinet in the room and to the door handle of patient room 581.

2. Observations on 11-2-10 at 8:24 am revealed patient room door 534 failed to latch when tested.

3. Observations on 11-2-10 at 8:40 am revealed patient room door 506 failed to latch when tested.

During an interview on 11-1-10 and 11-2-10 at times of findings, Maintenance B confirmed the doors failed to close.

NFPA Standard:
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4



04583


Observations on 11/1/10 at 2:40 pm revealed the double doors in several locations now had an automatic flush bolt installed but did not have a means of closing the inactive leaf when the active leaf was in the closed position. Documentation review revealed the following doors to be two leaf doors:

1. The small leaf of patient room 121 double doors failed to provide a means to close the inactive leaf.

2. The small leaf of patient room 122 double doors failed to provide a means to close the inactive leaf.

3. The small leaf of patient room 123 double doors failed to provide a means to close the inactive leaf.

4. The small leaf of patient room 124 double doors failed to provide a means to close the inactive leaf.

5. The small leaf of patient room 125 double doors failed to provide a means to close the inactive leaf.

6. The small leaf of patient room 126 double doors failed to provide a means to close the inactive leaf.

7. The small leaf of patient room 127 double doors failed to provide a means to close the inactive leaf.

8. The small leaf of patient room 128 double doors failed to provide a means to close the inactive leaf.

9. The small leaf of patient room 130 double doors failed to provide a means to close the inactive leaf.

10. The small leaf of patient room 131 double doors failed to provide a means to close the inactive leaf.

11. The small leaf of patient room 133 double doors failed to provide a means to close the inactive leaf.
12. The small leaf of patient room 134 double doors failed to provide a means to close the inactive leaf.

13. The small leaf of patient room 135 double doors failed to provide a means to close the inactive leaf.

14. The small leaf of Procedure room 154 double doors failed to provide a means to close the inactive leaf.

15. The small leaf of Procedure room 155 double doors failed to provide a means to close the inactive leaf.

16. The small leaf of shower room 156 double doors failed to provide a means to close the inactive leaf.

Administration M confirmed all observations at the times of the observations.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors shall be provided with positive latching hardware. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and interview, the facility failed to ensure that hazardous areas are separated from other areas by partitions and self-closing doors to ensure smoke resisting separation. This deficient practice affects all occupants where the storage of combustibles would not stop the spread of fire and smoke, in the event of a fire as there is no separation to the exit corridor. This facility has a capacity of 265 and a census of 141 patients.
Findings are:

1. Observation on 11/1/10 at 2:21 pm revealed the storage of two large carts of combustible linen storage on the shelves and stacked on top in the exit corridor of the ED department.

2. Observation on 11/2/10 at 10:09 am revealed the 1 hour fire rated double doors to Sterile processing room 1806 had a gap between the doors greater than 1/8 inch at the latch stile area. In addition the double doors to AV storage room 1318 had a gap between doors greater than 1/8 inch. The doors had no astragal in the latch stile area.

Administration M confirmed all observations at the times of the observations.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1



13879


Based on observation and interview, the facility failed to maintain the fire door allowable gap between doors on 6th floor. This deficient practice has the potential to affect all occupants of the east tower. The facility census was 206 patients.

Findings are:

Observations on 11-1-10 at 11:53 am in the revealed a greater than a 1/8 in gap between the 1 ? hour fire rated doors separating the north and south areas of the 6th floor east tower storage.

During an interview on 11-1-10 at 11:53 am, Maintenance B confirmed the gap between the fire doors.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 1998 Edition of NFPA 25, by ensuring that sprinkler heads are installed as required. The facility also failed to maintain the system with an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This deficient practice affected all patients, visitors and staff that use those areas. The facility census was 206 patients.

Findings are:

Observations on 11-1-10 between 4:20 pm and 4:39 pm on the fifth floor revealed:
1. Facility failed to maintain 18 inches of clear space from the sprinkler head to items on the top shelf in the linen closet between rooms 588 and 589.

