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Based on observation and interview, the facility failed to maintain a two hour construction rating around its chutes and conduits traveling between floors. This has the potential to affect all patients, staff, and visitors to the facility.

Findings include:

1. On 12/16/14 at 2:06 P.M. a tour was conducted of the eighth floor of the K building with Staff A1, A2, and A3. At 2:12 P.M. the doors to both the soiled linen and trash chutes were each observed to have self closer's; however, the self closer's on each door did not close the door completely.

On 12/16/14 at 2:06 P.M. in an interview, Staff A1 confirmed the observation.

2. On 12/16/14 at 2:48 P.M. a tour was conducted of the seventh floor of the K building with Staff A1, A2, and A3. At 2:48 P.M. in room 7K050 a black wire was observed to come out of an unsealed conduit that communicated to the eighth floor, also unsealed, thereby creating an unenclosed vertical opening between the two floors.

On 12/16/14 at 2:48 P.M. in an interview, Staff A1 confirmed the observation.

Based on observation and interview, the facility failed to maintain the ratings of its smoke barriers.

Findings include:

1. On 12/16/14 at 3:08 P.M. a tour was conducted of the sixth floor of the K building with Staff A1, A2, and A3. On 12/16/14 at 3:55 P.M. a two inch conduit with yellow wiring was observed unsealed on both sides of doors 6K034. The conduit was in a one hour rated barrier separating zone 6k1 for 6k2.

On 12/16/14 at 3:55 P.M. in an interview, Staff A1 confirmed the observation.

2. On 12/17/14 at 9:00 A.M. a tour was conducted of the fifth floor of the K building with Staff A1, A2, and A3. On 12/17/14 at 9:00 A.M. observation above the drop down ceiling over the double doors in the two hour rated barrier between zones 5e and 5k1 revealed a half inch open conduit in the center above the doors.

On 12/17/14 at 9:00 A.M. in an interview, Staff A1 confirmed the observation.

3. On 12/17/14 at 10:46 A.M. a tour was conducted of the second floor of the K building with Staff A1, A2, and A3. At 10:50 A.M. observation above the drop down ceiling of double doors 2k003 in the two hour rated wall separating zones 2e and 2k2 revealed black wires running through a two inch hole in the wall, and four half inch conduits with annular spaces between and above themselves.

On 12/17/14 at 10:50 A.M. in an interview, Staff A1 confirmed the observation.

4. On 12/17/14 at 10:58 A.M. observation above the drop down ceiling of the two hour rated wall between zones 2e and 2k2 and over doors 2k006 revealed an open half inch conduit with one wire coming out of it.

On 12/17/14 at 10:58 A.M. in an interview, Staff A1 confirmed the observation.

5. On 12/17/14 at 1:21 P.M. observation above the drop down ceiling of the one hour rated wall on the east side of double doors 2k002 revealed near the I-beam an L-shaped opening with two half inch conduits running through it.

On 12/17/14 at 1:21 P.M. in an interview, Staff A1 confirmed the observation.

6. On 12/17/14 at 1:32 P.M. observation above the drop down ceiling of the one hour rated wall on the east side of doors 2k125 revealed a one inch opening space above a round heating, ventilation and cooling conduit.

On 12/17/14 at 1:32 P.M. in an interview, Staff A1 confirmed the observation.

7. On 12/17/14 at 1:39 P.M. observation above the drop down ceiling of the one hour rated wall on the west side of doors 2k125 but closer to the bank of elevators, revealed a half inch wide by two inch long square opening in the drywall with a grey wire labeled "oxygen" coming out of it, and an open two inch conduit with blue wires running through it.

On 12/17/14 at 1:39 P.M. in an interview, Staff A1 confirmed the observation.

On 12/17/14 at 2:20 P.M. a tour was taken of the first floor of the K building with Staff A1, A2, and A3.

