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6847 N CHESTNUT

RAVENNA, OH 44266

No Description Available

Tag No.: K0017

Based on facility tour and staff interview and verification, the facility failed to ensure corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating. In sprinklered buildings, waiting areas may be open to the corridor under certain conditions specified in the Code. The facility had a capacity of 302 patient beds with a census of 67 patients.

Findings include:

On 02/03 through 02/05/14, tour of the facility was conducted between the hours 9:40 A.M. and 4:30 P.M. with facility staff. The following observations of waiting areas were noted with regard to lack of smoke detection or constant supervision:

1. On 02/03/14 at 10:20 A.M., tour of the third floor with Staff T and V revealed a family waiting area. Observation of the waiting area revealed the automatic sprinkler protection but no smoke detection system. There was no constant supervision by staff or surveillance camera.

2. On 02/03/14 at 2:00 P.M. observation of a second floor waiting area revealed the automatic sprinkler protection but no smoke detection system on the third floor nor constant surveillance of the waiting area.

3. On 02/04/14 at 11:00 A.M. tour of the first floor with Staff T and YY, revealed the presence of two waiting areas, cardiovascular/nuclear medicine and an area for families of surgical patients. Both waiting areas were noted to be provided automatic sprinkler protection, had no smoke detection. Staff in the waiting areas were present for limited hours during the day.

Staff V verified the need for smoke detection in the waiting areas had previously been identified by the facility and the smoke detectors had been ordered. The smoke detectors were in the facility but had not been installed.

No Description Available

Tag No.: K0020

Based on review of facility schematic, facility tour and staff interview and verification, the facility failed to ensure that vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour. The facility had a capacity of 302 patient beds with a census of 67 patients at the time of the survey completed on 02/06/14.

Findings include:

On 02/03/14 at 12:30 PM, review of the facility schematic with Staff T, V and U revealed a chase that extended from the first floor through the third floor of the building. Tour of the facility on 02/03/14 at 1:00 P.M. was conducted with Staff T and V.

Observation at 1:00 PM on 02/03/14 of the chase wall located on the second floor, near room 20386 revealed penetrations in the two hour fire rated barrier. Observation above the ceiling tiles at the chase barrier wall revealed three penetrations. One penetration was approximately two inches in diameter and two additional penetrations were approximately four inches square with cable and data wires through the openings.

Staff T and V verified the observation and findings.

No Description Available

Tag No.: K0025

Based on review of facility schematics, facility tour and staff interview and verification, the facility failed to ensure smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. The facility had a capacity of 302 patient beds with a census of 67 patients.

Findings include:

On 02/03 though 02/05/14, tour of the facility was conducted between the hours 9:40 A.M. and 4:30 P.M.. with facility Staff T and V. The following observations of smoke barrier walls were noted with regards to penetrations:

First Floor

On 02/03/14 tour of the first floor was conducted with Staff T and V between 2:20 P.M. and 4:30 P.M. Review of the first floor schematic revealed smoke barriers with a fire resistance rating of 30 minutes.

The following areas were noted to have penetrations in the smoke barrier wall:

Observation above the ceiling tiles in the MRI anteroom, 16308, revealed unsealed area at an I-beam and at the floor decking.

Observation above the ceiling tiles in the north wing corridor revealed unsealed area between the gypsum board and the floor decking above. Also observed in the north wing corridor at the outpatient ambulatory center, near the lab, gypsum board that was not taped and sealed. The area at the floor decking was open and multiple penetrations were observed. Cut out areas for a door installation in the gypsum board were noted.

Further observation of the north wing corridor revealed two conduit used as sleeves for yellow wire were not sealed.

Observations above the ceiling tiles in a storage room, in the radiology corridor, revealed a penetration approximately 3 inches square with wires inserted through the opening. A support column was not sealed around.

Observation of the smoke barrier above the ceiling tiles in the patient preoperative/ recovery area, revealed multiple conduits used as sleeves for wire, not sealed.

Observation above the ceiling tiles in the patient and family consult room revealed penetrations not sealed at the column and at the decking above.

Observation above the ceiling tiles in the radiology staff area revealed there was no seal at the gypsum board and floor decking above.

Staff present on tour observed and verified the findings.


On 02/04/14 between 9:40 A.M. and 4:30 P.M. observations of the first floor smoke barrier walls continued with Staff T and YY.

The following findings were noted:

Observation above the ceiling tiles in the radiology/ emergency room corridor, near room 16280 revealed a penetration surrounding a duct.

