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Based on observation and interview, the facility failed to maintain corridor walls with a fire resistance rating of not less than 1/2 hour and that were smoke resistive. The deficient practice affected smoke compartments on the first floor of this facility.
Findings are:
On 10/22/13 at 3:30 p.m., it was observed that the atrium corridor wall next to the Intensive Care Unit does not meet the rated corridor assembly requirements. The corridor walls were originally designed as outside walls with windows looking out from patient rooms. And when the corridor was constructed the windows were left intact. These windows do not carry a fire rating and are still operable from the patient room therefore reducing the fire rating of the corridor walls and not being smoke resistive. The corridor when added to this facility was attached to two corridors which both are properly protected with an automatic sprinkler system however there is no separation doors at either end of this corridor therefore it is part of the facility ' s exit plan to be used in an emergency. Interview with maintenance staff B acknowledged the facility was not aware of the separation requirements. Observations were acknowledged by the Administrative Staff and verified by Maintenance Staff B at the time of the observations and/or at the exit interview.

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. NFPA 101 Chapter 19-3.6.3.1
Based on observation and interview, the facility failed to maintain and provide doors protecting corridor openings constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. The deficient practice affected one smoke compartment on the first floor of this facility.
Findings are:
On 10/23/13 at 08:30 a.m., it was observed that the door to the cafeteria was a sliding glass type door to the corridor. Upon further observation of this door it was noted that the glass within this door was tempered glass not fire rated glass and that the door did not have any fire rating. This door did open to the corridor which was part of the facility ' s emergency plan. It must be noted that this corridor is not protected with an automatic sprinkler system. Interview with maintenance staff B acknowledged the facility was not aware of the fire rating requirement of corridor doors. Observations were acknowledged by the Administrative Staff and verified by Maintenance Staff B at the time of the observations and/or at the exit interview.

Fire window assemblies shall be permitted in fire barriers having a required fire resistance rating of 1 hour or less and shall be of an approved type with the appropriate fire protection rating for the location in which they are installed. Fire windows shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows, and shall comply with the following:
(1) * Fire windows used in fire barriers, other than existing fire window installations of wired glass and other fire-rated glazing material in approved metal frames, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 257, Standard on Fire Test for Window and Glass Block Assemblies.
(2) Fire windows used in fire barriers, other than existing fire window installations of wired glass and other fire-rated glazing material in approved metal frames, shall not exceed 25 percent of the area of the fire barrier in which they are used. NFPA 101 Chapters 8.2.3.2.2 and Chapter 19.3.6.3.8
Based on observation and interview, the facility is not maintaining the proper vision panels in corridor walls in one smoke zone. This deficient practice would allow the spread of fire and smoke and affect occupants who required the use of the exit corridor.
Findings are:
On 10/23/13 at 08:30 a.m., it was observed that the glass wall that separated the cafeteria to the exiting corridor exceeded 25 percent of the area of the fire barrier to the corridor. This glass wall was part of the corridor which was part of the facility ' s emergency plan. It must be noted that this corridor is not protected with an automatic sprinkler system. Interview with Maintenance staff B the facility was unaware of the 25 percent rule in facilities not protected with an automatic sprinkler system. Observations were acknowledged by the Administrative Staff and verified by Maintenance Staff B at the time of the observations and/or at the exit interview.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected 4 of 12 smoke compartments. Findings are:

1. Observation on October 22, 2013 between 8:00 A.M and 4:30 P.M., of the file storage room in the MOB revealed holes in the poured concrete ceiling that did not appear to have approved means to provide the proper separation. Maintenance Staff A confirmed these observations.
2. Observation on October 22, 2013 between 8:00 A.M and 4:30 P.M., of Exam 1 in the cath lab revealed that the room is used as a storage room without the proper separation provided between the room and the corridor.
3. Observation on October 22, 2013 between 8:00 A.M and 4:30 P.M., of the old changing room in Nuclear med revealed that this room is used as a storage area without the proper separation provided between the room and the corridor.
4. Observation on October 22, 2013 between 8:00 A.M and 4:30 P.M., of the MDF room revealed penetrations in the wall separating the room from the corridor.
5. . Observation on October 23, 2013 between 8:00 A.M and 4:30 P.M., of the east shower in 2 West revealed the room used for storage with the door not equipped with means to make it self-closing.
Maintenance Staff A confirmed these observations.


Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected recovery smoke compartment. Findings are:
Observation on October 22, 2013 between 8:00 A.M and 4:30 P.M., revealed the recovery storage room door not equipped with means to make it self-closing. Maintenance Staff A confirmed these observations.

Based on observations and interview the facility failed to provide residential smoke detectors or smoke detectors attached to the fire alarm system in the patient sleeping rooms in the Sleep Disorder Clinic. This clinic is business occupancy and has the potential of affecting the patients in each of the clinics sleep study rooms.
Finds are:
Observation on 10/23/13 at 2:30 p.m. revealed the patient rooms in the Sleep Disorder Clinic did not have either residential smoke detectors or smoke detectors attached to the fire alarm system installed to alert the patients of a possible fire. These rooms are in a business occupancy however they are used by the patients to sleep over night while a sleep study is taken place therefore are considered sleeping rooms. Interview with the Maintenance staff B revealed they did not know they needed smoke detectors in these rooms since they were using them as outpatient care. Observations were acknowledged by the Administrative Staff and verified by Maintenance Staff B at the time of the observations and/or at the exit interview.

Based on observations and interviews, the facility failed to provide protection throughout by an approved, supervised automatic sprinkler system within the sprinkler protected zones. This deficient practice would allow the spread of fire and smoke and affect occupants within the affected areas.
Observations on 10/22/13 during the hours of 8:00 a.m. and 5:00 p.m. of the survey day revealed the electrical room in the Birth and Infant Care Area and in the 4th floor storage room was missing automatic sprinkler protection. These rooms were also not separated from the remainder of these zones by a two hour fire separation rating which is required by code. Observations were acknowledged by the Administrative Staff and verified by Maintenance Staff B at the time of the observations and/or at the exit interview.
During an interview on 10/22/13 between 2:00 P.M. and 5:00 P.M. maintenance personnel stated that the sprinkler heads were removed because the State Electrical Inspector at that time had the facility remove them.



15537

Based on observations and interview the facility failed to provide a complete coverage by an approved supervised sprinkler system in accordance with NFPA 13. Where major renovations, alterations, or modernizations are made in a nonsprinklered facility, the automatic sprinkler requirements of Chapter 18, New Healthcare Occupancies, shall apply to a smoke compartment undergoing the renovation, alteration, or modernization. Findings are:

During the validation survey on 10/22 and 10/23/2013 it was observed that areas of the hospital that had undergone renovations had not had met the provisions of 19.1.1.4.5, 19.1.6 and 19.2.3.2 of NFPA 101, 2000 edition which require the installation of an approved supervised automatic sprinkler system in the entire smoke compartment undergoing the renovation, alteration, or modernization.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 25. This deficient practice could affect all occupants and residents by reducing the ability of the automatic fire sprinkler system to extinguish the fire, which could cause the fire to spread, in this facility. Findings are:
On 10/23/2013 between 8:00 A.M. and 4:30 P.M., it was observed that the fire sprinkler head located in room 311 was missing an escutcheon. Maintenance Staff A confirmed that the escutcheon was missing.

