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Based on observation and interview, the facility did not provide a common separation wall with closers on all doors, sealed wall penetrations, and taped joints on fire rated walls. These deficiencies occurred in 3 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 07/13/2015 at 11:27 am, observation revealed on the 1st floor in the 1454-Health Information Record Storage Room within smoke compartment 1H, that the separation door did not self-close because the automatic closer was not adequately secured to the door frame. One of the screw anchors was missing from the closer. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.1.1.4.

2. On 07/14/2015 at 9:31 am, observation revealed on the 3rd floor in the 3291-Day Room & Lounge, that penetrations were not sealed according to an approved method. The deficiencies included an area of the upper wall above the ceiling not properly constructed to a 2-hour fire-rated wall assembly. The integration between the concrete masonry unit blocks and drywall did not meet either UL or any other 3rd Party testing agency lab criteria. This wall was also serving as the separation barrier between two different Healthcare License entities (Hospital & Nursing Home). This observed situation was not compliant with NFPA 101 (2000 ed.), 18.1.1.4; and 8.2.3.2.4.

3. On 07/13/2015 at 3:32 pm, observation revealed on the 2nd floor in the 2301-Office, along the separation barrier to the nursing home, in smoke compartment 2C, that the enclosing wall was not constructed to a 2-hour fire resistance rating; not all the drywall screws were covered with joint compound as required for designs for rated walls. At top and bottom of the wall, the screws were not mudded. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.1.1.4.

4. On 07/13/2015 at 3:34 pm, observation revealed on the 2nd floor in the 2302-Office Room, along the separation barrier to the nursing home, in smoke compartment 2C, that the enclosing wall was not constructed to a 2-hour fire resistance rating; not all the drywall screws were covered with joint compound as required for designs for rated walls. At top and bottom of the wall, the screws were not mudded. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.1.1.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff II (Director PO & Maintenance), staff SS (Director of Quality), staff TT (EUA-Life Safety Code Cons.) and staff XX (Maintenance Group Leader).
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Based on observation and interview, the facility did not provide and maintain the required building construction type with support steel covered with rated fire proofing. This deficiency occurred in 1 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within this and upper smoke compartments.

FINDINGS INCLUDE:

On 07/13/2015 at 2:20 pm, observation revealed on the 2nd floor in the 2118-Child & Adolescent Activity Room, that fire proofing was missing from the structural steel beam. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.1.6.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (Director PO & Maintenance), staff SS (Director of Quality), staff TT (EUA-Life Safety Code Cons.) and staff XX (Maintenance Group Leader).
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Based on observation and interview, the facility did not provide corridor separation doors with double doors with an astragal seal at the meeting edge. This deficiency occurred in 2 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these two smoke compartments.

FINDINGS INCLUDE:

On 07/13/2015 at 2:16 pm, observation revealed on the 2nd floor in the entrance to the Child & Adolescent Dining Room, that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke between smoke compartments. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.5-exception 4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (Director PO & Maintenance), staff SS (Director of Quality), staff TT (EUA-Life Safety Code Cons.) and staff XX (Maintenance Group Leader).
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Based on observation and interview, the facility did not proper vertical openings between floors and construction having fire resistant rating of at least two hours per its Building Type II (222). This deficiency occurred in 1 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 07/13/2015 at 10:55 am, observation revealed on the 1st floor in the 1404-Stairwell H within smoke compartment 1H, that a penetration was not sealed according to an approved method. The deficiency included a 1 inch diameter cable sleeve. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

2. On 07/13/2015 at 10:56 am, observation revealed on the 1st floor in the 1404-Stairwell H within smoke compartment 1H, that a penetration was not sealed according to an approved method. The deficiency included a 1 inch electrical conduit. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (Director PO & Maintenance), staff SS (Director of Quality), staff TT (EUA-Life Safety Code Cons.) and staff XX (Maintenance Group Leader).
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Based on observation and interview, the facility failed to identify by appropriate exit signs to direct occupants toward the exit access door in one location in accordance with NFPA 101 7.10.1.4. This deficient practice occurred in 1 of 14 smoke compartments, and had the potential to affect an undetermined number of staff in the facility.

