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Based on observation and interview the facility failed to ensure that 1 set of smoke barrier doors could resist the passage of smoke.

Findings include:

Observation during tour on 02/11/15 between 1:30 p.m. and 4:00 p.m. with Staff A (Director of Plant Operations) and Staff B (Plant Operations) revealed that 1 set of smoke doors (located directly outside the lunch cafe) would not automatically close to a latched position when released. The door leaf closest to the cafe appeared to be warped and could not resist the passage of smoke.

Interview with Staff A and Staff B at the time of observation confirmed the finding and location.

Based on observation and interview the facility failed to ensure that smoke barriers are maintained to be continuous and prevent the passage of smoke.

Findings include:

Observation during tour on 02/12/15 between 9:00 a.m. and 12:00 p.m. with Staff A (Director of Plant Operations) and Staff B (Plant Operations) revealed the following smoke barrier locations that have unprotected penetrations through the smoke barriers.
1. Above the smoke doors near room #108 has 1 unsealed penetration (DX cable).
2. Above the smoke doors near the X-Ray room 1 unsealed penetration (bundle of "IT" cables).
3. Above the suspended ceiling in the X-Ray hallway has 4 unsealed penetrations (Electrical conduits).
4. Above the suspended ceiling in the X-Ray hallway has 1 unsealed penetration (3" galvanized pipe).
5. Above the suspended ceiling, over the door to PACU wing has 1 unprotected penetration (2" hole).
6. Above the suspended ceiling in the Cafe has 1 large unprotected penetration over the HVAC ductwork.
7. Above the smoke doors on the lower level near the "LAB" has 3 unprotected penetrations (2 DX cables and 1 "IT" cable).

Interview with Staff A and Staff B at the time of observation confirmed the findings and locations.

Based on record review and interview the facility failed to conduct the required semi-annual disaster drills.

Findings include:

Observation during record review and interview on 02/12/15 between 12:30 p.m. and 1:30 p.m. with Staff C (Emergency Preparedness Coordinator) revealed that the facility failed to conduct 3 of the last 4 semi-annual disaster drills. One disaster drill consisting of a large scale inoculation drill was held in late 2014.

Interview with Staff C confirmed the findings and indicated that they were new to the position and now has future drills planned.

9.2.3 NFPA 101 COMMERCIAL COOKING EQUIPMENT shall be in accordance with NFPA 96, STANDARD FOR VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS.

8-3.1 NFPA 96 Hoods, grease removal devices, fans, ducts and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the "AHJ" in accordance with Table 8-3.1

Based on observation and record review the facility failed to maintain regular cleaning of the "Cafe" exhaust hood.

Findings include:

Observation during tour on 02/11/15 between 1:30 p.m. and 4:00 p.m. with Staff A (Director of Plant Operations) and Staff B (Plant Operations) revealed the exhaust hood located in the "Cafe" does not have a current cleaning sticker/tag in place. Visual inspection revealed an extremely heavy build-up of grease and oily substances dripping from the exhaust hood. The fire suppression system on the exhaust hood has a current inspection tag.

Interview with Staff A confirmed the findings and location.

Based on observation and interview the facility failed to maintain 1 stairwell free of storage and obstructions for full instant access.

Findings include:

Observation during tour on 02/11/15 between 1:30 p.m. and 4:00 p.m. with Staff A (Director of Plant Operations) and Staff B (Plant operations) revealed that the stairwell at the end of the Materials Management wing, on the lower level is being used to store furniture and several stacks of boxes and supplies. Interview with Staff A and Staff B at the time of observation confirmed the findings and location.

The upper level, Medical-Surgical wing discharges on the upper level of the stairwell. The exit path was unobstructed at this level.

Based on observation and interview the facility failed to ensure that Medical Gas cylinders are individually secured.

Findings include:

Observation and interview during tour on 02/12/15 between 9:30 a.m. and 11:00 a.m. with Staff A (Director of Plant Operations) and Staff B (Plant Operations) revealed that the Medical Gas Manifold room (located behind the hospital) has several Medical Gas cylinders that are not individually secured. Some groups of 3 and 4 are secured together with a single chain. The Medical Air room (also behind the hospital) has a group of 3 gas cylinders secured with a single chain.

Interview with Staff A and Staff B at the time of observation confirmed the findings and locations.

