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Based on observations and staff interview the facility failed to ensure any door in an smoke barrier is held open only by devices arranged to automatically close such doors upon activation of: the manual fire alarm system, local smoke detector tied to the fire alarm system and installed automatic sprinkler system per 19.2.2.2.6 & 7.2.1.8.2. This effects both smoke compartments on this 1st Floor and ALL patients within the premises.

FINDINGS INCLUDE:
During this verification visit on 9/13/2010 at 4:15 PM, Surveyor 18107 observed while touring with Staff A (Administrative Secretary), Staff B (Administrator Clinical Services), Staff E (Director Facility Management) and Staff T (Facility Management Supervisor) that the ultrasound examination room door had the door closer dangling from the door and not attached to the door frame.

Based on observations and staff interview the facility failed to ensure the hospital's exit access is arranged so that exits are readily accessible at all times.

FINDINGS INCLUDE:
During this verification visit, Surveyor 18107 was blocked while walking out of the Surgical Suite West exit access door due to two pieces of equipment in the corridor. The mobile X-Ray C-arm and TV cart were left in the corridor blocking exit access. No one was standing next to these pieces of equipment. This occurred while touring with Staff T (Facility Management Supervisor) at 4:22 PM on 9/13/2010. This occurred in 1 of 2 smoke compartments at 1st Floor and effected 0 patients at the time of discovery.

Based on observations and staff interview the facility failed to ensure the hospital's exit access is arranged so that exits are readily accessible at all times. During this verification visit, Surveyor 18107 observed holes in the exit access and were a tripping hazard. This exit door represents 50% of the exits from this Lower Level. Inpatients and Outpatients are present in the Lower Level of this hospital for Physical and Occupational Therapy. There were three (3) patients at this Lower Level at the time of this observation in the other smoke compartment.

FINDINGS INCLUDE:
At Building No. 1 of the Lower Level at North corridor, surveyor 18107 observed at 2:30 PM while touring with Staff A (Administrative Secretary), Staff B (Administrator Clinical Services), Staff E (Director Facility Management) and Staff T (Facility Management Supervisor) two (2) holes in the corridor floor with temporary floor panels laying over the holes and projecting up at about a 30 degree angle covering a portion of the holes causing a tripping hazard. One of the holes was immediately in front of the exit door, less than 3 feet away requiring the exiting person to step over the one hole. The one hole would have blocked a wheelchair access. The facility stated this happened during a heavy Summer rain storm over three (3) weeks ago. Due to this finding the facility is out of compliance for readily accessible exit access.

Based on observations and staff interview the facility failed to ensure the hospital's required automatic sprinkler system was installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. This was found in 1 of 2 smoke compartments at the First Floor of the hospital and effected 4 patients at the time of discovery within this smoke compartment.

FINDINGS INCLUDED:
1. Surveyor 18107 observed on 9/13/2010 at 4 PM while touring with Staff A (Administrative Secretary), Staff B (Administrator Clinical Services), Staff E (Director Facility Management) and Staff T (Facility Management Supervisor) the mammography procedure room closet was without any sprinkler coverage, not meeting the minimum requirements for NFPA 13.
2. Surveyor 18107 observed on 9/13/2010 between 3:45 PM till 3:55 PM while touring with Staff A (Administrative Secretary), Staff B (Administrator Clinical Services), Staff E (Director Facility Management) and Staff T (Facility Management Supervisor) around the building, the canopies at Bulk Oxygen Tanks, Ambulance & Entry Door #1, Exit Doors #2, #3 & #5 were greater than 48 inches in lineal distance from the building and having a roofing system that required the automatic sprinkler system.

Based on observations and staff interview the facility failed to ensure the hospital's required automatic sprinkler system was installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. This was found in 1 of 2 smoke compartments at the lower level of the hospital and effected 3 patients at the time of discovery.