Findings include:

During a tour of the facility with Staff M1 (quality improvement manager), Staff M2 (architect, Eppstein Uhen Architects), and Staff HH (maintenance group leader) on 7/13/15, surveyor observed between 11:30 pm and 12:30 pm that there was no directional exit sign in the passage W2130 in the OR suite on 2nd Floor in the CVI building to direct occupants to the exit access corridor. Without the exit sign, it was not readily apparent that the passage leads to exit access corridor.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the quality improvement manager, the group leader of maintenance department), and the architect of Eppstein Uhen Architects on 7/14/15 at 2:50 pm.

NFPA 101 section 7.10.1.4
"Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs."



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Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent. This deficiency occurred in 2 of the 14 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 07/14/2015 at 2:10 pm, observation revealed on the 1st floor in the Egress Passage ways, in both aisles of the Emergency Department at the Smoke Barrier between 1Q & 1R smoke compartments, that the path of egress was not readily apparent and exit signs were not provided. The egress passage ways were running parallel to each other within the two suites and separated by a Won-Door, where missing Exit Signs where the Won-Door opened, allowing egress from one smoke compartment to another. The bulkhead at the passage ways was missing Exit Signs to show emergency egress from one smoke compartment to another in the event of a fire emergency. These observed situations were not compliant with NFPA 101 (2000 ed.), 7.10.1.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (Dir. P.O. & Maint.), staff SS (Dir. Of Quality), staff LL (Dir. P.O. & Maint.), and staff TT (EUA - LSC Consultant), staff UU (ED Medical Dir.), staff O (ED Director) and staff VV (Mgr. of ED).
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Based on observation and interview, the facility exceeded the limit for smoke compartment size. This deficiency occurred in 2 of the 30 smoke compartments and had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 07/15/2015 at 9:00 am surveyor observed in the LE & LD smoke compartment on the Lower Level floor, that the smoke compartments exceeds size limitations. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff EE (Vice President Facilities).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations. This deficiency occurred in 2 of the 14 smoke compartments and had the potential to affect 25 of the 314 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 7/13/2015 at 11:05 am surveyor observed in the Smoke Compartment 5R on the 5th floor in the W5050-Corridor, that penetration(s) were not sealed according to an approved method. The deficiency included four conduit sleeves where the ends were sealed but the annular space between the conduits was not sealed. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff KK (Director of Clinical Services), staff C (Director of Clinical Services), staff LL (Maintenance Group Leader), architect GG (Eppstein Uhen Architects) and staff MM (Director of Medical Group Operations).

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Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with compliant smoke doors. These deficiencies occurred in 2 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 07/14/2015 at 11:25 am, observation revealed on the 3rd floor in the Corridor Smoke Compartment Separation Door Set, that the smoke barrier door was not compliant. The smoke barrier door set in the corridor was shown to be not double-egress and not opening in opposite directions on the Life Safety Plan set. The actual double doors are installed as double-egress per code. Therefore, the Life Safety Plans are drawn incorrectly. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.6.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (Director PO & Maintenance), staff SS (Director of Quality), staff TT (EUA-Life Safety Code Cons.) and staff XX (Maintenance Group Leader).
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Based on observation and interview, the facility did not enclose hazardous rooms with doors having positive-latching hardware, sealed wall penetrations, rated wall construction and taped joints on rated walls. These deficiencies occurred in 3 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 07/13/2015 at 1:22 pm, observation revealed on the 1st floor in the 1306-Kitchen Storage Room, within smoke compartment 1F, that the door would not positively self-latch when released because the door did not have a closer. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.3.2.

2. On 07/14/2015 at 9:25 am, observation revealed on the 3rd floor in the 3200-Mental Health Public Elevator Lobby, that the door to the waste chute would not positively self-latch when released. The hazardous chute room door closer would not bring the door completely to the frame and latch. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.3.2.