2. Facility failed to maintain 18 inches of clear space from the sprinkler head to items on the top shelf in the linen closet between rooms 585 and 586.

3. Facility failed to maintain 18 inches of clear space from the sprinkler head to items on the top shelf in the linen closet between rooms 580 and 581.

Observations on 11-2-10 at 8:38 am on the fifth floor revealed:

4. Missing sprinkler escutcheon over the bed in patient room 503.

During an interview on 11-1-10 and 11-2-10 at times of observations, Maintenance B confirmed the findings.

NFPA Standard: Unacceptable obstructions to spray patterns shall be corrected. 1998 NFPA 25, 2-2.1.2

Based on observation and interview, the facility failed to secure portable fire extinguishers near the 6th floor construction office area. The facility census was 206 patients.

Findings are:

Observations on 11-1-10 at 11:49 am in the revealed, four unsecured fire extinguishers setting on the floor outside the 6th floor construction office.

During an interview 11-1-10 at 11:49 am, Maintenance B confirmed the fire extinguishers on the floor.

NFPA Standard:
Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer ' s instructions. Wheeled-type fire extinguishers shall be located in a designated location. 2000 NFPA 10, 1-6.7

Based on observation and staff interview, the facility failed to continuously maintain means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice affected all patients, visitors and staff that use the facility. The facility census was 206 patients.

Findings are:

Observations on 11-1-10 at 2:29 pm revealed an approximate 4 foot by 5 foot by 2 foot rolling supply cart with combustible packaging stored in the egress corridor in the Infusion/Dialysis front reception area.

During an interview on 11-1-10 at 2:29 pm, Maintenance B confirmed the storage cart in the corridor.

NFPA Standard:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on documentation review and interview the facility failed to not use an extension cord for permanent wiring. his facility has a capacity of 265 and a census of 141 patients.

Findings are:

Review of a photo provided by Administration M on 11/2/10 revealed an extension cord being used as permanent wiring for the sump pump in the tunnel. Administration M confirmed the wiring at this time.



13879


Based on staff interview and observation, the facility failed to ensure all electrical was installed in accordance with National Fire Protection Association 70 (electrical code). This deficient practice affected all patients, visitors and staff that are in the area of open junction boxes and power strips. The facility census was 206 patients.

Findings are:

Observations on 11-1-10 between 11:15 am and 3:32 pm revealed:

1. Microwave plugged into an extension cord in the Electrical Contractor ' s office on the 6th floor.

2. Refrigerator plugged into a power strip in the Asbestos Lab office on the 6th floor.

3. Two power strips plugged into each other in the Asbestos Lab office on the 6th floor.

4. Open electrical junction box above the ceiling tiles near the nurse station D six west in the south hall near the thermostat.

5. Open end taupe cable, unmarked as abandoned, located above ceiling tiles in corridor near nurse server 621.

6. Unsecured electrical junction box above ceiling tiles above the pop machine in East Galley 6037.

7. Observation on 11-2-10 at 2:47 pm revealed that the West Tower 3rd. Level, Upper Substation contained large electrical equipment and transformers over 112.5KVA, the exit door failed to close and latch within door frame.

During an interview on 11-1-10 and 11-2-10 at times of observations, Maintenance B confirmed all the findings.

NFPA Standard:
All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of 250.110 . An extension from the cover of an exposed box shall comply with 314.22 , Exception. 2002, NFPA 70, article 314.28

Based on observation and interview the facility failed to maintain the fire-resistance rating of the structure by having areas of the structure where unidentified yellow foam was on beams and not removed, the facility failed to maintain building construction type. This deficient practice affected all patients, staff, and visitors of the facility. The facility census was 206 patients.

Findings are:

Observations on 11-1-10 at 1:43 pm in the revealed:

1. Visible structural beam members above ceiling tiles near 6th floor west nurse station E where yellow foam was partly removed and some remained.