Observation above the ceiling tiles near room 16278 revealed penetrations surrounding a black pipe. Near the black pipe was a sign that noted the wall had a one hour fire resistance rating. Also noted in the same wall, an area surrounding a three inch sleeve pipe was not sealed.

Observation above the ceiling tiles in room 16272 of the back wall revealed unsealed areas between piece of gypsum board and an I-beam. A piece of gypsum board was noted to be cut and placed over a vent opening. The vent and piece of gypsum looked loose and dislodged from the wall.

Observation above the ceiling tiles in room 16146, revealed penetrations surrounding a column and unsealed pieces of gypsum board approximately three inches by eight inches. Gypsum board at the I-beam was not sealed.

Observation above the ceiling tiles in 16138, a bathroom, revealed unsealed gypsum board and areas at the floor decking above.

Observation above the ceiling tiles between room 16144 and the fire extinguisher on the wall, penetrations were noted surrounding conduit and a capped pipe . An opening approximately 12 inches by 18 inches was observed in the wall.

Observation above the ceiling tiles across from room 17120 revealed the gypsum board was not to the deck above.

Observation above the ceiling tiles at the sitting area near the Robinson Memorial display, revealed the gypsum was not sealed at the decking above.

Observation above the ceiling tiles at room 16102, revealed at the upper left corner, facing north, plastic one and one half inch pipe sleeve for gray wire, not sealed. Also noted in the same area, space surrounding an I-beam was not sealed.

Observation above the ceiling tiles at room 11124, revealed the barrier was not sealed at the decking.

Observation above the ceiling tiles at room 11268 , seams of the gypsum board were not sealed and conduit used as a sleeve for wire was not plugged.

Observation above the ceiling tiles at room 11259, revealed the barrier was not sealed at the decking.

Observation above the ceiling tiles at the corridor smoke doors, 12108 revealed multiple penetrations.

On 02/04/14, at 3:00 P.M., contracted Staff X was interviewed with Staff T and YY present, regarding the smoke barrier walls of the facility. Staff X revealed that smoke barrier walls were sealed in the locations most easily accessible to staff at the time. It was further verified the smoke barrier walls may not be the same continuous wall and may be on either side of a wall. This pattern made it very difficult to verify the facility had an intact 30 minute fire rated smoke barrier. Staff present during tour also verified it was difficult to locate the smoke barrier walls and determine if the barrier walls were intact.









30271

THIRD FLOOR

During the tour of the third floor on 02/03/14 at 10:35 A.M. it was observed the conduit over the smoke barrier door 33384 was not sealed. Staff U confirmed the finding at 10:36 A.M. on 02/03/14.


SECOND FLOOR


During the tour of the second floor on 02/03/14 at 12:45 P.M.observation of the compartment 2C smoke wall around the damper mechanism was not sealed. The full wall failed to be sealed to the upper deck.Staff U confirmed the finding at 12:46 P.M. on 02/03/14.

During the tour of the second floor on 02/03/14 at 1:05 P.M. observation of the compartment 2A smoke wall failed to be sealed to the upper deck. Staff U confirmed the finding at 1:06 P.M. on 02/03/14.


During the tour of the second floor on 02/03/14 at 1:43 P.M. it was observed that the one hour fire walled inside the electrical room with door number 23372 failed to seal to the deck above and around the cable chase. Staff U confirmed the finding at 1:44 P.M. on 02/03/14.


FIRST FLOOR


During the tour of the first floor on 02/03/14 at 3:02 P.M. it was observed the white pipe located in the left upper corner above the door 17266 was not sealed. Staff U confirmed the finding at 3:03 P.M. on 02/03/14.

During the tour of the first floor on 02/04/14 at 9:57 A.M. open penetrations were observed above door 17301. Staff U confirmed the finding at 9:58 P.M. on 02/04/14.

Observation of the first floor on 02/04/14 at 10:10 A.M. the electrical room behind door 10086 smoke wall failed to seal to upper deck. Staff U confirmed the finding at 10:10 A.M. on 02/04/14.

Observation of the first floor on 02/04/14 at 10:35 A.M. inside the exit alcove door 13202 were open penetrations and the smoke wall failed to seal to the upper deck.
Staff U confirmed the finding at 10:36 A.M. on 02/04/14.

Observation of the first floor on 02/04/14 at 10:41 A.M. to the left of door 13203 in the smoke wall was noted a small yellow wire passed through the wall and was not sealed around the wire. Staff U confirmed the finding at 10:41 A.M. on 02/04/14.

During the tour of the first floor on 02/04/14 at 10:50 A.M. observation of the south side of hallway, across from Respiratory Therapy area revealed the smoke wall failed to be sealed to the upper deck. Staff U confirmed the finding at 10:50 A.M. on 02/04/14.