3. On 07/13/2015 at 11:37 am, observation revealed on the 1st floor in the 1432-Laundry Storage Room, within smoke compartment 1H, that the penetration was not sealed according to an approved method. The deficiency included a 3 inch diameter penetration of cables not in a fire rated sleeve. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

4. On 07/14/2015 at 11:20 am, observation revealed on the 3rd floor in the 3143-Mental Health Clean Storage Room, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall was observed to have a 10" x 10" drywall patch that did not anchor properly to the existing wall and attach directly to wall supports within the wall. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

5. On 07/14/2015 at 10:12 am, observation revealed on the 3rd floor in the 3232-Oxygen Storage Room, that the enclosing wall was not constructed to a 1-hour fire resistance rating; not all of the drywall joints were covered with a the proper layers of drywall compound. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (Director PO & Maintenance), staff SS (Director of Quality), staff TT (EUA-Life Safety Code Cons.) and staff XX (Maintenance Group Leader).
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Based on observation and interview, the facility did not protect the facility from the contents of the hazardous gift shop by using construction methods required by the code. The adjoining gift shop storage room was missing a door with positive-latching hardware.

FINDINGS INCLUDE:

On 07/13/2015 at 11:41 am, observation revealed on the 1st floor in the 1360-Gift Shop Room within smoke compartment 1H, that the door would not positively self-latch when released because the door to the storage closet was missing. The gift shop room had a sufficient amount of combustibles within the space and was larger than 100 square feet, making the space hazardous to the surrounding corridor. The gift shop contained a quantity of stored combustible product that was considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (Director PO & Maintenance), staff SS (Director of Quality), staff TT (EUA-Life Safety Code Cons.) and staff XX (Maintenance Group Leader).
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Based on observation and interview, the facility did not provide and maintain at least 2 approved and remote exits as prescribed. This deficiency occurred in 1 of the 14 smoke compartments and had the potential to affect 2 of the 250 staff that were working.

FINDINGS INCLUDE:
On 7/13/2015 at 11:28 am surveyor observed in the Smoke Compartment 4R on the 4th floor in the W4644-Storage, that the egress path was not compliant. The storage room/shell space only had a single exit door and based on the total area and travel distance a second exit door is required. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff KK (Director of Clinical Services), staff C (Director of Clinical Services), staff LL (Maintenance Group Leader), architect GG (Eppstein Uhen Architects) and staff MM (Director of Medical Group Operations).

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Based on observation and interview, the facility did not provide and maintain all stairs with door assemblies, to meet code requirements with exits free of storage. This deficiency occurred in 1 of the 14 smoke compartments and had the potential to affect 5 of the 250 staff that were working.

FINDINGS INCLUDE:
On 7/13/2015 at 10:15 am surveyor observed in the Smoke Compartment 6Q smoke compartment on the 6th floor in the Penthouse Stair, that a portion of the stair enclosure was being used as usable space. The rated stair enclosure space was being used to store protective elevator pads, helipad maintenance supplies, two metal cabinets along with additional maintenance supplies. The code requires that "there shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress". This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.2.3 and 7.2.2.5.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff KK (Director of Clinical Services), staff C (Director of Clinical Services), staff LL (Maintenance Group Leader), architect GG (Eppstein Uhen Architects) and staff MM (Director of Medical Group Operations).

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Based on observation and interview, the facility did not provide egress paths at all times with a compliant egress path, no obstructions in the path of egress, and door hardware that operated with a single release motion. This deficiency occurred in 3 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 07/13/2015 at 12:15 pm, observation revealed on the 1st floor in the Mental Hospital Main Entry Vestibule, within smoke compartment 1H, that the egress path was not compliant. The panic hardware paddle on the door with the signage was worn away and a new sign was placed on the center horizontal mullion of the egress door. When one of the tour members tried to go through the door it did not open when pressing against the signage stating press here. That is because the real handle signage was missing or worn-away to properly operate the door to exit egress in the event of a fire. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.7 and 7.7.

2. On 07/13/2015 at 11:39 am, observation revealed on the 1st floor in the 1365-Egress Corridor, within smoke compartment 1H, that the exit path was not readily accessible. The fire shutter release would block the egress pathway to an exit. This fire shutter has been abandoned and is required by law to be removed. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.5.1.1.

