HospitalInspections.org

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey, that the facility failed to maintain the corridor walls to patient areas in accordance with the Life Safety Code. This was evidenced by:

The facility contained resident treatment/sleeping areas located off of the corridor without separation between the corridor and the sleeping area. This area was located in the SICU unit, between the "Pharmacy" office and the exit stairwell. These are also known as rooms A202, A204, A206 and A208.
Note: The facility called this area a "suite of rooms" however this area cannot meet the requirements of a "suite" under the provisions of the Life Safety Code, Chapter 19 due to travel to an exit through this room from other areas. This area must be referred to as a corridor.

The corridor separation deficiency was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey, that the facility failed to maintain the corridor doors in accordance with the Life Safety Code. This was evidenced by:

1) Doors with gaps larger than one half inch (1/2") between the door and the door stop:
A942, A706, A708, A710, A712, A716, A720, A722, A724, A726, A728, A730, A732, A734, A756, A760, A606, A608, A610, A612, A616, A618, A650, A652, A676, A678 and A680.

2) Door would not latch into the frame when closed
a. A758
b. Anesthesia work room door on the second floor (2nd)

3) The door to the Oxygen therapy storage room (A630) contained a padlock on the outside of the door on the corridor side of the door. If this door was locked, a person on the inside of the room could not get out of the room.

4) Doors to resident sleeping rooms would not latch into the frame off of the corridor as required:
Rooms #A210, A212, A214, A216, A218, A 220, A222, A224, A226, A228, A230, A232, A234, A236, A238 and A240.
Note: The facility was classifying these areas as suites and the areas will not meet the suite requirement as outlined in NFPA 101, Chapter 19.

The corridor door deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A2, known as Pavilion B.

It was determined through observation during the survey, that the facility failed to maintain the corridor doors in accordance with the Life Safety Code. This was evidenced by:

1) Patient room doors would not latch into the frame or latch properly into the frame:
a) Room B410
b) Room B412

2) Patient room B416 had a door in which the gap around the door frame and stop were larger than one half inch (1/2").

3) Patient room doors contained carts in front of the door, which blocked the doors from being closed and latched into the frame:
a) Room B262
b) Room B264

The corridor door deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A6, known as Pavilion C.

It was determined through observation during the survey, that the facility failed to maintain the corridor doors in accordance with the Life Safety Code. This was evidenced by:

Electrical closet #C396E contained a set of double doors off of the corridor. One (1) of the doors contained a slide lock type of locking device; this device would not positively latch into the frame.

The corridor door deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey that the facility failed to maintain the fire rated smoke barrier walls in accordance with the Life Safety Code. This was evidenced by:

Unsealed pipe penetration in smoke barrier walls:
a. Smoke wall outside soiled utility room A64150 contained one (1) unsealed pipe penetration.
b. Two (2) wire penetrations at the smoke wall at the SICU door near the elevator.
c. Two (2) unsealed penetration at the lab "Core Lab" smoke wall.
d. Two (2) unsealed penetrations at room A17, near the Psych ED.

The smoke barrier wall deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey that the facility failed to maintain the fire rated smoke barrier doors in accordance with the Life Safety Code. This was evidenced by:

1) Smoke barrier door, located outside room A824, contained one door which would not latch into the frame when closed. Note: this item was corrected during the survey.

2) Smoke barrier door sequencer would not work correctly, on smoke barrier door outside room A604, the sequencer would not hold open the door with the astragal. Note: this item was corrected during the survey.

The smoke barrier door deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey, that the facility failed to maintain and protect sprinkler protected hazardous areas in accordance with the Life Safety Code. This was evidenced by:

1) SICU oxygen storage room door would not latch into the frame when closed.

2) Operating room sterile storage room door contained a hold open device on the door. The device was a homemade device utilizing a chain and a hook to hold open the door.

3) Operating room storage rooms contained doors that did not contain self-closing devices or did not latch into the frame
a. Room A2105 and room A2106 contained two (2) sets of doors that did not latch into the frame and were of a swinging type door.
i. One (1) set of double doors, on each room
ii. One (1) single swing door, on each room
b. Ortho supply room contained one (1) door that did not latch into the frame.

4) The EVS closets in two locations on the basement floor of the facility failed to have self-closure devices installed, as required. Note: this item was corrected during the survey.

The hazardous area deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A6, known as Pavilion C.

It was determined through observation during the survey, that the facility failed to maintain and protect sprinkler protected hazardous areas in accordance with the Life Safety Code. This was evidenced by:

1) Room C411, contained a large amount of combustible items stored in the room (i.e. new baby bags with blankets, toys, diapers etc). The room door did not contain a self closing device.

2) The third floor (3rd), located off of the nurse station, contained an area in which combustible storage items were being stored. This area did not contain doors on either side of the area and was open to the corridor.

The hazardous area deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building AA, known as the East Grand Clinic.

It was determined through observation during the survey, that the facility failed to maintain and protect sprinkler protected hazardous areas in accordance with the Life Safety Code. This was evidenced by:

The door to the storage room, which housed a large amount of combustible material and was over 55 square feet in size, failed to have a self-closure device, as required.

The hazardous area deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey, that the facility failed to maintain the means of egress in accordance with the Life Safety Code. This was evidenced by:

1) Exit access wall penetrations:
a. The two-hour rated wall in the exit passageway, located on the first floor (1st) adjacent to the emergency department, contained three (3) unsealed pipe penetration in the wall.
b. One (1) unsealed penetration in the wall outside of the MRI suite.

2) The exit access corridor, located at the MRI suite, contained two (2) twenty (20) minute fire rated doors leading into the exit access corridor from the MRI Suite. Due to this being an exit access corridor, all doors must be rated at ninety minutes (90).

