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Based on interview and observation, the facility failed to ensure doors protecting corridor openings latched when closed. This has the potential to affect all staff, visitors, and patients in the building.

Findings:

On 06/19/12 at 10:00 A.M. a tour was conducted on the sixth floor with Staff P and R. This floor contained two in-patient sleeping units: a medical surgical unit and a hospice unit. Within the medical surgical unit the door of one patient room, designated 619, was observed at 11:41 A.M. to not latch when closed, and the door of the soiled linen room, designated 600.5, was observed at 11:38 A.M. not to latch when closed.

In interviews on 06/19/12 at 11:38 A.M. and 11:41 A.M., Staff P and R confirmed the observations.

Based on interview and observation, the facility failed to ensure all vertical openings, namely stairways had doors that latched when closed. This has the potential to affect all staff, visitors, and patients in the building.

Findings:

On 06/19/12 at 10:00 A.M. a tour was conducted on the sixth floor with Staff P and R. This floor contains two in-patient sleeping units: a medical surgical unit and a hospice unit. In the hospice unit, exit door designated 695.1 that led to the stairwell did not latch when allowed to close.

On 06/19/12 at 11:05 A.M. in an interview, Staff P and R confirmed the observation.

On 06/19/12 at 2:00 P.M. a tour was conducted with Staff P and R of the facility ' s fifth floor. The floor was observed to have on in-patient, medical surgical sleeping unit on the east side, and an outpatient clinic on the west side.

In the oncology exam rooms section of the oncology outpatient clinic door 595.1, which opens onto the exit stairwell, was observed at 3:13 P.M. to not latch when allowed to close.

On 06/19/12 at 3:13 P.M. in an interview, Staff P and R confirmed the observation.

On 06/21/12 at 2:40 P.M. a tour was conducted on the second floor area containing the cardiac care unit, the intensive care unit, and a step-down unit. At 2:50 P.M. the door to the western stairwell was observed not to latch when closed.

On 06/21/12 at 2:40 P.M. in an interview, Staff P and S confirmed the finding.

Based on facility tour and staff verification it was determined this facility failed to ensure all exit accesses were marked with visible signs in order to provide all occupants a readily available and safe access to exit discharges in the event of an emergency. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 94.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour of the lab observation was made from the southeast corner entrance facing west of no exit sign directing staff flow to the exit access stairwell located in the northwest section of the lab. This finding was verified by staff Q during tour of the lab.

21957

Based on facility tour and staff verification it was determined this facility failed to ensure smoke barriers were constructed with at least a one hour fire rated construction. This had the potential to affect all those utilizing these areas of the facility. The patient census was 94 at the beginning of the survey.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour of the emergency department one hour fire rated smoke barriers observation was made of several penetrations above the ceiling tiles in the following locations:

*Four open end curved conduits in room #26
*Three open end curved conduits in room #1054
*Unsealed water line and one unsealed conduit above door 1120.5
*Gap greater than one eighth inch between doors leafs when in the closed position for door 1120.5
*Three unsealed conduits in the northwest corner of the staff breakroom 1134
*One unsealed green flex conduit just at the dividing wall between the vending area and cafe seating area
*One open end conduit with data wires passing through at southeast corner of room 1089
*One open end conduit with data wires passing through outside room 1087
*Within the waiting area, one unsealed green flex conduit around the annular space and one open end conduit located beside a cement beam.
*Outside room 1066 a curved conduit was not sealed around the annular space
*Above the door of room 1061, two open end conduits, additionally the door to room 1061 failed to close properly.
*Door of room 1059 failed to close properly.
*One three inch unsealed sleeve with wires was observed above door 1123.3.
*One inch square opening above door number 1136.
*Three unsealed conduits around the annular space to the left of door (electrical room) 1129, two unsealed three inch conduits with wires passing through above door number 1129.
*From within room 103.00D, one unsealed conduit around the annular space.
*Gap greater than one eighth inch between door leafs when in the closed position on door 103.00E.
*From within room 1102, south wall, two small penetrations around the annular space and inside the conduit.

These findings were verified by staff Q during tour of this area.





On 06/21/12 at 9:00 A.M. a tour with Staff P and R was conducted of the second floor section containing the operating room suites and the post-anesthesia care units. At 9:03 A.M. the smoke barrier above the double doors perpendicular to room c1 was observed to be pierced by a communication conduit with an unsealed opening.

At 9:42 A.M. the smoke barrier above the double doors perpendicular to room 2032 was observed to contain a conduit (one of three), closest to room 13, to have unsealed openings.

At 10:26 A.M. smoke barrier dividing room 28 from the corridor was observed to be pierced with a communication conduit pipe that had an unsealed annular space surrounding it.

At 10:30 A.M. the smoke barrier above the double doors perpendicular to the soiled utility room 2040 was observed to be pierced by an unsealed communication conduit.

On 06/21/12 at 9:03 A.M., 9:42 A.M., 10:26 A.M., and at 10:30 A.M. in an interview, Staff P and R confirmed the observations.

21957

Based on facility tour and staff verification it was determined this facility failed to ensure smoke barriers were constructed with at least a one half hour fire rated construction. This had the potential to affect all those utilizing these areas of the facility. The patient census was 94 at the beginning of the survey.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour of the smoke barriers, observation was made of gaps greater than one eighth inch between door leafs when in the closed position, and several penetrations above the ceiling tiles in the following locations:

Ground floor:
*Gap between door leafs of door number G34.1A
*Facing east and to the right a few feet down the corridor, observation was made of an unsealed conduit with white and blue wires passing through.
*One open end conduit which was also not sealed around the annular space above door number G83B.
*From within room 326.18, observation was made of one open end conduit which was also not sealed around the annular space.
*Within the kitchen and at the east smoke barrier wall, observation was made of several penetrations around multiple conduits. At the south wall, observation was made of penetrations approximately one foot wide by one and a half foot long.
*Above door G38.18 of the cafeteria, one unsealed conduit, unsealed bundle of data wires and an unsealed area around a bracket.
*From the corridor and to the left of door G38.18 approximately 10 feet, observation was made of one unsealed water line, half inch conduit, and a junction box not sealed around the annular space.
*Further down the corridor through doors G90.3 and across from the elevators, observation was made of one unsealed conduit and one flex conduit not sealed around the annular space.
*In the corridor bordering the south wall of the cafeteria and at the curved section observation was made of two conduits sealed with duct tape and one insulated line not sealed around the annular space.
*Above door G41.1A, observation was made of an approximate two inch by three inch opening in the drywall and three unsealed copper lines, conduit and wires.

