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Based on observation and interview with facility staff, the facility failed to ensure structural members are properly protected to maintain the proper construction type of the building.

Findings Include:

On 12/08/2015 between 9:00 a.m. and 3:30 p.m. observation revealed FIre Protection Coating on structural I-beams in the basemant Inventory Storage in missing in several places causing the beams to be unprotected, thus changing the construction tyope.

Members of the maintenance staff confirmed the findings at the time of discovery on 12/08/2015.

Based on observation and interview with facility staff, the facility failed to ensure corridor walls and doors will resist the passage of smoke and/or fire. In the event of a fire in these areas all clients and staff may be affected.

Findingsa Include:

On 12/08/2015 between 9:00 a.m. and 3:30 p.m. observation revealed penetrations in corridor ceilings and walls on the 7T Hall, 1st floor Birth Center, and 3C/3D Hall and ceiling tiles missing in the Data Center. Observartion also revealed door DR01-0177 and door DM 0181 had more than a half inch gap when closed.

Members of the maintenance staff confirmed the findings at the time of discovery on 12/08/2015.

Based on observation and interview with facility staff, the facility failed to ensure exits are correctly marked. In the event of a fire or emergency in the affected area staff assigned to that area may be affected.

Findings Include:


On 12/08/2015 between 9:00 a.m. and 3:30p.m. observation revealed the exit signs in the basement do not mark egress to the D Stair as required. The signage directs egress to an elevator.

Members of the maintenance staff confirmed the findings at the time of discovery on 12/08/2015.

Based on observation and interview with facility staff, the facility failed to ensure exits are correctly marked. In the event of a fire or emergency in the affected area staff assigned to that area may be affected.

Findings Include:


On 12/08/2015 between 9:00 a.m. and 3:30p.m. observation revealed the exit signs on the 2nd floor direct egress to a door that swings in the opposite direction of egress travel at the elevator lobby.

Members of the maintenance staff confirmed the findings at the time of dsiscovery on 12/08/2015.

Based on observation and interview with facility staff, the facility failed to ensure hazardous rooms will resist the passage of smoke and fire. In the event of a fire in these areas all clients and staff may be affected.

Findings Include:

On 12/08/2015 between 9:00 a.m. and 3:30p.m. observation revealed the following doors to hazardous rooms are not self closing:
Cardiac Stress Test #2 Storage
Storage room 925
Storage room 926
MT 16016 has a permanent door stop
Suite 300 Storage room 636
Storage room 306

Members of the maintenance staff confirmed the findings at the time of discovery.

Based on observation and interview with facility staff, the facility failed to ensure hazardous rooms will resist the passage of smoke and fire. In the event of a fire in these areas all clients and staff may be affected.

Findings Include:

On 12/08/2015 between 9:00 a.m. and 3:30p.m. observation revealed the following doors to hazardous rooms are not self closing:
Medical Records Suite 400
Storage room #4

Members of the maintenance staff confirmed the findings at the time of discovery on 12/08/2015.

Based on observation and interview with facility staff, the facility failed to ensure hazardous rooms will resist the passage of smoke and fire. In the event of a fire in these areas all residents and staff may be affected.

Findings Include:

On 12/08/2015 between 9:00 a.m. and 3:30 p.m. observationj revealed the Utility Clean Storage room door on the 3rd Floor 3D and the Pharmacy storage door in the basement were not provided with self closing devices. Observation also revealed penetrations in the rated walls of the 5T Electrical room, 3d Low Voltage CLoset, 1st Floor Mechanical room, basement paint room, the carpenter shop, and the X-ray fan room were not sealed. The one hour wall in the paint room in the basement also had an HVAC penetration that was not provided with a damper.

Memvbers of the maintenance staff confirmed the findings at the time of discovery.

Based on observation and interview with facility staff, the facility failed to ensure corridor width and headroom is properly maintained. In the event of an emergency all residents and staff of the 1st floor may be affected.