3. On 07/13/2015 at 1:47 pm, observation revealed on the 1st floor in the 1324-Servery next to Cafeteria, within smoke compartment 1F, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a dead-bolt on both sets of the double doors out of the Servery. One set of doors has to be identified as an egress point in the event of a fire emergency from behind the Servery Counter. The door that will be selected must be clearly identified to all occupants within this Servery area. The double door set selected, must meet one-hand & one-motion to operate from within the Servery Area. This is applicable for both Business & Institutional Occupancies for egress. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.5.4.

4. On 07/13/2015 at 3:04 pm, observation revealed on the 1st floor in the West Entrance & Exit to Fresh Start Outpatient Mental Health Suite, in smoke compartment 1A, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a deadbolt on both exit egress doors. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.5.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (Director PO & Maintenance), staff SS (Director of Quality), staff TT (EUA-Life Safety Code Cons.) and staff XX (Maintenance Group Leader).
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Based on observation and interview, the facility did not ensure corridor doors were side-hinged and were the required clear width with the proper width of doors.

FINDINGS INCLUDE:

On 07/13/2015 at 2:40 pm, observation revealed on the 1st floor in the 1200-South Exit Vestibule - Double Glass Door set in smoke compartment 1B, that the doors in the exit / corridor used by outpatients was narrower than the required 41.5" minimum clear width. The doors were measured 29 inches in width. This South Vestibule exit doors are a required exit per the Life Safety Plans from the primary connecting corridor at 1st Floor between Mental Health Fresh Start Clinic Suite and Old Emergency Department Suite. This 1st floor area is now identified to be Business Occupancy, which is a Change of Occupancy (New Construction) from previous plans. These doors do not meet the minimum door exit width of 32 inches clear width per leaf in a double door configuration, where used in a corridor serving institutional patients on upper floors and Mental Health Clinic Outpatients on 1st Floor. This South & North Corridor connects to the Main Buildings Elevators serving Mental Health Inpatients on the upper floors (2nd & 3rd). These patient elevators transport these patients up and down between Inpatient Units and to the street level. Egress must be maintained from Inpatient Facilities through any Business Occupancies per 2000 NFPA s. 19.1.2.4 and meeting s. 39.2.2.2.1 with s. 7.2.1. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (Director PO & Maintenance), staff SS (Director of Quality), staff TT (EUA-Life Safety Code Cons.) and staff XX (Maintenance Group Leader).
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Based on observation and interview, the facility did not provide and maintain multiple fixtures or lamps in the interior and exterior means of egress so the path would still be illuminated if any single fixture or bulb failed on the egress paths with redundant lighting. This deficiency occurred in 1 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 07/13/2015 at 3:00 pm, observation revealed on the 1st floor in the Stairwell A, in smoke compartment 1A, that the path of egress was illuminated by a single fixture with a single lamp, and did not have the ability to provide 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. It was observed missing a double bulb. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.8.1.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (Director PO & Maintenance), staff SS (Director of Quality), staff TT (EUA-Life Safety Code Cons.) and staff XX (Maintenance Group Leader).
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Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure. This deficiency occurred in 1 of the 30 smoke compartments and had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 07/14/2015 at 1:44 pm surveyor observed in the LF smoke compartment on the Lower Level floor in Room 941, that the path of egress to the public way was not illuminated to at least 1 foot-candle. The emergency light did not light. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff EE (Vice President Facilities), staff FF (Mechanic) and architect GG (Eppstein Uhen Architects).

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 with a smoke detector at required locations. This deficiency occurred in 2 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 07/13/2015 at 1:11 pm, observation revealed on the 1st floor in the 1313-Kitchen Room, within smoke compartment 1F, that the smoke detector was not located in accordance with NFPA 72 requirements. The smoke detector was missing within five feet in front of the vertical shaft from the dumb waiter. These spaces are required to have smoke detection just like elevators. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 2-2.