First floor:
*Within room 103.00B, observation was made of three curved open end conduits.
*Within room 150.37, observation was made of one unsealed conduit.
*Above door 103.9, observation was made of three open sleeves and one unsealed conduit.
*Across from 106.4, observation was made of an area unsealed around a water line with wires passing through the annular space.
*At 145.23B, two unsealed conduits and wires around the annular space.
*Within electrical closet 106.5, unsealed wires, flex conduit and sleeve.
*One unsealed conduit above door number 22 (106.1).
*Above door 195.4, three unsealed conduits and wires.
*From within the lab at 135.22, observation was made of an open area around a row of approximately 30 conduits.
*From within room 135.16, observation was made of a PVC pipe not sealed around the annular space.
*From within room 135.2, observation was made of two unsealed ducts with a large open area around one of them.
*From within room 135.8, observation was made of unsealed fire junction box, two green flex conduits and silver conduits.
*From within room 135.13, observation was made of one unsealed curved conduit.
*From within room 130.70, south wall, observation was made of a fire alarm junction box that was missing the cover plate. This was the same for the south wall of 130.01.
*From within room 130.01, west wall back side of the chase, observation was made of blue and white data wire passing through an unsealed sleeve. To the right of that observation was made of an unsealed white insulated line around the annular space.
*Continuing north along the smoke barrier and to the left of 130.10 observation was made of four penetration around a conduit, copper lines, black water line and a white pvc pipe.
*Above 130.10 observation was made of an approximate 18 inch by 18 inch opening in the drywall and one unsealed conduit and wires.
*Above door 130.56 observation was made of an open end conduit with yellow and white wires passing through and wires that penetrated through the drywall which were not sealed around the annular space.
*From within room 130.51, observation was made of one unsealed flex conduit and one open end flex conduit.
*From within room 130.60, observation was made of two unsealed areas around steel I-beams, one which had gray wires passing through the annular space.
*From within the developmental office of the administration area, facing the south smoke barrier wall, observation was made of a duct which had what appeared to be residential insulation packed around the annular space.
*Adjacent to and west outside of the developmental office of the administration area and at the double smoke barrier doors of the waiting area, observation was made of six penetrations around wires and conduits.
*Above double doors 194.4 adjacent to the stairs, observation was made of one open end conduit with data wires passing through and unsealed wires around the annular space.
*Within 194.5, three round were observed to not be sealed.
*Within 191.2, observation was made of two unsealed flex ducts and one unsealed conduit.
*Within 140.5 observation was made of an approximate four inch by three inch opening and two round holes.
*Across from 194.13, observation was made of one open end conduit with yellow wires passing through.
*Across from 150.12, observation was made of seven penetrations around wires and conduits. Additionally, one duct was observed to not be sealed on one side and a few feet east one open end conduit was observed.
*Above doors 106.6 observation was made of two bundles of unsealed data wires.
*Within room 122.2, observation was made of one open end conduit.
*Across from 193.2, observation was made of two penetrations around conduits.
*Above 193.2, observation was made of three unsealed conduits.
*Above 193.3, observation was made of two penetrations.
*From within the cashier's office, observation was made of one open end conduit.
*One unsealed data cable above door 101.3.
*In the corridor at the back of room 150.23 observation was made of one unsealed copper line and one pvc line.

Third floor:
*Above doors 391.1, observation was made of one unsealed white wire, flex conduit and a open area around a damper motor box.
*Within the southwest corner of the waiting area observation was made of two unsealed conduits.

These findings were verified by staff Q during tour of these areas.



On 06/19/12 at 10:00 A.M. a tour was conducted on the sixth floor with Staff P and R. This floor contained two in-patient sleeping units: a medical surgical unit and a hospice unit. According to a review of the schematic of the floor completed on 06/19/12, the two units are separated by a smoke barrier that runs north/south between them.

At 10:05 A.M. the southern most wall of room 634 was observed to not terminate to the ceiling above, leaving a gap of not less than 22 inches long by 10 inches wide.

At 11:35 A.M. the most eastern wall in room 630 was observed to not terminate to the ceiling above, leaving a gap of not less than 22 inches long by 10 inches wide.

On 06/19/12 at 10:05 A.M. and 11:35 A.M. in an interview, Staff P and R confirmed the observation.

On 06/19/12 at 2:00 P.M. a tour was conducted with Staff P and R of the facility ' s fifth floor. The floor was observed to have an in-patient, medical surgical sleeping unit on the east side, and an outpatient clinic on the west side. According to the schematic review completed on 06/20/12, the floor has a smoke barrier that runs north/south between the two units

On 06/19/12 at 2:38 P.M. the smoke wall above door 591.3 was observed to have been pierced by a finger-wide conduit penetration.

On 06/19/12 at 2:47 P.M. the smoke wall above door 591.4 was observed to have been pierced by two copper pipes leaving unsealed annular spaces around each, as well as a finger-width conduit.

On 06/19/12 at 2:38 P.M. and 2:48 P.M. in an interview, Staff P and R confirmed the observation.

On 06/19/12 at 2:07 P.M. the area of the smoke wall opposite room 530 was observed to be pierced by ductwork leaving a finger-width, unsealed penetration.

On 06/21/12 at 11:15 A.M. a tour was conducted with Staff P and R on the second floor area containing the cardiac care unit, the intensive care unit, and a step-down unit. The smoke barrier above door 240.16 was observed at 3:42 P.M. to have two conduits with wires that pierced the barrier and, hence, were not sealed.

At 11:19 A.M. the area of the smoke wall above door 260.39 was observed to be pierced by a communication tray about 12 inches wide with an unsealed, empty space on its dorsal side.

At 2:42 P.M. the smoke barrier above door 226.04 was observed to have been pierced by a ventilation shaft leaving an unfilled, unsealed annular space.

At 3:35 P.M. the smoke barrier above door 240.20 was observed to have been pierced in the middle section by a junction box, leaving it surrounded by empty space, and by an unsealed conduit to the most southern part of the wall.

At 11:36 A.M. the smoke barrier dividing room 292 from the corridor was observed to be pierced by a cable tray of not less than 8 inches in width. The top of the cable tray was not sealed and left an empty space.

At 3:10 P.M. the smoke barrier above door 241.05 was observed to be pierced by two objects. The first was ventilation ductwork that had unsealed, empty space underneath and on the sides. The second was a communication cable canal that also was unsealed leaving an unsealed empty space surrounding it.

At 3:15 P.M. the smoke barrier above door 241.5 was observed to have been pierced by two objects. The first was a sprinkler pipe that was surrounded by an unfilled annular space, and the second was a communication conduit that had unsealed, empty space within it.

At 3:26 P.M. the smoke barrier above door 298.6 was observed to be pierced by conduit containing a single red wire and not containing any sealant.