A. Based on observation and interview, the facility failed to maintain the use of relocatable power taps, which are not permitted in areas of health care occupancies regularly occupied by patients. This includes general patient care areas and critical patient care areas.
General care areas include patient bedrooms, examining rooms, treatment rooms, clinics and similar areas where it is intended that the patient will come in contact with ordinary appliances such as nurse call systems, electrical beds, examining lamps, telephones and entertainment devices such as radios, televisions and computers. This will also include common spaces such as corridors, lounges, dining rooms and similarly occupied spaces where electrical appliances noted above may be found.
Findings are:
Observations on 10-21-13 thru 10-23-13 during the hours of 8:00 a.m. and 5:00 p.m., each survey day revealed that the facility was using non hospital grade power strips in multiple patient use areas on multiple floors. Interview with maintenance staff B the facility was unaware of the hospital grade requirement and stated that it was unclear how so many were put into use without the facility ' s knowledge. Observations were acknowledged by and verified by Maintenance Staff B at the time of the observations and/or at the exit interview.
B. Based on observation and interview, the facility did not prohibit the use of extension cords and power strips as a substitute for adequate wiring or to use them in a proper manner by preventing motor driven appliances, or overloaded circuits.
Findings are:
1) Observation on 10/22/13 during the hours of 8:00 a.m. and 5:00 p.m. revealed the facility was using power strips plugged into power strips in both the nursing lab classroom and the nurse ' s station in the intensive care unit. With one power strip plugged into another there is a potential of overloading the first power strip and causing the wiring to heat up and break down resulting in a fire. This would have the potential of affecting all the staff and patients in those areas. Interview with maintenance staff B advised that the facility was aware of the dangers of overloading and advised it was the facility ' s policy not to plug power strips into power strips. Observations were acknowledged by and verified by Maintenance Staff B at the time of the observations and/or at the exit interview.
2) There were motor driven appliances such as copy machines, medicine dispensing machines, and refrigerators plugged into power strips throughout the facility instead of having the proper wiring installed. Motor driven appliances can draw to much electrical current through the power strip, causing the wiring to heat up and break down resulting in a fire. This would have the potential of affecting all the staff and patients within those areas. Interview with maintenance staff B revealed the facility was unaware of the requirement of not plugging motor driven appliances into power strips. Observations were acknowledged by the Administrative Staff and verified by Maintenance Staff B at the time of the observations and/or at the exit interview.

Based on observation and interview, the facility failed to maintain corridor walls with a fire resistance rating of not less than 1/2 hour and that were smoke resistive. The deficient practice affected smoke compartments on the first floor of this facility.
Findings are:
On 10/22/13 at 3:30 p.m., it was observed that the atrium corridor wall next to the Intensive Care Unit does not meet the rated corridor assembly requirements. The corridor walls were originally designed as outside walls with windows looking out from patient rooms. And when the corridor was constructed the windows were left intact. These windows do not carry a fire rating and are still operable from the patient room therefore reducing the fire rating of the corridor walls and not being smoke resistive. The corridor when added to this facility was attached to two corridors which both are properly protected with an automatic sprinkler system however there is no separation doors at either end of this corridor therefore it is part of the facility ' s exit plan to be used in an emergency. Interview with maintenance staff B acknowledged the facility was not aware of the separation requirements. Observations were acknowledged by the Administrative Staff and verified by Maintenance Staff B at the time of the observations and/or at the exit interview.

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. NFPA 101 Chapter 19-3.6.3.1
Based on observation and interview, the facility failed to maintain and provide doors protecting corridor openings constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. The deficient practice affected one smoke compartment on the first floor of this facility.
Findings are:
On 10/23/13 at 08:30 a.m., it was observed that the door to the cafeteria was a sliding glass type door to the corridor. Upon further observation of this door it was noted that the glass within this door was tempered glass not fire rated glass and that the door did not have any fire rating. This door did open to the corridor which was part of the facility ' s emergency plan. It must be noted that this corridor is not protected with an automatic sprinkler system. Interview with maintenance staff B acknowledged the facility was not aware of the fire rating requirement of corridor doors. Observations were acknowledged by the Administrative Staff and verified by Maintenance Staff B at the time of the observations and/or at the exit interview.