Findings Include:

On 12/08/2015 between 9:00 a.m. and 3:30p.m. observation revealed cabinets that permanently mounted to the wall protrude out 7 inches into the corridor in the Radiation Oncology.

Members of the maintenance staff confirmed the findings at the time of discovery on 12/08/2015.

Based on observation and interview with facility staff, the facility failed to ensure corridor width and headroom is properly maintained. In the event of an emergency all residents and staff of the 7th floor may be affected.

Findings Include:

On 12/08/2015 between 9:00 a.m. and 3:30p.m. observation revealed cabinets that are permanently mounted to the wall protrude out 7 inches into the corridor on the 7th floor.

Members of the maintenance staff confirmed the findings at the time of discovery on 12/08/2015.

Based on record review and interview with facility staff, the facility failed to ensure emergency procedures can be properly carried out. In the event of an emergency all clients and staff of the 3rd floor may be affected.

Findings Include:

On 12/08/2015 between 9:00 a.m. and 3:30 p.m. record review revealed a hard copy of the Emergency Plan was not available to staff on the 3rd floor.

Members of the maintenance staff confirmed the findings at the time of discovery.

Based on observation and interview with facility stasff, the facility failed to insurance all parts of the sprinkler system are properly maintained in reliable working order. In the event of a fire all clients and staff may be affected.

Findings Include:

On 12/08/2015 between 9:00 a.m and 3:30 p.m. observation revealed wires supported by the sprinkler piping in the basement corridor, above the ceiling at rooms 303, 318, and 319, and in the corridor leading to Tower II. Observation also revealed the FDC on the West side of the building is obstructed by construction materials and debris and all FDC's and PIV's are not marked and identified as to which system they serve in accordance with NFPA 99 5-14.1.1.2, 5-14.1.1.12, and 5-15.2.3.4.

Members of the maintenance staff confirmed the findings at the time of discovery.

Based on observation and interview with facility stasff, the facility failed to insurance all parts of the sprinkler system are properly maintained in reliable working order. In the event of a fire all clients and staff may be affected.

Findings Include:

On 12/09/12/2015 between 8:00 a.m. and 12:00p.m. observation revealed the lens in the PIV was tarnished and the words open and closed could not be read and the PIV is not accessible in accordance with NFPA 13-25 due being obstructed by brush and vegetation.

Members of the maintenance staff confirmed the findings at the time of discovery on 12/09/2015.

Based on observation and interview with facility staff the facility failed to ensure unapproved space heaters were not being used. In the event of a fire caused by these devices, all staff and clients may be affected.

Findings Include:
On 12/08/2015 between 12:00 p.m. and 3:30 p.m. observation revealed an unapproved space heater in use in the Directors Office.
Maintenance staff members confirmed the findings at the time of discovery on 12/08/2015.

Based on observation and interview with facility staff the facility failed to ensure unapproved space heaters were not being used. In the event of a fire caused by these devices, all staff and clients may be affected.

Findings Include:
On 12/08/2015 between 12:00 p.m. and 3:30 p.m. observation revealed an unapproved space heater in use on the 6th Floor Suite 400.
Maintenance staff members confirmed the findings at the time of discovery on 12/08/2015

Based on observation and interview with facility staff the facility failed to ensure unapproved space heaters were not being used. In the event of a fire caused by these devices, all staff and clients may be affected.

Findings Include:
On 12/09/2015 between 8:00 a.m. and 12:00 p.m. observation revealed an unapproved space heater in use in the Nurse Managers office on the 2nd floor.
Maintenance staff members confirmed the findings at the time of discovery on 12/08/2015

Based on observation and interview with facility staff the facility failed to ensure unapproved space heaters were not being used. In the event of a fire caused by these devices, all staff and clients may be affected.

Findings include:
On 12/8/2015 between 9:00 a.m. and 3:30 p.m. observation revealed unapproved space heaters in use in the following locations: The basement admin area, the 2nd floor admin area, the 3rd floor admin area, the 5th floor admin area, and the 7th floor admin area.