At 3:58 P.M. the smoke barrier above room 298.8 was observed to be pierced by ventilation ductwork the top of which was unsealed leaving an empty space.

On 06/21/12 at 11:19 A.M., 2:42 P.M., 2:50 P.M., 3:10 P.M., 3:15 P.M., 3:26 P.M. 3:35 P.M., 3:42 P.M., and at 3:58 P.M. in an interview, Staff P and R confirmed the observations.

21957

Based on facility tour and staff verification it was determined this facility failed to ensure the door openings in smoke barriers provided at least a half hour fire resistance rating and were equipped with a self-closing or automatic closing device and were fire rated for at least 20 minutes. This had the potential to affect all those utilizing these areas of the facility. The facility census at the beginning of the survey was 94.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour of the smoke barriers, observation was made of doors which failed to close properly or lacked a closing device in the following locations:

Ground floor:
*Door G36.18 in the cafeteria failed to close properly.
*Door G37.1A lacked a closing device.

First floor:
*Door 135.2B failed to shut properly with two attempts.

These findings were verified by staff Q during tour of these areas.



On 06/19/12 at 2:00 P.M. a tour was conducted with Staff P and R of the facility ' s fifth floor. The floor was observed to have on in-patient, medical surgical sleeping unit on the east side, and an outpatient clinic on the west side. According to the schematic review completed on 06/20/12, the floor has a smoke barrier that runs north/south between the two units.

On 06/19/12 at 2:38 P.M. doors 591.3 automated medication dispensing machine 591.4 were observed to be in the smoke barrier and not unrated. It was uncertain as to whether they were 1.75 inch thick solid bonded core wood.

On 06/19/12 at 2:38 P.M. in an interview, Staff P and R confirmed the observation.

On 06/21/12 at 11:15 A.M. a tour was conducted with Staff P and R on the second floor area containing the cardiac care unit, the intensive care unit, and a step-down unit. At 11:43 A.M. the door of room 240.51 was to be in the smoke barrier. The door was not observed to have a self-closer.

On 06/21/12 at 2:40 P.M. in an interview, Staff P and R confirmed the observation.

Based on facility tour and staff verification it was determined this facility failed to ensure hazardous areas were constructed with at least a one hour fire rated construction. This had the potential to affect all those utilizing these areas of the facility. The patient census was 94 at the beginning of the survey.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour of the emergency department one hour fire rated hazardous areas observation was made of several penetrations above the ceiling tiles in the following locations:

*Room 1021 hole in the north wall, two unsealed sleeves and one open end conduit above the door.
*Room 1028 two holes with wires passing through in the north wall, two water lines passing through unsealed sleeves in the east wall and two unsealed sleeves in the south wall.
*Room 1044 unsealed duct above the door.
*Room 1055 a total of 11 open end conduits around the walls
*Room 1068 two open end conduits with green wires passing through in the north and west walls.
*Room 1084 unsealed one curved conduit.
*Room 1005 unsealed water line around the annular space at both ends.

These findings were verified by staff Q during tour of these rooms.

Based on observation and interview, the facility failed to ensure each exit had a safe access from the exit discharge to a public way. This affected two of three exit pathways.

Findings:

On 06/21/12 at 9:00 A.M. a tour of the building with Staff P and R was completed. The tour revealed the path of egress from the exit door perpendicular to room 15/6 had a concrete pad that terminated to grass that then led to a public way.

At 9:50 A.M. the path of egress from the exit door perpendicular to room 29 had a concrete pad that terminated to grass (without a ramp) that then led to a public way.

The concrete pad was observed to be surrounded by a wooden fence approximately 10 feet high surrounding the pad's perimeter. The pad had a handleless door, electronically locked. In spite of repeated attempts to open the fence's door, the door would not open until a staff member opened it from the outer side.

At 9:50 A.M. Staff P and R confirmed the findings.

Based on observation and interview, the facility failed to maintain a suite of rooms for the intensive care unit on the second floor to less than 5000 square feet according to National Fire Protection Association 101 Chapter 19.2.5.6.

Findings:

On 06/21/12 at 11:15 A.M. a tour was conducted with Staff P and R on the second floor area containing the cardiac care unit, the intensive care unit, and a step-down unit.

On 06/21/12 at 4:30 P.M. in an interview, Staff Q confirmed the intensive care unit suite of rooms had a combined square footage of greater than 5000 square feet.

Based on interview, the facility failed to ensure the building's emergency lighting was tested.

Findings:

On 06/21/11 at 4:30 P.M. in an interview Staff Q confirmed there wasn't any documentation of testing of the building's emergency lighting system.

Based on facility tour and staff verification it was determined this facility failed to ensure the exit and directional signs were illuminated continuously as required by the National Fire Protection Association. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 94.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour of the basement observation was made of an exit sign which was not lit. This sign was located at the double doors of the chiller room on the west end of the basement.

During tour of the ground floor electrical and mechanical rooms, observation was made of of approximately six exit signs which were not illuminating to the extent that this writer was able to discern if they were illuminated at all. The staff member present also verified they were unable to determine the same.

During tour of the ground floor boiler room number G36.1A, observation was made of an exit sign which was broken.

During tour of the first floor lab, observation was made of an exit sign located in the northwest section which was not illuminated.

These findings were verified by all staff members present during tour of these areas.

Based on observation during tour and staff verification it was determined this facility failed to ensure the automatic sprinkler system was maintained in reliable operating condition at all times, specifically in regards to dust and debris. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 94.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour of the ground floor observation was made of dirty sprinkler heads in rooms G13, staff breakroom within the pharmacy, and in the corridor G83 nearest the dock area.

During tour of the first floor observation was made of dirty sprinkler heads in rooms 122.2 and 135.16.

These findings were verified by staff Q during tour of these areas of the facility.

Based on observation during tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were readily accessible in the event of an emergency. This had the potential to affect all those utilizing this facility. The patient census was 94 at the beginning of the survey.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour of the ground floor maintenance and garage area this writer observed one fire extinguisher located on the floor of room G11.4 with the inspection tag missing monthly inspections for April and May of 2012.
Another fire extinguisher was observed to mounted above the five foot limit on the west wall of the garage.
On the east wall of the garage another fire extinguisher was missing the May monthly inspection. Additionally, access to it was blocked by a metal frame leaning against it.

These observations were verified by staff Q during tour of this area.

Based on interview and observation, the facility failed to ensure there weren ' t any portable space heating devices in patient care areas. This has the potential to affect all staff, visitors, and patients in the building.

