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Based on observation, document review and interview, it was determined the facility failed to maintain building construction requirements, such as a minimum two-hour fire resistive rating of structural components throughout the building, affecting the entire component.

Findings include:

1. Interview, observations and document review on March 14, 2018, between 8:00 AM and 11:00 AM, revealed the building is a seven story, Type II (000) unprotected noncombustible structure. This type of construction exceeds the maximum story height allowed.

Interview at the exit conference with the Director, Facilities Services, on March 15, 2018, at 2:30 PM, confirmed the building construction type and height.

Based on observation and interview, it was determined the facility failed to ensure that all rated, labeled, doors met the standard of NFPA 80 for fire rated assemblies, affecting eight of eight floors in this component.

Findings Include:

1. Observation on March 14 & 15, 2018, revealed all doors inside Stair Tower 1, 2, and 3, on all eight floors, did not meet the NFPA 80 standard for rated fire doors.

Exit interview with the COO, Director of Facilities Service, Administrator and Plant Operations Director on March 15, 2018, at 2:30 PM, confirmed the above doors did not meet the standard.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of an exit component enclosure, affecting one of eight floors of this component.

Findings include:

1. Observation on March 15, 2018, at 1:30 PM revealed there was an unsealed penetration of Stair Tower 1, on the 2nd floor, by sprinkler piping, on the wall by Patient Room 206.

Interview with the Director, Facilities Services on March 15, 2018, at 1:30 PM confirmed the penetration.

Based on observation and interview, it was determined the facility failed to ensure stair towers maintained a fire resistance rating, affecting one of two levels within this component.

Findings include:

1. Observation made on March 14, 2018, at 11:40 AM revealed by the OP clinic to the first-floor stair tower exit access door, the locking mechanism was in need of repair.

Exit interview with the COO, Director of Facilities Service, Administrator and Plant Operations Director on March 15, 2018, at 2:30 PM, confirmed the exit access door was not maintained.

Based on observation and interview, it was determined the facility failed to ensure vertical openings between floors and shaft walls are enclosed with the required fire resistive rated construction, affecting the entire component.

Findings include:

1. Interview, observations on March 14 & 15, 2018, revealed the shaft enclosures within this component lack the required two hour fire resistance rating.

Interview at the exit conference with the Director, Facilities Services on March 15, 2018, at 2:30 PM, confirmed the building shaft enclosures lack the required fire resistive construction.

Based on observation and interview, it was determined the facility failed to properly install Alcohol Based Hand Rub (ABHR) dispensers, affecting one of eight floors of this component.

Findings include:

1. Observation on March 15, 2018, at 10:10 AM revealed an ABHR dispenser was installed over an electrical wall night light, inside Patient Room 602.

Interview with the Director, Facilities Services on March 15, 2018, at 10:10 AM confirmed the installation over an ignition source.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system without obstructions, affecting two of eight floor in this component.

Findings include:

1. Observation on March 15, 2018, at 10:45 AM revealed there was storage within eighteen inches of the sprinkler inside room G112, file storage.

Exit interview with the COO, Director of Facilities Service, Administrator and Plant Operations Director on March 15, 2018, at 2:30 PM, confirmed the obstructed sprinkler coverage.

2. Observation on March 15, 2018, at 1:10 PM revealed there were data lines attached to the sprinkler piping hangers, on the 2nd Floor, in the corridor of the Elevator Lobby.

Interview with the Director, Facilities Services on, March 15, 2018, at 1:10 PM confirmed the sprinkler system was used to support non-system compoents.

Based on document review and interview, it was determined the facility failed to maintain inspection of the sprinkler system at required intervals, affecting 3 of 4 inspections.

Findings include:

1. Document review made on March 15, 2018, at 9:30 AM, revealed the facility could not produce documentation for the sprinkler system inspection for the second, third and forth quarters of 2017.

Exit interview with the COO, Director of Facilities Service, Administrator and Plant Operations Director on March 15, 2018, at 2:30 PM confirmed the sprinkler system quarterly inspection documentation was not available.

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers with identification, affecting three of eight floor in this component.

Findings include:

1. Observation on March 15, 2018, between 10:55 AM and 2:00 PM revealed the following fire extinguisher indicator lights were not lit;

a. 10:55 AM, 5th Floor Elevator Lobby, extinguisher # FEC038;
b. 12:05 PM, 3rd Floor Small Elevator Lobby, no number;
c. 2:00 PM, 2nd Floor back corridor, extinguisher # FHC080.


Interview with the Director, Facilities Services on March 15, 2018, at 2:00 PM confirmed these fire extinguisher lacked conspicuous signage.

Based on observation and interview, it was determined the facility failed to ensure corridor doors would positively latching into their frames and resist the passage of smoke, affecting six of eight floors within this component.

