HospitalInspections.org

Based on observation and interview, the facility failed to maintain the fire proofing coating to its steel I-beams. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings include:
1. On 03/24/14 at 11:20 A.M. a tour was conducted of the D level (with the exception of the south wing) with Staff AA and BB. At 11:26 A.M. observation above the drop down ceiling near room D300ZA revealed two horizontal, parallel I-beams, joined by one perpendicular to each, near the wall. At the joint of the I-beams, the fire resistive spray coating was observed to be missing.
On 03/24/14 at 11:26 A.M. in an interview, Staff AA confirmed the observation.

2. On 03/24/14 at 11:36 A.M. the I-beam in the electrical closet in oncology was also observed to be missing some of its fireproofing material.
On 03/24/14 at 11:36 A.M. in an interview, Staff AA confirmed the observation.

Based on observation and interview, the facility failed to ensure each opening onto a corridor had a smoke detector (where required) and each corridor was resistant to the passage of smoke. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings include:
1. On 03/17/14 at 3:02 P.M. a tour was conducted of the west and north wing of the ninth floor with Staff AA and BB. At 3:12 P.M. observation in the electrical closet close to the southern smoke doors revealed gaps in the tiles. Observation above the drop down ceiling in the electrical closet revealed a one inch open conduit communicating to the hallway.
On 03/17/14 at 3:12 P.M. in an interview, Staff BB confirmed the observations.

2. On 03/19/14 at 11:02 A.M. a tour was conducted of the north and west wing of the fifth floor with Staff AA and BB. Observation in room 5093 revealed the wall to have an opening to the corridor of six by six inches in size. The corridor is sprinklered, however, tiles in the corridor had corners that were missing and therefore would be unable to resist the passage of smoke from room 5093.
On 03/19/14 at 11:02 A.M. in an interview, Staff AA and BB confirmed the observation.

3. On 03/19/14 at 1:45 P.M. a tour was conducted of the 4th floor north and west wing with Staff AA and BB. At 2:22 P.M. the four west waiting area was observed to have sprinklers but no smoke detector or constant supervision by staff.
On 03/19/14 at 1:45 P.M. in an interview, Staff AA confirmed the observation.

4. At 2:40 P.M. observation of the chapel revealed it had a door which was open to the corridor, which had sprinklers, but no smoke detector.
On 03/19/14 at 2:40 P.M. in an interview, Staff AA confirmed the lack of a smoke detector.

5. On 03/24/14 at 11:20 A.M. a tour was conducted of the D level (with the exception of the south wing) with Staff AA and BB. At 12:18 P.M. clean supply room D528B was observed to open onto the corridor (i.e. it did not have a door) and it did not have a smoke detector.
On 03/24/14 at 11:20 A.M. in an interview, Staff AA confirmed the observation.

6. On 03/24/14 at 2:35 P.M. a tour was conducted of the B level of the Heart Center with Staff AA and BB. At 2:35 P.M. observation of the cardio vascular intensive care unit waiting area revealed it opened onto a corridor, the area in its totality was not monitored around the clock, and did not have a smoke detector.
On 03/24/14 at 2:35 P.M. in an interview, Staff AA confirmed the area did not have a smoke detector.

Based on observation and interview, the facility failed to ensure each corridor door had means suitable to stay closed. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings includes:
1. On 03/17/14 at 3:02 P.M. a tour was conducted of the north and west wing of the ninth floor with Staff AA and BB. At 3:25 P.M. observation of the staff bathroom door that opened onto the corridor revealed it did not close completely.
On 03/17/14 at 3:25 P.M. in an interview, Staff BB confirmed the observation.

2. On 03/19/14 at 11:02 A.M. a tour was conducted of the fifth floor of the west and north wing with Staff AA and BB. At 11:51 A.M. observation of the door to patient room 5679 revealed the door had a broken latch and would not close properly.
On 03/19/14 at 11:51 A.M. in an interview Staff BB confirmed the observation.

3. On 03/20/14 at 8:45 A.M. a tour was conducted of the first floor north and west wings with Staff AA and BB. At 10:27 A.M. a one hour rated wall with a one hour rated door leading to a biohazard room was observed to close but not latch because there was tape over the latch.
On 03/20/14 at 10:27 A.M. in an interview Staff C confirmed the latch was taped over because at one point the staff didn't have a key to the room.

4. On 03/20/14 at 10:45 A.M. a tour of the north and west wings of the A level was conducted with Staff AA and BB. Observation of double doors opening from the physician only dining area out onto the corridor revealed a gap of greater than an eighth of an inch.
At 1:30 P.M. the left half of the double doors at the entrance to the cafeteria's food service area were observed first to be propped open with a utensil dispenser, then observed not to close because the self closer was rubbing against the closing bar.
On 03/20/14 at 1:30 P.M. in an interview Staff AA confirmed the observation.

5. On 03/24/14 at 11:20 A.M. a tour was conducted of the D level (with the exception of the south wing) with Staff AA and BB. At 11:55 A.M. the corridor door to the tumor registry office space was observed not to entirely close.
On 03/24/14 at 11:55 A.M. in an interview, Staff BB confirmed the observation.

Based on observation and interview, the facility failed to ensure each door opening onto a corridor met the requirement at 18.3.6.3, life safety code 101, 2000 edition. This has the potential to affect all patients, staff, and visitors to the facility. The census was 362 patients at the beginning of the survey.

Findings include:
On 03/19/14 at 8:20 A.M. a tour of the 6th floor north and west wing was conducted with Staff AA and BB. Observation of the bathroom door opening to the corridor revealed the self closer did not close and latch the door.
On 03/19/14 at 8:20 A.M. in an interview Staff AA confirmed the observation.
At 9:50 A.M. a Dutch door was observed in the corridor of the west wing. It was not observed to have an astragal, sweep or flap between the doors.
On 03/19/14 at 9:50 A.M. in an interview, Staff AA and BB confirmed the observation.

Based on observation and interview, the facility failed to maintain the stated rating surrounding each vertical enclosure. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.


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Findings includes:

1. Tour of the 8th floor of the South Wing conducted on 03/19/14 revealed a 3/4 inch flex conduit with gray cables passing through and open on the end penetrating the two hour fire wall of the South stairwell visible from the South corridor which travels east and west. This was confirmed by Staff MM at the time of the observation on 03/29/14 at 1:56 PM.

2. Tour of the 4th floor of the South Wing conducted on 03/20/14 revealed access panels above the linen and trash chutes have inadequate securing devices and bends in the access panel corners allowing open space into the two hour rated vertical shaft. This was confirmed by Staff MM at the time of the observation on 03/20/14 at 10:30 AM.

3. Tour of the 2nd floor of the South Wing conducted on 3/20/14 revealed an 3/4 inch gap between the decking and the concrete block wall on the corridor side of the stairwell between the north stairwell and the elevator shaft. This was presented to Staff MM at the time of the observation on 03/20/14 at 2:25 PM.

4. Tour of the 1st floor of the South Wing conducted on 03/20/14 revealed a 3/4 inch conduit open on the end penetrating the south stairwell west wall located in the south egress corridor. This was confirmed by Staff MM at the time of the observation on 03/20/14 at 4:05 PM.

5. Tour of the B floor of the South Wing conducted on 03/21/14 revealed an 8 inch water pipe in the two hour west wall with a 2 inch gap around the pipe and a 2 inch water pipe in the south wall with a gap around the pipe in the north exit stairwell. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 8:23 AM.

Based on observation and interview, the facility failed to maintain the rating assigned to each of its rated walls that formed a smoke compartment. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings include:
1. On 03/17/14 at 3:02 P.M. a tour was conducted of the west wing and north wing of the ninth floor with Staff AA and BB. Review of the schematic revealed the wing to be bisected by a one hour smoke barrier that ran north/south. On 03/17/14 at 3:06 P.M. in that barrier at the southern double doors and above the drop down ceiling a copper line in a copper sleeve there was a communicating space between the line and the sleeve.
On 03/17/14 at 3:06 P.M. in an interview Staff BB confirmed the finding.

2. At 3:42 P.M. above the drop down ceiling in the wall perpendicular to west wing stairwell 1, a two foot by one foot penetration was observed with three two inch conduits communicating through it.
On 03/17/14 at 3:42 P.M. Staff AA and BB confirmed the observation.

3. On the ninth floor, on 03/18/14 at 9:31 A.M. observation above the drop down ceiling over the north/south smoke barrier located in the northeast portion of the west wing revealed two heating, ventilation and cooling ducts with annular spaces.
On 03/18/14 at 9:31 A.M. in an interview Staff BB confirmed the observation.