2. On 07/13/2015 at 2:27 pm, observation revealed on the 1st floor in the 1246-Elevator Chute Room, in smoke compartment 1B, that the smoke detector was not located in accordance with NFPA 72 requirements. The smoke detector was missing within the room in front of the vertical shaft from the chute room door. This space is required to have smoke detection within the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 2-2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (Director PO & Maintenance), staff SS (Director of Quality), staff TT (EUA-Life Safety Code Cons.) and staff XX (Maintenance Group Leader).
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Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code Section 9.7.1.1 due to sprinkler heads of wrong temperature ratings. This deficiency occurred in 4 of 30 smoke compartments, and had the potential to affect an undetermined number of patients, staff and visitors.FINDINGS INCLUDE
On 7/14/15 between 9:15 am and 11:45 am, surveyor observed in the 2A, 2B, 2C and 2D smoke compartments on the 2nd floor of Main Building that sprinkler heads were of intermediate temperature rating, 175 deg F, and not of ordinary temperature rating (135 deg F - 170 deg F) required for light hazard occupancies in accordance with NFPA 13 (1999 edition) 5-3.1.4.1. The deficient practice was confirmed at the time of discovery by a concurrent observation and interview with Staff M1 (quality improvement manager), Staff KK (project manager), Staff M2 (architect, Eppstein Uhen Architects), and Staff HH (maintenance group leader).



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Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with sprinklers that were too far from the ceiling. This deficiency occurred in of the smoke compartments, and had the potential to affect of the residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/14/2015 at 1:45 pm surveyor observed in the LF smoke compartment on the Lower Level floor in the 941, that the sprinkler was placed farther than 22" below the ceiling. This situation would delay release of water and does not satisfy listing. Requirements. This observed situation was not compliant with NFPA 13 (1999 edition), 5-5.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff EE (Vice President Facilities), staff FF (Mechanic) and staff GG (Eppstein Uhen Architects).

2. On 07/15/2015 at 2:18 pm surveyor observed in the 1D smoke compartment on the First floor in the 1436, that the sprinkler installation was not compliant. A sprinkler pipe too low. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff EE (Vice President Facilities), staff II (Mechanic), staff FF (Mechanic), and staff GG (Eppstein Uhen Architects).

Surveyor: Kosarzycki, Henry
Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with sprinklers that were too far from the ceiling. This deficiency occurred in 1 of the 30 smoke compartments and had the potential to affect 5 of the 314 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 7/13/2015 at 1:24 pm surveyor observed in the Smoke Compartment 3E on the 3rd floor in the 3202-Electrical Room, that the sprinkler was placed farther than 22" below the ceiling. This distance would delay the release of water and does not satisfy listing requirements. This observed situation was not compliant with NFPA 13 (1999 edition), 5-5.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff KK (Director of Clinical Services), staff C (Director of Clinical Services), staff LL (Maintenance Group Leader), architect GG (Eppstein Uhen Architects) and staff MM (Director of Medical Group Operations).

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Based on observation and interview, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have sprinklers free of corrosion, intact escutcheon rings, ceilings sealed above the sprinklers to collect heat, and sprinklers free of lint/dust/dirt. These deficiencies occurred in 7 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 07/13/2015 at 11:28 am, observation revealed on the 1st floor in the Corridor Room within smoke compartment 1H, that the sprinkler showed signs of corrosion that would affect the operation of the sprinkler. The sprinkler location was outside of Room 1449 in the Corridor. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

2. On 07/13/2015 at 3:45 pm, observation revealed on the 2nd floor in the 2252-Corridor outside of one of the abandoned OR Rooms, in smoke compartment 2C, that the sprinkler showed signs of corrosion and the escutcheon ring was damaged and rusty. These observed situations were not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

3. On 07/13/2015 at 2:37 pm, observation revealed on the 1st floor in the Exterior Canopy at Old Emergency Canopy, outside smoke compartment 1B and below smoke compartment 2C, that the escutcheon ring on the sprinkler was missing and the hole around the escutcheon ring was open. The second 2C floor over-hanged this space. This gap would reduce the response time of the sprinkler in the space and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

4. On 07/13/2015 at 5:08 pm, observation revealed on the 2nd floor in the 2350-Mental Health Room within smoke compartment 2A, that the escutcheon ring on the sprinkler was missing. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

5. On 07/13/2015 at 1:16 pm, observation revealed on the 1st floor in the 1307-Kitchen Work area, within smoke compartment 1F, that there was one unsealed hole near the ceiling. The hole included a 3 inch diameter penetration around a 3 inch diameter pipe at the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