3) The secured cross-corridor doors in the following locations failed to unlock with activation of the fire alarm system, as required:
a. The southwest cross-corridor doors on the fourth (4th) floor,
b. The southeast cross-corridor doors on the fourth (4th) floor,
c. The northwest cross-corridor doors on the fourth (4th) floor,
d. The northeast cross-corridor doors on the fourth (4th) floor, and
e. The northwest cross-corridor doors on the fifth (5th) floor.
(Note: All of the above doors unlock with activation of two smoke detectors on the floor, following a re-confirmation sequence for each individual detector. In accordance with the Life Safety Code, these doors must unlock with initial activation of the fire alarm system.)

4) Exit 11 on the first floor was labeled as having delayed egress, but was not set up with such.

5) The cross-corridor doors separating the Pediatric ED from the remainder of the facility are labeled as an exit, but are locked to egress unless a wall-mounted override button is depressed first.

The means of egress deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A6, known as Pavilion C.

It was determined through observation during the survey, that the facility failed to maintain the means of egress in accordance with the Life Safety Code. This was evidenced by:

The building contained locked doors in the means of egress without a delayed egress or access controlled type of locking device. Theses locked doors contained a "Blue" pull station to open the door when locked on the egress side:
a) Fourth (4th) floor contained two (2) doors locked at the elevators.
b) Second (2nd) floor had the following doors locked in this fashion:
i) The southeast cross-corridor doors,
ii) The center section cross-corridor doors,
iii) The southwest corridor doors at the north bank of elevators,
iv) The southwest cross-corridor doors at the south bank of elevators, and
v) The single corridor door at the south bank of elevators.
c) Third (3rd) floor contained two (2) doors locked at the elevators.

The means of egress deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A6, known as Pavilion C.

It was determined through observation during the survey, that the facility failed to maintain the forces required to open a door in the means of egress in accordance with the Life Safety Code. This was evidenced by:

Exit access doors were hard to open and required more than fifteen foot lbs. of force to open.
a) Stairwell exit door, C24, and
b) Stairwell exit door C33.

The forces to open a door deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A5, known as Pavilion K.

It was determined through observation during the survey that the facility failed to maintain the battery backed-up emergency lighting in accordance with the Life Safety Code. This was evidenced by:

The facility failed to provide a reliable means of emergency egress lighting throughout the entire building. Note: this item was corrected during the survey.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A7, known as the Central Plant.

It was determined through observation during the survey that the facility failed to maintain the battery backed-up emergency lighting in accordance with the Life Safety Code. This was evidenced by:

The facility failed to provide a battery backed-up emergency light at the transfer switch location. Note: this item was corrected during the survey.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building AA, known as the East Grand Clinic.

It was determined through observation during the survey, that the facility failed to maintain the battery backed-up emergency lighting in accordance with the Life Safety Code. This was evidenced by:

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation and document review during the survey, that the facility failed to perform fire drills in accordance with the Life Safety Code. This was evidenced by:

1) Documentation was not provided at the time of the survey to show the following drills had been completed:

a. One (1) during the second shift in the second quarter of 2011. (Note: The facility provided documentation at the time of the survey to reflect that a drill had taken place on April 9, 2011; however, this drill was documented during a false alarm of the fire and smoke detection system. Fire drills must be pre-planned events and the facility may not utilize false alarms of the fire and smoke detection system or real events in lieu of these pre-planned events.)

2) A fire drill was held on September 2, 2011 at 09:37 on the 8th floor of the facility during which responders failed to employ the written procedures of the facility's response to fire emergencies. This was evidenced by the following:

a. The initial responder stated that she had never participated in a fire drill in the nine years she had been on staff and did not know the procedures. The staff member was prompted by the surveyor to get help, at which time she left the room of fire origin without closing the corridor door.

b. The second responder stated she was not aware of the procedures to be employed during a fire. After being prompted by the surveyor, the second responder initiated the evacuation of the room at which time a third responder removed the mock patient from the room and closed the corridor door to the room of fire origin; these actions were complete four minutes and twenty-eight seconds after the initiation of the fire drill.

c. A manual pull station was not activated immediately upon discovery of the mock fire, as outlined in the facility's written procedures for response to fire emergencies. (Note: This occurred five minutes and ten seconds into the drill.)

d. A coded announcement was not made immediately upon discovery of the mock fire, as outlined in the facility's written procedures for response to fire emergencies. (Note: This occurred at the same time that the manual pull station was activated.)

The fire drill deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A2, known as Pavilion B.

It was determined through observation and document review during the survey, that the facility failed to perform fire drills in accordance with the Life Safety Code. This was evidenced by:

A fire drill was held on September 2, 2011 on the 3rd floor of the facility during which responders failed to employ the written procedures of the facility's response to fire emergencies. This was evidenced by the following:

a. The initial responder, after stating she was not sure what to do, was prompted by the surveyor to get help, to remove the patient from the room of fire origin, to close the corridor door to the room of origin, to initiate the fire alarm system, and to initiate the coded announcement.

b. A manual pull station was not activated immediately upon discovery of the mock fire, as outlined in the facility's written procedures for response to fire emergencies. (Note: This occurred two minutes and fifty-three seconds into the drill.)

c. A coded announcement was not made immediately upon discovery of the mock fire, as outlined in the facility's written procedures for response to fire emergencies. (Note: This occurred four minutes and forty seconds into the drill.)

The fire drill deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A5, known as Pavilion K.

It was determined through observation and document review during the survey, that the facility failed to perform fire drills in accordance with the Life Safety Code. This was evidenced by:

The facility failed to provide documentation at the time of the survey to show that a fire drills had taken place annually for the past two years. Note: The facility provided documentation at the time of the survey to reflect that a drill had taken place on June 11, 2010; however, this drill was documented during a false alarm of the fire and smoke detection system. Fire drills must be pre-planned events and the facility may not utilize false alarms of the fire and smoke detection system or real events in lieu of these pre-planned events.