4. On the ninth floor on 03/18/14 at 9:50 A.M. in the smoke barrier by conference room 9109 and perpendicular to a distal pair of double doors, an annular space was observed around a two inch cast iron ring in the wall above the drop down ceiling.
On 03/18/14 at 9:50 A.M. in an interview Staff BB confirmed the observation.

5. On 03/18/14 at 10:09 A.M. a tour was conducted of the eighth floor north and west wing with Staff AA and BB and others. At 10:25 A.M. observation above the drop down ceiling over the double doors leading to the wing revealed two one inch open conduits.
On 03/18/14 at 10:25 A.M. in an interview, Staff BB confirmed the observation.

6. On 03/18/14 at 11:48 A.M. the two hour rated barrier surrounding the lift room for the dumb waiters was observed to be penetrated by a sprinkler line and a one inch conduit with an annular space and the door was not rated.
On 03/18/14 at 11:48 A.M. in an interview Staff BB confirmed the observation.

7. On 03/19/14 at 11:02 A.M. a tour was conducted of the fifth floor of the west and north wing with Staff AA and BB. Observation above the drop down ceiling at the double doors leading to the corridor to either northwest stairwell two or three, at 11:18 A.M., revealed four one inch conduits with annular spaces.
On 03/19/14 at 11:02 A.M. in an interview, Staff BB confirmed the observation.

8. On 03/19/14 at 1:45 P.M. a tour was conducted of the 4th floor north and west wing with Staff AA and BB. Review of the 4th floor schematic revealed a data closet (4133) with a one hour fire rated perimeter. Observation above the drop down ceiling revealed a two to three inch conduits open to air in the wall over the door to the room.
On 03/19/14 at 1:45 P.M. in an interview, Staff BB confirmed the observation.

9. At 2:29 P.M. observation of the northern part of the smoke barrier that separates the wing into two smoke compartments revealed above the drop down ceiling revealed two one inch conduits open to air, one with two orange wires coming out of it.
On 03/19/14 at 2:29 P.M. in an interview, Staff BB confirmed the observation.

10. On 03/19/14 at 3:35 P.M. a tour was conducted of the second floor north and west wing with Staff AA and BB. Observation above the double doors that lead to the south wing revealed an open junction box with an open conduit leading through the two hour fire barrier.
On 03/19/14 at 3:35 P.M. in an interview Staff BB confirmed the observation.

11. On 03/20/14 at 8:45 A.M. a tour of the first floor west and north wing was conducted with Staff AA and BB. At 8:56 A.M. the doors in the fire barrier leading to the south wing were observed to be not rated.
On 03/20/14 at 8:45 A.M. in an interview, Staff AA confirmed the observation.

12. At 9:01 A.M. observation of the door in a two hour rated stairway (not an exit) near the chapel, revealed the door to be not rated.
On 03/20/14 at 9:01 A.M. in an interview, Staff AA confirmed the observation.

13. On 03/20/14 at 8:45 A.M. a tour was conducted of the first floor north and west wings with Staff AA and BB. Observation of the double doors in the one fire rated barrier across the northeast corridor in the north wing revealed the right door closed but did not latch.
On 03/20/14 at 8:45 A.M. in an interview, Staff AA confirmed the observation.

14. At 10:17 A.M. observation of the one hour rated wall above the drop down ceiling in the soiled utility room of the west wing revealed a one inch by one inch square opening in the wall.
On 03/20/14 at 10:17 A.M. in an interview, Staff BB confirmed the observation.

15. At 10:35 A.M. observation above drop down ceiling over the double doors that separated the west wing from the courtyard building revealed an open junction box with a one inch open conduit that communicated through the two hour rated wall.
On 03/20/14 at 10:35 A.M. in an interview Staff BB confirmed the observation.

16. On 03/20/14 at 10:45 A.M. a tour of the north and west wings of the A level was conducted with Staff AA and BB. Observation above the double doors, in a two hour rated wall, that leads to the north wing revealed four or more conduits with conjoined annular spaces.
On 03/20/14 at 10:45 A.M. in an interview Staff BB confirmed the observation.

17. At 11:58 A.M. observation of the door in the two hour rated wall between a corridor and legal services revealed the door to legal services had its label painted over and the rating indiscernible.
At 11:58 A.M. in an interview Staff AA confirmed the observation.

18. At 12:02 P.M. observation above the drop down ceiling of the two hour rated wall at the right angle formed between the wall shared by legal services and the north/south wall, two two inch conduits with gray wires were observed open to air and another penetration was created by a blue wire.
At 12:02 P.M. in an interview, Staff BB confirmed the observation.

19. At 2:00 P.M. observation above the drop down ceiling over the double doors in the corridor leading to the heart center revealed the two hour rated wall did not extend all the way across to the outside wall that formed an acute angle with the heart center's outside wall.
On 03/20/14 at 2:00 P.M. in an interview Staff BB confirmed the observation.

20. On 03/21/14 at 8:22 A.M. a tour was conducted of the north and west wings, surgical areas, and post/pre operative areas with Staff AA and BB.

21. At 8:22 A.M. observation above the drop down ceiling over the double doors across the corridor leading to stairwell North West 2, revealed three three inch open conduits, one of which had a white rag stuffed into it.
At 8:22 A.M. in an interview, Staff BB confirmed the observation.

22. On 03/21/14 at 8:40 A.M. a tour was conducted of the central supply room of the B level with Staff AA and BB and others.
At 8:45 A.M. observation of the sliding doors leading into the clean storage area, and within a two hour rated wall, revealed their labels to be painted over and the rating indiscernible.
At 8:45 A.M. in an interview, Staff AA confirmed the observation.

23. At 9:00 A.M. observation of the most western double doors leading into the central supply room (from a corridor leading to the heart center), revealed the doors were in a two hour fire rated wall, but were themselves not rated.
At 9:00 A.M. in an interview Staff AA confirmed the observation.

24. At 9:12 A.M. just south of those double doors, observation of above the drop down ceiling of another set of double doors in a one hour rated wall revealed a one inch conduit with two grey wires coming out of it and it was unstopped.
At 9:12 A.M. in an interview, Staff BB confirmed the observation.

25. Continuing south down the corridor, at 9:18 A.M. observation above the drop down ceiling over double doors revealed a one inch conduit open to air. This is near post operative area.
At 9:18 A.M. in an interview Staff BB confirmed the findings.

26. Continuing south down the corridor along the postoperative suite, at 9:38 A.M. a junction box with a one inch communicating conduit from the one hour rated wall, was observed to have a one inch open hole.
At 9:38 A.M. in an interview Staff BB confirmed the findings.

27. Continuing south down the corridor and making a left turn to the east, at 9:48 A.M. observation above the drop down ceiling over the double doors there (and near sign for OR 9-12) revealed there wasn't a barrier there in the one hour rated wall.

28. On 03/21/14 at 10:35 A.M. observation above the drop down ceiling of the two hour rated wall that separated the south wing from the area of the operating rooms revealed an open junction box.
On 03/21/14 at 10:35 A.M. in an interview, Staff BB confirmed the observation.

29. On 03/24/14 at 11:20 A.M. a tour was conducted of the D level (with the exception of the south wing) with Staff AA and BB and others. At 11:55 A.M. observation above the drop down ceiling of the two hour rated wall running in back of the tumor registry office space, a two inch by two inch square penetration was observed.
On 03/24/14 at 11:55 A.M. in an interview, Staff BB confirmed the observation.

30. On 03/24/14 at 2:35 P.M. a tour was conducted of the B level of the Heart Center with Staff AA and BB. At 3:29 P.M. observation above the drop down ceiling of the two hour rated wall over the double doors from the heart center to same day surgery revealed a two inch hole.
On 03/24/14 at 3:39 P.M. in an interview, Staff BB confirmed the observation.

31. On 03/24/14 at 3:45 P.M. a tour was conducted of C floor of Heart Center with Staff AA and BB. At 4:23 P.M. observation above the drop down ceiling of the two hour rated wall over the double doors heading to C west and computed tomography and heart catheterization labs revealed a penetration with two Garey wires coming out of it.
On 03/24/14 at 4:23 P.M. in an interview, Staff BB confirmed the observation.

32. At 4:26 P.M. observation above the drop down ceiling of the one hour rated wall above the double doors in the eastern most corridor revealed a three inch open to air conduit.
On 03/24/14 at 4:26 P.M. in an interview, Staff BB confirmed the observation.





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33. Tour of the 9th floor of the South Tower conducted on 03/19/14 revealed a one and a half inch conduit with multiple cables passing through was open on the end and a 3/4 inch conduit open on the end both penetrating the three hour wall of the separation between the South Tower and the North Tower above the corridor doors. This was confirmed by Staff MM at the time of the observation on 03/19/14 at 11:15 AM.