8. On 12/17/14 at 2:20 P.M. observation of the two hour rated wall above the drop down ceiling and over the double doors separating zone 1k1 and 1a revealed one elbow conduit open to air, one flex conduit with an unsealed annular space, and one sprinkler line with an unsealed annular space.

On 12/17/14 at 2:20 P.M. in an interview, Staff A1 confirmed the observation.

9. On 12/17/14 at 2:33 P.M. observation above the drop down ceiling of the two hour rated wall in the health resource library that separates zone 1k1 from 1a revealed in the back corner of the room, a straight unsealed half inch conduit with a grey wiring running through it.

On 12/17/14 at 2:33 P.M. in an interview, Staff A1 confirmed the observation.

10. On 12/17/14 at 2:56 P.M. observation above the drop ceiling of the one hour rated wall in corridor 1k030 near a display case with a sign reading "gift shop located in lobby" revealed an open area above the trunk of the heating, ventilation and cooling ductwork.

On 12/17/14 at 2:56 P.M. in an interview, Staff A1 confirmed the observation.

11. On 12/17/14 at 2:58 P.M. observation above the drop down ceiling of the one hour rated north wall of gift shop office 1k022 revealed a two inch by two inch square opening with a grey wire running through it.

On 12/17/14 at 2:58 P.M. in an interview, Staff A1 confirmed the observation.

12. On 12/17/14 at 3:29 P.M. observation on the one hour rated wall above the drop down ceiling in spiritual care room 1k041 revealed an open one inch by one inch square with a corrugated conduit and two blue wires running out of it.

On 12/17/14 at 3:29 P.M. in an interview, Staff A1 confirmed the observation.

13. On 12/17/14 at 3:40 P.M. observation on the one hour rated wall above the drop down ceiling over the door next to room 1k059a revealed an open one inch square next to the heating, ventilation and cooling ductwork and an open one inch conduit with a blue wire running through it.

On 12/17/14 at 3:40 P.M. in an interview, Staff A1 confirmed the observation.

Based on schematic review, observation and staff conformation, the facility failed to ensure the doors in the fire rated smoke walls were at the proper rating. This has the potential to affect all patients, staff, and visitors in the facility. The facility's census at the time of the survey was 271.

Findings include:

1. Tour of Zones 7B and 7A was conducted on 12/18/14 between the hours of 2:30 PM and 4:30 PM, the following findings were noted at the time of the tour.
At 2:30 PM the doors in the 2 hour fire rated wall between Zone 7A and 7E had a half inch gap between the door leafs when in the closed position. Additionally, the label on the doors was painted over so the fire rating not visible. This was verified by Staff A5 at the time of the observation.

2. Tour of Zones 5B and 5A was conducted on 12/18/14 between the hours of 9:30 AM and 10:30 AM, the following findings were noted at the time of the tour.
At 9:45 AM it was noted that the doors in the 2 hour fire rated wall between the 5A lobby and the B4, B5, and B6 elevators had a 20 minute rating. This was verified by Staff A5 at the time of the observation.

3. Tour of Zones 4B and 4A was conducted on 12/18/14 between the hours of 10:50 AM and 12:00 PM, the following findings were noted at the time of the tour.
At 11:00 AM 20 minute doors were noted in the 1 hour fire rated wall of the South Corridor for Zone B. This was verified by Staff A5 at the time of the observation.

4. Tour of Zones 2B and 2A was conducted on 12/18/14 between the hours of 2:00 PM and 3:40 PM, the following findings were noted at the time of the tour.
At 2:10 PM the doors in the 2 hour fire rated wall across from the AA stairwell did not have a fire rating marked on them. This was verified by Staff A4 and A5 at the time of the observation.

5. On 12/18/14 at 2:25 P.M. a tour was conducted of zone 1C1 and 1C2 with Staff A1, A2, and A3. At 2:33 P.M. observation of door 1C005B in the two hour rated wall between zone 1C1 and zone 1A revealed it to have more than half of its construction to be unrated glass.
On 12/18/14 at 2:33 P.M. in an interview, Staff A1 confirmed the observation.