The fire drill deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building AA, known as the East Grand Clinic.

It was determined through observation and document review during the survey, that the facility failed to perform fire drills in accordance with the Life Safety Code. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that any fire drills had taken place in the last 12-month period.

The fire drill deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation and record review during the survey that the facility failed to install the Fire Alarm System in accordance with the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by:

All operating rooms, twelve (12) rooms total), did not contain visual fire alarm signals in the operating rooms.

The Fire Alarm System deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building AA, known as the East Grand Clinic.

It was determined through observation and record review during the survey, that the facility failed to inspect and maintain the Fire Alarm System in accordance with the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by:

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) The facility failed to provide records at the time of survey to reflect that the fire alarm system had been serviced and inspected annually, as required.

The Fire Alarm System deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey, that the facility failed to install the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13. This was evidenced by:

1) The second floor (2nd) contained a "shell space" that had a mock up of a possible remodel change. The area contained walls and a drop ceiling in the area however the sprinkler coverage did not extend to under the drop ceiling area. The sprinkler system in this area consisted of upright sprinkler heads only.

2) Sprinkler protection not extended to the following areas:
a. Electrical closet A425E,
b. Electrical closet A447E,
c. Small closet in room A408.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey, that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

1) Escutcheon plates missing:
a. Outside stairwell A49 in the corridor
b. One (1) in room A802
c. One in room A654
d. Two missing in second floor (2nd) SICU nurse lounge
i. One (1) in the bathroom
ii. One (1) in the closet
e. Oxygen storage room on second floor (2nd), outside room A245
f. In second floor (2nd) laboratory area, outside room A2601E
g. One (1) missing in the Microbiology lab
h. One (1) missing in pre-op stall #5
i. One (1) missing in post-op stall #9
j. One (1) missing at the anesthesia work station in the post op area
k. One (1) missing in the sub-sterile compartment adjacent to OR #2
l. One (1) missing in room A1305B
m. One (1) missing in CT scan core room
n. One (1) missing in CT conference room
o. Two (2) missing in CT room #2
p. Outside freezer #2 in AB53

2) Sprinkler head obstructions:
a. Shower room curtain, located on the seventh floor (7th) did not contain a mesh on the curtain and/or was not located at eighteen inches (18") below the sprinkler head, which caused an obstruction to the sprinkler head.
b. Room A728 contained a curtain track located directly adjacent to a concealed sprinkler head. This track was one inch deep (1") and the concealed sprinkler head was spaced on half inch (1/2") from the track. Per NFPA 13, 1999 Edition section 5-6.5.1.2, heads closer than one foot (1') cannot have any sprinkler obstruction.
c. Cath Lab area contained two (2) rooms with sprinkler obstructions due to the tracks of the imaging equipment.
i. Room 2404 contained one (1) obstructed head
ii. Room 2402 contained one (1) obstructed head
d. First floor (1st) shower room #A1218S contained one (1) obstructed sprinkler head from a light fixture

3) Pendant-style sprinkler heads with gaps in ceiling:
a. In the closet of room A360,
b. The clean utility room in PEDS

4) The sprinkler head located above the first wash station in the main dish room was found to be bent.

5) The two (2) upright sprinkler heads located in electrical room AB06B are located approximately six to eight feet below the ceiling.

6) Five gauges on the main system pump were more than five years old and the facility failed to provide documentation that these gauges had been re-calibrated at any time. Note: The dates on the gauges ranged from 2002 to 2004.

7) Sprinkler gauges on floors six (6), seven (8) and eight (8) stairwells have been replaced with "Winter" manufactured gauges. It could not be verified that these gauges were listed to be used on a sprinkler system. Note: The facility showed an invoice indicating that they purchased the gauges from a sprinkler contractor, but we need more information indicating that these are listed to be used on sprinkler systems.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A2, known as Pavilion B.

It was determined through observation during the survey, that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

1) Sprinkler were loaded (contained a high amount of dust or debris on the working parts of the sprinkler head:
a) Outside of room B420
b) Inside room B418
c) Office 4B (office area at southeast stairwell)
d) Two (2) in room B218
e) One (1) in room B234
f) One (1) in room B246
g) One near the elevators on the first floor by the coffee shop
h) Several in the main lobby of the facility on the first floor
i) In room B219, covered in plastic.

2) Sprinkler heads, located in the bathrooms, contained paint or other material on the working parts of the sprinkler head:
a) Room B310
b) Room B316
c) Room B318
d) Room B320
e) Room B336

3) Escutcheon plates were missing in the following areas:
a) Conference room B224.
b) Room B234.
c) By the smoke barrier located outside room BB53 in CCMF.
d) In the corridor outside the main entry to CCMF.

4) Gauges not replaced not re-calibrated in five (5) years:
a) Main riser gauge in room BB29 - dated 2002.

5) Sprinkler heads damaged:
a) In the corridor outside the coffee shop entrance on the first floor.

6) The facility failed to provide sprinkler protection to the fabric overhang that is not non-combustible in nature and is approximately eight feet by twenty feet in size, located above the sally port entrance to CCMF.

7) The pendant-style light fixtures located in the main lobby of the facility obstruct several of the sprinkler heads located above them.

8) The sprinkler head located in room B141 has the potential to be fully obstructed by the x-ray machine.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A4, known as Pavilion D.

It was determined through observation during the survey, that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

Building contained five (5) gauges that had not been calibrated or replaced. Two (2) of the gauges were dates 1994 and the other three (3) gauges did not have dates on the gauges.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A6, known as Pavilion C.

It was determined through observation during the survey, that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

1) Building contained four (4) sprinkler gauges dated 2005. Three (3) gauges were located on the penthouse dry pipe riser, one (1) located on the penthouse wet pipe riser.