34. Tour of the 9th floor of the South Tower conducted on 03/19/14 revealed three, 3/4 inch conduits open on end penetrating the two hour fire rated wall of the east elevator shaft located in the west wall of room 9172. This was confirmed by Staff MM at the time of the observation on 03/19/14 at 11:52 AM.

35. Tour of the 8th floor of the South Tower conducted on 03/19/14 revealed an 8 inch and a 6 inch water/steam pipe with a 3 inch gap below the pipes which penetrates the north three hour wall in room 8154A separating the South Tower from the North Tower. This was confirmed by Staff MM at the time of the observation on 03/19/14 at 12:03 PM.

36. Tour of the 4th floor of the South Tower conducted on 03/20/14 revealed a 3/4 inch conduit with 1/2 inch gap above the conduit, penetrating the three hour wall separating the South Tower from the North Tower in the physical therapy room's North wall. This was confirmed by Staff MM at the time of the observation on 03/20/14 at 10:09 AM.

37. Tour of the 1st floor of the South Tower conducted on 03/20/14 revealed a 3/4 flex conduit and a 3/4 inch conduit penetrating the north wall of the south exit corridor across from the exit doors with a half inch open gap around the penetrations. This was confirmed by Staff MM at the time of the observation on 03/20/14 at 4:15 PM.

38. Tour of the A floor of the South Tower conducted on 03/20/14 revealed the 1 1/2 rated northwest corner doors of the exit corridor had a self closer but did not latch when released from the magnetic holder. This was confirmed by Staff MM at the time of the observation on 03/20/14 at 4:45 PM.

39. Tour of the A floor of the South Tower conducted on 03/20/14 revealed an 6 inch pneumatic tube open on the end and a 10 inch by 10 inch junction box without a cover with a 1 1/2 inch conduit connected to the box open on end. Both penetrated the two hour wall above the south exit access doors in the exit corridor. This was confirmed by Staff MM at the time of the observation on 03/20/14 at 5:00 PM.

40. Tour of the B floor of the South Tower conducted on 03/21/14 revealed a 1/2 inch gap above a 6 inch pneumatic tube penetrating the north two hour separation in the north corridor traveling east and west. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 8:15 AM.

41. Tour of the pharmacy on the B floor of the South Tower conducted on 03/21/14 revealed an 8 inch pipe penetrating the north two hour wall with a 3 inch gap above the pipe. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 8:34 AM.

42. Tour of the B floor of the South Tower conducted on 03/21/14 revealed a 5 inch by 5 inch hole in the one hour wall above the corridor doors in the west non-sterile corridor on the OR side of the corridor. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 8:40 AM.

43. Tour of the Radiology office waiting area on the C floor of the South Tower conducted on 03/21/14 revealed 3/4 inch flex conduit and 3/4 inch conduit penetrating the west two hour wall with opening around both conduits. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 9:40 AM.

44. Tour of the Radiology office "dark imaging reading room" on the C floor of the South Tower conducted on 03/21/14 revealed multiple penetrations of varying size from 2 feet to 6 inches with multiple pipes of varying size passing through. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 9:45 AM.

45. Tour of the South corridor below the lab on the C floor of the South Tower conducted on 03/21/14 revealed multiple penetrations of varying size above the west corridor doors. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 10:37 AM.

Based on observation and interview, the facility failed to maintain the rating assigned to each of its rated walls that formed a smoke compartment. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings include:
1. On 03/18/14 at 10:09 A.M. a tour was conducted of the eighth floor north and west wing with Staff AA and BB. At 10:25 A.M. observation above the drop down ceiling over the double doors leading to the wing revealed two one inch open conduits.
On 03/18/14 at 10:25 A.M. in an interview, Staff BB confirmed the observation.
2. On 03/18/14 at 11:48 A.M. the two hour rated barrier surrounding the lift room for the dumb waiters was observed to be penetrated by a sprinkler line and a one inch conduit with an annular space and the door was not rated.
On 03/18/14 at 11:48 A.M. in an interview Staff BB confirmed the observation.
3. On 03/18/14 at 2:05 P.M. a blue wire was observed to penetrate the one hour smoke barrier opposite room 8066 and next to kitchenette
On 03/18/14 at 2:05 P.M. in an interview, Staff BB confirmed the observation.
4. On 03/18/14 at 2:58 P.M. a tour was conducted of the seventh floor north and west wing with Staff AA and BB. At 4:27 P.M. room 7100, a room containing dumb waiters, was observed per schematic to be wrapped in two hour fire rated construction. However, at 4:27 P.M. the door was observed to be not rated and above the drop down ceiling an annular space was observed around a sprinkler line.
On 03/18/14 at 4:27 P.M. Staff BB confirmed the observation.
5. On 03/18/14 at 4:37 P.M. a tour was conducted of the 6th floor with Staff AA and BB. At 4:38 P.M. observation above the drop down ceiling in the chute room revealed the barrier with one one inch conduit with an annular space, and two flex conduits open to air.
On 03/19/14 at 4:38 P.M. in an interview, Staff BB confirmed the observation.
6. On 03/19/14 at 8:20 A.M. the tour of the 6th floor resumed with Staff AA and BB. At 9:04 A.M. observation above the double doors leading to the west wing clinical unit revealed a one inch conduit in an open junction box communicating through the barrier.
On 03/19/14 at 8:20 A.M. in an interview Staff BB confirmed the observation.
7. On 03/21/14 at 11:34 A.M. a tour was conducted of the C level of the west wing/courtyard building with Staff AA and BB. At 11:34 A.M., observation of the one hour rated wall above drop down ceiling over the double doors leading to the heart station area and near west wing stairwell 1, revealed three tubes with annular spaces and one conduit with a blue wire but open to air.
On 03/21/14 at 11:34 A.M. in an interview, Staff BB confirmed the observation.
8. On 03/21/14 at 11:48 A.M. observation of the two hour rated wall above the drop down ceiling near the double doors near the imaging library revealed an approximate one yard by one yard square opening.
On 03/21/14 at 11:48 A.M. in an interview, Staff BB confirmed the observation.
9. On 03/21/14 at 12:10 P.M. near the outpatient center 1 stairwell, observation above the drop ceiling of the one hour rated wall dividing an office space from the heart station suite, revealed an annular space around a sprinkler line.
On 03/21/14 at 12:10 P.M. in an interview, Staff BB confirmed the observation.
10. On 03/21/14 at 2:28 P.M. observation above the drop down ceiling of the one hour rated wall from the other side of room C361, revealed an unsealed one inch conduit and two one inch holes.
On 03/21/14 at 2:28 P.M. in an interview, Staff BB confirmed the observation.
11. At 3:10 P.M. observation of the one hour wall above the drop down ceiling surrounding data closet c370a revealed an open junction box with two communicating conduits open to air.
At 3:10 P.M. in an interview, Staff BB confirmed the observation.

Based on observation and interview, the facility failed to ensure doors in each smoke barrier closed. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings include:
On 03/24/14 at 2:35 P.M. a tour was conducted of the B level of the Heart Center with Staff AA and BB and others. At 3:12 P.M. the double doors in the smoke barrier across from room B715 to B764 failed to close.
On 03/24/14 at 2:35 P.M. in an interview, Staff AA confirmed the observation.

Based on observation and interview, the facility failed to ensure each storage area with a rated wall maintained the rating to that wall. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings:
1. On 03/17/14 at 1:55 P.M. a tour was conducted of the 10th floor, west and north wing, with Staff AA, BB. At 2:26 P.M. observation above the drop down ceiling of storage/collection room 9914 revealed the west wall to have a one yard wide by one yard high penetration with steel conduits running through it.
On 03/17/14 at 2:26 P.M. Staff BB confirmed the finding.

2. At 2:45 P.M. observation above the drop down ceiling of supply room 9110 revealed two one inch open conduits in the east wall. At 2:48 P.M. observation above the drop down ceiling of the same room revealed two one inch conduits running from the wall to an open junction box, two one foot, insulated pipes with annular spaces, and a sprinkler line coming from the north wall with an annular space.
On 03/17/14 at 2:48 P.M. Staff BB confirmed the findings.

3. On 03/17/14 at 3:21 P.M., on the 9th floor of the north and west wing, in the biohazard room, observation above the drop down ceiling in the east wall an open one inch conduit was observed, in the north wall a water pipe with an annular space was observed, and in the south wall a one inch conduit traveling to an open conduit was observed.
On 03/17/14 at 3:21 P.M. in an interview Staff BB confirmed the finding.

4. On 03/24/14 at 2:35 P.M. a tour was conducted of the B level of the Heart Center with Staff AA and BB. At 2:42 P.M. observation above the drop down ceiling of the one hour rated wall around a storage area located on the southern end revealed a two inch pipe with an annular space.
On 03/24/14 at 2:42 P.M. in an interview, Staff BB confirmed the observation.

