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Based on observations and staff interview the facility's smoke barriers were not maintained.

The findings are:

On the morning of 7/23/13 an observation of the facility's smoke barrier walls revealed the following penetrations.

a) there was an unsealed supply duct penetration in the smokewall of the 7 th. floor Nurses Lounge, and four unsealed telemetry wire penetrations in a corridor wall near the entrance to the 7 th. floor Medical Intensive Care Unit.

b) there were multiple unsealed data wire penetrations over the 4 th. floor smoke barrier doors #19 and #20.

c) there was one unsealed data wire penetration in the vicinity of the 2nd. floor Service Lobby.

e) there was one unsealed data wire penetration in the smoke wall, in the vicinity of the 1st. floor Recovery Room, and two unsealed air duct penetrations found in the Elevator Lobby smoke barrier wall.

f) there was an unsealed bundle of data wires found in the ground floor corridor smoke barrier wall.

The above mentioned observations were concurrently confirmed by Employee #17.

Based on observation and staff interview, the facility's exit components did not maintain the required fire resistance ratings. Specifically: 1. emergency exit door penetrations; and 2. wall penetrations.

The findings are:

1. a) On the morning of 7/22/13, an observation revealed that the 90 minute fire-rated exterior fire exit door and roll-down gate had unsealed penetrations.

b) On the morning of 7/23/13, an observation revealed that the 90 minute fire-rated exit door for Emergency Exit Stairwell #2 had three unsealed penetrations.

c) On the morning of 7/26/13, an observation at the Alcohol Rehabilitation Clinic revealed that the fire-rated door and frame for the Emergency Exit Stairwell had multiple unsealed penetrations.

2. On the afternoon of 7/25/13, an observation of the two hour fire-rated wall barrier between the Hospital and the Business Occupancy on the 6 th. floor had one partially sealed duct penetration and two partially sealed duct penetrations.

The above mentioned observations were concurrently confirmed by Employee #17.

Based on observation and staff interview, the facility's exit access corridors were not clear and unobstructed.

The finding is:

On 7/22/13 at 2:00 PM, an observation revealed that the exit corridor for the Emergency Department medical offices was blocked by two medical carts and two stretchers.

The above mentioned observation was concurrently confirmed by Employee #17.

Based on observation, record review and staff interviews, the facility's staff was not familiar with the hospital fire drill procedures.

The findings are:

a) On 7/22/13 at approximately 11:45 AM, observation and staff interview revealed that when asked what are the steps in case of a fire in the kitchen, Employee #18 stated he would i) use the fire extinguisher; ii) call #7140; iii) pull the Fire Alarm Pull Station; and iv) evacuate. Staff #18 did not know the differences between the ABC fire extinguisher and the water-based fire extinguisher.

On 7/22/13 at approximately 12:00 PM, observation and staff interview revealed that when asked what are the steps in case of a fire in the kitchen, Employee #19 stated he would: i) yell fire!, fire!; ii) remove himself from the kitchen; iii) alarm by calling #7140; iv) close the doors; v) evacuate.

On 7/22/13 at approximately 12:10 PM, observation and staff interview revealed that when asked what are the steps in case of a fire in the kitchen, Employee #20 stated he would: i) call code 3; i) use the fire extinguisher; iii) yell fire!, fire! and tell people to get out of area; iv) close doors and evacuate.

On 7/26/13, a record review of the Food Service Personnel section of the Fire Regulations Policy, which was effective March 12, 2004, confirmed that the food service personnel were not aware of the proper procedures in case of a fire. It also revealed that the Food Service Personnel fire regulations were different from the Hospital and Nursing Home Personnel fire regulations that were revised January 1, 2007.

b) On 7/24/13 at approximately 2:30 PM, observation and staff interview revealed that when asked what are the steps in case of a fire in the 5 th. Floor Medical/Surgical Unit, staff #21 stated she would: i) call code 7140 and then code 3; ii) remove patients; iii) contain the fire; iv) evacuate patients. Although Employee #21 never mentioned "pull the Fire Alarm Pull Station", she was able to identify the location of the closest pull station.

On 7/24/13, at approximately 2:45 PM, observation and staff interview revealed that when asked what are the steps in case of a fire in the 5 th. Floor Medical/Surgical Unit, Employee #22 stated she would: i) call code 3 and then code 7140; ii) remove patients; iii) alarm by pulling alarm panel by the stairwell; iv) contain the fire; v) evacuate.

On 7/25/13 at 2:30 PM, observation and staff interview revealed that when asked what are the steps in case of a fire in the Decontamination Room, Employee #23 stated she would:first call 7140. Employee #23 was unsure on how to react when the surveyor asked her "what if the phone was broken". Upon further interview and observation, Employee #23 did not know where to find either the Fire Alarm Pull Station or the Fire Alarm Code Directory.

