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Based on observation and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the emergency department suite. Findings include:

1. Observation at 10:45 a.m. revealed the double-doors from the corridor to the emergency department suite would not positively latch into the frame. Interview with the maintenance supervisor at the time of the observation confirmed the finding. He indicated that following construction it had been decided to install an automatic opening device on the doors. Rather than installing the proper electronic latching mechanism the latching plates were removed.

Based on observation and interview, the provider failed to maintain the fire-resistive rating of one of four stair enclosures (south stair first floor) and one of one laundry chute (second floor) with construction having a fire-resistance rating of at least one hour. Findings include:

1. Observation at 9:45 a.m. revealed the 90 minute fire rated door assembly to the south stair enclosure on the first floor would not latch into the frame. Inspection of the door revealed the panic hardware was dogged down, so the latching bolt was fixed in the open position. Interview with the maintenance supervisor at the time of the observation indicated he was unaware why the panic hardware was dogged down. The door frame was equipped with an electronic strike and automatic door opening device. Both of those devices were operating properly. The door would have operated properly with the panic hardware left in the latching position.

2. Observation at 11:15 a.m. revealed the 90 minute fire rated door assembly to the laundry chute on the second floor would not latch into the frame. The door was self-closing, but the latching hardware had been broken and not repaired. Interview with the maintenance supervisor at the time of the observation confirmed the finding and was unaware of that condition.

Based on observation and interview, the provider failed to maintain proper separation of two randomly observed hazardous areas. The double-doors to the receiving area and dry storage room would not positively latch into the frame. Findings include:

1. Observation at 10:15 a.m. revealed the double-doors from the corridor to the receiving room would not positively latch into the frame. The inactive leaf of the double-doors was equipped with manual flush bolts that were not latched into the frame. The active leaf would not close and latch into the inactive leaf. If the inactive leaf was not manually secured, positive latching of the assembly could not occur. Interview with the maintenance supervisor at the time of the interview confirmed the finding. He was unaware the doors were in that condition.

2. Observation at 10:20 a.m. revealed the double-doors from the corridor to the dry storage room would not positively latch into the frame. Interview with the maintenance supervisor at the time of the observation confirmed the automatic flush bolt on the inactive leaf was not operating properly.

Based on observation and document review, the provider failed to maintain at least two conforming exits from each floor of the building. The exit from the east basement and the exit from the elevator pit basement did not meet the standard for means of egress. Each of the two basement locations only had one means of egress (stair enclosure) that opened onto the main floor corridor system instead of directly outside. Findings include:

1. Observation at 10:00 a.m. revealed two basement areas were not provided with an approved means of egress. The exit from the east current medical record storage basement and the exit from the elevator mechanical room basement did not meet the standard for means of egress. Each of the two basement locations only had one means of egress and each means of egress opened onto the main floor corridor system instead of directly outside. Document review of previous survey data indicated that condition was part of the original construction.

The building meets the FSES. Please mark an "F" in the completion date column (X5) to indicate the provider's intent to correct deficiencies identified in K000.

Based on observation and interview, the provider failed to maintain a one hour fire-resistive path of egress from the basement to the exterior of the building. The east basement stairway from the archived medical record storage, the east stair enclosure from the obstetrics department on the second level, and the north stair enclosure from the medical wing of the second level discharged onto the main level corridor system. Findings include:

1. Observation beginning at 1:00 p.m. revealed the east basement stairway from the archived medical records storage, the east stair enclosure from the obstetrics department on the second level, and the north stair enclosure from the medical wing of the second level discharged into the main level corridor system. Interview with the maintenance supervisor at the time of the observations confirmed those findings. He stated the stair enclosures were part of the original construction or were boxed in from construction additions.

The building meets the FSES. Please mark an "F" in the completion date column (X5) to indicate correction of the deficiencies identified in K000.

Based on observation and interview, the provider failed to maintain conforming exit stairs. Items were stored along side and under the stairs on the basement level. The basement level of the stair enclosure was used for storage of dietary overflow. Findings include:

1. Observation at 10:10 a.m. revealed piles of cardboard boxes labeled dietary were stored on the basement level of the west stair enclosure. Further observation revealed behind the boxes the space was used to store other items such as walkers and other metal objects. Interview with the maintenance supervisor at the time of observation confirmed those findings. He indicated he was aware the storage of combustible items were not allowed in the stair enclosures but was unaware the metal objects must also be removed. He was unaware that dietary was storing items in the space.

The provider must comply with the National Fire Protection Association (NFPA 99), Standard for Health Care Facilities, section 8-3.1.11.2(h) Storage Requirements. (See Attachment.)
Based on observation and interview, the provider failed to restrain five of five Air Gas compressed gas cylinders in a secured position. All of the Air Gas cylinders were not secured in the oxygen storage room used by the operating rooms. Findings include:

1. Observation at 12:30 p.m. revealed two H size Air Gas cylinders and three E sized Air Gas cylinders unrestrained in the oxygen storage room used to supply the operating rooms. Interview with the maintenance supervisor at the time of the observation confirmed the finding. He indicated the supplier must have dropped of the cylinders and failed had to properly secure them to the wall.