5. On 03/24/14 at 2:50 P.M. observation above the drop down ceiling of the one hour rated wall around clean storage room B754 revealed a three inch conduit holding a yellow and blue wire, open to air, and a one inch square penetration. Also at 2:50 P.M. the door to soiled utility room B757 was observed not to close shut because a cart in the room was stopping it from doing so.
On 03/24/14 at 2:50 P.M. in an interview, Staff BB and AA confirmed the observations

6. On 03/24/14 at 2:52 P.M. observation above the drop down ceiling of the one hour rated wall in biohazard room B757 revealed a sprinkler line with annular space and a heating, ventilation and cooling conduit with a gap underneath.
On 03/24/14 at 2:52 P.M. in an interview, Staff BB confirmed the observation.

7. On 03/24/14 at 3:05 P.M. observation above the drop down ceiling of the one hour rated wall around clean storage room B763 revealed on the east wall a penetration by a Garey wire and on the west wall a one inch open to air conduit with a blue wire.
On 03/24/14 at 3:05 P.M. in an interview, Staff BB confirmed the observation.

8. On 03/24/14 at 3:45 P.M. a tour was conducted of C floor of Heart Center with Staff AA and BB. At 4:05 P.M. observation above the drop down ceiling of the one hour rated wall in soiled utility room C760 revealed a one foot by one foot opening in the right corner of the room.
On 03/24/14 at 4:05 P.M. in an interview, Staff BB confirmed the observation.

9. On 03/24/14 at 4:13 P.M. observation above the drop down ceiling of the one hour rated wall in the room adjacent to room C760, entered from the most eastern corridor, revealed over the door an orange conduit holding a Garey wire open to air and an heating, ventilation and cooling conduit with a half inch gap underneath supported by a wooden triangle.
On 03/24/14 at 4:13 P.M. in an interview, Staff BB confirmed the observation.

10. On 03/24/14 at 3:45 P.M. a tour was conducted of C floor of Heart Center with Staff AA and BB. At 4:35 P.M. observation above the drop down ceiling of the one hour rated wall around soiled utility room C742 revealed over the door an orange sleeve open to air holding Garey wires.
On 03/24/14 at 4:35 P.M. in an interview, Staff BB confirmed the observation.




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11. Tour of the 7th floor of the South Tower conducted on 03/19/14 revealed a 1/2 inch conduit with gray cables penetrating the one hour west wall of the soiled utility room (7042) from the corridor side of the wall. This was confirmed by Staff MM at the time of the observation on 03/19/14 at 2:42 PM.

12. Tour of the 6th floor of the South Tower conducted on 03/20/14 revealed a 3/4 inch conduit open on end penetrating the one hour wall between the clean utility room and the East corridor. This was confirmed by Staff MM at the time of the observation on 03/20/14 at 8:50 AM.

13. Tour of the 5th floor of the South Tower conducted on 03/20/14 revealed a 2 inch sleeve open on both sides of the wall with gray and blue wiring passing through the one hour wall between the clean utility room (5043) and the East corridor. This was confirmed by Staff MM at the time of the observation on 03/20/14 at 9:45 AM.

14. Tour of the 3rd floor of the South Tower conducted on 03/20/14 revealed a 1/2 inch penetration of the East one hour wall of room 3038. This was confirmed by Staff MM at the time of the observation on 03/20/14 at 11:41 AM.

15. Tour of the Lab located on the C floor of the South Tower conducted on 03/21/14 revealed the door of the Southwest storage room (C025) with a one hour enclosure was propped open with 10 large boxes. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 10:05 AM.

16. Tour of the Lab located on the C floor of the South Tower conducted on 03/21/14 revealed a 1 inch conduit open on the end of both sides of the one hour West wall of room C013. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 10:15 AM.

17. Tour of the C floor of the South Tower conducted on 03/21/14 revealed multiple penetrations of varying size in all 4 walls of the one hour enclosure of room C014A in the South corridor. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 10:35 AM.

18. Tour of the C floor of the South Tower conducted on 03/21/14 revealed multiple penetrations varying in size on the North one hour wall of the south corridor between the Southwest lab storage room (C025) and the corridor. This was confirmed by Staff MM at the time of the observation on 03/24/14 at 11:55 AM.
This was verified by Staff MM on 03/24/14 at 11:55 AM.

Based on observation and interview, the facility failed to ensure each of its stairways used as exits were in accordance with 7.1 of NFPA 101, 2000 edition. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings include:
1. On 03/18/14 at 10:09 A.M. a tour was conducted of the eighth floor north and west wing with Staff AA and BB and others. At 10:56 A.M. observation above the drop down ceiling near northwest stair one, near women ' s locker room number 8150 revealed a small penetration to the wall.
In an interview, on 03/18/14 at 10:56 A.M. Staff BB confirmed the observation.
2. On 03/18/14 at 10:58 A.M. observation of the wall above the drop down ceiling near the women's locker room and near northwest stairwell 1, revealed open wire mesh on one side of the wall and an open junction box with a one inch communicating conduit.
On 03/18/14 at 10:58 A.M. Staff BB confirmed the observation.
3. On 03/18/14 at 11:02 A.M. observation above the drop down ceiling near the women's bathroom door and northwest stair 2 revealed a one inch conduit with a blue wire with an annular space.
On 03/18/14 at 11:02 A.M. in an interview Staff BB confirmed the observation.
4. On 03/18/14 at 2:58 P.M. a tour was conducted of the west wing and north wing of the seventh floor with Staff AA and BB. Observation of the door of northwest stair 3, an exit stair, revealed the door did not fully open as wheelchairs were observed to be on the landing obstructing it.
On 03/18/14 at 2:58 P.M. in an interview, Staff AA confirmed the observation.
5. On 03/18/14 at 3:45 P.M. observation above the drop down ceiling in the three hour wall in locker room 7177 revealed a two inch conduit with an annular space
On 03/18/14 at 3:45 P.M. in an interview, Staff BB confirmed the observation.
6. On 03/19/14 at 8:20 A.M. a tour of the 6th floor north and west wing was conducted with Staff AA and BB. Observation of the fire stairway exit doors revealed at the northwest stairway 1 revealed the double doors to be unrated.
On 03/19/14 at 8:20 A.M. in an interview Staff AA confirmed the observation.
7. At 8:37 A.M. above the drop down ceiling in northwest stairway 1 observation revealed at the stairway itself, an open junction box with an open communicating one inch conduit.
On 03/19/14 at 8:37 A.M. in an interview Staff BB confirmed the observation.
8. On 03/19/14 at 8:38 A.M. observation above the drop down ceiling over the east doors of the stairway revealed an open junction box with a communicating two inch conduit.
On 03/19/14 at 8:38 A.M. in an interview Staff BB confirmed the observation.
9. At 9:45 A.M. the fire door at fire exit stairwell west wing 2 was observed to close and not latch.
On 03/19/14 at 9:45 A.M. in an interview Staff AA confirmed the observation.

Based on observation and interview, the facility failed to ensure each of its stairways used as exits were in accordance with 7.1 of NFPA 101, 2000 edition. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings include:
1. On 03/18/14 at 8:30 A.M. the tour of the ninth floor west and north wing resumed with Staff AA and BB. At 9:08 A.M. observation above the drop down ceiling over the double doors near north wing stair 1 and the women ' s locker room, revealed annular spaces around three conduits and one flex conduit.
On 03/18/14 at 9:08 A.M. in an interview, Staff BB confirmed the observation.

2. At 9:12 A.M. observation above the drop down ceiling over the double doors near the men ' s locker room revealed a two inch fiber duct that communicated through the two hour rated barrier and had been spliced open.
On 03/18/14 at 9:12 A.M. in an interview, Staff BB confirmed the observation.

3. On 03/19/14 at 11:02 A.M. a tour was conducted of the fifth floor of the west wing and north wing with Staff AA and BB. Observation of the double doors in the fire exit leading North West stairwell 1 revealed they were not rated and did not close because the coordinator did not work.
On 03/19/14 at 11:02 A.M. in an interview, Staff AA confirmed the observation.

4. At 11:05 A.M. observation of the door out of the respiratory storage room and into the northwest stairway 1, revealed the door was not rated.
On 03/19/14 at 11:05 A.M. in an interview Staff AA confirmed the observation.

5. On 03/19/14 at 1:45 P.M. a tour was conducted of the 4th floor north and west wing with Staff AA and BB. At 1:52 P.M. observation of the wall above the double doors in the corridor that lead to exit stairway northwest 1 revealed a fist sized opening near the heating, ventilation and cooling tube.
On 03/19/14 at 1:45 P.M. in an interview Staff BB confirmed the observation.