On 02/04/14 at 11:06 A.M. on the first floor above the doorway 13260 there were unsealed penetrations and the east smoke wall was not sealed to the upper deck.
Staff U confirmed the finding at 11:06 A.M. on 02/04/14.

On 02/04/14 at 11:45 A.M. on the first floor observation of the smoke wall above door 12168 had an open junction box penetrating the wall and penetrations were observed to the south west corner. The north side corner was not sealed at the top of the wall. Staff U confirmed the finding at 11:45 A.M. on 02/04/14.

During the tour of the first floor on 02/04/14 at 11:50 A.M. observation of the smoke wall to the east side hallway, outside Respiratory services, did not seal to the upper deck and had open penetrations to the wall. Staff U confirmed the finding 11:51 A.M. on 02/04/14.

During the tour of the first floor on 02/04/14 at 12:02 P.M. the smoke walls, between Respiratory and Nuclear Med., along both the south and north wall failed to be sealed to the upper deck and multiple open penetrations were also noted. Staff U confirmed the findings at 12:03 P.M. on 02/04/14.

During the tour of the first floor on 02/04/14 at 1:38 P.M. above doorway 12782 was observed an open conduit penetrating the smoke wall, the smoke wall failed to be sealed to the upper deck along the full length. Staff U confirmed the findings at 1:40 P.M. on 02/04/14.

During the tour of the first floor on 02/04/14 at 2:10 P.M. the smoke wall to the west of PACU failed to be sealed to the upper deck and had multiple unsealed penetrations. Staff U confirmed the findings at 2:10 P.M. on 02/04/14.


During the tour of the first floor on 02/04/14 at 3:37 P.M. it was noted the east smoke wall outside of PACU on the hallway side failed to seal to the upper deck the full length. The same wall had a large conduit penetrating the smoke wall about 16 feet north of the door number 12320. The floor plan provided failed to identify this as the smoke wall. Staff U confirmed that the drawing did fail to properly identify the correct wall. Staff U confirmed the finding at 4:00 P.M. on 02/04/14.

On 02/04/14 at 4:08 P.M. observation of the first floor east smoke wall outside the Anesthesia office on the hallway side revealed the wall failed to be sealed to the upper deck the full length. A penetration was found half way down the wall from the doorway. Staff U confirmed the finding at 4:08 P.M. on 02/04/14.

During the tour of the first floor on 02/04/14 at 4:17 P.M. the smoke wall to the north of Surgical Support the hallway side was observed not to be sealed to the upper deck the full length. Unsealed penetrations were noted above the doorway entering Surgical Support. Staff U confirmed the findings at 4:18 P.M. on 02/04/14.

No Description Available

Tag No.: K0025

Based on facility observation and staff interview and verification, it was determined the facility failed to maintain the one-hour fire resistant rated smoke barrier wall. Facility has had eight operating rooms at the time of survey.

Findings include:

During the tour of the first floor on 02/04/14 at 2:28 P.M. the smoke wall on the south side of hallway outside the operating room (OR) had a penetration surrounding a pipe, located above the fire extinguisher. Staff U confirmed the finding at 2:28 P.M. on 02/04/14.

During the tour of the first floor on 02/04/14 at 2:41 P.M. the west side smoke wall outside OR at the corner was noted to have an open penetration. Staff U confirmed the finding at 2:41 P.M. on 02/04/14.

During the tour of the first floor on 02/04/14 at 3:03 P.M. inside the riser room, at the end of the hallway, the smoke wall above the doorway was noted to have an open junction box that penetrated the smoke wall. The floor plan provided failed to identify this wall as a smoke wall. Staff V confirmed that the smoke wall did extend to this wall at 11:55 A.M. on 02/05/14. Staff U confirmed the finding at 3:04 P.M. on 02/04/14.

Tour of the first floor on 02/04/14 at 3:21 P.M. revealed the hallway side of the west wall outside of PACU failed to be sealed to the upper deck and conduit passing through the wall was not sealed. Staff U confirmed the finding at 3:22 P.M. on 02/04/14.

During the tour of the first floor on 02/04/14 at 3:33 P.M. the north side of the south wall outside PACU was noted not to be sealed to the upper deck. Staff U confirmed the finding at 3:33 P.M. on 02/04/14.

No Description Available

Tag No.: K0027

Based on observation and staff interview the facility failed to maintain the smoke doors in two smoke compartments on the first floor, Emergency Room and Cardio Suite. The facility has 302 beds and census at the time of survey was 67.

