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Based on observation and interview, the facility failed to protect hazardous areas.

The finding includes:

Observation and interview on 5/27/15 at 2:15PM revealed the storage room in the receiving hallway was not one hour rated and the door was not self-closing. The space was previously an office, and its usage changed to a storage room.
19.3.2.1

This finding was verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 5/28/15.

Based on observation and interview, the facility failed to maintain the exit door locking arrangements.
Observation and interview on 5/27/15 between 9:00 AM and 3:00 PM revealed the following:

1. The staff in the Poplar wing did not have individual keys to unlock the exit doors. The keys were shared and located at the nurse's station.
2. A dietary staff member was asked to unlock dining room exit door and did not have a key, the dietary manager had the key.
3. A staff member in Cedar wing was asked to unlock exit door at the end of the corridor was unsure how to unlock the exit door.
4. One of two courtyard exit gates was magnetically locked and was not provided with a means of readily unlocking the door at all times. This door can only be unlocked with fire alarm activation.
NFPA 101 - 19.2.2.2.4 (exception No. 1)

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 5/28/15.

Based on observation, the facility failed to install smoke detectors away from HVAC air flow.

The findings include:

Observation on 5/26/14 and 5/27/15 between 8:00 AM and 4:00 PM revealed the following locations have smoke detectors within 3 feet of air flow:
1. PET corridor by room LN381.
2. Radiation Oncology conference room LN284.
3. 2nd floor ICU elevator lobby area.
4. Room 3034.
5. Room 4034.
6. Room 5034.
7. Room 5220.
8. Room 5223.
9. Corridor by door 2800.
10. Corridor by room 2625.
11. Soil holding on 2nd floor by door 2046.
12. Gym on the 6th floor.

These findings were verified by the facility director and acknowledged by administration during the exit conference on 5/28/15.
NFPA 72 2-3.5.1*

Based on observation and interview, the facility failed to have magnetically locked doors release with fire alarm activation.

The finding includes:

Six magnetically locked exit doors do not release immediately with fire alarm activation. Once fire alarm is activated, the six magnetically locked exit doors remain locked for 30-seconds and then release.

This finding was verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 5/28/15.
NFPA 72 3-9.7.2

Based on observation, the facility failed to install and maintain the automatic sprinkler system.

The findings include:

1. Observation on 5/26/15 at 2:50 PM revealed the back loading dock area is not provided with sprinkler protection due to the storage of wooden pallets, cardboard boxes, and a cardboard box compactor.
NFPA 13 5-13.8.2*
2. Observation on 5/27/15 at 9:20 AM revealed the PET/LINAC corridor has mixed sprinkler heads of quick response and standard response.
NFPA 13 5-3.1.5.2

This finding was verified by the facility director and acknowledged by administration during the exit conference on 5/28/15.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system and its components.

The finding includes:

Observation and interview on 5/27/15 between 9:00 AM and 3:00 PM revealed there were mixed sprinkler heads in the kitchen. There were quick response and standard response heads.

This finding was verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 5/28/15.
NFPA 13, 5-3.1.5.2

Based on observation, the facility failed to maintain the automatic sprinkler system and its components.

The findings include:

Observation on 5/26/15 and 5/27/15 between 8:00 AM and 3:30 PM revealed the following:
1. The Sani-Pak breezeway has a sidewall sprinkler head that is obstructed by a newly installed heater.
NFPA 25 2-2.1.2*
2. The sprinkler head by materials management on the lower level floor is recessed into the ceiling.
NFPA 25 2-2.1.2* & 3-2.7.2*
3. 6 out of 45 sprinkler heads in dietary department are recessed into the ceiling.
NFPA 25 2-2.1.2* & 3-2.7.2*
4. A Sprinkler head is recessed into the ceiling on the 6th floor by the medical gas storage room.
NFPA 25 2-2.1.2* & 3-2.7.2*
5. Sprinkler heads throughout the dietary department are corroded and tarnished.
NFPA 25 2-2.1.1*
6. 3 sprinkler heads in the clean linen room on the lower level floor are within 4 inches of the header in the center of the room.
NFPA 13 5-6.3.3
7. Radiation Oncology electrical room 0936 has a sidewall sprinkler head that is obstructed by a light fixture.
NFPA 25 2-2.1.2* & 3-2.7.2*
8. Room 2426 has paint on sprinkler deflector.
NFPA 25 2-2.1.1*
9. Bathroom of room 6407 has paint on sprinkler deflector.
NFPA 25 2-2.1.1*
10. Room 2614 on 6th floor is loaded with lint.
NFPA 25 2-2.1.1*
11. Room 2836 on 6th floor is loaded with lint.
NFPA 25 2-2.1.1*
12. Soiled linen room on 6th floor is loaded with lint.
NFPA 25 2-2.1.1*
13. 2 of 2 sprinkler head are loaded with lint on the 2nd floor nurses station in Children's Hospital.
NFPA 25 2-2.1.1*
14. Sprinkler head in the corridor loaded with lint by room C216.
NFPA 25 2-2.1.1*
15. Sprinkler heads in rooms C206, C211, C213, and C215 in Children's Hospital are loaded with lint.
NFPA 25 2-2.1.1*

These findings were verified by the facility director and acknowledged by administration during the exit conference on 5/28/15.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in a safe and reliable operating condition.