6. On 03/19/14 at 3:15 P.M. a tour was conducted of the third floor north and west wing with Staff AA and BB. At 3:15 P.M. observation above drop down ceiling of the two hour fire barrier over the west double doors in the area leading to fire stairway northwest 1, revealed a one inch conduit open in the junction box that communicated from the barrier.
On 03/19/14 at 3:15 P.M. in an interview, Staff BB confirmed the observation.

7. On 03/19/14 at 3:35 P.M. a tour was conducted of the second floor north and west wing with Staff AA and BB. At 3:58 P.M. observation of the door to fire stairwell northwest 1 revealed it was not rated.
On 03/19/14 at 3:35 P.M. in an interview Staff AA confirmed the observation.

8. On 03/20/14 at 8:45 A.M. a tour was conducted of the first floor north and west wings with Staff AA and BB. At 9:21 A.M. observation above the drop down ceiling over the double doors that lead to the northwest stairwell area revealed one open electrical junction box and another junction box with an open one inch conduit.
On 03/20/14 at 8:45 A.M. in an interview, Staff BB confirmed the observation.

9. At 9:45 A.M. observation of the door at the northwest three fire stairwell revealed the door was not rated and did not close and latch.
On 03/20/14 at 9:45 A.M. in an interview Staff AA confirmed the observation.

10. On 03/20/14 at 10:45 A.M. a tour of the north and west wings of the A level was conducted with Staff AA and BB. At 11:11 A.M. the door to the fire exit stairwell west wing 2 was observed to not be rated.
On 03/20/14 at 10:45 A.M. in an interview Staff AA confirmed the observation.

11. At 1:59 P.M. the door of the fire exit stairwell west wing 2 was observed to have its label painted over.
On 03/20/14 at 1:59 P.M. in an interview, Staff AA confirmed the observation.

12. On 03/24/14 at 2:00 P.M. a tour was conducted of the A level of the Heart Center with Staff AA and BB. Observation of the door on fire exit stairwell heart center 1 revealed the label to be painted over and the rating indiscernible.
On 03/24/14 at 2:00 P.M. in an interview, Staff AA confirmed the observation.

13. At 2:12 P.M. observation of the door on fire stairwell exit heart center stair 2 revealed the label was painted over and the rating was not discernible.
On 03/24/14 at 2:12 P.M. in an interview, Staff AA confirmed the observation.

Based on observation and interview, the facility failed to ensure each path of egress was free of impediments. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings:
On 03/22/14 at 10:38 A.M. the tour of the C level of the west wing/courtyard building with Staff AA and BB and others was resumed. At 11:00 A.M. observation of the sliding doors on the path of egress out of the computed tomography suite revealed they were not of the breakaway type and did not unlock and release with the triggering of the fire alarm.
On 03/21/14 at 11:00 A.M. in an interview, Staff AA confirmed the observation.

Based on observation and staff confirmation the corridor was obstructed decreasing the corridor with to less than 4 feet. This has the potential to affect all patients, and visitors within this area of the facility. The census at the beginning of the survey was 362.

Findings include:

Tour of the corridor behind the operating room areas on B floor of South Tower completed on 03/21/14 revealed 3 pallets filled with boxes of various items located in the central corridor traveling east to west and boxes/equipment not being used immediately by staff was located the south east corridor traveling north and south both decreasing the size of the corridor to less than 4 feet. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 8:55 AM.

Based on observation, staff confirmation, and document review the facility failed to test emergency lighting in the exit stairwell. This has the potential to affect all patients, staff, and visitors that enter the facility.

Findings include:

Tour of the surgery center conducted on 03/24/14 revealed the emergency lights failed to illuminate when staff conducted a test during the survey. The areas in which the lights failed to illuminate was in the North Exit Stairwell between the basement and first floor and between the first and second floor. This was confirmed by Staff MM at the time of the observation on 03/24/14 at 1:45 PM.

Review of the Monthly emergency light and exit sign testing documentation completed on 03/25/14 revealed the emergency lights in the North Exit Stairwell are not tested by the facility. This was confirmed by Staff NN on 03/25/14 at 1:30 PM.

Based on observation and interview, the facility failed to ensure exit signage was placed in accordance with NFPA life safety code 101, 2000 edition. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings include:
1. On 03/18/14 at 10:09 A.M. a tour was conducted of the eighth floor of the west wing and north wing with Staff AA and BB and others. Observation of the corridor leading to the west wing revealed a "recovery and holding" sign occluding an exit sign on the path of egress from the waiting area.
On 03/18/14 at 10:09 A.M. Staff AA confirmed the finding.
2. At 12:00 P.M. observation of egress paths from the post anesthesia care unit did not reveal where they were marked with exit signs.
At 12:00 P.M. in an interview Staff AA confirmed the finding.

Based on observation, and staff confirmation the facility failed to have exit signs visible and displayed to mark the path of egress. This has the potential to affect all patients, visitors, and staff that enter the hospital. The patient census at the beginning of the survey was 362.

Findings include:

1. On 03/18/14 at 10:00 A.M. a tour was conducted of the c-section area of the ninth floor. Observation did not reveal an exit sign to a path of egress.
On 03/18/14 at 10:00 A.M. in an interview, Staff AA confirmed the observation.

2. On 03/20/14 at 8:45 A.M. a tour was conducted of the first floor north and south wings with Staff AA and BB. At 10:22 A.M. observation of exit signage at the west wing 2 stairwell revealed a sign was not in the line of sight of people entering the stairwell to direct them to go to the left.
On 03/20/14 at 8:45 A.M. in an interview, Staff AA and BB confirmed the observation.





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3. Observation of A floor in the administration corridor completed on 03/22/14 revealed two paths of egress: one going west in the corridor and then turning north, the other going east then turning north toward the exit corridor. The exit sign was not visible on the far west end of the corridor due to a directional sign showing where different departments were located was directly in front of the sign. The east exit was not marked with an exit sign showing the path of travel to the north exit corridor. This was confirmed by Staff MM at the time of the observation on 03/22/14 at 8:00 AM.

Based on review of the facility's fire drill documentation, fire response plan and interview, the facility failed to ensure fire drills were held under random, varying conditions, and that its fire response plan was followed. This has the potential to affect all patients, staff, and visitors to the facility. The patient census at the beginning of the survey was 362.
Findings include:
Review of the facility's fired drills for 2013 revealed a lack of variability. For each quarter of 2013, the third shift fire drill was held at 01:00 A.M., except for the summer quarter, when it was held at 01:05 A.M.
On 03/24/14 at 2:00 P.M. in an interview, Staff GG confirmed the observation.
In January 2014 a fire occurred in the operating room. Review of the facility's fire and safety documentation did not reveal who, if any, fire safety authority was notified.
On 03/20/14 at 2:35 P.M. in an interview with Staff GG, he/she said he/she knew nothing about the fire until Monday, 03/17/14, when he/she saw it mentioned in the paper work for the state ' s survey. He/she said if a flame has been extinguished, the fire department was to be called.
On 03/24/14 at 3:10 P.M. in an interview Staff FF confirmed a fire alarm was never triggered and the clinical staff alone made the decision the fire was satisfactorily extinguished using normal saline.
Review of the facility's Fire Response Plan, number 1.03.105, and effective on 10/2013 was completed on 03/24/14. Review of the aforementioned Fire Response Plan revealed: "Whomever discovers a fire should pull the nearest fire alarm box and/or dial"111" (Telecommunications Operator) and report the exact location of the fire; the Telecommunications Operator notified the (local) fire department of the fire alarm and location by telephone .....When the alarm is activated in the hospital, the fire system will announce within the building in alarm: 'code red' and the exact location....if it can be done safely, fight the fire using proper fire extinguishers...The (local) fire department will arrive, responding to a pre planned location. A safety/security officer will meet them and advise them of the situation...When the fire has been extinguished, the ALL CLEAR is given by the (local) fire department official in charge."

Based on document review and staff confirmation the facility failed to activate audible alarms during the fire drills conducted quarterly. This has the potential to affect all patients, visitors, and staff who enter the facility.

Findings include:

Review of the Fire Report/Evaluation completed on 03/25/14 revealed the fire alarm was not activated for the drills conducted on 01/28/13, 06/18/13, 08/27/13, and 02/25/14 due to other tenants in the building. This was confirmed by Staff NN on 03/25/14 at 12:15 PM.

Based on staff interview the facility failed to have fire drills at least every year. This has the potential to affect all patients served by the facility. The census was zero during the facility tour on 03/25/14.

Findings include:

Interview with Staff OO completed on 03/25/14 revealed no fire drills have been conducted for the facility.