Based on observation and interview the facility failed to ensure that 1 set of smoke barrier doors could resist the passage of smoke.

Findings include:

Observation during tour on 02/11/15 between 1:30 p.m. and 4:00 p.m. with Staff A (Director of Plant Operations) and Staff B (Plant Operations) revealed that 1 set of smoke doors (located directly outside the lunch cafe) would not automatically close to a latched position when released. The door leaf closest to the cafe appeared to be warped and could not resist the passage of smoke.

Interview with Staff A and Staff B at the time of observation confirmed the finding and location.

Based on observation and interview the facility failed to ensure that smoke barriers are maintained to be continuous and prevent the passage of smoke.

Findings include:

Observation during tour on 02/12/15 between 9:00 a.m. and 12:00 p.m. with Staff A (Director of Plant Operations) and Staff B (Plant Operations) revealed the following smoke barrier locations that have unprotected penetrations through the smoke barriers.
1. Above the smoke doors near room #108 has 1 unsealed penetration (DX cable).
2. Above the smoke doors near the X-Ray room 1 unsealed penetration (bundle of "IT" cables).
3. Above the suspended ceiling in the X-Ray hallway has 4 unsealed penetrations (Electrical conduits).
4. Above the suspended ceiling in the X-Ray hallway has 1 unsealed penetration (3" galvanized pipe).
5. Above the suspended ceiling, over the door to PACU wing has 1 unprotected penetration (2" hole).
6. Above the suspended ceiling in the Cafe has 1 large unprotected penetration over the HVAC ductwork.
7. Above the smoke doors on the lower level near the "LAB" has 3 unprotected penetrations (2 DX cables and 1 "IT" cable).

Interview with Staff A and Staff B at the time of observation confirmed the findings and locations.

Based on record review and interview the facility failed to conduct the required semi-annual disaster drills.

Findings include:

Observation during record review and interview on 02/12/15 between 12:30 p.m. and 1:30 p.m. with Staff C (Emergency Preparedness Coordinator) revealed that the facility failed to conduct 3 of the last 4 semi-annual disaster drills. One disaster drill consisting of a large scale inoculation drill was held in late 2014.

Interview with Staff C confirmed the findings and indicated that they were new to the position and now has future drills planned.

9.2.3 NFPA 101 COMMERCIAL COOKING EQUIPMENT shall be in accordance with NFPA 96, STANDARD FOR VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS.

8-3.1 NFPA 96 Hoods, grease removal devices, fans, ducts and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the "AHJ" in accordance with Table 8-3.1

Based on observation and record review the facility failed to maintain regular cleaning of the "Cafe" exhaust hood.

Findings include:

Observation during tour on 02/11/15 between 1:30 p.m. and 4:00 p.m. with Staff A (Director of Plant Operations) and Staff B (Plant Operations) revealed the exhaust hood located in the "Cafe" does not have a current cleaning sticker/tag in place. Visual inspection revealed an extremely heavy build-up of grease and oily substances dripping from the exhaust hood. The fire suppression system on the exhaust hood has a current inspection tag.

Interview with Staff A confirmed the findings and location.

Based on observation and interview the facility failed to maintain 1 stairwell free of storage and obstructions for full instant access.

Findings include:

Observation during tour on 02/11/15 between 1:30 p.m. and 4:00 p.m. with Staff A (Director of Plant Operations) and Staff B (Plant operations) revealed that the stairwell at the end of the Materials Management wing, on the lower level is being used to store furniture and several stacks of boxes and supplies. Interview with Staff A and Staff B at the time of observation confirmed the findings and location.

The upper level, Medical-Surgical wing discharges on the upper level of the stairwell. The exit path was unobstructed at this level.

Based on observation and interview the facility failed to ensure that Medical Gas cylinders are individually secured.

Findings include:

Observation and interview during tour on 02/12/15 between 9:30 a.m. and 11:00 a.m. with Staff A (Director of Plant Operations) and Staff B (Plant Operations) revealed that the Medical Gas Manifold room (located behind the hospital) has several Medical Gas cylinders that are not individually secured. Some groups of 3 and 4 are secured together with a single chain. The Medical Air room (also behind the hospital) has a group of 3 gas cylinders secured with a single chain.

Interview with Staff A and Staff B at the time of observation confirmed the findings and locations.