2) Escutcheon plates missing in the following areas
a) Room C350.

3) There was a greater than one inch diameter gap surrounding the pendant style sprinkler head in room CB40A.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A7, known as the Central Plant.

It was determined through observation during the survey, that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

Seven of seven gauges on the main system riser were more than five years old and the facility failed to provide documentation that these gauges had been re-calibrated at any time. Note: The dates on the gauges ranged from 2002 to 2005.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building AA, known as the East Grand Clinic.

It was determined through observation and record review during the survey, that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

1) Documentation was not available for showing that the fire sprinkler system has been service in the past 12 months.

2) The facility failed to provided sprinkler protection to the following locations:
a. The oxygen storage closet in the store room, and
b. The utility closet across from the storage room.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey that the facility failed to maintain the emergency exit corridors free of all obstructions or impediments to full instant use in the case of fire or other emergency in accordance with the Life Safety Code. This was evidenced by:

1) The corridor, outside of the Cath lab, contained an exit sign pointing occupants to go through the Cath Lab suite as an exit. The corridor outside of the Cath labs contained items stored in the corridor.
a. One (1) ultrasound machine
b. One (1) cart which held gloves and gowns

2) Items stored in the corridor
a. Two (2) wheelchairs and one (1) wheeled cart at 11:00 a.m. and again at 11:20 a.m. outside of room A120, outside of MRI suite.

The exit corridor deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A2, known as Pavilion B.

It was determined through observation during the survey that the facility failed to maintain the emergency exit corridors free of all obstructions or impediments to full instant use in the case of fire or other emergency in accordance with the Life Safety Code. This was evidenced by:

One (1) computer monitor stand, located on the wall, contained a fold down keyboard that was in the down position and did not automatically retracted back when not in use. This monitor extended thirteen inches (13") into the corridor. Note: This item was corrected during the survey.

The exit corridor deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building AA, known as the East Grand Clinic.

It was determined through observation during the survey that the facility failed to provide draperies and other loose hanging fabrics in accordance with the Life Safety Code. This was evidenced by:

The facility failed to provide documentation at the time of the survey to reflect that the loose hanging drapery, concealing the shelving unit above the dryer, was flame resistant.

The loose hanging fabric deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey, that the facility failed to maintain the oxygen storage areas in accordance with the Life Safety Code and NFPA 99, Healthcare Facilities. This was evidenced by:

Two (2) unsecured CO2 tanks in the tank storage closet on the first floor, outside of the MRI suite. Note: this item was corrected during the survey.

The oxygen storage area deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey that the facility failed to maintain the piped medical gas system in accordance with the Life Safety Code and NFPA 99, Healthcare Facilities. This was evidenced by:

The Radiology department, outside of room A1128, contained one (1) oxygen outlet in the same compartment as the emergency shut off valve.

The piped medical gas system deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation and record review during the survey that the facility failed to maintain the dry chemical extinguishing system serving the hazmat trailer in accordance with the Life Safety Code. This was evidenced by:

1) The dry chemical extinguishing system serving the hazmat trailer had not been inspected or serviced since October of 2009. Note: this item was corrected during the survey.

2) The facility failed to provide documentation at the time of the survey to reflect that the dry chemical extinguishing system serving the hazmat trailer had been inspected monthly, as required.

The dry chemical extinguishing system deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A6, known as Pavilion C.

It was determined through observation during the survey that the facility failed to maintain the two-hour fire rated occupancy separation in accordance with the Life Safety Code. This was evidenced by:

The facility failed to provide automatic latching hardware on the hour and a half fire rated doors that are part of the two-hour fire rated fire barrier separating Pavilion C (on a separate fire alarm system and surveyed using Chapter 18 of NFPA 101) and Pavilion B (on a separate fire alarm system and surveyed using chapter 19 of NFPA 101, which will not meet the requirements of Chapter 18 without further modification) in the following locations:
a. In the basement corridor, and
b. On the second (2nd) floor corridor.

The occupancy separation deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building AA, known as the East Grand Clinic.

It was determined through observation during the survey that the facility failed to maintain the one-hour fire rated occupancy separation in accordance with the Life Safety Code. This was evidenced by:

The facility failed to provide automatic latching hardware on the one-hour fire rated occupancy separation doors at the front entry of the facility between the East Grand Clinic location, certified under the Hospital, and an adjacent space that is not licensed or certified under the Hospital, as required.

The occupancy separation deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey that the facility failed to utilize the building's electrical system in accordance with the Life Safety Code. This was evidenced by:

1) One (1) multi tap outlet being utilized in the office of the Molecular Lab. (corrected on site)

2) An extension cord utilized as permanent wiring in office A372.

3) A surge protected power strip into a second surge protected power strip in office A324.

4) A surge protected power strip into a second surge protected power strip in office A530.

The electrical deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A5, known as Pavilion K.

It was determined through observation during the survey that the facility failed to utilize the building's electrical system in accordance with the Life Safety Code. This was evidenced by:

Surge protected power strips plugged in as a series in the following locations:
a. Room 9-0101
b. Room 9-0115
c. Southwest cubicle on the east side of the second floor.

The electrical deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building AA, known as the East Grand Clinic.

It was determined through observation during the survey that the facility failed to utilize the building's electrical system in accordance with the Life Safety Code. This was evidenced by:

There was one (1) six-plug multi tap outlet without over-current or surge protection being utilized in the physician office.

The electrical deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey that the facility failed to install Alcohol Based Hand Rub Dispensers in a safe and appropriate manner. This was evidenced by:

Hand sanitizers located above an electrical device
a. One (1) hand sanitizer was located above an electrical source on the seventh floor (7th) outside room A718. This hand sanitizer was located above a floor light.
b. Pre-Anesthesia office contained one (1) hand sanitizer located above a duplex electrical receptacle.