Based on observation and interview, the facility failed to ensure its sprinkler system was in compliance with NFPA 25 and 13. This has the potential to affect all patients, staff, and visitors to the facility. The patient census at the beginning of the survey was 362.
Findings include:
1. On 03/17/14 at 3:02 P.M. a tour was conducted of the west wing and north wing of the ninth floor with Staff AA and BB. Observation of the side-mounted quick-response sprinkler head in room 9064 revealed it to cover in dust.
At 3:03 P.M. in an interview, Staff BB confirmed the observation.

2. At 3:30 P.M. in storage room 9104 boxes were observed stacked in the center room up to less than 18 inches from the ceiling.
On 03/17/14 at 3:30 P.M. in an interview Staff AA and BB confirmed the observation.

3. On 03/18/14 at 8:30 A.M. the tour of the ninth floor resumed with Staff AA and BB. At 8:30 A.M. in the men's locker room a dirty sprinkler head was observed near the air handler near the lockers.
On 03/18/14 at 8:30 A.M. in an interview Staff BB confirmed the findings.

4. On 03/18/14 at 8:41 A.M. in the women's locker room two dirty sprinkler heads were observed near the air handler in the back of the locker room.
On 03/18/14 at 8:41 A.M. Staff AA confirmed the observation in an interview.

5. On 03/19/14 at 11:36 A.M. treatment coordinator room 5090 had cubicle dividers less than 18 inches from the ceiling with sprinklers.
On 03/19/14 at 11:36 A.M. Staff AA confirmed the observation.

6. On 03/19/14 at 11:02 A.M. a tour was conducted of the fifth floor of the north wing and west wing with Staff AA and BB. At 11:51 A.M. in housekeeping room 5108 a sprinkler head was observed immediately next to a box light.
On 03/19/14 at 11:51 A.M. in an interview, Staff AA confirmed the observation.

7. At 12:04 P.M. in room 5103 was observed to have paper stacked less than 18 inches from a ceiling with sprinkler heads.
On 03/19/14 at 12:04 P.M. Staff AA confirmed the observation.

8. On 03/19/14 at 3:35 P.M. a tour was conducted of the second floor north and west wing with Staff AA and BB. At 4:41 P.M. in rooms 2093B, 2114, and 2100 sprinklers were observed to be missing their cover plates.
On 03/19/14 at 4:41 P.M. in an interview, Staff AA confirmed the observation.

9. On 03/20/14 at 10:45 A.M. a tour of the north and west wings of the A level was conducted with Staff AA and BB. At 11:02 A.M. observation in the office space near the eastern exit revealed a missing cover plate to a sprinkler head.
On 03/20/14 at 11:02 A.M. in an interview Staff BB confirmed the observation.

10. On 03/21/14 at 8:40 A.M. a tour was conducted of the central supply room of the B level with Staff AA and BB. At 8:55 A.M. a sign hanging from the ceiling grid work holding ceiling tiles in place and reading "carts B001-B017" was observed approximately less than 6 inches horizontally from a sprinkler head. Cart 42 was observed to have a height such that it extended to less than 18 inches from the ceiling, and had material on the top shelf.
At 8:55 A.M. Staff AA confirmed the observation.

11. On 03/21/14 at 9:40 A.M. a sprinkler head escutcheon ring was observed missing. The sprinkler was observed over the double doors leading to the post operative area.
On 03/21/14 at 9:40 A.M. in an interview Staff AA confirmed the observation.

12. On 03/24/14 at 11:20 A.M. a tour was conducted of the D level (with the exception of the south wing) with Staff AA and BB. At 12:16 P.M. in the men's locker room a sprinkler was missing the escutcheon ring.
On 03/24/14 at 12:16 P.M. in an interview, Staff AA confirmed the observation.





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13. Tour of the Lab located on the C floor of the South Tower conducted on 03/21/14 revealed boxes on middle shelves of the southwest storage room (C025) approximately 8 inches from the sprinkler heads potentially influencing changes in spray pattern. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 10:05 AM.

Based on observation and interview, the facility failed to ensure space heaters were not kept in patient care areas. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings include:
On 03/21/14 at 11:34 A.M. a tour was conducted of the C level of the west wing/courtyard building with Staff AA and BB and others. At 2:43 P.M. observation inside room c312, which was near a radiology patient treatment area, revealed a space heater plugged into a mechanical timer mechanism plugged into an extension cord, suggesting it could turn on without any supervision whatsoever.
On 03/21/14 at 11:34 A.M. Staff AA confirmed the observation.

Based on observation and interview, the facility failed to keep patient care areas free of space heaters. This had the potential to affect all patients, staff and visitors to the facility. The patient census was 362 at the beginning of the survey.

Findings include:

On 03/17/14 at 3:02 P.M. a tour was conducted of the north and west wing of the ninth floor with staff AA and BB. At 3:24 P.M. in room 9107 an office space within a smoke compartment shared by patients, a space heater was found.

Based on observation and interview, the facility failed to ensure trash collection receptacles with capacities greater than 32 gallons were located in a room protected as hazardous when not attended. This has the potential to affect all patients, staff, and visitors to the facility. The patient census at the beginning of the survey was 362.
Findings include:
1. On 03/20/14 at 10:45 A.M. a tour of the north and west wings of the A level was conducted with Staff AA and BB. At 11:50 A.M. in the north/south corridor of the north wing a waste receptacle of greater than 32 gallons was observed in the corridor for more than 30 minutes.
On 03/20/14 at 11:50 A.M. in an interview, Staff AA confirmed the observation.

2. On 03/24/14 at 11:20 A.M. a tour was conducted of the D level (with the exception of the south wing) with Staff AA and BB. At 12:10 P.M. a garbage receptacle of greater than 32 gallons was observed parked for more than 30 minutes on the path of egress to west wing 1 stairwell.
On 03/24/14 at 12:10 P.M. in an interview, Staff AA confirmed the observation.

Based on observation and staff conformation the facility failed to have extra sprinkler heads and a sprinkler head wrench at the sprinkler riser, as per NFPA 101 39.1.2.2 in accordance with 9.7.5 and NFPA 25 section 2-4.1.4. The patient census at the beginning of the survey was 15.

Findings include:

Tour of the facility completed on 03/24/14 revealed rapid sprinkler heads with red bulbs were installed throughout the physical therapy area and no spare rapid sprinkler heads with red bulbs were noted to be in the red sprinkler head box by the riser. No sprinkler head wrench was noted to be in or near the box as well. This was confirmed by Staff MM at the time of the observation on 03/24/14 at 11:55 AM.

Interview with the building maintenance person completed on 03/24/14 at 11:50 AM revealed that he/she did not know where the wrench was at but stated the company that works on the sprinkler system must keep it and bring it when it is needed. He/she also did not know of any other spare sprinkler heads in the building.

Based on observation the facility failed to provide safe access to public way, as per NFPA 101 section 38.2.7 in accordance with section 7.7.1. This has the potential to affect all patients that receive services from the facility. The census was zero during the facility tour on 03/25/14.

Findings include:

Tour of the facility conducted on 03/24/14 revealed an exit discharge at the Southeast stairwell that exited to a 4 feet by 4 feet concrete pad then to a grass covered area encompassing an approximate 20 foot distance to the nearest paved common way. This was presented to Staff MM on 03/24/14 at 11:00 AM.

Based on observation and interview, the facility failed to maintain the fire proofing coating to its steel I-beams. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings include:
1. On 03/24/14 at 11:20 A.M. a tour was conducted of the D level (with the exception of the south wing) with Staff AA and BB. At 11:26 A.M. observation above the drop down ceiling near room D300ZA revealed two horizontal, parallel I-beams, joined by one perpendicular to each, near the wall. At the joint of the I-beams, the fire resistive spray coating was observed to be missing.
On 03/24/14 at 11:26 A.M. in an interview, Staff AA confirmed the observation.

2. On 03/24/14 at 11:36 A.M. the I-beam in the electrical closet in oncology was also observed to be missing some of its fireproofing material.
On 03/24/14 at 11:36 A.M. in an interview, Staff AA confirmed the observation.

Based on observation and interview, the facility failed to ensure each opening onto a corridor had a smoke detector (where required) and each corridor was resistant to the passage of smoke. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings include:
1. On 03/17/14 at 3:02 P.M. a tour was conducted of the west and north wing of the ninth floor with Staff AA and BB. At 3:12 P.M. observation in the electrical closet close to the southern smoke doors revealed gaps in the tiles. Observation above the drop down ceiling in the electrical closet revealed a one inch open conduit communicating to the hallway.
On 03/17/14 at 3:12 P.M. in an interview, Staff BB confirmed the observations.

2. On 03/19/14 at 11:02 A.M. a tour was conducted of the north and west wing of the fifth floor with Staff AA and BB. Observation in room 5093 revealed the wall to have an opening to the corridor of six by six inches in size. The corridor is sprinklered, however, tiles in the corridor had corners that were missing and therefore would be unable to resist the passage of smoke from room 5093.
On 03/19/14 at 11:02 A.M. in an interview, Staff AA and BB confirmed the observation.