Fire window assemblies shall be permitted in fire barriers having a required fire resistance rating of 1 hour or less and shall be of an approved type with the appropriate fire protection rating for the location in which they are installed. Fire windows shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows, and shall comply with the following:
(1) * Fire windows used in fire barriers, other than existing fire window installations of wired glass and other fire-rated glazing material in approved metal frames, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 257, Standard on Fire Test for Window and Glass Block Assemblies.
(2) Fire windows used in fire barriers, other than existing fire window installations of wired glass and other fire-rated glazing material in approved metal frames, shall not exceed 25 percent of the area of the fire barrier in which they are used. NFPA 101 Chapters 8.2.3.2.2 and Chapter 19.3.6.3.8
Based on observation and interview, the facility is not maintaining the proper vision panels in corridor walls in one smoke zone. This deficient practice would allow the spread of fire and smoke and affect occupants who required the use of the exit corridor.
Findings are:
On 10/23/13 at 08:30 a.m., it was observed that the glass wall that separated the cafeteria to the exiting corridor exceeded 25 percent of the area of the fire barrier to the corridor. This glass wall was part of the corridor which was part of the facility ' s emergency plan. It must be noted that this corridor is not protected with an automatic sprinkler system. Interview with Maintenance staff B the facility was unaware of the 25 percent rule in facilities not protected with an automatic sprinkler system. Observations were acknowledged by the Administrative Staff and verified by Maintenance Staff B at the time of the observations and/or at the exit interview.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected 4 of 12 smoke compartments. Findings are:

1. Observation on October 22, 2013 between 8:00 A.M and 4:30 P.M., of the file storage room in the MOB revealed holes in the poured concrete ceiling that did not appear to have approved means to provide the proper separation. Maintenance Staff A confirmed these observations.
2. Observation on October 22, 2013 between 8:00 A.M and 4:30 P.M., of Exam 1 in the cath lab revealed that the room is used as a storage room without the proper separation provided between the room and the corridor.
3. Observation on October 22, 2013 between 8:00 A.M and 4:30 P.M., of the old changing room in Nuclear med revealed that this room is used as a storage area without the proper separation provided between the room and the corridor.
4. Observation on October 22, 2013 between 8:00 A.M and 4:30 P.M., of the MDF room revealed penetrations in the wall separating the room from the corridor.
5. . Observation on October 23, 2013 between 8:00 A.M and 4:30 P.M., of the east shower in 2 West revealed the room used for storage with the door not equipped with means to make it self-closing.
Maintenance Staff A confirmed these observations.


Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected recovery smoke compartment. Findings are:
Observation on October 22, 2013 between 8:00 A.M and 4:30 P.M., revealed the recovery storage room door not equipped with means to make it self-closing. Maintenance Staff A confirmed these observations.

Based on observations and interview the facility failed to provide residential smoke detectors or smoke detectors attached to the fire alarm system in the patient sleeping rooms in the Sleep Disorder Clinic. This clinic is business occupancy and has the potential of affecting the patients in each of the clinics sleep study rooms.
Finds are:
Observation on 10/23/13 at 2:30 p.m. revealed the patient rooms in the Sleep Disorder Clinic did not have either residential smoke detectors or smoke detectors attached to the fire alarm system installed to alert the patients of a possible fire. These rooms are in a business occupancy however they are used by the patients to sleep over night while a sleep study is taken place therefore are considered sleeping rooms. Interview with the Maintenance staff B revealed they did not know they needed smoke detectors in these rooms since they were using them as outpatient care. Observations were acknowledged by the Administrative Staff and verified by Maintenance Staff B at the time of the observations and/or at the exit interview.

Based on observations and interviews, the facility failed to provide protection throughout by an approved, supervised automatic sprinkler system within the sprinkler protected zones. This deficient practice would allow the spread of fire and smoke and affect occupants within the affected areas.
Observations on 10/22/13 during the hours of 8:00 a.m. and 5:00 p.m. of the survey day revealed the electrical room in the Birth and Infant Care Area and in the 4th floor storage room was missing automatic sprinkler protection. These rooms were also not separated from the remainder of these zones by a two hour fire separation rating which is required by code. Observations were acknowledged by the Administrative Staff and verified by Maintenance Staff B at the time of the observations and/or at the exit interview.
During an interview on 10/22/13 between 2:00 P.M. and 5:00 P.M. maintenance personnel stated that the sprinkler heads were removed because the State Electrical Inspector at that time had the facility remove them.