Maintenance staff members confirmed the findings at the time of discovery on 12/08/2015.

Based on observation and interview with facility staff, the facility failed to ensure proper storage of medical gas in accordance with NFPA 99 8.3.1.11.2. All staff and clients in the affected area may be affected.

Findings Include:

On 12/08/2015 between 9:00 a.m. anmd 3:30p.m. observation revealed Oxygen stored at the Nurses Station on the 2nd floor is within 5 feet of combustibles.

Members of the maintenance staff confirmed the findings at the time of discovery.

Based on observation and interview with facility staff, the facility faciled to ensure all electrical items are properly marked and identified in accordance with NFPA 70 2014 Edition Article 408.38 and the facility failed to ensure all transient voltafge surge suppressors are properly mounted and secuered. All staff and guests may be affected should they come in contact with live parts.

Findings Include:

On 12/08/2015 between 9:00 a.m. and 3:30 p.m. observation revealed electrical rooms throughout the building are not properly marked as hazardous rooms and circuits are not properly identified in electrical panels NH#2, 2EQL #1, 2CL #1, and 2 CL #1D. Observation also revealed surge suppressors are not mounted a minimum of 4 inches off the floor throughout the admin areas.

Maintenance staff members confirmed the findings at the time of discovery.

Based on observation and interview with facility staff, the facility faciled to ensure all electrical items are properly marked and identified in accordance with NFPA 70 2014 Edition Article 408.38 and the facility failed to ensure all transient voltafge surge suppressors are properly mounted and secuered. All staff and guests may be affected should they come in contact with live parts.

Findings Include:

On 12/08/2015 between 9:00 a.m. and 3:30 p.m. observation revealed electrical rooms throughout the building are not properly marked as hazardous rooms and circuits are not properly identified in the main electrical panel. Observation also revealed surge suppressors are not mounted a minimum of 4 inches off the floor throughout the admin areas.

Maintenance staff members confirmed the findings at the time of discovery.

Based on observation and interview with facility staff, the facility failed to ensure structural members are properly protected to maintain the proper construction type of the building.

Findings Include:

On 12/08/2015 between 9:00 a.m. and 3:30 p.m. observation revealed FIre Protection Coating on structural I-beams in the basemant Inventory Storage in missing in several places causing the beams to be unprotected, thus changing the construction tyope.

Members of the maintenance staff confirmed the findings at the time of discovery on 12/08/2015.

Based on observation and interview with facility staff, the facility failed to ensure corridor walls and doors will resist the passage of smoke and/or fire. In the event of a fire in these areas all clients and staff may be affected.

Findingsa Include:

On 12/08/2015 between 9:00 a.m. and 3:30 p.m. observation revealed penetrations in corridor ceilings and walls on the 7T Hall, 1st floor Birth Center, and 3C/3D Hall and ceiling tiles missing in the Data Center. Observartion also revealed door DR01-0177 and door DM 0181 had more than a half inch gap when closed.

Members of the maintenance staff confirmed the findings at the time of discovery on 12/08/2015.

Based on observation and interview with facility staff, the facility failed to ensure exits are correctly marked. In the event of a fire or emergency in the affected area staff assigned to that area may be affected.

Findings Include:


On 12/08/2015 between 9:00 a.m. and 3:30p.m. observation revealed the exit signs in the basement do not mark egress to the D Stair as required. The signage directs egress to an elevator.

Members of the maintenance staff confirmed the findings at the time of discovery on 12/08/2015.

Based on observation and interview with facility staff, the facility failed to ensure exits are correctly marked. In the event of a fire or emergency in the affected area staff assigned to that area may be affected.

Findings Include:


On 12/08/2015 between 9:00 a.m. and 3:30p.m. observation revealed the exit signs on the 2nd floor direct egress to a door that swings in the opposite direction of egress travel at the elevator lobby.

Members of the maintenance staff confirmed the findings at the time of dsiscovery on 12/08/2015.