FINDINGS INCLUDED:
Surveyor 18107 observed on 9/13/2010 at 3:30 PM while touring with Staff A (Administrative Secretary), Staff B (Administrator Clinical Services), Staff E (Director Facility Management) and Staff T (Facility Management Supervisor) the elevator equipment room was without any sprinkler coverage, not meeting the minimum requirements for NFPA 13.

Based on observations and staff interview the facility failed to ensure the hospital's required automatic sprinkler system is continuously maintained in reliable operating condition and inspected periodically. During this verification visit, Surveyor 18107 observed throughout the hospital in numerous locations at 1st Floor and in 2 of 2 smoke compartments effecting at least 15 patients, ceiling tiles were damaged, broken or removed that would effect the timely discharge of the sprinkler head(s) effected.

FINDINGS INCLUDE:
1. Surveyor 18107 observed on 9/13/2010 between 2:30 PM till 4:30 PM while touring with Staff A (Administrative Secretary), Staff B (Administrator Clinical Services), Staff E (Director Facility Management) and Staff T (Facility Management Supervisor) numerous ceiling tiles with openings in them to allow smoke and hot gases to by-pass the sprinkler head(s) and delay disbursement of water to the effected areas in a fully-sprinkled facility. These areas included; the 1st Flr (1F) corridors, Surgical Suite, Central Sterile Supply, Ambulance Entrance Corridor, 1F Storage Connector (off ambulance entrance) and Surgery Locker Room.
2. Surveyor 18107 observed on 9/13/2010 between 2:30 PM till 4:30 PM while touring with Staff A (Administrative Secretary), Staff B (Administrator Clinical Services), Staff E (Director Facility Management) and Staff T (Facility Management Supervisor) numerous cubicle curtains without the required 1/2" diagonal openings at least 18 inches from the finished ceiling for proper disbursement of water spray from the sprinkler head(s). Areas included; all inpatient sleeping rooms, patient treatment spaces having cubicle curtains, areas using cubicle curtains to cover linens on storage shelves and at shower areas not at least 18 inches down from finished ceiling areas.

Based on observations and staff interview the facility failed to ensure the hospital's required automatic sprinkler system is continuously maintained in reliable operating condition and inspected periodically. During this verification visit, Surveyor 18107 observed throughout the hospital in numerous locations at Lower Level and in 2 of 2 smoke compartments effecting at least three (3) patients, ceiling tiles were damaged, broken or removed that would effect the timely discharge of the sprinkler head(s) effected.

FINDINGS INCLUDE:
1. Surveyor 18107 observed on 9/13/2010 between 2:30 PM till 4:30 PM while touring with Staff A (Administrative Secretary), Staff B (Administrator Clinical Services), Staff E (Director Facility Management) and Staff T (Facility Management Supervisor) numerous ceiling tiles with openings in them to allow smoke and hot gases to by-pass the sprinkler head(s) and delay disbursement of water to the effected areas in a fully-sprinkled facility. These areas included; the Lower Level (LL) corridors, LL Office Suite, LL Microbiology Lab, LL Medical Records, LL Physical & Occupational Therapy, LL Dining/Cafe, LL Kitchen and LL Kitchen Storage.
2. Surveyor 18107 observed on 9/13/2010 between 2:30 PM till 4:30 PM while touring with Staff A (Administrative Secretary), Staff B (Administrator Clinical Services), Staff E (Director Facility Management) and Staff T (Facility Management Supervisor) numerous cubicle curtains without the required 1/2" diagonal openings at least 18 inches from the finished ceiling for proper disbursement of water spray from the sprinkler head(s). Areas included; all patient treatment spaces having cubicle curtains, areas using cubicle curtains to cover linens on storage shelves and at shower areas not at least 18 inches down from finished ceiling areas.

Based on observations and staff interview the facility failed to ensure any door in an smoke barrier is held open only by devices arranged to automatically close such doors upon activation of: the manual fire alarm system, local smoke detector tied to the fire alarm system and installed automatic sprinkler system per 19.2.2.2.6 & 7.2.1.8.2. This effects both smoke compartments on this 1st Floor and ALL patients within the premises.