Findings:

On 06/19/12 at 10:00 A.M. a tour was conducted on the sixth floor with Staff P and R. Within the in-patient medical surgical unit, located on the East side of the building, a space heater was located in room designated as 645.4. (This was not a patient room.)

On 06/19/12 at 11:20 A.M. in an interview, Staff P and R confirmed the observation.

Within the in-patient hospice unit located on the West side of the building, at 10:20 A.M. a space heater was located in room designated as 632. (This room was not in use as a patient room.)

On 06/19/12 at 10:20 A.M. in an interview, Staff P and R confirmed the observation.

Based on observation and interview, , the facility failed to ensure there weren ' t any portable space heating devices in patient care areas. This has the potential to affect all staff, visitors, and patients in the building.

Findings:

On 06/21/12 at 9:00 A.M. a tour with Staff P and R was conducted of the second floor section containing the operating room suites and the post-anesthesia care units. At 10:50 A.M. a space heater was found in room 2011.

On 06/21/12 at 10:50 A.M. in an interview, Staff P and R confirmed the observation.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure the trash and laundry chute was constructed to proved at least a one hour fire resistance rating, specifically in regards to the chute discharge doors. This had the potential to affect all those utilizing the floors in which the chute penetrated. The facility census at the beginning of the survey was 94.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour of the ground floor laundry and trash chute discharge rooms observation was made of each chute door when in the closed position, having a one to two inch gap between the door and the bottom of the chute. This would enable smoke or fire to travel up the chute in the event of an emergency.
Additionally, within the mechanical room a laundry chute was observed. This chute had a door that was closed and latched shut. Staff Q stated this chute was not used any longer. This writer had staff Q open and close the chute door. When the door was tested, it failed to latch shut.

These findings were verified by staff Q during tour of these areas.

Based on operating room (OR) and labor and delivery (L & D) room relative humidity (RH) documentation review and staff verification it was determined this facility failed to ensure the RH was maintained at the required 35% or greater in all 10 operating rooms and the labor and delivery room. This had the potential to affect all those who utilized these areas of the facility. The patient census was 94 at the beginning of the survey.

Findings include:

The documentation review for the operating room and labor and delivery room RH levels were reviewed on 06/18/12 with staff members P and Q. During review observation was made of several days during the months of November 2011 through March 2012 where the RH levels were below the required 35%. The number of days below the required 35% RH were:

OR # 1:
November 2011, 13 days.
December 2011, 16 days
January 2012, 18 days.
February 2012, 19 days.
March 2012, 11 days.

OR #2:
November 2011, 11 days.
December 2011, 16 days.
January 2012, 18 days.
February 2012, 20 days.
March 2012, 13 days.

OR #3:
November 2011, 7 days.
December 2011, 12 days.
January 2012, 17 days.
February 2012, 14 days.
March 2012, 10 days.

OR #4:
November 2011, 10 days.
December 2011, 12 days.
January 2012, 18 days.
February 2012, 16 days.
March 2012, 9 days.

OR #5:
November 2011, 12 days.
December 2011, 13 days.
January 2012, 18 days.
February 2012, 18 days.
March 2012, 12 days.

OR #6:
November 2011, 11 days.
December 2011, 14 days.
January 2012, 19 days.
February 2012, 20 days.
March 2012, 11 days.

OR #7:
November 2011, 12 days.
December 2011, 14 days.
January 2012, 19 days.
February 2012, 18 days.
March 2012, 11 days.

OR #8:
November 2011, 11 days.
December 2011, 14 days.
January 2012, 20 days.
February 2012, 18 days.
March 2012, 11 days.

OR #9:
November 2011, 12 days.
December 2011, 14 days.
January 2012, 19 days.
February 2012, 20 days.
March 2012, 11 days.

OR #10:
November 2011, 10 days.
December 2011, 15 days.
January 2012, 18 days.
February 2012, 19 days.
March 2012, 10 days.

L & D:
January 2012, 28 days.
February 2012, 29 days.
March 2012, 7 days.

These findings were verified by both staff members during the documentation review of the RH levels in the OR's and L& D rooms.

Based on documentation review and staff verification it was determined this facility failed to ensure quarterly sprinkler tests according to NFPA 25 Chapter 2-1. This facility failed to ensure the testing of the emergency battery operated lights were documented monthly and annually as required by NFPA 101 Chapter 7.9.3. This facility failed to ensure the testing of smoke detectors as required by NFPA 72, Chapter 7-3.2.1 This had potential to affect all those utilizing this facility.
Findings:
On 06/21/11 at 4:30 P.M. in an interview Staff Q confirmed there wasn ' t any documentation of testing on the building ' s smoke detectors, the sprinkler system was not tested quarterly, and there wasn ' t any documentation of the building ' s emergency lighting system being tested.

Based on documentation review and staff verification it was determined this facility failed to ensure quarterly sprinkler tests according to NFPA 25 Chapter 2-1. This facility failed to ensure the testing of the emergency battery operated lights were documented monthly and annually as required by NFPA 101 Chapter 7.9.3. This had the potential to affect all those utilizing this facility. The facility census was zero at the time of the survey.

Findings include:

Documentation review for the quarterly sprinkler system tests took place on 06/18/12 with staff members P and Q. During review the sprinkler systems test report provided indicated the testing had taken place by an outside professional company on 04/08/11. This writer questioned staff members P and Q if they were performing quarterly sprinkler tests at this location and they replied "no" and they were not aware quarterly sprinkler testing were required.

Also during documentation review this writer requested the documentation for the emergency battery operated egress light monthly and annual tests. Staff Q replied they do perform the tests but they have no documentation to verify it had been completed.

Based on observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The facility census was 94 at the beginning of the survey.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour observation was made of several smoke detectors which were located near air flow devices in the following locations:

Ground floor:
*Two within the biomedical department
*Within the men's and women's restroom near the biomedical department.
*Within the health information office.
*In room G21.2
*In front of elevators G90.
*In room G42.1A.
*In volunteer room G45.
*In room G41.1A.
*In men's locker room near SPD.

First floor:
*In room 130.46
*In lab room 135.16 and near front entrance. Also by the back stairs of lab by room 135.23.
*Waiting area of radiology, east end. By 195.3 and 148.8.
*In rooms 110.5 and 110.3 of administration department.
*Within the gift shop storage.
*In front of elevator numbers 1, 2 and 5.
*In room 194.6.
*By doors 101.1, 150.02, 150.01C, 150.18, 150.25, 150.28A, 150.50, 150.51, 150.57, 150.43, 103.00A, 103.00B and 103.00C.

Third floor:
*By 393.1 and 320.4

Fourth floor:
*In front of elevators of corridor 491.

These findings were verified by staff Q during tour of these areas.