15537

Based on observations and interview the facility failed to provide a complete coverage by an approved supervised sprinkler system in accordance with NFPA 13. Where major renovations, alterations, or modernizations are made in a nonsprinklered facility, the automatic sprinkler requirements of Chapter 18, New Healthcare Occupancies, shall apply to a smoke compartment undergoing the renovation, alteration, or modernization. Findings are:

During the validation survey on 10/22 and 10/23/2013 it was observed that areas of the hospital that had undergone renovations had not had met the provisions of 19.1.1.4.5, 19.1.6 and 19.2.3.2 of NFPA 101, 2000 edition which require the installation of an approved supervised automatic sprinkler system in the entire smoke compartment undergoing the renovation, alteration, or modernization.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 25. This deficient practice could affect all occupants and residents by reducing the ability of the automatic fire sprinkler system to extinguish the fire, which could cause the fire to spread, in this facility. Findings are:
On 10/23/2013 between 8:00 A.M. and 4:30 P.M., it was observed that the fire sprinkler head located in room 311 was missing an escutcheon. Maintenance Staff A confirmed that the escutcheon was missing.

A. Based on observation and interview, the facility failed to maintain the use of relocatable power taps, which are not permitted in areas of health care occupancies regularly occupied by patients. This includes general patient care areas and critical patient care areas.
General care areas include patient bedrooms, examining rooms, treatment rooms, clinics and similar areas where it is intended that the patient will come in contact with ordinary appliances such as nurse call systems, electrical beds, examining lamps, telephones and entertainment devices such as radios, televisions and computers. This will also include common spaces such as corridors, lounges, dining rooms and similarly occupied spaces where electrical appliances noted above may be found.
Findings are:
Observations on 10-21-13 thru 10-23-13 during the hours of 8:00 a.m. and 5:00 p.m., each survey day revealed that the facility was using non hospital grade power strips in multiple patient use areas on multiple floors. Interview with maintenance staff B the facility was unaware of the hospital grade requirement and stated that it was unclear how so many were put into use without the facility ' s knowledge. Observations were acknowledged by and verified by Maintenance Staff B at the time of the observations and/or at the exit interview.
B. Based on observation and interview, the facility did not prohibit the use of extension cords and power strips as a substitute for adequate wiring or to use them in a proper manner by preventing motor driven appliances, or overloaded circuits.
Findings are:
1) Observation on 10/22/13 during the hours of 8:00 a.m. and 5:00 p.m. revealed the facility was using power strips plugged into power strips in both the nursing lab classroom and the nurse ' s station in the intensive care unit. With one power strip plugged into another there is a potential of overloading the first power strip and causing the wiring to heat up and break down resulting in a fire. This would have the potential of affecting all the staff and patients in those areas. Interview with maintenance staff B advised that the facility was aware of the dangers of overloading and advised it was the facility ' s policy not to plug power strips into power strips. Observations were acknowledged by and verified by Maintenance Staff B at the time of the observations and/or at the exit interview.
2) There were motor driven appliances such as copy machines, medicine dispensing machines, and refrigerators plugged into power strips throughout the facility instead of having the proper wiring installed. Motor driven appliances can draw to much electrical current through the power strip, causing the wiring to heat up and break down resulting in a fire. This would have the potential of affecting all the staff and patients within those areas. Interview with maintenance staff B revealed the facility was unaware of the requirement of not plugging motor driven appliances into power strips. Observations were acknowledged by the Administrative Staff and verified by Maintenance Staff B at the time of the observations and/or at the exit interview.