Findings include:

1. Observation on March 15, 2018, between 9:45 AM and 1:35 PM revealed the following corridor door deficiencies:

6th Floor
a. 9:45 AM, Patient Room 628, would not close and latch due to the bed blocking the door;
b. 10:02 AM, Patient Room 611, would not close and latch due to the brackets from a isolation rack;

5th Floor
c. 10:35 AM, Patient Room 522, which had a self-closure installed, which was disconnected;


2. Observation on March 15, 2018, between 10:51 AM and 1:35 PM, revealed the following corridor door deficiencies:

Basement
10:51 AM, Clean laundry closet corridor door, did not latch;

4th Floor
e. 11:05 AM, 2 Electrical Closet, in the East corridor outside the double corridor doors, had gaps greater than 1/8 inch;
f. 11:08 AM, ICU #4, the sliding doors very difficult to open, close and latch;
g. 11:10 AM, ICU #11, the sling door had black tape on the latch and strike hole and had the strike plate removed;
h. 11:12 AM, ICU #16, the sling door did not latch;
i. 11:13 AM, ICU #18, the sling door did not latch;
j. 11:17 AM, ICU #17, the sling door did not latch;
k. 11:25 AM, 2 Electrical Closet, in the West corridor outside the ICU, had gaps greater than 1/8 inch;

3rd Floor
l. 11:35 AM, 3 Electrical Closet, in the East corridor outside the Telemetry, had gaps greater than 1/8 inch;
m. 11:40 AM, Patient Room 324, would not close and latch due to the brackets from a isolation rack;
n. 11:45 AM, Patient Room 322, would not close and latch due to the brackets from a isolation rack;
o. 11:50 AM, Patient Room 321, would not close and latch due to waste container impeding the door;
p. 11:52 AM, Patient Room 320, would not close and latch due to the brackets from a isolation rack;
q. 11:55 AM, Patient Room 318, would not close and latch due to the brackets from a isolation rack;
r. 12:00 PM, Patient Rooms 312 and 311, would not close and latch due fall mats impeding the door;
s. 12:03 PM, Patient Rooms 305, would not close and latch;

2nd Floor
t. 1:15 PM, double doors to the Lounge, which had closures and a coordinator, would not close and latch;
u. 1:25 PM, Patient Room 205, had a gap greater than 1/2 inch between the door face and the door stop;
v. 1:35 PM, double doors to Tender Care, which had closures and a coordinator, would not close and latch.

Exit interview with the COO, Director of Facilities Service, Administrator and Plant Operations Director on March 15, 2018, at 2:30 PM, confirmed the above corridor doors failed to close and latch when tested.

Based on observation and interview, it was determined the facility failed to maintain corridor doors to close, affecting one of one floor within the component.
Findings include:

1. Observation on March 14, 2018, at 2:07 PM revealed corridor doors failed to close and latch, at the first-floor, clean linen closet;

Exit interview with the COO, Director of Facilities Service, Administrator and Plant Operations Director on March 15, 2018, at 2:30 PM confirmed the corridor door failed to close and latch when tested.

Based on observation and interview, it was determined the facility failed to maintain corridor doors to positively latch and close in their frames, affecting two of three smoke compartments within the component.
Findings include:

1. Observation on March 14, 2018, between 12:00 PM and 12:20 PM, revealed corridor doors failed to close and latch, at the following locations:

a. 12:00 PM, 1st floor, PACU equipment room, door was propped open with a metal shelf unit;
b. 12:20 PM 1st floor, door by the stair tower, positive latching and laminate were missing.

Exit interview with the COO, Director of Facilities Service, Administrator and Plant Operations Director on March 15, 2018, at 2:30 PM, confirmed the above corridor doors failed to close and latch when tested.

Based on observation and interview, it was determined the facility failed to provide two smoke compartments on every sleeping room floor with greater than 30 residents, affecting six of eight floors.

Findings include:

1. Observation on March 14 & 15, 2018, revealed the facility lacked smoke compartments on floors two through seven.

Interview at the exit conference with the Director, Facilities Services on March 15, 2018, at 2:30 PM, confirmed the lack of smoke compartments on the above floors.

Based on observation and interview, it was determined the facility failed to properly store soiled linen or trash receptacles, with combined or single capacities exceeding 32 gallons when left unattended, affecting two of eight floors.

Findings include:

1. Observation on March 14, 2018, at 12:15 PM revealed a Shred-it and waste containers was located in the 7th Floor CBM Directors Office, which was stored outside of a protected hazardous storage area.

Interview with the Director, Facilities Services on March 14, 2018, at 12:15 PM confirmed the Shred-it and waste containers were stored outside of a protected hazardous storage area.


2. Observation on March 15, 2018, between 9:50 AM and 10:05 AM revealed the following containers with combined or single capacities exceeding 32 gallons, stored outside a protected hazardous storage area:

6th Floor
a. 9:50 AM, at the Nurses Station, by Patient Room 619, 2 soiled linen containers;
b. 10:00 AM, Center Nurses Station, by Patient Room 614, a shredder container;
c. 10:05 AM, in cross corridor, by Patient Room 603, 2 soiled linen containers.

Interview with the Director, Facilities Services on March 15, 2018, at 10:05 AM confirmed the Shred-it and waste containers were stored outside of a protected hazardous storage area.

Based on observation and interview, it was determined the facility failed to monitor for the unauthorized use of power taps, affecting one of eight floors.

Findings Include:

1. Observation on February 8, 2017, between 10:33 AM and 11:45 AM, revealed the following electrical issues;

a. At 10:33 AM, a microwave and refrigerator were powered by a power tap inside the finance office, in the basement;

b. At 10:30 AM, a microwave was owered by a power tap inside the G117F, in the basement;

c. At 10:43 AM, a microwave and two refrigerators were powered by a power tap inside the IT workroom;

d. At 11:45 AM, a microwave was powered by a power tap inside the physician ' s office.

Exit interview with the COO, Director of Facilities Service, Administrator and Plant Operations Director on March 15, 2018, at 3:30 PM, confirmed the unauthorized use of electrical devices.