Based on interview and observation, the facility failed to ensure doors protecting corridor openings latched when closed. This has the potential to affect all staff, visitors, and patients in the building.

Findings:

On 06/19/12 at 10:00 A.M. a tour was conducted on the sixth floor with Staff P and R. This floor contained two in-patient sleeping units: a medical surgical unit and a hospice unit. Within the medical surgical unit the door of one patient room, designated 619, was observed at 11:41 A.M. to not latch when closed, and the door of the soiled linen room, designated 600.5, was observed at 11:38 A.M. not to latch when closed.

In interviews on 06/19/12 at 11:38 A.M. and 11:41 A.M., Staff P and R confirmed the observations.

Based on interview and observation, the facility failed to ensure all vertical openings, namely stairways had doors that latched when closed. This has the potential to affect all staff, visitors, and patients in the building.

Findings:

On 06/19/12 at 10:00 A.M. a tour was conducted on the sixth floor with Staff P and R. This floor contains two in-patient sleeping units: a medical surgical unit and a hospice unit. In the hospice unit, exit door designated 695.1 that led to the stairwell did not latch when allowed to close.

On 06/19/12 at 11:05 A.M. in an interview, Staff P and R confirmed the observation.

On 06/19/12 at 2:00 P.M. a tour was conducted with Staff P and R of the facility ' s fifth floor. The floor was observed to have on in-patient, medical surgical sleeping unit on the east side, and an outpatient clinic on the west side.

In the oncology exam rooms section of the oncology outpatient clinic door 595.1, which opens onto the exit stairwell, was observed at 3:13 P.M. to not latch when allowed to close.

On 06/19/12 at 3:13 P.M. in an interview, Staff P and R confirmed the observation.

On 06/21/12 at 2:40 P.M. a tour was conducted on the second floor area containing the cardiac care unit, the intensive care unit, and a step-down unit. At 2:50 P.M. the door to the western stairwell was observed not to latch when closed.

On 06/21/12 at 2:40 P.M. in an interview, Staff P and S confirmed the finding.

Based on facility tour and staff verification it was determined this facility failed to ensure all exit accesses were marked with visible signs in order to provide all occupants a readily available and safe access to exit discharges in the event of an emergency. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 94.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour of the lab observation was made from the southeast corner entrance facing west of no exit sign directing staff flow to the exit access stairwell located in the northwest section of the lab. This finding was verified by staff Q during tour of the lab.

21957

Based on facility tour and staff verification it was determined this facility failed to ensure smoke barriers were constructed with at least a one hour fire rated construction. This had the potential to affect all those utilizing these areas of the facility. The patient census was 94 at the beginning of the survey.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour of the emergency department one hour fire rated smoke barriers observation was made of several penetrations above the ceiling tiles in the following locations:

*Four open end curved conduits in room #26
*Three open end curved conduits in room #1054
*Unsealed water line and one unsealed conduit above door 1120.5
*Gap greater than one eighth inch between doors leafs when in the closed position for door 1120.5
*Three unsealed conduits in the northwest corner of the staff breakroom 1134
*One unsealed green flex conduit just at the dividing wall between the vending area and cafe seating area
*One open end conduit with data wires passing through at southeast corner of room 1089
*One open end conduit with data wires passing through outside room 1087
*Within the waiting area, one unsealed green flex conduit around the annular space and one open end conduit located beside a cement beam.
*Outside room 1066 a curved conduit was not sealed around the annular space
*Above the door of room 1061, two open end conduits, additionally the door to room 1061 failed to close properly.
*Door of room 1059 failed to close properly.
*One three inch unsealed sleeve with wires was observed above door 1123.3.
*One inch square opening above door number 1136.
*Three unsealed conduits around the annular space to the left of door (electrical room) 1129, two unsealed three inch conduits with wires passing through above door number 1129.
*From within room 103.00D, one unsealed conduit around the annular space.
*Gap greater than one eighth inch between door leafs when in the closed position on door 103.00E.
*From within room 1102, south wall, two small penetrations around the annular space and inside the conduit.

These findings were verified by staff Q during tour of this area.





On 06/21/12 at 9:00 A.M. a tour with Staff P and R was conducted of the second floor section containing the operating room suites and the post-anesthesia care units. At 9:03 A.M. the smoke barrier above the double doors perpendicular to room c1 was observed to be pierced by a communication conduit with an unsealed opening.

At 9:42 A.M. the smoke barrier above the double doors perpendicular to room 2032 was observed to contain a conduit (one of three), closest to room 13, to have unsealed openings.

At 10:26 A.M. smoke barrier dividing room 28 from the corridor was observed to be pierced with a communication conduit pipe that had an unsealed annular space surrounding it.

At 10:30 A.M. the smoke barrier above the double doors perpendicular to the soiled utility room 2040 was observed to be pierced by an unsealed communication conduit.

On 06/21/12 at 9:03 A.M., 9:42 A.M., 10:26 A.M., and at 10:30 A.M. in an interview, Staff P and R confirmed the observations.

21957

Based on facility tour and staff verification it was determined this facility failed to ensure smoke barriers were constructed with at least a one half hour fire rated construction. This had the potential to affect all those utilizing these areas of the facility. The patient census was 94 at the beginning of the survey.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour of the smoke barriers, observation was made of gaps greater than one eighth inch between door leafs when in the closed position, and several penetrations above the ceiling tiles in the following locations:

Ground floor:
*Gap between door leafs of door number G34.1A
*Facing east and to the right a few feet down the corridor, observation was made of an unsealed conduit with white and blue wires passing through.
*One open end conduit which was also not sealed around the annular space above door number G83B.
*From within room 326.18, observation was made of one open end conduit which was also not sealed around the annular space.
*Within the kitchen and at the east smoke barrier wall, observation was made of several penetrations around multiple conduits. At the south wall, observation was made of penetrations approximately one foot wide by one and a half foot long.
*Above door G38.18 of the cafeteria, one unsealed conduit, unsealed bundle of data wires and an unsealed area around a bracket.
*From the corridor and to the left of door G38.18 approximately 10 feet, observation was made of one unsealed water line, half inch conduit, and a junction box not sealed around the annular space.
*Further down the corridor through doors G90.3 and across from the elevators, observation was made of one unsealed conduit and one flex conduit not sealed around the annular space.
*In the corridor bordering the south wall of the cafeteria and at the curved section observation was made of two conduits sealed with duct tape and one insulated line not sealed around the annular space.
*Above door G41.1A, observation was made of an approximate two inch by three inch opening in the drywall and three unsealed copper lines, conduit and wires.

