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Based on observation during tour and staff interview it was determined this facility failed to ensure all common walls with a nonconforming building is a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition and communicating openings are protected by approved self-closing fire doors. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

Facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the sixth floor of the main building specifically at the connector to the medical office building observation was made of double metal and glass doors that lacked a fire resistance rating. This finding was acknowledged by all those who were present during tour of this area.

Based on observation during tour and staff verification it was determined this facility failed to ensure all vertical openings, specifically stairs between floors, are enclosed with construction having a fire resistance rating of at least one hour and the vertical opening was not utilized for storage. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the sixth floor and within smoke compartment 6.07, observation was made of two stairwell doors, 0684.10a and 4683.1, which had the fire rating tag layered with a coat of paint. This writer was not able to verify the fire resistance rating of either door.

Within smoke compartment 6.09 observation was made of a stairwell equipped with a non-fire rated metal door identified as 0687.30.

During tour of the basement and within smoke compartment 00.2, observation was made of stairwell door 00143 which failed to shut properly when tested. Additionally, observation was made of storage under stairs ST-3 within smoke compartment 00.4. The storage consisted of wood, insulation, electrical junction boxes and a metal stud.
These findings were verified by all staff members during tour of these areas of the facility.

Based on observation during tour, staff verification and review of the fire escape plans it was determined this facility failed to ensure accesses to exits were marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

Facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the main building observation was made of exits signs lacking or exit signs that were placed in corridors that were not designated accesses to exits. These observations were made in the following locations:

11th floor:
*Within smoke compartment 11.8 and directly in front of the communicating stairs which continue down to the seventh floor observation was made of a fire escape plan posted on an adjacent wall indicating this communicating stairs as an emergency exit. Observation was made of no exit sign mounted at the stairs or on either side of the corridor door south of the communicating stairs directing traffic flow from the south side of the door to the communicating stairs or from the north side of the door to another stairwell located in adjacent smoke compartment 11.1.

10th floor
*Within smoke compartment 10.1 standing in the corridor by the exercise rooms facing southeast down the corridor, observation was made that the exit directional sign further down the corridor was obstructed by the bulkhead.
*Within suite B of smoke compartment 10.2 observation was made of no directional signs located within the suite providing directions for a path of egress to either corridor which led to the stairwell within this smoke compartment or to another stairwell in the adjacent smoke compartment. Exit access from this suite was not obvious.

6th floor:
*Within smoke compartment 6.02 and in the angled corridor 0610.3 facing northeast, observation was made of no exit sign directing traffic flow to the stairwell located at the end of corridor 0610.2. Additionally, the exit sign mounted in front of the stairwell was not positioned in a manner that would be obvious to traffic flow from the south end of corridor 0610.2.

During tour of the 2nd and 3rd floors, on 03/13/13 with staff E5, L9, M10, two areas of the building containing offices were observed without approved, readily visible exit signs where the way to reach the exit was not readily apparent. These areas were located in Human Resources and Medical Records as follows:

On the 2nd floor in Suite C,
*The Human Resources (HR) offices was observed with a paper exit sign on the back of door 0252, located by office 0245. Door 0252 was observed dividing two different areas of the office. Staff accompanying the surveyor on tour verbalized this exit access door was used by potential employees when leaving the HR area. This door opened into a room with three doorways. Two of these door were at the entrances to offices, and one of the doors led to the exit access corridor. None of these three doors were equipped with an exit sign.

On the 3rd floor in Smoke Compartment SC-3.02,
*The Medical Records area was observed with an exit sign that led to a maze of offices and the physicians' lounge. The only visible exit sign in this area was located at the exit access door leading to the exit access corridor. The maze of rooms was not equipped with a directional exit sign.
In the main area of medical records storage, eixt access doo 0320 lacked an exit sign. Staff accompanying the survey on tour stated this door was used for staff and visitors to exit the area.


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This finding was verified by all staff members present during the tour of this area of the facility.

Based on observation during tour and staff verification it was determined this facility failed to ensure all smoke/fire barriers were constructed with at least a one hour fire resistance rating. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the main building observation was made of penetrations in smoke/fire barriers at the following locations:

*At the smoke barrier doors separating smoke barrier 8.06 from 8.10 a gap greater than one eighth inch was observed between the door leafs when in a closed position.