Based on observation and interview with facility staff, the facility failed to ensure hazardous rooms will resist the passage of smoke and fire. In the event of a fire in these areas all clients and staff may be affected.

Findings Include:

On 12/08/2015 between 9:00 a.m. and 3:30p.m. observation revealed the following doors to hazardous rooms are not self closing:
Cardiac Stress Test #2 Storage
Storage room 925
Storage room 926
MT 16016 has a permanent door stop
Suite 300 Storage room 636
Storage room 306

Members of the maintenance staff confirmed the findings at the time of discovery.

Based on observation and interview with facility staff, the facility failed to ensure hazardous rooms will resist the passage of smoke and fire. In the event of a fire in these areas all clients and staff may be affected.

Findings Include:

On 12/08/2015 between 9:00 a.m. and 3:30p.m. observation revealed the following doors to hazardous rooms are not self closing:
Medical Records Suite 400
Storage room #4

Members of the maintenance staff confirmed the findings at the time of discovery on 12/08/2015.

Based on observation and interview with facility staff, the facility failed to ensure hazardous rooms will resist the passage of smoke and fire. In the event of a fire in these areas all residents and staff may be affected.

Findings Include:

On 12/08/2015 between 9:00 a.m. and 3:30 p.m. observationj revealed the Utility Clean Storage room door on the 3rd Floor 3D and the Pharmacy storage door in the basement were not provided with self closing devices. Observation also revealed penetrations in the rated walls of the 5T Electrical room, 3d Low Voltage CLoset, 1st Floor Mechanical room, basement paint room, the carpenter shop, and the X-ray fan room were not sealed. The one hour wall in the paint room in the basement also had an HVAC penetration that was not provided with a damper.

Memvbers of the maintenance staff confirmed the findings at the time of discovery.

Based on observation and interview with facility staff, the facility failed to ensure corridor width and headroom is properly maintained. In the event of an emergency all residents and staff of the 1st floor may be affected.

Findings Include:

On 12/08/2015 between 9:00 a.m. and 3:30p.m. observation revealed cabinets that permanently mounted to the wall protrude out 7 inches into the corridor in the Radiation Oncology.

Members of the maintenance staff confirmed the findings at the time of discovery on 12/08/2015.

Based on observation and interview with facility staff, the facility failed to ensure corridor width and headroom is properly maintained. In the event of an emergency all residents and staff of the 7th floor may be affected.

Findings Include:

On 12/08/2015 between 9:00 a.m. and 3:30p.m. observation revealed cabinets that are permanently mounted to the wall protrude out 7 inches into the corridor on the 7th floor.

Members of the maintenance staff confirmed the findings at the time of discovery on 12/08/2015.

Based on record review and interview with facility staff, the facility failed to ensure emergency procedures can be properly carried out. In the event of an emergency all clients and staff of the 3rd floor may be affected.

Findings Include:

On 12/08/2015 between 9:00 a.m. and 3:30 p.m. record review revealed a hard copy of the Emergency Plan was not available to staff on the 3rd floor.

Members of the maintenance staff confirmed the findings at the time of discovery.

Based on observation and interview with facility stasff, the facility failed to insurance all parts of the sprinkler system are properly maintained in reliable working order. In the event of a fire all clients and staff may be affected.

Findings Include:

On 12/08/2015 between 9:00 a.m and 3:30 p.m. observation revealed wires supported by the sprinkler piping in the basement corridor, above the ceiling at rooms 303, 318, and 319, and in the corridor leading to Tower II. Observation also revealed the FDC on the West side of the building is obstructed by construction materials and debris and all FDC's and PIV's are not marked and identified as to which system they serve in accordance with NFPA 99 5-14.1.1.2, 5-14.1.1.12, and 5-15.2.3.4.

Members of the maintenance staff confirmed the findings at the time of discovery.

Based on observation and interview with facility stasff, the facility failed to insurance all parts of the sprinkler system are properly maintained in reliable working order. In the event of a fire all clients and staff may be affected.