3. On 03/19/14 at 1:45 P.M. a tour was conducted of the 4th floor north and west wing with Staff AA and BB. At 2:22 P.M. the four west waiting area was observed to have sprinklers but no smoke detector or constant supervision by staff.
On 03/19/14 at 1:45 P.M. in an interview, Staff AA confirmed the observation.

4. At 2:40 P.M. observation of the chapel revealed it had a door which was open to the corridor, which had sprinklers, but no smoke detector.
On 03/19/14 at 2:40 P.M. in an interview, Staff AA confirmed the lack of a smoke detector.

5. On 03/24/14 at 11:20 A.M. a tour was conducted of the D level (with the exception of the south wing) with Staff AA and BB. At 12:18 P.M. clean supply room D528B was observed to open onto the corridor (i.e. it did not have a door) and it did not have a smoke detector.
On 03/24/14 at 11:20 A.M. in an interview, Staff AA confirmed the observation.

6. On 03/24/14 at 2:35 P.M. a tour was conducted of the B level of the Heart Center with Staff AA and BB. At 2:35 P.M. observation of the cardio vascular intensive care unit waiting area revealed it opened onto a corridor, the area in its totality was not monitored around the clock, and did not have a smoke detector.
On 03/24/14 at 2:35 P.M. in an interview, Staff AA confirmed the area did not have a smoke detector.

Based on observation and interview, the facility failed to ensure each corridor door had means suitable to stay closed. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings includes:
1. On 03/17/14 at 3:02 P.M. a tour was conducted of the north and west wing of the ninth floor with Staff AA and BB. At 3:25 P.M. observation of the staff bathroom door that opened onto the corridor revealed it did not close completely.
On 03/17/14 at 3:25 P.M. in an interview, Staff BB confirmed the observation.

2. On 03/19/14 at 11:02 A.M. a tour was conducted of the fifth floor of the west and north wing with Staff AA and BB. At 11:51 A.M. observation of the door to patient room 5679 revealed the door had a broken latch and would not close properly.
On 03/19/14 at 11:51 A.M. in an interview Staff BB confirmed the observation.

3. On 03/20/14 at 8:45 A.M. a tour was conducted of the first floor north and west wings with Staff AA and BB. At 10:27 A.M. a one hour rated wall with a one hour rated door leading to a biohazard room was observed to close but not latch because there was tape over the latch.
On 03/20/14 at 10:27 A.M. in an interview Staff C confirmed the latch was taped over because at one point the staff didn't have a key to the room.

4. On 03/20/14 at 10:45 A.M. a tour of the north and west wings of the A level was conducted with Staff AA and BB. Observation of double doors opening from the physician only dining area out onto the corridor revealed a gap of greater than an eighth of an inch.
At 1:30 P.M. the left half of the double doors at the entrance to the cafeteria's food service area were observed first to be propped open with a utensil dispenser, then observed not to close because the self closer was rubbing against the closing bar.
On 03/20/14 at 1:30 P.M. in an interview Staff AA confirmed the observation.

5. On 03/24/14 at 11:20 A.M. a tour was conducted of the D level (with the exception of the south wing) with Staff AA and BB. At 11:55 A.M. the corridor door to the tumor registry office space was observed not to entirely close.
On 03/24/14 at 11:55 A.M. in an interview, Staff BB confirmed the observation.

Based on observation and interview, the facility failed to ensure each door opening onto a corridor met the requirement at 18.3.6.3, life safety code 101, 2000 edition. This has the potential to affect all patients, staff, and visitors to the facility. The census was 362 patients at the beginning of the survey.

Findings include:
On 03/19/14 at 8:20 A.M. a tour of the 6th floor north and west wing was conducted with Staff AA and BB. Observation of the bathroom door opening to the corridor revealed the self closer did not close and latch the door.
On 03/19/14 at 8:20 A.M. in an interview Staff AA confirmed the observation.
At 9:50 A.M. a Dutch door was observed in the corridor of the west wing. It was not observed to have an astragal, sweep or flap between the doors.
On 03/19/14 at 9:50 A.M. in an interview, Staff AA and BB confirmed the observation.

Based on observation and interview, the facility failed to maintain the stated rating surrounding each vertical enclosure. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.


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Findings includes:

1. Tour of the 8th floor of the South Wing conducted on 03/19/14 revealed a 3/4 inch flex conduit with gray cables passing through and open on the end penetrating the two hour fire wall of the South stairwell visible from the South corridor which travels east and west. This was confirmed by Staff MM at the time of the observation on 03/29/14 at 1:56 PM.

2. Tour of the 4th floor of the South Wing conducted on 03/20/14 revealed access panels above the linen and trash chutes have inadequate securing devices and bends in the access panel corners allowing open space into the two hour rated vertical shaft. This was confirmed by Staff MM at the time of the observation on 03/20/14 at 10:30 AM.

3. Tour of the 2nd floor of the South Wing conducted on 3/20/14 revealed an 3/4 inch gap between the decking and the concrete block wall on the corridor side of the stairwell between the north stairwell and the elevator shaft. This was presented to Staff MM at the time of the observation on 03/20/14 at 2:25 PM.

4. Tour of the 1st floor of the South Wing conducted on 03/20/14 revealed a 3/4 inch conduit open on the end penetrating the south stairwell west wall located in the south egress corridor. This was confirmed by Staff MM at the time of the observation on 03/20/14 at 4:05 PM.

5. Tour of the B floor of the South Wing conducted on 03/21/14 revealed an 8 inch water pipe in the two hour west wall with a 2 inch gap around the pipe and a 2 inch water pipe in the south wall with a gap around the pipe in the north exit stairwell. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 8:23 AM.

Based on observation and interview, the facility failed to maintain the rating assigned to each of its rated walls that formed a smoke compartment. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings include:
1. On 03/17/14 at 3:02 P.M. a tour was conducted of the west wing and north wing of the ninth floor with Staff AA and BB. Review of the schematic revealed the wing to be bisected by a one hour smoke barrier that ran north/south. On 03/17/14 at 3:06 P.M. in that barrier at the southern double doors and above the drop down ceiling a copper line in a copper sleeve there was a communicating space between the line and the sleeve.
On 03/17/14 at 3:06 P.M. in an interview Staff BB confirmed the finding.

2. At 3:42 P.M. above the drop down ceiling in the wall perpendicular to west wing stairwell 1, a two foot by one foot penetration was observed with three two inch conduits communicating through it.
On 03/17/14 at 3:42 P.M. Staff AA and BB confirmed the observation.

3. On the ninth floor, on 03/18/14 at 9:31 A.M. observation above the drop down ceiling over the north/south smoke barrier located in the northeast portion of the west wing revealed two heating, ventilation and cooling ducts with annular spaces.
On 03/18/14 at 9:31 A.M. in an interview Staff BB confirmed the observation.

4. On the ninth floor on 03/18/14 at 9:50 A.M. in the smoke barrier by conference room 9109 and perpendicular to a distal pair of double doors, an annular space was observed around a two inch cast iron ring in the wall above the drop down ceiling.
On 03/18/14 at 9:50 A.M. in an interview Staff BB confirmed the observation.

5. On 03/18/14 at 10:09 A.M. a tour was conducted of the eighth floor north and west wing with Staff AA and BB and others. At 10:25 A.M. observation above the drop down ceiling over the double doors leading to the wing revealed two one inch open conduits.
On 03/18/14 at 10:25 A.M. in an interview, Staff BB confirmed the observation.

6. On 03/18/14 at 11:48 A.M. the two hour rated barrier surrounding the lift room for the dumb waiters was observed to be penetrated by a sprinkler line and a one inch conduit with an annular space and the door was not rated.
On 03/18/14 at 11:48 A.M. in an interview Staff BB confirmed the observation.

7. On 03/19/14 at 11:02 A.M. a tour was conducted of the fifth floor of the west and north wing with Staff AA and BB. Observation above the drop down ceiling at the double doors leading to the corridor to either northwest stairwell two or three, at 11:18 A.M., revealed four one inch conduits with annular spaces.
On 03/19/14 at 11:02 A.M. in an interview, Staff BB confirmed the observation.

8. On 03/19/14 at 1:45 P.M. a tour was conducted of the 4th floor north and west wing with Staff AA and BB. Review of the 4th floor schematic revealed a data closet (4133) with a one hour fire rated perimeter. Observation above the drop down ceiling revealed a two to three inch conduits open to air in the wall over the door to the room.
On 03/19/14 at 1:45 P.M. in an interview, Staff BB confirmed the observation.