Based on observation and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the emergency department suite. Findings include:

1. Observation at 10:45 a.m. revealed the double-doors from the corridor to the emergency department suite would not positively latch into the frame. Interview with the maintenance supervisor at the time of the observation confirmed the finding. He indicated that following construction it had been decided to install an automatic opening device on the doors. Rather than installing the proper electronic latching mechanism the latching plates were removed.

Based on observation and interview, the provider failed to maintain the fire-resistive rating of one of four stair enclosures (south stair first floor) and one of one laundry chute (second floor) with construction having a fire-resistance rating of at least one hour. Findings include:

1. Observation at 9:45 a.m. revealed the 90 minute fire rated door assembly to the south stair enclosure on the first floor would not latch into the frame. Inspection of the door revealed the panic hardware was dogged down, so the latching bolt was fixed in the open position. Interview with the maintenance supervisor at the time of the observation indicated he was unaware why the panic hardware was dogged down. The door frame was equipped with an electronic strike and automatic door opening device. Both of those devices were operating properly. The door would have operated properly with the panic hardware left in the latching position.

2. Observation at 11:15 a.m. revealed the 90 minute fire rated door assembly to the laundry chute on the second floor would not latch into the frame. The door was self-closing, but the latching hardware had been broken and not repaired. Interview with the maintenance supervisor at the time of the observation confirmed the finding and was unaware of that condition.

Based on observation and interview, the provider failed to maintain proper separation of two randomly observed hazardous areas. The double-doors to the receiving area and dry storage room would not positively latch into the frame. Findings include:

1. Observation at 10:15 a.m. revealed the double-doors from the corridor to the receiving room would not positively latch into the frame. The inactive leaf of the double-doors was equipped with manual flush bolts that were not latched into the frame. The active leaf would not close and latch into the inactive leaf. If the inactive leaf was not manually secured, positive latching of the assembly could not occur. Interview with the maintenance supervisor at the time of the interview confirmed the finding. He was unaware the doors were in that condition.

2. Observation at 10:20 a.m. revealed the double-doors from the corridor to the dry storage room would not positively latch into the frame. Interview with the maintenance supervisor at the time of the observation confirmed the automatic flush bolt on the inactive leaf was not operating properly.

Based on observation and document review, the provider failed to maintain at least two conforming exits from each floor of the building. The exit from the east basement and the exit from the elevator pit basement did not meet the standard for means of egress. Each of the two basement locations only had one means of egress (stair enclosure) that opened onto the main floor corridor system instead of directly outside. Findings include:

1. Observation at 10:00 a.m. revealed two basement areas were not provided with an approved means of egress. The exit from the east current medical record storage basement and the exit from the elevator mechanical room basement did not meet the standard for means of egress. Each of the two basement locations only had one means of egress and each means of egress opened onto the main floor corridor system instead of directly outside. Document review of previous survey data indicated that condition was part of the original construction.

The building meets the FSES. Please mark an "F" in the completion date column (X5) to indicate the provider's intent to correct deficiencies identified in K000.

Based on observation and interview, the provider failed to maintain a one hour fire-resistive path of egress from the basement to the exterior of the building. The east basement stairway from the archived medical record storage, the east stair enclosure from the obstetrics department on the second level, and the north stair enclosure from the medical wing of the second level discharged onto the main level corridor system. Findings include:

1. Observation beginning at 1:00 p.m. revealed the east basement stairway from the archived medical records storage, the east stair enclosure from the obstetrics department on the second level, and the north stair enclosure from the medical wing of the second level discharged into the main level corridor system. Interview with the maintenance supervisor at the time of the observations confirmed those findings. He stated the stair enclosures were part of the original construction or were boxed in from construction additions.

The building meets the FSES. Please mark an "F" in the completion date column (X5) to indicate correction of the deficiencies identified in K000.

Based on observation and interview, the provider failed to maintain conforming exit stairs. Items were stored along side and under the stairs on the basement level. The basement level of the stair enclosure was used for storage of dietary overflow. Findings include:

1. Observation at 10:10 a.m. revealed piles of cardboard boxes labeled dietary were stored on the basement level of the west stair enclosure. Further observation revealed behind the boxes the space was used to store other items such as walkers and other metal objects. Interview with the maintenance supervisor at the time of observation confirmed those findings. He indicated he was aware the storage of combustible items were not allowed in the stair enclosures but was unaware the metal objects must also be removed. He was unaware that dietary was storing items in the space.

The provider must comply with the National Fire Protection Association (NFPA 99), Standard for Health Care Facilities, section 8-3.1.11.2(h) Storage Requirements. (See Attachment.)
Based on observation and interview, the provider failed to restrain five of five Air Gas compressed gas cylinders in a secured position. All of the Air Gas cylinders were not secured in the oxygen storage room used by the operating rooms. Findings include:

1. Observation at 12:30 p.m. revealed two H size Air Gas cylinders and three E sized Air Gas cylinders unrestrained in the oxygen storage room used to supply the operating rooms. Interview with the maintenance supervisor at the time of the observation confirmed the finding. He indicated the supplier must have dropped of the cylinders and failed had to properly secure them to the wall.