6. On 07/13/2015 at 1:36 pm, observation revealed on the 1st floor in the 1324-Kitchen Work Area, within smoke compartment 1F, that there was one or more unsealed holes near the ceiling. The hole included a 2" x 4" opening in the ceiling tile. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

7. On 07/13/2015 at 2:13 pm, observation revealed on the 1st floor in the 1301-Data Closet, within smoke compartment 1G, that there was one or more unsealed holes near the ceiling. The hole(s) included a 3" diameter sleeve was not properly sealed smoke-tight to prevent passage of smoke in the event of a fire emergency. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

8. On 07/13/2015 at 3:06 pm, observation revealed on the 1st floor in the 1162-EVS Closet, Fresh Start Outpatient Mental Health Suite, in smoke compartment 1A, that there was one unsealed hole near the ceiling. The hole included a 1" diameter hole near the light fixture. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

9. On 07/13/2015 at 3:51 pm, observation revealed on the 2nd floor in the 2240-East Corridor outside of the abandoned OR Room, in smoke compartment 2C, that there was one or more unsealed holes near the ceiling. The holes included missing one ceiling tile 24" x 24" and one 1" diameter hole near tile. These holes would reduce the response time of the sprinklers in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. These observed situations were not compliant with NFPA 25 (1998 ed.), 1-11.1.

10. On 07/13/2015 at 3:54 pm, observation revealed on the 2nd floor in the 2246-Old abandoned OR Room, in smoke compartment 2C, that there was one unsealed hole near the ceiling. The hole included an open access panel. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

11. On 07/13/2015 at 3:56 pm, observation revealed on the 2nd floor in the 2246-Old abandoned OR Room, in smoke compartment 2C, that there was one unsealed hole near the ceiling. The hole included one open 24" x 48" ceiling tile. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

12. On 07/13/2015 at 11:29 am, observation revealed on the 1st floor in the 1440-Passageway Room within smoke compartment 1H, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

13. On 07/13/2015 at 11:45 am, observation revealed on the 1st floor in the 1360-Gift Shop Room within smoke compartment 1H, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. Several sprinkler heads within the Gift Shop Room were dusty and dirty and not maintained per NFPA 25. These observed situations were not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

14. On 07/13/2015 at 11:50 am, observation revealed on the 1st floor in the 1353-Vending Machine Alcove open to the Corridor within smoke compartment 1H, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

These conditiosn were confirmed at the time of discovery by a concurrent observation and interview with staff II (Director PO & Maintenance), staff SS (Director of Quality), staff TT (EUA-Life Safety Code Cons.) and staff XX (Maintenance Group Leader).
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Based on observation and interview, the facility did not provide and maintain portable fire extinguishers as required by the codes with accessible extinguisher. This deficiency occurred in 2 of the 11 smoke compartments and had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/13/2015 at 3:04 pm surveyor observed in the LY smoke compartment on the Lower Level floor in the EO 810 Central Processing, that a fire extinguisher was not accessible for immediate use because carts were stored in front of fire extinguisher no. WC9A. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.6, 9.7.4.1 and NFPA 10 (1998 edition) 1-6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff EE (Vice President Facilities) and staff FF (Mechanic).

2. On 07/13/2015 at 3:24 pm surveyor observed in the LY smoke compartment on the Lower Level floor in the EO 003 Stair Y, that a fire extinguisher was not accessible for immediate use because a chair and a table blocked access to a fire extinguisher and a pull station. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.6, 9.7.4.1 and NFPA 10 (1998 edition) 1-6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff EE (Vice President Facilities) and staff FF (Mechanic).

Based on observation and interview, the facility did not provide a kitchen extinguishing system as required by NFPA 96 (1998 ed.). These deficiencies occurred in 1 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 07/13/2015 at 1:13 pm, observation revealed on the 1st floor in the 1313-Kitchen Room, within smoke compartment 1F, that access to the kitchen hood suppression manual pull was obstructed. Metal storage racks were placed near the pull station and kitchen equipment blocks the view at times. Visual recognition of the pull station location is required in the event of a fire emergency. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.6, 9.2.3 and NFPA 96 (1998 ed.), 7-5.1.