First floor:
*Within room 103.00B, observation was made of three curved open end conduits.
*Within room 150.37, observation was made of one unsealed conduit.
*Above door 103.9, observation was made of three open sleeves and one unsealed conduit.
*Across from 106.4, observation was made of an area unsealed around a water line with wires passing through the annular space.
*At 145.23B, two unsealed conduits and wires around the annular space.
*Within electrical closet 106.5, unsealed wires, flex conduit and sleeve.
*One unsealed conduit above door number 22 (106.1).
*Above door 195.4, three unsealed conduits and wires.
*From within the lab at 135.22, observation was made of an open area around a row of approximately 30 conduits.
*From within room 135.16, observation was made of a PVC pipe not sealed around the annular space.
*From within room 135.2, observation was made of two unsealed ducts with a large open area around one of them.
*From within room 135.8, observation was made of unsealed fire junction box, two green flex conduits and silver conduits.
*From within room 135.13, observation was made of one unsealed curved conduit.
*From within room 130.70, south wall, observation was made of a fire alarm junction box that was missing the cover plate. This was the same for the south wall of 130.01.
*From within room 130.01, west wall back side of the chase, observation was made of blue and white data wire passing through an unsealed sleeve. To the right of that observation was made of an unsealed white insulated line around the annular space.
*Continuing north along the smoke barrier and to the left of 130.10 observation was made of four penetration around a conduit, copper lines, black water line and a white pvc pipe.
*Above 130.10 observation was made of an approximate 18 inch by 18 inch opening in the drywall and one unsealed conduit and wires.
*Above door 130.56 observation was made of an open end conduit with yellow and white wires passing through and wires that penetrated through the drywall which were not sealed around the annular space.
*From within room 130.51, observation was made of one unsealed flex conduit and one open end flex conduit.
*From within room 130.60, observation was made of two unsealed areas around steel I-beams, one which had gray wires passing through the annular space.
*From within the developmental office of the administration area, facing the south smoke barrier wall, observation was made of a duct which had what appeared to be residential insulation packed around the annular space.
*Adjacent to and west outside of the developmental office of the administration area and at the double smoke barrier doors of the waiting area, observation was made of six penetrations around wires and conduits.
*Above double doors 194.4 adjacent to the stairs, observation was made of one open end conduit with data wires passing through and unsealed wires around the annular space.
*Within 194.5, three round were observed to not be sealed.
*Within 191.2, observation was made of two unsealed flex ducts and one unsealed conduit.
*Within 140.5 observation was made of an approximate four inch by three inch opening and two round holes.
*Across from 194.13, observation was made of one open end conduit with yellow wires passing through.
*Across from 150.12, observation was made of seven penetrations around wires and conduits. Additionally, one duct was observed to not be sealed on one side and a few feet east one open end conduit was observed.
*Above doors 106.6 observation was made of two bundles of unsealed data wires.
*Within room 122.2, observation was made of one open end conduit.
*Across from 193.2, observation was made of two penetrations around conduits.
*Above 193.2, observation was made of three unsealed conduits.
*Above 193.3, observation was made of two penetrations.
*From within the cashier's office, observation was made of one open end conduit.
*One unsealed data cable above door 101.3.
*In the corridor at the back of room 150.23 observation was made of one unsealed copper line and one pvc line.

Third floor:
*Above doors 391.1, observation was made of one unsealed white wire, flex conduit and a open area around a damper motor box.
*Within the southwest corner of the waiting area observation was made of two unsealed conduits.

These findings were verified by staff Q during tour of these areas.



On 06/19/12 at 10:00 A.M. a tour was conducted on the sixth floor with Staff P and R. This floor contained two in-patient sleeping units: a medical surgical unit and a hospice unit. According to a review of the schematic of the floor completed on 06/19/12, the two units are separated by a smoke barrier that runs north/south between them.

At 10:05 A.M. the southern most wall of room 634 was observed to not terminate to the ceiling above, leaving a gap of not less than 22 inches long by 10 inches wide.

At 11:35 A.M. the most eastern wall in room 630 was observed to not terminate to the ceiling above, leaving a gap of not less than 22 inches long by 10 inches wide.

On 06/19/12 at 10:05 A.M. and 11:35 A.M. in an interview, Staff P and R confirmed the observation.

On 06/19/12 at 2:00 P.M. a tour was conducted with Staff P and R of the facility ' s fifth floor. The floor was observed to have an in-patient, medical surgical sleeping unit on the east side, and an outpatient clinic on the west side. According to the schematic review completed on 06/20/12, the floor has a smoke barrier that runs north/south between the two units

On 06/19/12 at 2:38 P.M. the smoke wall above door 591.3 was observed to have been pierced by a finger-wide conduit penetration.

On 06/19/12 at 2:47 P.M. the smoke wall above door 591.4 was observed to have been pierced by two copper pipes leaving unsealed annular spaces around each, as well as a finger-width conduit.

On 06/19/12 at 2:38 P.M. and 2:48 P.M. in an interview, Staff P and R confirmed the observation.

On 06/19/12 at 2:07 P.M. the area of the smoke wall opposite room 530 was observed to be pierced by ductwork leaving a finger-width, unsealed penetration.

On 06/21/12 at 11:15 A.M. a tour was conducted with Staff P and R on the second floor area containing the cardiac care unit, the intensive care unit, and a step-down unit. The smoke barrier above door 240.16 was observed at 3:42 P.M. to have two conduits with wires that pierced the barrier and, hence, were not sealed.

At 11:19 A.M. the area of the smoke wall above door 260.39 was observed to be pierced by a communication tray about 12 inches wide with an unsealed, empty space on its dorsal side.

At 2:42 P.M. the smoke barrier above door 226.04 was observed to have been pierced by a ventilation shaft leaving an unfilled, unsealed annular space.

At 3:35 P.M. the smoke barrier above door 240.20 was observed to have been pierced in the middle section by a junction box, leaving it surrounded by empty space, and by an unsealed conduit to the most southern part of the wall.

At 11:36 A.M. the smoke barrier dividing room 292 from the corridor was observed to be pierced by a cable tray of not less than 8 inches in width. The top of the cable tray was not sealed and left an empty space.

At 3:10 P.M. the smoke barrier above door 241.05 was observed to be pierced by two objects. The first was ventilation ductwork that had unsealed, empty space underneath and on the sides. The second was a communication cable canal that also was unsealed leaving an unsealed empty space surrounding it.

At 3:15 P.M. the smoke barrier above door 241.5 was observed to have been pierced by two objects. The first was a sprinkler pipe that was surrounded by an unfilled annular space, and the second was a communication conduit that had unsealed, empty space within it.

At 3:26 P.M. the smoke barrier above door 298.6 was observed to be pierced by conduit containing a single red wire and not containing any sealant.