Findings include:

During the tour of the first floor on 02/04/14 at 2:45 P.M. it was observed that the gap between the two smoke doors 18104 was greater than one eighth of an inch when in the closed position. Staff U confirmed the finding at 2:45 P.M. on 02/04/14.

During the tour of the first floor on 02/04/14 at 2:48 P.M. it was observed that the gap between two closed smoke doors 18118 was greater the one eighth of an inch. Staff U confirmed the finding at 2:48 P.M. on 02/04/14.

During the tour of the first floor on 02/04/14 at 3:13 P.M. it was observed that the gap between the two smoke doors 117218 was greater than one eighth of an inch when in the closed position. Staff U confirmed the finding at 3:13 P.M. on 02/04/14.

During the tour of the first floor on 02/04/14 at 3:24 P.M. it was observed that the gap between the two closed smoke doors 17220 was greater the one eighth of an inch. Staff U confirmed the finding at 3:24 P.M. on 02/04/14.

No Description Available

Tag No.: K0029

Based on review of the facility schematic, facility observation and staff interview and verification, it was determined the facility failed to ensure that one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. When the approved automatic fire extinguishing system option was used, the areas were to be separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing .The facility had a capacity of 302 patient beds with a census of 67 patients at the time of the survey completed on 02/06/14.

Findings include:

The following areas were observed to be considered hazardous areas and failed to meet the requirement with regard to lack of proper construction or self closing devices on the doors to the rooms.

On 02/03 though 02/05/14, tour of the facility was conducted between the hours 9:40 A.M. and 4:30 P.M. with facility Staff T and the following observations were made:

Observation of an electrical room on third floor, room 33366, was noted be a room with one hour fire rated construction. Observation above the ceiling tiles revealed the barrier wall was not sealed at the decking above. Pipes that penetrated the wall were not sealed completely around the pipe.

Observation of electrical room, 33356, located on the third floor, revealed no self-closing device on the door to the room.

Observation of storage room 20386, located on the second floor, revealed no self-closing device on the door to the room.

Observation of an equipment storage room, 20180 , located on the second floor, revealed no self-closing device on the door to the room.

Observation of a housekeeping closet, 20384, located on the second floor, revealed no self-closing device on the door to the room.

Observation of an electrical room on first floor, 16282, was noted be a room with one hour fire rated construction. Observation above the ceiling tiles revealed two conduits that pentrated the wall and were not sealed in the space surrounding conduits. A duct vent was observed to penetrate the wall, loose and dislodged from the wall.

Observation of room, 11272, a storage room for financial counseling records revealed there was no self closing device on the door to the room.

Staff Tpresent during the tour observed and verified the findings.

No Description Available

Tag No.: K0054

Based on review of facility documentation, facility observation and staff interview and verification, it was determined the facility failed to ensure all required smoke detectors were maintained, inspected and tested in accordance with the manufacturer's specifications. The facility had a capacity of 302 patient beds with a census of 67 patients.

Findings include:

On 02/05/14 tour of the main server area of the hospital was conducted with Staff T, U and WW. Observation of the area revealed a separate suppression system for the secure area. The fire protection system for the area included smoke detectors that were separate from the main facility. Interview of Staff WW revealed the system was checked annually by an outside contracted company.

Observation of the main server area revealed at least one smoke detector that was connected with the main facility and the remainder of the smoke detectors were a separate system.

Review of testing information dated April 2013, revealed there were 10 photo smoke detectors and four ion smoke detectors. The documentation did not indicate that smoke sensitivity testing had been conducted. Staff WW was interviewed regarding the smoke sensitivity testing and was unable to confirm if the testing had been completed.

On 02/06/14 at 10:30 A.M. Staff V verified smoke sensitively testing had not been completed. Staff V also verified the contracted company had been notified testing would be completed in the near future.

No Description Available

Tag No.: K0067

Based on review of facility documentation and staff interview and verification, the facility failed to ensure that fire and smoke dampers complied with the provisions of NFPA 90A with regards to testing. The facility had a census of 67 patients at the time of the survey.

Findings include:


On 02-05-14 at 11:30 AM review of documented fire/smoke damper testing was conducted with Staff V and revealed the most recent testing was completed November 2012. Documentation of the testing revealed multiple smoke and fire dampers failed or the facility was unable to test the dampers due to inaccessibility.

Review of the documented testing for the hospital dampers revealed 37 of the 175 dampers were not tested due to accessibility. This was verified by Staff V on 02/05/14 at 11:30 AM.

Review of the documented testing for the hospital dampers revealed 44 of the 175 dampers failed testing. No documentation was provided to confirm these dampers were repaired and are in working order. This was verified by Staff V at 11:30 AM.