The finding includes:

Observation and interview on 5/27/15 between 9:00 AM and 3:00 PM revealed the sprinkler piping was supporting non system components. The receiving hallway has wires zip-tied, draped and corrugated conduit resting on the sprinkler pipe.
NFPA 13 6-1.1.5*

This finding was verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 5/28/15.

Based on observation and interview, the facility failed to have manual pull stations identified for the hazard it protects and staff trained and knowledgeable for the hood suppression system.

The findings include:

1. Observation on 5/26/15 at 4:10 PM revealed the 2 manual activation pull stations for the 2 kitchen hoods are not clearly identified for which hood it serves.
2. Interview with kitchen staff on 5/26/15 at 4:15 PM revealed the staff is not trained on which manual activation pull station is to be used if needed. Kitchen staff has been trained only on 1 manual activation pull station but is not aware of what the other manual activation pull station serves.

These findings were verified by the facility director and acknowledged by administration during the exit conference on 5/28/15.
NFPA 96 7-5.1

Based on observation and interview, the facility failed to provide appropriate egress pathway from the dining room.

The finding includes:

Observation and interview on 5/27/15 at 1:55PM revealed there was no non-slip, hard surface exit pathway leading from the dining room exit to the public way. NFPA 101 7.1.6.4

This finding was verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 5/28/15.

Based on observation and interview, the facility failed to maintain the electrical wiring and equipment.

The finding includes:

Observation and interview on 5/27/15 between 9:00 AM and 3:00 PM revealed the facility failed to provide ground fault circuit interrupter (GFCI) receptacles in the following areas:

1. Cedar wing pharmacy by the sink in the nurse's station.
2. Willow wing by the sink in the classroom.
3. Kitchen by the sinks.
4. Laundry behind washer.
NFPA 70, 210-8(a)(7)
These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 5/28/15.

Based on observation and interview, the facility failed to protect hazardous areas.

The finding includes:

Observation and interview on 5/27/15 at 2:15PM revealed the storage room in the receiving hallway was not one hour rated and the door was not self-closing. The space was previously an office, and its usage changed to a storage room.
19.3.2.1

This finding was verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 5/28/15.

Based on observation and interview, the facility failed to maintain the exit door locking arrangements.
Observation and interview on 5/27/15 between 9:00 AM and 3:00 PM revealed the following:

1. The staff in the Poplar wing did not have individual keys to unlock the exit doors. The keys were shared and located at the nurse's station.
2. A dietary staff member was asked to unlock dining room exit door and did not have a key, the dietary manager had the key.
3. A staff member in Cedar wing was asked to unlock exit door at the end of the corridor was unsure how to unlock the exit door.
4. One of two courtyard exit gates was magnetically locked and was not provided with a means of readily unlocking the door at all times. This door can only be unlocked with fire alarm activation.
NFPA 101 - 19.2.2.2.4 (exception No. 1)

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 5/28/15.

Based on observation, the facility failed to install smoke detectors away from HVAC air flow.

The findings include:

Observation on 5/26/14 and 5/27/15 between 8:00 AM and 4:00 PM revealed the following locations have smoke detectors within 3 feet of air flow:
1. PET corridor by room LN381.
2. Radiation Oncology conference room LN284.
3. 2nd floor ICU elevator lobby area.
4. Room 3034.
5. Room 4034.
6. Room 5034.
7. Room 5220.
8. Room 5223.
9. Corridor by door 2800.
10. Corridor by room 2625.
11. Soil holding on 2nd floor by door 2046.
12. Gym on the 6th floor.

These findings were verified by the facility director and acknowledged by administration during the exit conference on 5/28/15.
NFPA 72 2-3.5.1*

Based on observation and interview, the facility failed to have magnetically locked doors release with fire alarm activation.

The finding includes:

Six magnetically locked exit doors do not release immediately with fire alarm activation. Once fire alarm is activated, the six magnetically locked exit doors remain locked for 30-seconds and then release.

This finding was verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 5/28/15.
NFPA 72 3-9.7.2

Based on observation, the facility failed to install and maintain the automatic sprinkler system.