Findings Include:

On 12/09/12/2015 between 8:00 a.m. and 12:00p.m. observation revealed the lens in the PIV was tarnished and the words open and closed could not be read and the PIV is not accessible in accordance with NFPA 13-25 due being obstructed by brush and vegetation.

Members of the maintenance staff confirmed the findings at the time of discovery on 12/09/2015.

Based on observation and interview with facility staff the facility failed to ensure unapproved space heaters were not being used. In the event of a fire caused by these devices, all staff and clients may be affected.

Findings Include:
On 12/08/2015 between 12:00 p.m. and 3:30 p.m. observation revealed an unapproved space heater in use in the Directors Office.
Maintenance staff members confirmed the findings at the time of discovery on 12/08/2015.

Based on observation and interview with facility staff the facility failed to ensure unapproved space heaters were not being used. In the event of a fire caused by these devices, all staff and clients may be affected.

Findings Include:
On 12/08/2015 between 12:00 p.m. and 3:30 p.m. observation revealed an unapproved space heater in use on the 6th Floor Suite 400.
Maintenance staff members confirmed the findings at the time of discovery on 12/08/2015

Based on observation and interview with facility staff the facility failed to ensure unapproved space heaters were not being used. In the event of a fire caused by these devices, all staff and clients may be affected.

Findings Include:
On 12/09/2015 between 8:00 a.m. and 12:00 p.m. observation revealed an unapproved space heater in use in the Nurse Managers office on the 2nd floor.
Maintenance staff members confirmed the findings at the time of discovery on 12/08/2015

Based on observation and interview with facility staff the facility failed to ensure unapproved space heaters were not being used. In the event of a fire caused by these devices, all staff and clients may be affected.

Findings include:
On 12/8/2015 between 9:00 a.m. and 3:30 p.m. observation revealed unapproved space heaters in use in the following locations: The basement admin area, the 2nd floor admin area, the 3rd floor admin area, the 5th floor admin area, and the 7th floor admin area.

Maintenance staff members confirmed the findings at the time of discovery on 12/08/2015.

Based on observation and interview with facility staff, the facility failed to ensure proper storage of medical gas in accordance with NFPA 99 8.3.1.11.2. All staff and clients in the affected area may be affected.

Findings Include:

On 12/08/2015 between 9:00 a.m. anmd 3:30p.m. observation revealed Oxygen stored at the Nurses Station on the 2nd floor is within 5 feet of combustibles.

Members of the maintenance staff confirmed the findings at the time of discovery.

Based on observation and interview with facility staff, the facility faciled to ensure all electrical items are properly marked and identified in accordance with NFPA 70 2014 Edition Article 408.38 and the facility failed to ensure all transient voltafge surge suppressors are properly mounted and secuered. All staff and guests may be affected should they come in contact with live parts.

Findings Include:

On 12/08/2015 between 9:00 a.m. and 3:30 p.m. observation revealed electrical rooms throughout the building are not properly marked as hazardous rooms and circuits are not properly identified in electrical panels NH#2, 2EQL #1, 2CL #1, and 2 CL #1D. Observation also revealed surge suppressors are not mounted a minimum of 4 inches off the floor throughout the admin areas.

Maintenance staff members confirmed the findings at the time of discovery.

Based on observation and interview with facility staff, the facility faciled to ensure all electrical items are properly marked and identified in accordance with NFPA 70 2014 Edition Article 408.38 and the facility failed to ensure all transient voltafge surge suppressors are properly mounted and secuered. All staff and guests may be affected should they come in contact with live parts.

Findings Include:

On 12/08/2015 between 9:00 a.m. and 3:30 p.m. observation revealed electrical rooms throughout the building are not properly marked as hazardous rooms and circuits are not properly identified in the main electrical panel. Observation also revealed surge suppressors are not mounted a minimum of 4 inches off the floor throughout the admin areas.

Maintenance staff members confirmed the findings at the time of discovery.