FINDINGS INCLUDE:
During this verification visit on 9/13/2010 at 4:15 PM, Surveyor 18107 observed while touring with Staff A (Administrative Secretary), Staff B (Administrator Clinical Services), Staff E (Director Facility Management) and Staff T (Facility Management Supervisor) that the ultrasound examination room door had the door closer dangling from the door and not attached to the door frame.

Based on observations and staff interview the facility failed to ensure the hospital's exit access is arranged so that exits are readily accessible at all times.

FINDINGS INCLUDE:
During this verification visit, Surveyor 18107 was blocked while walking out of the Surgical Suite West exit access door due to two pieces of equipment in the corridor. The mobile X-Ray C-arm and TV cart were left in the corridor blocking exit access. No one was standing next to these pieces of equipment. This occurred while touring with Staff T (Facility Management Supervisor) at 4:22 PM on 9/13/2010. This occurred in 1 of 2 smoke compartments at 1st Floor and effected 0 patients at the time of discovery.

Based on observations and staff interview the facility failed to ensure the hospital's required automatic sprinkler system was installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. This was found in 1 of 2 smoke compartments at the First Floor of the hospital and effected 4 patients at the time of discovery within this smoke compartment.

FINDINGS INCLUDED:
1. Surveyor 18107 observed on 9/13/2010 at 4 PM while touring with Staff A (Administrative Secretary), Staff B (Administrator Clinical Services), Staff E (Director Facility Management) and Staff T (Facility Management Supervisor) the mammography procedure room closet was without any sprinkler coverage, not meeting the minimum requirements for NFPA 13.
2. Surveyor 18107 observed on 9/13/2010 between 3:45 PM till 3:55 PM while touring with Staff A (Administrative Secretary), Staff B (Administrator Clinical Services), Staff E (Director Facility Management) and Staff T (Facility Management Supervisor) around the building, the canopies at Bulk Oxygen Tanks, Ambulance & Entry Door #1, Exit Doors #2, #3 & #5 were greater than 48 inches in lineal distance from the building and having a roofing system that required the automatic sprinkler system.

Based on observations and staff interview the facility failed to ensure the hospital's required automatic sprinkler system is continuously maintained in reliable operating condition and inspected periodically. During this verification visit, Surveyor 18107 observed throughout the hospital in numerous locations at 1st Floor and in 2 of 2 smoke compartments effecting at least 15 patients, ceiling tiles were damaged, broken or removed that would effect the timely discharge of the sprinkler head(s) effected.

FINDINGS INCLUDE:
1. Surveyor 18107 observed on 9/13/2010 between 2:30 PM till 4:30 PM while touring with Staff A (Administrative Secretary), Staff B (Administrator Clinical Services), Staff E (Director Facility Management) and Staff T (Facility Management Supervisor) numerous ceiling tiles with openings in them to allow smoke and hot gases to by-pass the sprinkler head(s) and delay disbursement of water to the effected areas in a fully-sprinkled facility. These areas included; the 1st Flr (1F) corridors, Surgical Suite, Central Sterile Supply, Ambulance Entrance Corridor, 1F Storage Connector (off ambulance entrance) and Surgery Locker Room.
2. Surveyor 18107 observed on 9/13/2010 between 2:30 PM till 4:30 PM while touring with Staff A (Administrative Secretary), Staff B (Administrator Clinical Services), Staff E (Director Facility Management) and Staff T (Facility Management Supervisor) numerous cubicle curtains without the required 1/2" diagonal openings at least 18 inches from the finished ceiling for proper disbursement of water spray from the sprinkler head(s). Areas included; all inpatient sleeping rooms, patient treatment spaces having cubicle curtains, areas using cubicle curtains to cover linens on storage shelves and at shower areas not at least 18 inches down from finished ceiling areas.