2. Visible structural beam members above ceiling tiles near the north corner of 6th floor west nurse station E where yellow foam remained and was partially covered with hand packed fire safing, which exposed the yellow foam underneath.

During an interview on 11-1-10 at 11:43 pm, Construction Superintendent confirmed the yellow foam remained on the structural beams.

Based on observation and interview the facility failed to maintain the doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas such that they are substantial doors, such as those constructed of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes and are provided with a positive latching means for keeping the door closed. They shall also resist the passage of smoke. The facility census was 206 patients.

Findings are:

1. Observations on 11-1-10 at 4:36 pm revealed a Gait Belt tied to a cabinet in the room and to the door handle of patient room 581.

2. Observations on 11-2-10 at 8:24 am revealed patient room door 534 failed to latch when tested.

3. Observations on 11-2-10 at 8:40 am revealed patient room door 506 failed to latch when tested.

During an interview on 11-1-10 and 11-2-10 at times of findings, Maintenance B confirmed the doors failed to close.

NFPA Standard:
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4



04583


Observations on 11/1/10 at 2:40 pm revealed the double doors in several locations now had an automatic flush bolt installed but did not have a means of closing the inactive leaf when the active leaf was in the closed position. Documentation review revealed the following doors to be two leaf doors:

1. The small leaf of patient room 121 double doors failed to provide a means to close the inactive leaf.

2. The small leaf of patient room 122 double doors failed to provide a means to close the inactive leaf.

3. The small leaf of patient room 123 double doors failed to provide a means to close the inactive leaf.

4. The small leaf of patient room 124 double doors failed to provide a means to close the inactive leaf.

5. The small leaf of patient room 125 double doors failed to provide a means to close the inactive leaf.

6. The small leaf of patient room 126 double doors failed to provide a means to close the inactive leaf.

7. The small leaf of patient room 127 double doors failed to provide a means to close the inactive leaf.

8. The small leaf of patient room 128 double doors failed to provide a means to close the inactive leaf.

9. The small leaf of patient room 130 double doors failed to provide a means to close the inactive leaf.

10. The small leaf of patient room 131 double doors failed to provide a means to close the inactive leaf.

11. The small leaf of patient room 133 double doors failed to provide a means to close the inactive leaf.
12. The small leaf of patient room 134 double doors failed to provide a means to close the inactive leaf.

13. The small leaf of patient room 135 double doors failed to provide a means to close the inactive leaf.

14. The small leaf of Procedure room 154 double doors failed to provide a means to close the inactive leaf.

15. The small leaf of Procedure room 155 double doors failed to provide a means to close the inactive leaf.

16. The small leaf of shower room 156 double doors failed to provide a means to close the inactive leaf.

Administration M confirmed all observations at the times of the observations.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors shall be provided with positive latching hardware. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and interview, the facility failed to ensure that hazardous areas are separated from other areas by partitions and self-closing doors to ensure smoke resisting separation. This deficient practice affects all occupants where the storage of combustibles would not stop the spread of fire and smoke, in the event of a fire as there is no separation to the exit corridor. This facility has a capacity of 265 and a census of 141 patients.
Findings are:

1. Observation on 11/1/10 at 2:21 pm revealed the storage of two large carts of combustible linen storage on the shelves and stacked on top in the exit corridor of the ED department.

2. Observation on 11/2/10 at 10:09 am revealed the 1 hour fire rated double doors to Sterile processing room 1806 had a gap between the doors greater than 1/8 inch at the latch stile area. In addition the double doors to AV storage room 1318 had a gap between doors greater than 1/8 inch. The doors had no astragal in the latch stile area.

Administration M confirmed all observations at the times of the observations.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1



13879


Based on observation and interview, the facility failed to maintain the fire door allowable gap between doors on 6th floor. This deficient practice has the potential to affect all occupants of the east tower. The facility census was 206 patients.

Findings are:

Observations on 11-1-10 at 11:53 am in the revealed a greater than a 1/8 in gap between the 1 ? hour fire rated doors separating the north and south areas of the 6th floor east tower storage.