2. On 07/13/2015 at 1:34 pm, observation revealed on the 1st floor in the 1324-Kitchen Work Area, within smoke compartment 1F, that access to the kitchen hood suppression manual pull station was obstructed. Kitchen equipment and supplies were placed in front of the kitchen hood emergency pull station, blocking its view and access in a fire emergency. Visual recognition of the pull station location is required in the event of a fire emergency. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.6, 9.2.3 and NFPA 96 (1998 ed.), 7-5.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (Director PO & Maintenance), staff SS (Director of Quality), staff TT (EUA-Life Safety Code Cons.) and staff XX (Maintenance Group Leader).
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Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 (1999) with compliant maintenance. This deficiency affected 2 of 19 operation rooms in 1 of 14 smoke compartments in the facility.FINDINGS INCLUDE
During a tour of the facility with Staff J (director of Cardio Vascular Institute) on 07/13/15, surveyor observed in the Cardio Vascular Institute building at 12:30 pm that the medical gas and vacuum system zone shutoff valves located outside of CVOR#1 and CVOR#2 on the 2nd Floor for oxygen, vacuum, medical air and nitrogen were not labeled to reflect the rooms served CV1 and CV2 in accordance with NFPA 99 4-3.5.4.2, 4-3.2.2.3. The valves that control supply to CV1 and CV2 were wrongly labeled as OR#15 and OR#14 respectively.

The above deficient practice was acknowledged at the time of discovery by a concurrent observation and interview with the director of CVI, and later confirmed with Staff M1 (quality improvement manager), Staff HH (maintenance group leader), and Staff M2 (architect, Eppstein Uhen Architects) on 7/14/15 at 2:50 pm.



18107

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping and operational medical gas gauges. This deficiency occurred in 2 of the 14 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments of CMS Building 06.

FINDINGS INCLUDE:

On 07/14/2015 at 1:20 pm, observation revealed on the 1st floor in the Emergency Department East End Treatment & Exam Rooms, that medical gas piping or pressure gauges were not installed or maintained according to the requirements of the Medical Gas Codes NFPA 99 (1999 ed.), Chapter 4. The inappropriate piping installation included medical air gauges were not recording proper pressures at the shut-off locations at the majority of rooms on the East & West Ends of the emergency department. The medical air pressure gauges were showing 58 psi at the following locations; A1-3, B1-3, T-1, H1-3, G1-3 and I-1. Regular maintenance checks should have discovered this anomaly. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.4 and NFPA 99 (1999 ed.), Chapter 4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (Dir. P.O. & Maint.), staff SS (Dir. Of Quality), staff LL (Dir. P.O. & Maint.), and staff TT (EUA - LSC Consultant), staff UU (ED Medical Dir.), staff O (ED Director) and staff VV (Mgr. of ED).
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Based on observation and interview, the facility did not provide space for oxygen transfer with a concrete or ceramic floor. This deficiency occurred in 1 of the 30 smoke compartments and had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 07/14/2015 at 9:02 am surveyor observed in the LE smoke compartment on the Lower Level floor in the 742 Oxygen Storage Room, that the flooring material did not meet the code requirements because it had vinyl flooring. This observed situation was not compliant with NFPA 99 (1999 edition) 8-6.2.5.2(b). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff EE (Vice President Facilities), staff FF (Mechanic) and architect GG (Eppstein Uhen Architects).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with electrical panels having complete directories. These deficiencies occurred in 4 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 07/13/2015 at 11:05 am, observation revealed on the 1st floor in the 1365-Corridor Room, within smoke compartment 1H, that the electrical panel breaker was not labeled to identify the loads it fed. Panel #EM-1-C, breaker #16 was in an 'ON' position, but the identification card stated the circuit was abandoned at 3rd and 4th Floors. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

2. On 07/13/2015 at 11:55 am, observation revealed on the 1st floor in the 1351-Corridor Room, within smoke compartment 1H, that electrical panel breakers were not labeled to identify the loads they fed. The Panel #(missing), breakers 9, 19, 24 & 28 were in an 'ON' position and the panel legend stated they were Spares. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