6. On 12/18/14 at 2:25 P.M. a tour was conducted of zone 1C1 and 1C2 with Staff A1, A2, and A3. On 12/18/14 at 2:36 P.M. observation of the door near room 1C113 and in the two hour rated wall that separates zone 1C1 from 1A revealed it not to have a two hour rating.
On 12/18/14 at 2:36 P.M. in an interview, Staff A1 confirmed the observation.

7. On 12/18/14 at 4:07 P.M. observation of the door in the two hour barrier separating zone 1C2 from zone 1D3 revealed it to be unrated.
On 12/18/14 at 4:07 P.M. in an interview, Staff A1 confirmed the observation.




31007

Based on observation and interview, the facility failed to maintain the ratings of the walls of areas it considered as hazardous. This has the potential to affect all patients, staff, and visitors to the facility.

Findings include:

On 12/17/14 at 10:03 A.M. a tour was taken of the K building with Staff A1, A2, and A3. At 10:03 A.M. in linen room 4k065 a two inch annular space was observed above heating, ventilation and cooling ducting and was diagonal to the letter R in the word RATED stenciled on the wall. The wall was rated as one hour.

On 12/17/14 at 10:03 A.M. in an interview, Staff A1 confirmed the observation.

Based on observation and interview, the facility failed to ensure the stairways of the exit components in this nine story building had a fire resistance rating of at least two hours. This has the potential to affect all patients, staff, and visitors to the facility.

Findings include:

1. On 12/17/14 at 9:00 A.M. a tour was conducted of the fifth floor of the K building with Staff A1, A2, and A3. At 9:11 A.M. a half inch opening in the drywall of the two hour rated wall on the hallway side of stairwell KA was observed in the letter A of the word RATING stenciled on the wall.

On 12/17/14 at 9:11 A.M. in an interview, Staff A1 confirmed the observation.

2. On 12/17/14 at 9:33 A.M. a half inch open conduit was observed with a blue wire running out of it in the two hour rated wall on the hall side of stair KB.

On 12/17/14 at 9:33 A.M. in an interview, Staff A1 confirmed the observation.

Based on observation and interview, the facility failed to ensure the width of its aisles or corridors were kept to at least eight feet. This has the potential to affect all patients, staff, and visitors.

Findings include:

On 12/17/14 at 2:20 P.M. a tour was conducted of the K building with Staff A1, A2, and A3. At 2:45 P.M. multiple palates of combustible material belonging to a popular coffee chain was observed to be in corridor 1K030. The combustible material was observed in place greater than 30 minutes and to shorten the corridor to four feet. The corridor had exit signage leading to it from the "high street mall" and multiple patients were observed going through the corridor by cart.

On 12/17/14 at 2:20 P.M. in an interview, Staff A1 confirmed the observation.

Based on staff interview and documentation review the facility failed to test the battery emergency lighting at least 30 seconds monthly and 90 minutes annually. This has the potential to affect all patients, staff, and visitors in the medical office building. The census for the 12 month period was 1182.

Findings include:

1. Interview with Staff A1 on 12/22/14 at 5:00 PM revealed the facility was unable to obtain documents to verify the battery powered emergency illumination was tested at least 30 seconds monthly and 90 minutes annually.

Based on staff interview and documentation review the facility failed to perform fire drills annually. This has the potential to affect all patients, staff, and visitors in the medical office building. The census for the 12 month period was 1182.

Findings include:

1. Interview with Staff A1 on 12/22/14 at 5:00 PM revealed the facility was unable to obtain fire drill documents in order to verify that the staff fire drills were completed at least annually.

Based on observation and interview, the facility failed to ensure the emergency department was free of portable space heating devices. This has the potential to affect all patients, staff, and visitors to the facility. The facility census at the time of the survey was 271.