The alcohol based hand rub dispenser deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey, that the facility failed to maintain the corridor walls to patient areas in accordance with the Life Safety Code. This was evidenced by:

The facility contained resident treatment/sleeping areas located off of the corridor without separation between the corridor and the sleeping area. This area was located in the SICU unit, between the "Pharmacy" office and the exit stairwell. These are also known as rooms A202, A204, A206 and A208.
Note: The facility called this area a "suite of rooms" however this area cannot meet the requirements of a "suite" under the provisions of the Life Safety Code, Chapter 19 due to travel to an exit through this room from other areas. This area must be referred to as a corridor.

The corridor separation deficiency was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey, that the facility failed to maintain the corridor doors in accordance with the Life Safety Code. This was evidenced by:

1) Doors with gaps larger than one half inch (1/2") between the door and the door stop:
A942, A706, A708, A710, A712, A716, A720, A722, A724, A726, A728, A730, A732, A734, A756, A760, A606, A608, A610, A612, A616, A618, A650, A652, A676, A678 and A680.

2) Door would not latch into the frame when closed
a. A758
b. Anesthesia work room door on the second floor (2nd)

3) The door to the Oxygen therapy storage room (A630) contained a padlock on the outside of the door on the corridor side of the door. If this door was locked, a person on the inside of the room could not get out of the room.

4) Doors to resident sleeping rooms would not latch into the frame off of the corridor as required:
Rooms #A210, A212, A214, A216, A218, A 220, A222, A224, A226, A228, A230, A232, A234, A236, A238 and A240.
Note: The facility was classifying these areas as suites and the areas will not meet the suite requirement as outlined in NFPA 101, Chapter 19.

The corridor door deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A2, known as Pavilion B.

It was determined through observation during the survey, that the facility failed to maintain the corridor doors in accordance with the Life Safety Code. This was evidenced by:

1) Patient room doors would not latch into the frame or latch properly into the frame:
a) Room B410
b) Room B412

2) Patient room B416 had a door in which the gap around the door frame and stop were larger than one half inch (1/2").

3) Patient room doors contained carts in front of the door, which blocked the doors from being closed and latched into the frame:
a) Room B262
b) Room B264

The corridor door deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A6, known as Pavilion C.

It was determined through observation during the survey, that the facility failed to maintain the corridor doors in accordance with the Life Safety Code. This was evidenced by:

Electrical closet #C396E contained a set of double doors off of the corridor. One (1) of the doors contained a slide lock type of locking device; this device would not positively latch into the frame.

The corridor door deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey that the facility failed to maintain the fire rated smoke barrier walls in accordance with the Life Safety Code. This was evidenced by:

Unsealed pipe penetration in smoke barrier walls:
a. Smoke wall outside soiled utility room A64150 contained one (1) unsealed pipe penetration.
b. Two (2) wire penetrations at the smoke wall at the SICU door near the elevator.
c. Two (2) unsealed penetration at the lab "Core Lab" smoke wall.
d. Two (2) unsealed penetrations at room A17, near the Psych ED.

The smoke barrier wall deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey that the facility failed to maintain the fire rated smoke barrier doors in accordance with the Life Safety Code. This was evidenced by:

1) Smoke barrier door, located outside room A824, contained one door which would not latch into the frame when closed. Note: this item was corrected during the survey.

2) Smoke barrier door sequencer would not work correctly, on smoke barrier door outside room A604, the sequencer would not hold open the door with the astragal. Note: this item was corrected during the survey.

The smoke barrier door deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey, that the facility failed to maintain and protect sprinkler protected hazardous areas in accordance with the Life Safety Code. This was evidenced by:

1) SICU oxygen storage room door would not latch into the frame when closed.

2) Operating room sterile storage room door contained a hold open device on the door. The device was a homemade device utilizing a chain and a hook to hold open the door.

3) Operating room storage rooms contained doors that did not contain self-closing devices or did not latch into the frame
a. Room A2105 and room A2106 contained two (2) sets of doors that did not latch into the frame and were of a swinging type door.
i. One (1) set of double doors, on each room
ii. One (1) single swing door, on each room
b. Ortho supply room contained one (1) door that did not latch into the frame.

4) The EVS closets in two locations on the basement floor of the facility failed to have self-closure devices installed, as required. Note: this item was corrected during the survey.

The hazardous area deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A6, known as Pavilion C.

It was determined through observation during the survey, that the facility failed to maintain and protect sprinkler protected hazardous areas in accordance with the Life Safety Code. This was evidenced by:

1) Room C411, contained a large amount of combustible items stored in the room (i.e. new baby bags with blankets, toys, diapers etc). The room door did not contain a self closing device.

2) The third floor (3rd), located off of the nurse station, contained an area in which combustible storage items were being stored. This area did not contain doors on either side of the area and was open to the corridor.

The hazardous area deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building AA, known as the East Grand Clinic.

It was determined through observation during the survey, that the facility failed to maintain and protect sprinkler protected hazardous areas in accordance with the Life Safety Code. This was evidenced by:

The door to the storage room, which housed a large amount of combustible material and was over 55 square feet in size, failed to have a self-closure device, as required.

The hazardous area deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey, that the facility failed to maintain the means of egress in accordance with the Life Safety Code. This was evidenced by:

1) Exit access wall penetrations:
a. The two-hour rated wall in the exit passageway, located on the first floor (1st) adjacent to the emergency department, contained three (3) unsealed pipe penetration in the wall.
b. One (1) unsealed penetration in the wall outside of the MRI suite.

2) The exit access corridor, located at the MRI suite, contained two (2) twenty (20) minute fire rated doors leading into the exit access corridor from the MRI Suite. Due to this being an exit access corridor, all doors must be rated at ninety minutes (90).