At 3:58 P.M. the smoke barrier above room 298.8 was observed to be pierced by ventilation ductwork the top of which was unsealed leaving an empty space.

On 06/21/12 at 11:19 A.M., 2:42 P.M., 2:50 P.M., 3:10 P.M., 3:15 P.M., 3:26 P.M. 3:35 P.M., 3:42 P.M., and at 3:58 P.M. in an interview, Staff P and R confirmed the observations.

21957

Based on facility tour and staff verification it was determined this facility failed to ensure the door openings in smoke barriers provided at least a half hour fire resistance rating and were equipped with a self-closing or automatic closing device and were fire rated for at least 20 minutes. This had the potential to affect all those utilizing these areas of the facility. The facility census at the beginning of the survey was 94.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour of the smoke barriers, observation was made of doors which failed to close properly or lacked a closing device in the following locations:

Ground floor:
*Door G36.18 in the cafeteria failed to close properly.
*Door G37.1A lacked a closing device.

First floor:
*Door 135.2B failed to shut properly with two attempts.

These findings were verified by staff Q during tour of these areas.



On 06/19/12 at 2:00 P.M. a tour was conducted with Staff P and R of the facility ' s fifth floor. The floor was observed to have on in-patient, medical surgical sleeping unit on the east side, and an outpatient clinic on the west side. According to the schematic review completed on 06/20/12, the floor has a smoke barrier that runs north/south between the two units.

On 06/19/12 at 2:38 P.M. doors 591.3 automated medication dispensing machine 591.4 were observed to be in the smoke barrier and not unrated. It was uncertain as to whether they were 1.75 inch thick solid bonded core wood.

On 06/19/12 at 2:38 P.M. in an interview, Staff P and R confirmed the observation.

On 06/21/12 at 11:15 A.M. a tour was conducted with Staff P and R on the second floor area containing the cardiac care unit, the intensive care unit, and a step-down unit. At 11:43 A.M. the door of room 240.51 was to be in the smoke barrier. The door was not observed to have a self-closer.

On 06/21/12 at 2:40 P.M. in an interview, Staff P and R confirmed the observation.

Based on facility tour and staff verification it was determined this facility failed to ensure hazardous areas were constructed with at least a one hour fire rated construction. This had the potential to affect all those utilizing these areas of the facility. The patient census was 94 at the beginning of the survey.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour of the emergency department one hour fire rated hazardous areas observation was made of several penetrations above the ceiling tiles in the following locations:

*Room 1021 hole in the north wall, two unsealed sleeves and one open end conduit above the door.
*Room 1028 two holes with wires passing through in the north wall, two water lines passing through unsealed sleeves in the east wall and two unsealed sleeves in the south wall.
*Room 1044 unsealed duct above the door.
*Room 1055 a total of 11 open end conduits around the walls
*Room 1068 two open end conduits with green wires passing through in the north and west walls.
*Room 1084 unsealed one curved conduit.
*Room 1005 unsealed water line around the annular space at both ends.

These findings were verified by staff Q during tour of these rooms.

Based on observation and interview, the facility failed to ensure each exit had a safe access from the exit discharge to a public way. This affected two of three exit pathways.

Findings:

On 06/21/12 at 9:00 A.M. a tour of the building with Staff P and R was completed. The tour revealed the path of egress from the exit door perpendicular to room 15/6 had a concrete pad that terminated to grass that then led to a public way.

At 9:50 A.M. the path of egress from the exit door perpendicular to room 29 had a concrete pad that terminated to grass (without a ramp) that then led to a public way.

The concrete pad was observed to be surrounded by a wooden fence approximately 10 feet high surrounding the pad's perimeter. The pad had a handleless door, electronically locked. In spite of repeated attempts to open the fence's door, the door would not open until a staff member opened it from the outer side.

At 9:50 A.M. Staff P and R confirmed the findings.

Based on observation and interview, the facility failed to maintain a suite of rooms for the intensive care unit on the second floor to less than 5000 square feet according to National Fire Protection Association 101 Chapter 19.2.5.6.

Findings:

On 06/21/12 at 11:15 A.M. a tour was conducted with Staff P and R on the second floor area containing the cardiac care unit, the intensive care unit, and a step-down unit.

On 06/21/12 at 4:30 P.M. in an interview, Staff Q confirmed the intensive care unit suite of rooms had a combined square footage of greater than 5000 square feet.

Based on interview, the facility failed to ensure the building's emergency lighting was tested.

Findings:

On 06/21/11 at 4:30 P.M. in an interview Staff Q confirmed there wasn't any documentation of testing of the building's emergency lighting system.

Based on facility tour and staff verification it was determined this facility failed to ensure the exit and directional signs were illuminated continuously as required by the National Fire Protection Association. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 94.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour of the basement observation was made of an exit sign which was not lit. This sign was located at the double doors of the chiller room on the west end of the basement.

During tour of the ground floor electrical and mechanical rooms, observation was made of of approximately six exit signs which were not illuminating to the extent that this writer was able to discern if they were illuminated at all. The staff member present also verified they were unable to determine the same.

During tour of the ground floor boiler room number G36.1A, observation was made of an exit sign which was broken.

During tour of the first floor lab, observation was made of an exit sign located in the northwest section which was not illuminated.

These findings were verified by all staff members present during tour of these areas.

Based on observation during tour and staff verification it was determined this facility failed to ensure the automatic sprinkler system was maintained in reliable operating condition at all times, specifically in regards to dust and debris. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 94.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour of the ground floor observation was made of dirty sprinkler heads in rooms G13, staff breakroom within the pharmacy, and in the corridor G83 nearest the dock area.

During tour of the first floor observation was made of dirty sprinkler heads in rooms 122.2 and 135.16.

These findings were verified by staff Q during tour of these areas of the facility.

Based on observation during tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were readily accessible in the event of an emergency. This had the potential to affect all those utilizing this facility. The patient census was 94 at the beginning of the survey.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour of the ground floor maintenance and garage area this writer observed one fire extinguisher located on the floor of room G11.4 with the inspection tag missing monthly inspections for April and May of 2012.
Another fire extinguisher was observed to mounted above the five foot limit on the west wall of the garage.
On the east wall of the garage another fire extinguisher was missing the May monthly inspection. Additionally, access to it was blocked by a metal frame leaning against it.

These observations were verified by staff Q during tour of this area.

Based on interview and observation, the facility failed to ensure there weren ' t any portable space heating devices in patient care areas. This has the potential to affect all staff, visitors, and patients in the building.

Findings:

On 06/19/12 at 10:00 A.M. a tour was conducted on the sixth floor with Staff P and R. Within the in-patient medical surgical unit, located on the East side of the building, a space heater was located in room designated as 645.4. (This was not a patient room.)