Findings include:

On 12/18/14 at 7:45 A.M. a tour was conducted of the detached emergency department with Staff A1, A2, and A3. Review of the drawing revealed the department was not divided by any rated wall. At 8:48 P.M. in the physician lounge a space heater was observed on a table and about two feet from combustible material, a fabric upholstered chair.
On 12/18/14 at 8:48 P.M. Staff A1 confirmed the observation and said staff were not allowed to bring the heaters in.

Based on interview and observation, the facility failed to maintain a fire barrier of at least one hour fire resistive rating between the ambulatory surgery center and other tenants or occupancies. The facility census at the time of the survey was 271.

Findings include:

On 12/19/14 at 1:10 P.M. a tour was conducted of the facility with Staff A1, A2, and A3. At 1:20 P.M. observation above the drop down ceiling of the one hour rated wall to the left of the entrance of the ambulatory surgery center as one would enter, a 2.5 inch conduit was observed open to air with red wires coming out of it and a 1.5 inch hole was observed cut from the drywall.
On 12/19/14 at 1:20 P.M. in an interview, Staff A1 confirmed the observation.
2. On 12/19/14 at 1:25 P.M. observation above the drop down ceiling of the one hour rated wall in the lobby and over the door labeled for staff only revealed a two inch by two inch open box in the dry wall, and one three inch open conduit with red, white, and blue lines coming out of it, and one 1.5 inch conduit open to air with grey wires traveling out of it.
On 12/19/14 at 1:25 P.M. in an interview, Staff A1 confirmed the observation.
3. Continuing to travel along the fire barrier from west to east, but now in the corridor in the ambulatory surgery center, on 12/19/14 at 1:34 P.M. opposite janitor closet 160, observation above the drop down ceiling of the one hour rated wall revealed a half inch green conduit open to air with orange, white, and blue wires traveling from it.
On 12/19/14 at 1:34 P.M. in an interview, Staff A1 confirmed the observation.
4. Returning to the corridor outside the ambulatory surgery center, on 12/19/14 at 1:41 P.M. observation above the drop down ceiling of the one hour rated wall about four feet from double doors 101 revealed a two inch by two inch square opening in the drywall.
On 12/19/14 at 1:41 P.M. in an interview, Staff A1 confirmed the observation.
5. On 12/19/14 at 1:44 P.M. observation above the drop down ceiling of the one hour rated wall over the door in the 90 degree bend in the corridor revealed a quarter inch hole in the drywall.
On 12/19/14 at 1:44 P.M. in an interview, Staff A1 confirmed the observation.

National Fire Protection Association 101, 2000 edition
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

National Fire Protection Association 25 2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100°F (38°C).

And,

2-4.1.6* A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. One sprinkler wrench shall be provided for each type of sprinkler installed.

Based on observation and interview, the facility failed to have on its premises spare sprinkler heads and their special wrench in a cabinet on the premises. This has the potential to affect all patients, staff, and visitors to the facility. The facility census at the time of the survey was 271.

Findings include:

On 12/19/14 at 1:58 P.M. a tour was conducted of the sprinkler system with Staff A1, A3, and F4. Observation of the riser room did not reveal any spare sprinkler heads or their special wrench.
On 12/19/14 at 1:58 P.M. in an interview, Staff F4 said, " I don't know what you're talking about" and "I don't have a box that I know of".

Based on observation and interview, the facility failed to comply with Chapter 3 of National Fire Protection Association 110, 1999 edition. This has the potential to affect all staff, visitors, and staff to the facility.

Findings include:

On 12/19/14 at 2:03 P.M. a tour was conducted of the outside diesel generator with Staff A1 and F4. Observation of the alarm panel revealed a warning light for low engine temperature. The cover for the light was observed to be dangling out from the panel. When the lamp was tested, it failed to illuminate.
On 12/19/14 at 2:03 P.M. in an interview, Staff A1 confirmed the observation.