3) The secured cross-corridor doors in the following locations failed to unlock with activation of the fire alarm system, as required:
a. The southwest cross-corridor doors on the fourth (4th) floor,
b. The southeast cross-corridor doors on the fourth (4th) floor,
c. The northwest cross-corridor doors on the fourth (4th) floor,
d. The northeast cross-corridor doors on the fourth (4th) floor, and
e. The northwest cross-corridor doors on the fifth (5th) floor.
(Note: All of the above doors unlock with activation of two smoke detectors on the floor, following a re-confirmation sequence for each individual detector. In accordance with the Life Safety Code, these doors must unlock with initial activation of the fire alarm system.)

4) Exit 11 on the first floor was labeled as having delayed egress, but was not set up with such.

5) The cross-corridor doors separating the Pediatric ED from the remainder of the facility are labeled as an exit, but are locked to egress unless a wall-mounted override button is depressed first.

The means of egress deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A6, known as Pavilion C.

It was determined through observation during the survey, that the facility failed to maintain the means of egress in accordance with the Life Safety Code. This was evidenced by:

The building contained locked doors in the means of egress without a delayed egress or access controlled type of locking device. Theses locked doors contained a "Blue" pull station to open the door when locked on the egress side:
a) Fourth (4th) floor contained two (2) doors locked at the elevators.
b) Second (2nd) floor had the following doors locked in this fashion:
i) The southeast cross-corridor doors,
ii) The center section cross-corridor doors,
iii) The southwest corridor doors at the north bank of elevators,
iv) The southwest cross-corridor doors at the south bank of elevators, and
v) The single corridor door at the south bank of elevators.
c) Third (3rd) floor contained two (2) doors locked at the elevators.

The means of egress deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A6, known as Pavilion C.

It was determined through observation during the survey, that the facility failed to maintain the forces required to open a door in the means of egress in accordance with the Life Safety Code. This was evidenced by:

Exit access doors were hard to open and required more than fifteen foot lbs. of force to open.
a) Stairwell exit door, C24, and
b) Stairwell exit door C33.

The forces to open a door deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A5, known as Pavilion K.

It was determined through observation during the survey that the facility failed to maintain the battery backed-up emergency lighting in accordance with the Life Safety Code. This was evidenced by:

The facility failed to provide a reliable means of emergency egress lighting throughout the entire building. Note: this item was corrected during the survey.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A7, known as the Central Plant.

It was determined through observation during the survey that the facility failed to maintain the battery backed-up emergency lighting in accordance with the Life Safety Code. This was evidenced by:

The facility failed to provide a battery backed-up emergency light at the transfer switch location. Note: this item was corrected during the survey.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building AA, known as the East Grand Clinic.

It was determined through observation during the survey, that the facility failed to maintain the battery backed-up emergency lighting in accordance with the Life Safety Code. This was evidenced by:

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation and document review during the survey, that the facility failed to perform fire drills in accordance with the Life Safety Code. This was evidenced by:

1) Documentation was not provided at the time of the survey to show the following drills had been completed:

a. One (1) during the second shift in the second quarter of 2011. (Note: The facility provided documentation at the time of the survey to reflect that a drill had taken place on April 9, 2011; however, this drill was documented during a false alarm of the fire and smoke detection system. Fire drills must be pre-planned events and the facility may not utilize false alarms of the fire and smoke detection system or real events in lieu of these pre-planned events.)

2) A fire drill was held on September 2, 2011 at 09:37 on the 8th floor of the facility during which responders failed to employ the written procedures of the facility's response to fire emergencies. This was evidenced by the following:

a. The initial responder stated that she had never participated in a fire drill in the nine years she had been on staff and did not know the procedures. The staff member was prompted by the surveyor to get help, at which time she left the room of fire origin without closing the corridor door.

b. The second responder stated she was not aware of the procedures to be employed during a fire. After being prompted by the surveyor, the second responder initiated the evacuation of the room at which time a third responder removed the mock patient from the room and closed the corridor door to the room of fire origin; these actions were complete four minutes and twenty-eight seconds after the initiation of the fire drill.

c. A manual pull station was not activated immediately upon discovery of the mock fire, as outlined in the facility's written procedures for response to fire emergencies. (Note: This occurred five minutes and ten seconds into the drill.)

d. A coded announcement was not made immediately upon discovery of the mock fire, as outlined in the facility's written procedures for response to fire emergencies. (Note: This occurred at the same time that the manual pull station was activated.)

The fire drill deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A2, known as Pavilion B.

It was determined through observation and document review during the survey, that the facility failed to perform fire drills in accordance with the Life Safety Code. This was evidenced by:

A fire drill was held on September 2, 2011 on the 3rd floor of the facility during which responders failed to employ the written procedures of the facility's response to fire emergencies. This was evidenced by the following:

a. The initial responder, after stating she was not sure what to do, was prompted by the surveyor to get help, to remove the patient from the room of fire origin, to close the corridor door to the room of origin, to initiate the fire alarm system, and to initiate the coded announcement.

b. A manual pull station was not activated immediately upon discovery of the mock fire, as outlined in the facility's written procedures for response to fire emergencies. (Note: This occurred two minutes and fifty-three seconds into the drill.)

c. A coded announcement was not made immediately upon discovery of the mock fire, as outlined in the facility's written procedures for response to fire emergencies. (Note: This occurred four minutes and forty seconds into the drill.)

The fire drill deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A5, known as Pavilion K.

It was determined through observation and document review during the survey, that the facility failed to perform fire drills in accordance with the Life Safety Code. This was evidenced by:

The facility failed to provide documentation at the time of the survey to show that a fire drills had taken place annually for the past two years. Note: The facility provided documentation at the time of the survey to reflect that a drill had taken place on June 11, 2010; however, this drill was documented during a false alarm of the fire and smoke detection system. Fire drills must be pre-planned events and the facility may not utilize false alarms of the fire and smoke detection system or real events in lieu of these pre-planned events.