During an interview on 11-1-10 at 11:53 am, Maintenance B confirmed the gap between the fire doors.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 1998 Edition of NFPA 25, by ensuring that sprinkler heads are installed as required. The facility also failed to maintain the system with an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This deficient practice affected all patients, visitors and staff that use those areas. The facility census was 206 patients.

Findings are:

Observations on 11-1-10 between 4:20 pm and 4:39 pm on the fifth floor revealed:
1. Facility failed to maintain 18 inches of clear space from the sprinkler head to items on the top shelf in the linen closet between rooms 588 and 589.

2. Facility failed to maintain 18 inches of clear space from the sprinkler head to items on the top shelf in the linen closet between rooms 585 and 586.

3. Facility failed to maintain 18 inches of clear space from the sprinkler head to items on the top shelf in the linen closet between rooms 580 and 581.

Observations on 11-2-10 at 8:38 am on the fifth floor revealed:

4. Missing sprinkler escutcheon over the bed in patient room 503.

During an interview on 11-1-10 and 11-2-10 at times of observations, Maintenance B confirmed the findings.

NFPA Standard: Unacceptable obstructions to spray patterns shall be corrected. 1998 NFPA 25, 2-2.1.2

Based on observation and interview, the facility failed to secure portable fire extinguishers near the 6th floor construction office area. The facility census was 206 patients.

Findings are:

Observations on 11-1-10 at 11:49 am in the revealed, four unsecured fire extinguishers setting on the floor outside the 6th floor construction office.

During an interview 11-1-10 at 11:49 am, Maintenance B confirmed the fire extinguishers on the floor.

NFPA Standard:
Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer ' s instructions. Wheeled-type fire extinguishers shall be located in a designated location. 2000 NFPA 10, 1-6.7

Based on observation and staff interview, the facility failed to continuously maintain means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice affected all patients, visitors and staff that use the facility. The facility census was 206 patients.

Findings are:

Observations on 11-1-10 at 2:29 pm revealed an approximate 4 foot by 5 foot by 2 foot rolling supply cart with combustible packaging stored in the egress corridor in the Infusion/Dialysis front reception area.

During an interview on 11-1-10 at 2:29 pm, Maintenance B confirmed the storage cart in the corridor.

NFPA Standard:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on documentation review and interview the facility failed to not use an extension cord for permanent wiring. his facility has a capacity of 265 and a census of 141 patients.

Findings are:

Review of a photo provided by Administration M on 11/2/10 revealed an extension cord being used as permanent wiring for the sump pump in the tunnel. Administration M confirmed the wiring at this time.



13879


Based on staff interview and observation, the facility failed to ensure all electrical was installed in accordance with National Fire Protection Association 70 (electrical code). This deficient practice affected all patients, visitors and staff that are in the area of open junction boxes and power strips. The facility census was 206 patients.

Findings are:

Observations on 11-1-10 between 11:15 am and 3:32 pm revealed:

1. Microwave plugged into an extension cord in the Electrical Contractor ' s office on the 6th floor.

2. Refrigerator plugged into a power strip in the Asbestos Lab office on the 6th floor.

3. Two power strips plugged into each other in the Asbestos Lab office on the 6th floor.

4. Open electrical junction box above the ceiling tiles near the nurse station D six west in the south hall near the thermostat.

5. Open end taupe cable, unmarked as abandoned, located above ceiling tiles in corridor near nurse server 621.

6. Unsecured electrical junction box above ceiling tiles above the pop machine in East Galley 6037.

7. Observation on 11-2-10 at 2:47 pm revealed that the West Tower 3rd. Level, Upper Substation contained large electrical equipment and transformers over 112.5KVA, the exit door failed to close and latch within door frame.

During an interview on 11-1-10 and 11-2-10 at times of observations, Maintenance B confirmed all the findings.

NFPA Standard:
All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of 250.110 . An extension from the cover of an exposed box shall comply with 314.22 , Exception. 2002, NFPA 70, article 314.28