*At the smoke barrier doors separating smoke barrier 8.09 from 8.10 a gap greater than one eighth inch was observed between the door leafs when in a closed position.

These findings were verified by all staff members present during tour of this area of the facility.

Based on facility tour and staff verification it was determined this facility failed to ensure all smoke barrier doors which were not constructed of at least a one and three quarter inch solid bonded core wood were equipped with a fire resistance rating identification tag with at least a 20 minute fire resistance rating. Additionally, this facility failed to ensure all smoke barrier doors which had a fire resistance rating identification tag was legible, that is free from paint and mars which would not allow proper identification of the fire resistance rating and were equipped with a self closing or automatic closing device. The facility also failed to ensure the doors self closed and latched. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the main building an observation was made of metal smoke barrier doors lacking the required fire resistance rating identification tag at the following locations:

15th floor:
*At the double smoke barrier doors located between smoke compartments 15.1 and 15.3

14th floor:
*The door leading into the manager/charge office from smoke compartment 14.2 lacked a self closing or automatic closing device.

10th floor:
*At the double smoke barrier doors located between smoke compartment 10.4 and suite A of 10.2

8th floor:
*Door 870.0 separating smoke compartments 8.02 from 8.03 had fire rating tags painted over
*Staff lounge door 0892.3 separating smoke compartment 8.04 from 8.05 lacked a self or automatic closing device.

7th floor:
*Single smoke barrier door 0747 separating smoke compartment 7.06 from 7.08 lacked a self or automatic closing device.
*At the smoke barrier doors 0799.3 separating smoke barrier 7.04 from 7.05 a gap greater than one eighth inch was observed between the door leafs when in a closed position.
*At the smoke barrier doors separating smoke barrier 7.08 from 7.09 located by the public elevators a gap greater than one eighth inch was observed between the door leafs when in a closed position.

6th floor:
*At the smoke barrier doors 0675.5 separating smoke barrier 6.06 from 6.12 a gap greater than one eighth inch was observed between the door leafs when in a closed position.
*At the smoke barrier doors 0673 separating smoke barrier 6.04 from 6.06 a gap greater than one eighth inch was observed between the door leafs when in a closed position.

5th floor:
The double smoke barrier doors of the waiting room area identified as 0550.36 near elevators 12 and 13 was observed to be constructed of non-fire rated wood and glass.

A facility tour took place on 03/13/13 staff members E5, F6, L9, and M10. A pair of fire barrier doors was observed in SC-4.6, on the 4th floor. Although equipped with latching hardware, these doors failed to latch when tested. This was verified with staff who accompanied the surveyor on tour.


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These findings were verified by all staff members present during tour of these areas.

Based on observation during tour and staff verification it was determined this facility failed to ensure all hazardous areas were constructed with at least a one hour fire resistance rating, specifically in regard to fire resistance ratings of the hazardous room doors. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the main building observation was made of one door which lacked a fire resistance rating at the following location:

8th floor:
*Within smoke compartment 8.03 and specifically room 0870.27, observation was made of a non-fire rated wood door.

This finding was verified by all staff members present during the tour of these penetrations.

Based on observation during tour and staff verification it was determined this facility failed to maintain a clear path of egress to all exit discharges. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the seventh floor of the main building specifically in smoke compartment 7.01 and at stair K-3 observation was made of the exit access being obstructed with four chairs. This finding was acknowledged by all those who were present during tour of this area.

Based on observation during tour and staff verification it was determined this facility failed to ensure continuous illumination of means of egress, including exit discharge, is arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the seventh floor of the main building specifically in smoke compartment 7.01 and at stair K-3 observation was made once the stair door was opened that the area was in total darkness. This writer, and those who were present, made the observation that the stairs were not visible at all without a flashlight and all emergency lights located in the stairwell were either burned out or not functioning properly.

Based on observation during tour and staff verification it was determined this facility failed to ensure the fire alarm system with approved components, devices or equipment is installed according to NFPA 72, National Fire Alarm Code, to provide effective warning of fire in any part of the building specifically in regard to manual fire pull devices. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the fifth floor of the main building, specifically in smoke compartment 5.2, observation was made at the exit located by elevator 2 having no manual fire pull device mounted near the exit access. This finding was verified by all staff present during tour of this area of the facility.