The fire drill deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building AA, known as the East Grand Clinic.

It was determined through observation and document review during the survey, that the facility failed to perform fire drills in accordance with the Life Safety Code. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that any fire drills had taken place in the last 12-month period.

The fire drill deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation and record review during the survey that the facility failed to install the Fire Alarm System in accordance with the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by:

All operating rooms, twelve (12) rooms total), did not contain visual fire alarm signals in the operating rooms.

The Fire Alarm System deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building AA, known as the East Grand Clinic.

It was determined through observation and record review during the survey, that the facility failed to inspect and maintain the Fire Alarm System in accordance with the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by:

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) The facility failed to provide records at the time of survey to reflect that the fire alarm system had been serviced and inspected annually, as required.

The Fire Alarm System deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey, that the facility failed to install the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13. This was evidenced by:

1) The second floor (2nd) contained a "shell space" that had a mock up of a possible remodel change. The area contained walls and a drop ceiling in the area however the sprinkler coverage did not extend to under the drop ceiling area. The sprinkler system in this area consisted of upright sprinkler heads only.

2) Sprinkler protection not extended to the following areas:
a. Electrical closet A425E,
b. Electrical closet A447E,
c. Small closet in room A408.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey, that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

1) Escutcheon plates missing:
a. Outside stairwell A49 in the corridor
b. One (1) in room A802
c. One in room A654
d. Two missing in second floor (2nd) SICU nurse lounge
i. One (1) in the bathroom
ii. One (1) in the closet
e. Oxygen storage room on second floor (2nd), outside room A245
f. In second floor (2nd) laboratory area, outside room A2601E
g. One (1) missing in the Microbiology lab
h. One (1) missing in pre-op stall #5
i. One (1) missing in post-op stall #9
j. One (1) missing at the anesthesia work station in the post op area
k. One (1) missing in the sub-sterile compartment adjacent to OR #2
l. One (1) missing in room A1305B
m. One (1) missing in CT scan core room
n. One (1) missing in CT conference room
o. Two (2) missing in CT room #2
p. Outside freezer #2 in AB53

2) Sprinkler head obstructions:
a. Shower room curtain, located on the seventh floor (7th) did not contain a mesh on the curtain and/or was not located at eighteen inches (18") below the sprinkler head, which caused an obstruction to the sprinkler head.
b. Room A728 contained a curtain track located directly adjacent to a concealed sprinkler head. This track was one inch deep (1") and the concealed sprinkler head was spaced on half inch (1/2") from the track. Per NFPA 13, 1999 Edition section 5-6.5.1.2, heads closer than one foot (1') cannot have any sprinkler obstruction.
c. Cath Lab area contained two (2) rooms with sprinkler obstructions due to the tracks of the imaging equipment.
i. Room 2404 contained one (1) obstructed head
ii. Room 2402 contained one (1) obstructed head
d. First floor (1st) shower room #A1218S contained one (1) obstructed sprinkler head from a light fixture

3) Pendant-style sprinkler heads with gaps in ceiling:
a. In the closet of room A360,
b. The clean utility room in PEDS

4) The sprinkler head located above the first wash station in the main dish room was found to be bent.

5) The two (2) upright sprinkler heads located in electrical room AB06B are located approximately six to eight feet below the ceiling.

6) Five gauges on the main system pump were more than five years old and the facility failed to provide documentation that these gauges had been re-calibrated at any time. Note: The dates on the gauges ranged from 2002 to 2004.

7) Sprinkler gauges on floors six (6), seven (8) and eight (8) stairwells have been replaced with "Winter" manufactured gauges. It could not be verified that these gauges were listed to be used on a sprinkler system. Note: The facility showed an invoice indicating that they purchased the gauges from a sprinkler contractor, but we need more information indicating that these are listed to be used on sprinkler systems.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A2, known as Pavilion B.

It was determined through observation during the survey, that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

1) Sprinkler were loaded (contained a high amount of dust or debris on the working parts of the sprinkler head:
a) Outside of room B420
b) Inside room B418
c) Office 4B (office area at southeast stairwell)
d) Two (2) in room B218
e) One (1) in room B234
f) One (1) in room B246
g) One near the elevators on the first floor by the coffee shop
h) Several in the main lobby of the facility on the first floor
i) In room B219, covered in plastic.

2) Sprinkler heads, located in the bathrooms, contained paint or other material on the working parts of the sprinkler head:
a) Room B310
b) Room B316
c) Room B318
d) Room B320
e) Room B336

3) Escutcheon plates were missing in the following areas:
a) Conference room B224.
b) Room B234.
c) By the smoke barrier located outside room BB53 in CCMF.
d) In the corridor outside the main entry to CCMF.

4) Gauges not replaced not re-calibrated in five (5) years:
a) Main riser gauge in room BB29 - dated 2002.

5) Sprinkler heads damaged:
a) In the corridor outside the coffee shop entrance on the first floor.

6) The facility failed to provide sprinkler protection to the fabric overhang that is not non-combustible in nature and is approximately eight feet by twenty feet in size, located above the sally port entrance to CCMF.

7) The pendant-style light fixtures located in the main lobby of the facility obstruct several of the sprinkler heads located above them.

8) The sprinkler head located in room B141 has the potential to be fully obstructed by the x-ray machine.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A4, known as Pavilion D.

It was determined through observation during the survey, that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

Building contained five (5) gauges that had not been calibrated or replaced. Two (2) of the gauges were dates 1994 and the other three (3) gauges did not have dates on the gauges.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A6, known as Pavilion C.