On 7/26/13 record review of the Fire Regulations Policy, which was last revised January 1, 2007, revealed that the facility's order for fire regulations is Remove, Alarm, Start, Close, and Evacuate or Extinguish. The policy states that when a staff member alarms he/she would "Pull the nearest fire alarm and inform the operator by dialing ext. 7140 of the the location of the fire." The policy further stated that "upon discovery of fire, personnel should immediately take the following action: The discover should go to the aid of any endangered person, calling aloud the established code phrase, "Nurse Red. Upon hearing the established code phrase, personnel should activate the building fire alarm using the nearest manual alarm station and dial ext. 7140....."

The above mentioned observations were concurrently confirmed by Employee#17.

Based on observation and staff interview, the facility's smoke detectors were not maintained, inspected and tested in accordance with the manufacturer's specifications.

The finding was:

On the morning of 7/26/13 an observation of the Alcohol Rehabilitation Clinic revealed that the two battery operated smoke detectors in the "main" room had no batteries.

The above mentioned observations were concurrently confirmed by Employee #17.

Based on observation and staff interview, the facility's fire extinguishers were not provided in all health care occupancies in accordance with 9.7.4.1, 19.3.5.6.

The finding is:

On 7/25/13 at approximately 11:30 AM, an observation of the Family Health Center Extension Clinic revealed that inside the Telephone Room (i.e. room 146) there was a fire extinguisher that had not had any monthly, yearly, or five-year maintenance done since 1996.

The above mentioned observation was concurrently confirmed by Employee #17.

Based on observation and staff interview, the facility's Emergency Exits were not maintained. Specifically: 1. the exit stairwell door assemblies were not maintained; 2. there were two opening devices installed on a exit door.

The findings are:

1. On the morning of 7/23/13, an observation in the 5 th. Floor Medical/Surgical Unit revealed that the door assembly fire-rating label for Emergency Exit Stairwell #2 Fire Exit Door was painted over.

On 7/25/13 at approximately 11:30 AM an observation of the Family Health Center Extension Clinic revealed that the door assembly fire-rating label for the only Emergency Exit Stairwell was painted over.

2) Based on observation and staff interview, the Alcohol Rehabilitation Clinic's vertical openings (i.e. Emergency Exit Stairwell) was not maintained.

The finding is:

On the morning of 7/26/13, an observation revealed that the fire-rated door for the Emergency Exit Stairwell had two opening devices on the door (i.e. a door knob and a push-bar).

The above mentioned observations were concurrently confirmed by staff #17.

Based on observation and staff interview, the facility's electrical equipment was not maintained in accordance with NFPA 70, National Electrical Code 9.1.2.

The finding is:

On 7/25/13 at approximately 11:30 AM an observation of the Family Health Center Extension Clinic revealed that none of the facility's electrical panels had identification labels.

The above mentioned observations were concurrently confirmed by Employee #17.

Based on observations and staff interview the facility's smoke barriers were not maintained.

The findings are:

On the morning of 7/23/13 an observation of the facility's smoke barrier walls revealed the following penetrations.

a) there was an unsealed supply duct penetration in the smokewall of the 7 th. floor Nurses Lounge, and four unsealed telemetry wire penetrations in a corridor wall near the entrance to the 7 th. floor Medical Intensive Care Unit.

b) there were multiple unsealed data wire penetrations over the 4 th. floor smoke barrier doors #19 and #20.

c) there was one unsealed data wire penetration in the vicinity of the 2nd. floor Service Lobby.

e) there was one unsealed data wire penetration in the smoke wall, in the vicinity of the 1st. floor Recovery Room, and two unsealed air duct penetrations found in the Elevator Lobby smoke barrier wall.

f) there was an unsealed bundle of data wires found in the ground floor corridor smoke barrier wall.

The above mentioned observations were concurrently confirmed by Employee #17.

Based on observation and staff interview, the facility's exit components did not maintain the required fire resistance ratings. Specifically: 1. emergency exit door penetrations; and 2. wall penetrations.

The findings are:

1. a) On the morning of 7/22/13, an observation revealed that the 90 minute fire-rated exterior fire exit door and roll-down gate had unsealed penetrations.

b) On the morning of 7/23/13, an observation revealed that the 90 minute fire-rated exit door for Emergency Exit Stairwell #2 had three unsealed penetrations.

c) On the morning of 7/26/13, an observation at the Alcohol Rehabilitation Clinic revealed that the fire-rated door and frame for the Emergency Exit Stairwell had multiple unsealed penetrations.

2. On the afternoon of 7/25/13, an observation of the two hour fire-rated wall barrier between the Hospital and the Business Occupancy on the 6 th. floor had one partially sealed duct penetration and two partially sealed duct penetrations.

The above mentioned observations were concurrently confirmed by Employee #17.

Based on observation and staff interview, the facility's exit access corridors were not clear and unobstructed.

The finding is:

On 7/22/13 at 2:00 PM, an observation revealed that the exit corridor for the Emergency Department medical offices was blocked by two medical carts and two stretchers.

The above mentioned observation was concurrently confirmed by Employee #17.

Based on observation, record review and staff interviews, the facility's staff was not familiar with the hospital fire drill procedures.

The findings are:

a) On 7/22/13 at approximately 11:45 AM, observation and staff interview revealed that when asked what are the steps in case of a fire in the kitchen, Employee #18 stated he would i) use the fire extinguisher; ii) call #7140; iii) pull the Fire Alarm Pull Station; and iv) evacuate. Staff #18 did not know the differences between the ABC fire extinguisher and the water-based fire extinguisher.