Based on observation during tour and staff verification, the facility failed to ensure the sprinkler system was continuously maintained in reliable operating condition and inspected and tested periodically specifically in regard to dust, debris and missing escutcheon rings from the sprinkler heads. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During facility tour observation was made of sprinkler heads that were coated with dust and/or debris or escutcheon rings missing in the following locations:

8th floor:
*Within smoke compartment 8.07 and within room 8802 observation was made of a dirty sprinkler head.
*Within smoke compartment 8.05 dirty sprinkler heads observed in rooms 0863.9A, 865.1A and 0892.2. Within the corridor observation was made of one dirty sprinkler head near 0867.2, escutcheon ring missing and open area in the ceiling tile around the escutcheon ring by 0899.12.
*Within smoke compartment 8.04, within room 0892 and within the corridor by 0890, dirty sprinkler heads were observed.
*Within smoke compartment 8.03, in storage room 0870.7and by door 0870.28; missing escutcheon rings.
*Within smoke compartment 8.01 and in room 0873.2; missing escutcheon ring.

7th floor:
*Within smoke compartment 7.09 dirty sprinkler heads were observed in the corridor near 0736
*Within smoke compartment 7.02 observation was made of two sprinkler heads which had missing escutcheon rings near 0799.144 and at the nurse ' s station. Additionally, a dirty sprinkler head was observed in corridor 0799.200.

6th floor:
*Within smoke compartment 6.05 observation was made of a ceiling tile which had a hole cut out too large for the escutcheon ring.
*Within smoke compartment 6.04 observation was made of a missing escutcheon ring in room 0613.
*Within smoke compartment 6.08 observation was made of a missing escutcheon ring around the corner from blue elevator numbers 36 and 37.
*Within smoke compartment 6.09 and near the two hour fire rated occupancy separation and the stairs, observation was made of a dirty sprinkle head.

5th floor:
*Within smoke compartment 5.9 and within the trash chute, observation was made of a dirty sprinkler head.
*Within smoke compartment 5.2 by elevator # 2, observation was made of a sprinkler head with a missing cover plate.

Basement:
*Within smoke compartment 00.2 observation was made of four dirty sprinkler heads near 0015.
*Within smoke compartment 00.3 and in the soiled linen room, observation was made of a sprinkler head which had a piece of plastic attached to it.

A facility tour took place on 03/13/13 staff members E5, F6, L9, and M10. During tour observation was made of sprinkler heads with a heavy buildup of dust and debris, or were missing escutcheon rings from the sprinkler heads. These sprinkler heads were located as follows:

1st floor:

*The admitting office, room 0108.3, was observed with 2 sprinkler heads which were heavily coated with dust and debris.

*Corridor 0109.2, located near the admitting office, was observed with a sprinkler head which was heavily coated with dust and debris.

4th floor:

*The mechanical space F-G was observed with a sprinkler head outside the linen chute discharge room. This sprinkler head was missing the escutcheon ring.

*The pharmacy office was observed with a missing escutcheon ring around one sprinkler head.

These sprinkler heads were verified with the aformentioned staff during tour.



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These findings were verified by all staff members present during tour of these areas.

Based on observation during tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were mounted less than five feet from the floor, and were readily visible. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

A tour was conducted in the facility on 03/13/13 with staff E5, F6, L9, M10. During this tour, fire extinguishers were not clearly identified as to location in the following areas:

2nd floor:
*In the administration office area, a fire extinguisher was observed located behind a door (258), and lacked signage to indicate the location.

4th floor:
*In the fitness center, Staff E5 and the surveyor were unable to locate the fire extinguisher. Staff F6 discovered the fire extinguisher located under a television. The extinguisher was observed in a recessed area in the wall. The area surrounding the fire extinguisher was observed congested with a portable soiled linen hamper and a chair with a milkcrate of folders. There was no signage indicating the location of the fire extinguisher.
*In the egress corridor by the radiology/oncology suite, the fire extinguisher was located in an alcove and was not visible when facing the exit discharge door. The extinguisher was visible only when entering the corridor from the exit discharge door.

These fire extinguishers were verified with staff who accompanied the surveyor during tour.



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Findings include:
A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the main building observation was made of several fire extinguishers that were mounted above the required level of not higher that five feet from the floor in the following locations:

11th floor:
Within the lab area of smoke compartment 11.8 observation was made of two fire extinguishers mounted above the required five foot level. They were also mounted on a wall over a counter top which made them more difficult to reach in the event of an emergency.