It was determined through observation during the survey, that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

1) Building contained four (4) sprinkler gauges dated 2005. Three (3) gauges were located on the penthouse dry pipe riser, one (1) located on the penthouse wet pipe riser.

2) Escutcheon plates missing in the following areas
a) Room C350.

3) There was a greater than one inch diameter gap surrounding the pendant style sprinkler head in room CB40A.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A7, known as the Central Plant.

It was determined through observation during the survey, that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

Seven of seven gauges on the main system riser were more than five years old and the facility failed to provide documentation that these gauges had been re-calibrated at any time. Note: The dates on the gauges ranged from 2002 to 2005.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building AA, known as the East Grand Clinic.

It was determined through observation and record review during the survey, that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

1) Documentation was not available for showing that the fire sprinkler system has been service in the past 12 months.

2) The facility failed to provided sprinkler protection to the following locations:
a. The oxygen storage closet in the store room, and
b. The utility closet across from the storage room.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey that the facility failed to maintain the emergency exit corridors free of all obstructions or impediments to full instant use in the case of fire or other emergency in accordance with the Life Safety Code. This was evidenced by:

1) The corridor, outside of the Cath lab, contained an exit sign pointing occupants to go through the Cath Lab suite as an exit. The corridor outside of the Cath labs contained items stored in the corridor.
a. One (1) ultrasound machine
b. One (1) cart which held gloves and gowns

2) Items stored in the corridor
a. Two (2) wheelchairs and one (1) wheeled cart at 11:00 a.m. and again at 11:20 a.m. outside of room A120, outside of MRI suite.

The exit corridor deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A2, known as Pavilion B.

It was determined through observation during the survey that the facility failed to maintain the emergency exit corridors free of all obstructions or impediments to full instant use in the case of fire or other emergency in accordance with the Life Safety Code. This was evidenced by:

One (1) computer monitor stand, located on the wall, contained a fold down keyboard that was in the down position and did not automatically retracted back when not in use. This monitor extended thirteen inches (13") into the corridor. Note: This item was corrected during the survey.

The exit corridor deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building AA, known as the East Grand Clinic.

It was determined through observation during the survey that the facility failed to provide draperies and other loose hanging fabrics in accordance with the Life Safety Code. This was evidenced by:

The facility failed to provide documentation at the time of the survey to reflect that the loose hanging drapery, concealing the shelving unit above the dryer, was flame resistant.

The loose hanging fabric deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey, that the facility failed to maintain the oxygen storage areas in accordance with the Life Safety Code and NFPA 99, Healthcare Facilities. This was evidenced by:

Two (2) unsecured CO2 tanks in the tank storage closet on the first floor, outside of the MRI suite. Note: this item was corrected during the survey.

The oxygen storage area deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey that the facility failed to maintain the piped medical gas system in accordance with the Life Safety Code and NFPA 99, Healthcare Facilities. This was evidenced by:

The Radiology department, outside of room A1128, contained one (1) oxygen outlet in the same compartment as the emergency shut off valve.

The piped medical gas system deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation and record review during the survey that the facility failed to maintain the dry chemical extinguishing system serving the hazmat trailer in accordance with the Life Safety Code. This was evidenced by:

1) The dry chemical extinguishing system serving the hazmat trailer had not been inspected or serviced since October of 2009. Note: this item was corrected during the survey.

2) The facility failed to provide documentation at the time of the survey to reflect that the dry chemical extinguishing system serving the hazmat trailer had been inspected monthly, as required.

The dry chemical extinguishing system deficiency items were discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A6, known as Pavilion C.

It was determined through observation during the survey that the facility failed to maintain the two-hour fire rated occupancy separation in accordance with the Life Safety Code. This was evidenced by:

The facility failed to provide automatic latching hardware on the hour and a half fire rated doors that are part of the two-hour fire rated fire barrier separating Pavilion C (on a separate fire alarm system and surveyed using Chapter 18 of NFPA 101) and Pavilion B (on a separate fire alarm system and surveyed using chapter 19 of NFPA 101, which will not meet the requirements of Chapter 18 without further modification) in the following locations:
a. In the basement corridor, and
b. On the second (2nd) floor corridor.

The occupancy separation deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building AA, known as the East Grand Clinic.

It was determined through observation during the survey that the facility failed to maintain the one-hour fire rated occupancy separation in accordance with the Life Safety Code. This was evidenced by:

The facility failed to provide automatic latching hardware on the one-hour fire rated occupancy separation doors at the front entry of the facility between the East Grand Clinic location, certified under the Hospital, and an adjacent space that is not licensed or certified under the Hospital, as required.

The occupancy separation deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A1, known as Pavilion A.

It was determined through observation during the survey that the facility failed to utilize the building's electrical system in accordance with the Life Safety Code. This was evidenced by:

1) One (1) multi tap outlet being utilized in the office of the Molecular Lab. (corrected on site)

2) An extension cord utilized as permanent wiring in office A372.

3) A surge protected power strip into a second surge protected power strip in office A324.

4) A surge protected power strip into a second surge protected power strip in office A530.

The electrical deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building A5, known as Pavilion K.

It was determined through observation during the survey that the facility failed to utilize the building's electrical system in accordance with the Life Safety Code. This was evidenced by:

Surge protected power strips plugged in as a series in the following locations:
a. Room 9-0101
b. Room 9-0115
c. Southwest cubicle on the east side of the second floor.

The electrical deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.

This portion applies to Building AA, known as the East Grand Clinic.

It was determined through observation during the survey that the facility failed to utilize the building's electrical system in accordance with the Life Safety Code. This was evidenced by:

There was one (1) six-plug multi tap outlet without over-current or surge protection being utilized in the physician office.

The electrical deficiency item was discussed during the survey and again during the exit conference on September 9, 2011.