On 7/22/13 at approximately 12:00 PM, observation and staff interview revealed that when asked what are the steps in case of a fire in the kitchen, Employee #19 stated he would: i) yell fire!, fire!; ii) remove himself from the kitchen; iii) alarm by calling #7140; iv) close the doors; v) evacuate.

On 7/22/13 at approximately 12:10 PM, observation and staff interview revealed that when asked what are the steps in case of a fire in the kitchen, Employee #20 stated he would: i) call code 3; i) use the fire extinguisher; iii) yell fire!, fire! and tell people to get out of area; iv) close doors and evacuate.

On 7/26/13, a record review of the Food Service Personnel section of the Fire Regulations Policy, which was effective March 12, 2004, confirmed that the food service personnel were not aware of the proper procedures in case of a fire. It also revealed that the Food Service Personnel fire regulations were different from the Hospital and Nursing Home Personnel fire regulations that were revised January 1, 2007.

b) On 7/24/13 at approximately 2:30 PM, observation and staff interview revealed that when asked what are the steps in case of a fire in the 5 th. Floor Medical/Surgical Unit, staff #21 stated she would: i) call code 7140 and then code 3; ii) remove patients; iii) contain the fire; iv) evacuate patients. Although Employee #21 never mentioned "pull the Fire Alarm Pull Station", she was able to identify the location of the closest pull station.

On 7/24/13, at approximately 2:45 PM, observation and staff interview revealed that when asked what are the steps in case of a fire in the 5 th. Floor Medical/Surgical Unit, Employee #22 stated she would: i) call code 3 and then code 7140; ii) remove patients; iii) alarm by pulling alarm panel by the stairwell; iv) contain the fire; v) evacuate.

On 7/25/13 at 2:30 PM, observation and staff interview revealed that when asked what are the steps in case of a fire in the Decontamination Room, Employee #23 stated she would:first call 7140. Employee #23 was unsure on how to react when the surveyor asked her "what if the phone was broken". Upon further interview and observation, Employee #23 did not know where to find either the Fire Alarm Pull Station or the Fire Alarm Code Directory.

On 7/26/13 record review of the Fire Regulations Policy, which was last revised January 1, 2007, revealed that the facility's order for fire regulations is Remove, Alarm, Start, Close, and Evacuate or Extinguish. The policy states that when a staff member alarms he/she would "Pull the nearest fire alarm and inform the operator by dialing ext. 7140 of the the location of the fire." The policy further stated that "upon discovery of fire, personnel should immediately take the following action: The discover should go to the aid of any endangered person, calling aloud the established code phrase, "Nurse Red. Upon hearing the established code phrase, personnel should activate the building fire alarm using the nearest manual alarm station and dial ext. 7140....."

The above mentioned observations were concurrently confirmed by Employee#17.

Based on observation and staff interview, the facility's smoke detectors were not maintained, inspected and tested in accordance with the manufacturer's specifications.

The finding was:

On the morning of 7/26/13 an observation of the Alcohol Rehabilitation Clinic revealed that the two battery operated smoke detectors in the "main" room had no batteries.

The above mentioned observations were concurrently confirmed by Employee #17.

Based on observation and staff interview, the facility's fire extinguishers were not provided in all health care occupancies in accordance with 9.7.4.1, 19.3.5.6.

The finding is:

On 7/25/13 at approximately 11:30 AM, an observation of the Family Health Center Extension Clinic revealed that inside the Telephone Room (i.e. room 146) there was a fire extinguisher that had not had any monthly, yearly, or five-year maintenance done since 1996.

The above mentioned observation was concurrently confirmed by Employee #17.

Based on observation and staff interview, the facility's Emergency Exits were not maintained. Specifically: 1. the exit stairwell door assemblies were not maintained; 2. there were two opening devices installed on a exit door.

The findings are:

1. On the morning of 7/23/13, an observation in the 5 th. Floor Medical/Surgical Unit revealed that the door assembly fire-rating label for Emergency Exit Stairwell #2 Fire Exit Door was painted over.

On 7/25/13 at approximately 11:30 AM an observation of the Family Health Center Extension Clinic revealed that the door assembly fire-rating label for the only Emergency Exit Stairwell was painted over.

2) Based on observation and staff interview, the Alcohol Rehabilitation Clinic's vertical openings (i.e. Emergency Exit Stairwell) was not maintained.

The finding is:

On the morning of 7/26/13, an observation revealed that the fire-rated door for the Emergency Exit Stairwell had two opening devices on the door (i.e. a door knob and a push-bar).

The above mentioned observations were concurrently confirmed by staff #17.

Based on observation and staff interview, the facility's electrical equipment was not maintained in accordance with NFPA 70, National Electrical Code 9.1.2.

The finding is:

On 7/25/13 at approximately 11:30 AM an observation of the Family Health Center Extension Clinic revealed that none of the facility's electrical panels had identification labels.

The above mentioned observations were concurrently confirmed by Employee #17.