5th floor:
Within smoke compartment 5.6 and located by stairwell D near 0514, observation was made of a portable fire extinguisher mounted higher than five feet from the floor.

These findings were verified by all staff members present during tour of these areas.

Based on observations and staff interviews, the facility failed to ensure portable heating devices did not exceed 212 degrees Fahrenheit (F.), and failed to be aware of the areas in which the devices were located. The census on the first survey day was 355.

Findings include:

A tour was conducted in the facility on 03/13/13 with staff E5, L9, M10. During this tour, portable space heaters were observed in different non-sleeping areas of the facility as follows:

*On the first floor under the information desk, and
*On the second floor in Human Resources offices. One employee stated the area is cold, and this employee had to bring in their own portable space heater. An employee across the hall stated the facility provided these employees with a space heater 5 years ago. Interviews with staff E5 and M10, during tour, revealed the facility was not aware of these heaters being used, and verified they had not been evaluated by maintenance for safety. These employees also verified they did not know if the heating elements remained less than 212 degrees Fahrenheit.

Based on observation during tour and staff verification it was determined this facility failed to ensure the trash and laundry chutes accesses were located within rooms used exclusively for that purpose and which contained at least a one hour fire rated construction, and failed to ensure either the chute doors were equipped with a key lock or the door to the chute room was secured. This is in accordance with the National Fire Protection Association (NFPA) 101 Chapter 9.5.1, NFPA 82 Chapter 3-2.4.3 and 3-2.4.3.2. The trash chute discharge door, in one location, was observed blocked with bags of trash. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

A tour was conducted on 03/13/13 with staff E5, F6, L9, M10. During this tour, the trash chute discharge room was observed at 4:43 PM with a large mobile container located underneath the trash chute opening. The mobile container was observed overflowing with bags of trash, resulting in the trash being backed up into the trash chute, and blocking the chute discharge door. This door was observed equipped with a fusible link which would melt in the event of heat, causing the chute door to slide closed. Staff M10 verified the trash was backed up into the chute, stating this would not permit the chute door to close in the event the fusible link melted during a fire.


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Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the 15th floor specifically in smoke compartment 15.3, observation was made within soiled holding room 1501 of a trash and laundry chute access. The laundry chute access was disabled and according to staff A during interview on 03/07/13 at approximately 9:00 AM this chute access was disabled for several floors below the 15th floor although at one unspecified floor the laundry chute becomes assessable again.
The door to the chute access room was observed to be a 20 minute fire rated door and was noted to be unsecured. The trash chute door was also unsecured and observation was made of several items stored within this room such as cleaning supplies, boxes and miscellaneous items. Additionally, this room was observed to have double elevator access for employees transporting various types of stock and equipment.

During the interview with staff A it was stated that this finding will be the same all the way through the entire 15 stories and into the basement of this section of this building and as the tour progressed this writer and all staff members who were present during tour verified this to be true.

Additionally, tour of the seventh floor smoke compartment 7.03 reveals a room adjacent to a large mechanical room which housed a linen chute. The entrance to this room was equipped with a double wood door that lacked a fire resistance rating. This door was not secured nor was the linen chute access door. From within this room and at the opposite side from the double wood doors were double metal doors which were not fire rated. These doors were the entrance doors which lead into the mechanical room. Within the mechanical room observation was made of a trash chute access which was also noted to be unsecured.

During tour of the sixth floor and within smoke compartment 6.11, observation was made of trash and linen chutes located in separate rooms in which neither the access door to the room nor the chute access doors were secured.

During tour of the fifth floor and within smoke compartment 5.9, observation was made of a trash and linen chute located in the same room. The door to this room and the access doors to the chutes were not secured. Additionally, within smoke compartment 5.2, observation was made of a trash and linen chute located within a restroom.

All of these findings were verified by all staff present during tour of these areas of this facility.

Based on observation during tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were located as to be readily visible. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A tour was conducted in the facility on 03/14/13 with staff L9, R15, and Q14 between 8:00 AM and 9:00 AM. Observations revealed a fire extinguisher located under the receptionist's desk, which was not visible except when inside the receptionist desk area. There was no signage indicating a fire extinguisher was located underneath the desk. This was verified with the aforementioned staff during tour.