On 06/19/12 at 11:20 A.M. in an interview, Staff P and R confirmed the observation.

Within the in-patient hospice unit located on the West side of the building, at 10:20 A.M. a space heater was located in room designated as 632. (This room was not in use as a patient room.)

On 06/19/12 at 10:20 A.M. in an interview, Staff P and R confirmed the observation.

Based on observation and interview, , the facility failed to ensure there weren ' t any portable space heating devices in patient care areas. This has the potential to affect all staff, visitors, and patients in the building.

Findings:

On 06/21/12 at 9:00 A.M. a tour with Staff P and R was conducted of the second floor section containing the operating room suites and the post-anesthesia care units. At 10:50 A.M. a space heater was found in room 2011.

On 06/21/12 at 10:50 A.M. in an interview, Staff P and R confirmed the observation.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure the trash and laundry chute was constructed to proved at least a one hour fire resistance rating, specifically in regards to the chute discharge doors. This had the potential to affect all those utilizing the floors in which the chute penetrated. The facility census at the beginning of the survey was 94.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour of the ground floor laundry and trash chute discharge rooms observation was made of each chute door when in the closed position, having a one to two inch gap between the door and the bottom of the chute. This would enable smoke or fire to travel up the chute in the event of an emergency.
Additionally, within the mechanical room a laundry chute was observed. This chute had a door that was closed and latched shut. Staff Q stated this chute was not used any longer. This writer had staff Q open and close the chute door. When the door was tested, it failed to latch shut.

These findings were verified by staff Q during tour of these areas.

Based on operating room (OR) and labor and delivery (L & D) room relative humidity (RH) documentation review and staff verification it was determined this facility failed to ensure the RH was maintained at the required 35% or greater in all 10 operating rooms and the labor and delivery room. This had the potential to affect all those who utilized these areas of the facility. The patient census was 94 at the beginning of the survey.

Findings include:

The documentation review for the operating room and labor and delivery room RH levels were reviewed on 06/18/12 with staff members P and Q. During review observation was made of several days during the months of November 2011 through March 2012 where the RH levels were below the required 35%. The number of days below the required 35% RH were:

OR # 1:
November 2011, 13 days.
December 2011, 16 days
January 2012, 18 days.
February 2012, 19 days.
March 2012, 11 days.

OR #2:
November 2011, 11 days.
December 2011, 16 days.
January 2012, 18 days.
February 2012, 20 days.
March 2012, 13 days.

OR #3:
November 2011, 7 days.
December 2011, 12 days.
January 2012, 17 days.
February 2012, 14 days.
March 2012, 10 days.

OR #4:
November 2011, 10 days.
December 2011, 12 days.
January 2012, 18 days.
February 2012, 16 days.
March 2012, 9 days.

OR #5:
November 2011, 12 days.
December 2011, 13 days.
January 2012, 18 days.
February 2012, 18 days.
March 2012, 12 days.

OR #6:
November 2011, 11 days.
December 2011, 14 days.
January 2012, 19 days.
February 2012, 20 days.
March 2012, 11 days.

OR #7:
November 2011, 12 days.
December 2011, 14 days.
January 2012, 19 days.
February 2012, 18 days.
March 2012, 11 days.

OR #8:
November 2011, 11 days.
December 2011, 14 days.
January 2012, 20 days.
February 2012, 18 days.
March 2012, 11 days.

OR #9:
November 2011, 12 days.
December 2011, 14 days.
January 2012, 19 days.
February 2012, 20 days.
March 2012, 11 days.

OR #10:
November 2011, 10 days.
December 2011, 15 days.
January 2012, 18 days.
February 2012, 19 days.
March 2012, 10 days.

L & D:
January 2012, 28 days.
February 2012, 29 days.
March 2012, 7 days.

These findings were verified by both staff members during the documentation review of the RH levels in the OR's and L& D rooms.

Based on documentation review and staff verification it was determined this facility failed to ensure quarterly sprinkler tests according to NFPA 25 Chapter 2-1. This facility failed to ensure the testing of the emergency battery operated lights were documented monthly and annually as required by NFPA 101 Chapter 7.9.3. This facility failed to ensure the testing of smoke detectors as required by NFPA 72, Chapter 7-3.2.1 This had potential to affect all those utilizing this facility.
Findings:
On 06/21/11 at 4:30 P.M. in an interview Staff Q confirmed there wasn ' t any documentation of testing on the building ' s smoke detectors, the sprinkler system was not tested quarterly, and there wasn ' t any documentation of the building ' s emergency lighting system being tested.

Based on documentation review and staff verification it was determined this facility failed to ensure quarterly sprinkler tests according to NFPA 25 Chapter 2-1. This facility failed to ensure the testing of the emergency battery operated lights were documented monthly and annually as required by NFPA 101 Chapter 7.9.3. This had the potential to affect all those utilizing this facility. The facility census was zero at the time of the survey.

Findings include:

Documentation review for the quarterly sprinkler system tests took place on 06/18/12 with staff members P and Q. During review the sprinkler systems test report provided indicated the testing had taken place by an outside professional company on 04/08/11. This writer questioned staff members P and Q if they were performing quarterly sprinkler tests at this location and they replied "no" and they were not aware quarterly sprinkler testing were required.

Also during documentation review this writer requested the documentation for the emergency battery operated egress light monthly and annual tests. Staff Q replied they do perform the tests but they have no documentation to verify it had been completed.

Based on observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The facility census was 94 at the beginning of the survey.

Findings include:

Facility tour took place with staff member Q on 06/18/12 to 6/21/12. During tour observation was made of several smoke detectors which were located near air flow devices in the following locations:

Ground floor:
*Two within the biomedical department
*Within the men's and women's restroom near the biomedical department.
*Within the health information office.
*In room G21.2
*In front of elevators G90.
*In room G42.1A.
*In volunteer room G45.
*In room G41.1A.
*In men's locker room near SPD.

First floor:
*In room 130.46
*In lab room 135.16 and near front entrance. Also by the back stairs of lab by room 135.23.
*Waiting area of radiology, east end. By 195.3 and 148.8.
*In rooms 110.5 and 110.3 of administration department.
*Within the gift shop storage.
*In front of elevator numbers 1, 2 and 5.
*In room 194.6.
*By doors 101.1, 150.02, 150.01C, 150.18, 150.25, 150.28A, 150.50, 150.51, 150.57, 150.43, 103.00A, 103.00B and 103.00C.

Third floor:
*By 393.1 and 320.4

Fourth floor:
*In front of elevators of corridor 491.

These findings were verified by staff Q during tour of these areas.