3. On 07/13/2015 at 1:32 pm, observation revealed on the 1st floor in the 1324A-Kitchen Work Area, within smoke compartment 1F, that electrical panel breakers were not labeled to identify the loads they fed. Panel # 1/E, breakers #28 & #30, were in an 'ON' position and the identification sheet was missing on what outlets or electrical items they were assigned to. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

4. On 07/13/2015 at 1:38 pm, observation revealed on the 1st floor in the 1324-Kitchen Work Area, within smoke compartment 1F, the electrical panel breakers were not labeled to identify the loads it fed. Panel # K1 Right, breaker #26 was in a 'ON' position and not identified on the identification card within panel. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

5. On 07/13/2015 at 1:41 pm, observation revealed on the 1st floor in the 1324-Kitchen Work Area, within smoke compartment 1F, that electrical panel breakers were not labeled to identify the loads they fed. Panel # K 1 Left, breakers #27 & 29 were in an 'ON' position and not identified on the identification card within panel. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

6. On 07/13/2015 at 2:57 pm, observation revealed on the 1st floor in the 1138-Room, Fresh Start Outpatient Mental Health Suite, in smoke compartment 1A, the electrical panel breaker was not labeled to identify the loads it fed. Panel #1/B, breaker #2 was in an 'ON' position and the identification card stated it was a spare. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

7. On 07/13/2015 at 3:11 pm, observation revealed on the 1st floor in the 1163-Electrical Closet, Fresh Start Outpatient Mental Health Suite, in smoke compartment 1A, that electrical panel breakers were not labeled to identify the loads they fed. Panel #1/A Left, breakers 24 & 26 were in an 'ON' position but the identification card stated they were spares. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

8. On 07/13/2015 at 3:11 pm, observation revealed on the 1st floor in the 1163-Electrical Closet, Fresh Start Outpatient Mental Health Suite, in smoke compartment 1A, that electrical panel breakers were not labeled to identify the loads they fed. Panel #1/A Right, breakers 20, 22 & 24 were in an 'ON' position but the identification card stated they were spares. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

9. On 07/13/2015 at 3:14 pm, observation revealed on the 1st floor in the 1163-Electrical Closet, Fresh Start Outpatient Mental Health Suite, in smoke compartment 1A, that electrical panel breakers were not labeled to identify the loads they fed. Panel # 1/CA, breakers 8 & 10, were in an 'ON' position and the identification card stated they were Blanks. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

10. On 07/13/2015 at 2:18 pm, observation revealed on the 2nd floor in the 2263-Room, that electrical panel breakers were not labeled to identify the loads they fed. The electrical panel in Room, several breakers within the panel, were in an 'ON' position and the identification card stated they were Blanks. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

11. On 07/13/2015 at 2:28 pm, observation revealed on the 2nd floor in the 2113-Kitchen Pantry, that electrical panel breakers were not labeled to identify the loads they fed. The electrical panel in Room, several breakers within the panel, were in an 'ON' position and the identification card stated they were Blanks. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

12. On 07/13/2015 at 2:34 pm, observation revealed on the 2nd floor in the 2143-Electrical Room, that electrical panel breakers were not labeled to identify the loads they fed. The 1st electrical panel in Room, several breakers within the panel, were in an 'ON' position and the identification card stated they were Blanks. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

13. On 07/13/2015 at 2:36 pm, observation revealed on the 2nd floor in the 2143-Electrical Room, that electrical panel breakers were not labeled to identify the loads they fed. The 2nd electrical panel in Room, several breakers within the panel, were in an 'ON' position and the identification card stated they were Blanks. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

14. On 07/13/2015 at 2:38 pm, observation revealed on the 2nd floor in the 2143-Electrical Room, that electrical panel breakers were not labeled to identify the loads they fed. The 3rd electrical panel in Room, several breakers within the panel, were in an 'ON' position and the identification card stated they were Blanks. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (Director PO & Maintenance), staff SS (Director of Quality), staff TT (EUA-Life Safety Code Cons.) and staff XX (Maintenance Group Leader).
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