The findings include:

1. Observation on 5/26/15 at 2:50 PM revealed the back loading dock area is not provided with sprinkler protection due to the storage of wooden pallets, cardboard boxes, and a cardboard box compactor.
NFPA 13 5-13.8.2*
2. Observation on 5/27/15 at 9:20 AM revealed the PET/LINAC corridor has mixed sprinkler heads of quick response and standard response.
NFPA 13 5-3.1.5.2

This finding was verified by the facility director and acknowledged by administration during the exit conference on 5/28/15.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system and its components.

The finding includes:

Observation and interview on 5/27/15 between 9:00 AM and 3:00 PM revealed there were mixed sprinkler heads in the kitchen. There were quick response and standard response heads.

This finding was verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 5/28/15.
NFPA 13, 5-3.1.5.2

Based on observation, the facility failed to maintain the automatic sprinkler system and its components.

The findings include:

Observation on 5/26/15 and 5/27/15 between 8:00 AM and 3:30 PM revealed the following:
1. The Sani-Pak breezeway has a sidewall sprinkler head that is obstructed by a newly installed heater.
NFPA 25 2-2.1.2*
2. The sprinkler head by materials management on the lower level floor is recessed into the ceiling.
NFPA 25 2-2.1.2* & 3-2.7.2*
3. 6 out of 45 sprinkler heads in dietary department are recessed into the ceiling.
NFPA 25 2-2.1.2* & 3-2.7.2*
4. A Sprinkler head is recessed into the ceiling on the 6th floor by the medical gas storage room.
NFPA 25 2-2.1.2* & 3-2.7.2*
5. Sprinkler heads throughout the dietary department are corroded and tarnished.
NFPA 25 2-2.1.1*
6. 3 sprinkler heads in the clean linen room on the lower level floor are within 4 inches of the header in the center of the room.
NFPA 13 5-6.3.3
7. Radiation Oncology electrical room 0936 has a sidewall sprinkler head that is obstructed by a light fixture.
NFPA 25 2-2.1.2* & 3-2.7.2*
8. Room 2426 has paint on sprinkler deflector.
NFPA 25 2-2.1.1*
9. Bathroom of room 6407 has paint on sprinkler deflector.
NFPA 25 2-2.1.1*
10. Room 2614 on 6th floor is loaded with lint.
NFPA 25 2-2.1.1*
11. Room 2836 on 6th floor is loaded with lint.
NFPA 25 2-2.1.1*
12. Soiled linen room on 6th floor is loaded with lint.
NFPA 25 2-2.1.1*
13. 2 of 2 sprinkler head are loaded with lint on the 2nd floor nurses station in Children's Hospital.
NFPA 25 2-2.1.1*
14. Sprinkler head in the corridor loaded with lint by room C216.
NFPA 25 2-2.1.1*
15. Sprinkler heads in rooms C206, C211, C213, and C215 in Children's Hospital are loaded with lint.
NFPA 25 2-2.1.1*

These findings were verified by the facility director and acknowledged by administration during the exit conference on 5/28/15.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in a safe and reliable operating condition.

The finding includes:

Observation and interview on 5/27/15 between 9:00 AM and 3:00 PM revealed the sprinkler piping was supporting non system components. The receiving hallway has wires zip-tied, draped and corrugated conduit resting on the sprinkler pipe.
NFPA 13 6-1.1.5*

This finding was verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 5/28/15.

Based on observation and interview, the facility failed to have manual pull stations identified for the hazard it protects and staff trained and knowledgeable for the hood suppression system.

The findings include:

1. Observation on 5/26/15 at 4:10 PM revealed the 2 manual activation pull stations for the 2 kitchen hoods are not clearly identified for which hood it serves.
2. Interview with kitchen staff on 5/26/15 at 4:15 PM revealed the staff is not trained on which manual activation pull station is to be used if needed. Kitchen staff has been trained only on 1 manual activation pull station but is not aware of what the other manual activation pull station serves.

These findings were verified by the facility director and acknowledged by administration during the exit conference on 5/28/15.
NFPA 96 7-5.1

Based on observation and interview, the facility failed to provide appropriate egress pathway from the dining room.

The finding includes:

Observation and interview on 5/27/15 at 1:55PM revealed there was no non-slip, hard surface exit pathway leading from the dining room exit to the public way. NFPA 101 7.1.6.4

This finding was verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 5/28/15.

Based on observation and interview, the facility failed to maintain the electrical wiring and equipment.

The finding includes:

Observation and interview on 5/27/15 between 9:00 AM and 3:00 PM revealed the facility failed to provide ground fault circuit interrupter (GFCI) receptacles in the following areas:

1. Cedar wing pharmacy by the sink in the nurse's station.
2. Willow wing by the sink in the classroom.
3. Kitchen by the sinks.
4. Laundry behind washer.
NFPA 70, 210-8(a)(7)
These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 5/28/15.