9. At 2:29 P.M. observation of the northern part of the smoke barrier that separates the wing into two smoke compartments revealed above the drop down ceiling revealed two one inch conduits open to air, one with two orange wires coming out of it.
On 03/19/14 at 2:29 P.M. in an interview, Staff BB confirmed the observation.

10. On 03/19/14 at 3:35 P.M. a tour was conducted of the second floor north and west wing with Staff AA and BB. Observation above the double doors that lead to the south wing revealed an open junction box with an open conduit leading through the two hour fire barrier.
On 03/19/14 at 3:35 P.M. in an interview Staff BB confirmed the observation.

11. On 03/20/14 at 8:45 A.M. a tour of the first floor west and north wing was conducted with Staff AA and BB. At 8:56 A.M. the doors in the fire barrier leading to the south wing were observed to be not rated.
On 03/20/14 at 8:45 A.M. in an interview, Staff AA confirmed the observation.

12. At 9:01 A.M. observation of the door in a two hour rated stairway (not an exit) near the chapel, revealed the door to be not rated.
On 03/20/14 at 9:01 A.M. in an interview, Staff AA confirmed the observation.

13. On 03/20/14 at 8:45 A.M. a tour was conducted of the first floor north and west wings with Staff AA and BB. Observation of the double doors in the one fire rated barrier across the northeast corridor in the north wing revealed the right door closed but did not latch.
On 03/20/14 at 8:45 A.M. in an interview, Staff AA confirmed the observation.

14. At 10:17 A.M. observation of the one hour rated wall above the drop down ceiling in the soiled utility room of the west wing revealed a one inch by one inch square opening in the wall.
On 03/20/14 at 10:17 A.M. in an interview, Staff BB confirmed the observation.

15. At 10:35 A.M. observation above drop down ceiling over the double doors that separated the west wing from the courtyard building revealed an open junction box with a one inch open conduit that communicated through the two hour rated wall.
On 03/20/14 at 10:35 A.M. in an interview Staff BB confirmed the observation.

16. On 03/20/14 at 10:45 A.M. a tour of the north and west wings of the A level was conducted with Staff AA and BB. Observation above the double doors, in a two hour rated wall, that leads to the north wing revealed four or more conduits with conjoined annular spaces.
On 03/20/14 at 10:45 A.M. in an interview Staff BB confirmed the observation.

17. At 11:58 A.M. observation of the door in the two hour rated wall between a corridor and legal services revealed the door to legal services had its label painted over and the rating indiscernible.
At 11:58 A.M. in an interview Staff AA confirmed the observation.

18. At 12:02 P.M. observation above the drop down ceiling of the two hour rated wall at the right angle formed between the wall shared by legal services and the north/south wall, two two inch conduits with gray wires were observed open to air and another penetration was created by a blue wire.
At 12:02 P.M. in an interview, Staff BB confirmed the observation.

19. At 2:00 P.M. observation above the drop down ceiling over the double doors in the corridor leading to the heart center revealed the two hour rated wall did not extend all the way across to the outside wall that formed an acute angle with the heart center's outside wall.
On 03/20/14 at 2:00 P.M. in an interview Staff BB confirmed the observation.

20. On 03/21/14 at 8:22 A.M. a tour was conducted of the north and west wings, surgical areas, and post/pre operative areas with Staff AA and BB.

21. At 8:22 A.M. observation above the drop down ceiling over the double doors across the corridor leading to stairwell North West 2, revealed three three inch open conduits, one of which had a white rag stuffed into it.
At 8:22 A.M. in an interview, Staff BB confirmed the observation.

22. On 03/21/14 at 8:40 A.M. a tour was conducted of the central supply room of the B level with Staff AA and BB and others.
At 8:45 A.M. observation of the sliding doors leading into the clean storage area, and within a two hour rated wall, revealed their labels to be painted over and the rating indiscernible.
At 8:45 A.M. in an interview, Staff AA confirmed the observation.

23. At 9:00 A.M. observation of the most western double doors leading into the central supply room (from a corridor leading to the heart center), revealed the doors were in a two hour fire rated wall, but were themselves not rated.
At 9:00 A.M. in an interview Staff AA confirmed the observation.

24. At 9:12 A.M. just south of those double doors, observation of above the drop down ceiling of another set of double doors in a one hour rated wall revealed a one inch conduit with two grey wires coming out of it and it was unstopped.
At 9:12 A.M. in an interview, Staff BB confirmed the observation.

25. Continuing south down the corridor, at 9:18 A.M. observation above the drop down ceiling over double doors revealed a one inch conduit open to air. This is near post operative area.
At 9:18 A.M. in an interview Staff BB confirmed the findings.

26. Continuing south down the corridor along the postoperative suite, at 9:38 A.M. a junction box with a one inch communicating conduit from the one hour rated wall, was observed to have a one inch open hole.
At 9:38 A.M. in an interview Staff BB confirmed the findings.

27. Continuing south down the corridor and making a left turn to the east, at 9:48 A.M. observation above the drop down ceiling over the double doors there (and near sign for OR 9-12) revealed there wasn't a barrier there in the one hour rated wall.

28. On 03/21/14 at 10:35 A.M. observation above the drop down ceiling of the two hour rated wall that separated the south wing from the area of the operating rooms revealed an open junction box.
On 03/21/14 at 10:35 A.M. in an interview, Staff BB confirmed the observation.

29. On 03/24/14 at 11:20 A.M. a tour was conducted of the D level (with the exception of the south wing) with Staff AA and BB and others. At 11:55 A.M. observation above the drop down ceiling of the two hour rated wall running in back of the tumor registry office space, a two inch by two inch square penetration was observed.
On 03/24/14 at 11:55 A.M. in an interview, Staff BB confirmed the observation.

30. On 03/24/14 at 2:35 P.M. a tour was conducted of the B level of the Heart Center with Staff AA and BB. At 3:29 P.M. observation above the drop down ceiling of the two hour rated wall over the double doors from the heart center to same day surgery revealed a two inch hole.
On 03/24/14 at 3:39 P.M. in an interview, Staff BB confirmed the observation.

31. On 03/24/14 at 3:45 P.M. a tour was conducted of C floor of Heart Center with Staff AA and BB. At 4:23 P.M. observation above the drop down ceiling of the two hour rated wall over the double doors heading to C west and computed tomography and heart catheterization labs revealed a penetration with two Garey wires coming out of it.
On 03/24/14 at 4:23 P.M. in an interview, Staff BB confirmed the observation.

32. At 4:26 P.M. observation above the drop down ceiling of the one hour rated wall above the double doors in the eastern most corridor revealed a three inch open to air conduit.
On 03/24/14 at 4:26 P.M. in an interview, Staff BB confirmed the observation.





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33. Tour of the 9th floor of the South Tower conducted on 03/19/14 revealed a one and a half inch conduit with multiple cables passing through was open on the end and a 3/4 inch conduit open on the end both penetrating the three hour wall of the separation between the South Tower and the North Tower above the corridor doors. This was confirmed by Staff MM at the time of the observation on 03/19/14 at 11:15 AM.

34. Tour of the 9th floor of the South Tower conducted on 03/19/14 revealed three, 3/4 inch conduits open on end penetrating the two hour fire rated wall of the east elevator shaft located in the west wall of room 9172. This was confirmed by Staff MM at the time of the observation on 03/19/14 at 11:52 AM.

35. Tour of the 8th floor of the South Tower conducted on 03/19/14 revealed an 8 inch and a 6 inch water/steam pipe with a 3 inch gap below the pipes which penetrates the north three hour wall in room 8154A separating the South Tower from the North Tower. This was confirmed by Staff MM at the time of the observation on 03/19/14 at 12:03 PM.

36. Tour of the 4th floor of the South Tower conducted on 03/20/14 revealed a 3/4 inch conduit with 1/2 inch gap above the conduit, penetrating the three hour wall separating the South Tower from the North Tower in the physical therapy room's North wall. This was confirmed by Staff MM at the time of the observation on 03/20/14 at 10:09 AM.

37. Tour of the 1st floor of the South Tower conducted on 03/20/14 revealed a 3/4 flex conduit and a 3/4 inch conduit penetrating the north wall of the south exit corridor across from the exit doors with a half inch open gap around the penetrations. This was confirmed by Staff MM at the time of the observation on 03/20/14 at 4:15 PM.

38. Tour of the A floor of the South Tower conducted on 03/20/14 revealed the 1 1/2 rated northwest corner doors of the exit corridor had a self closer but did not latch when released from the magnetic holder. This was confirmed by Staff MM at the time of the observation on 03/20/14 at 4:45 PM.

39. Tour of the A floor of the South Tower conducted on 03/20/14 revealed an 6 inch pneumatic tube open on the end and a 10 inch by 10 inch junction box without a cover with a 1 1/2 inch conduit connected to the box open on end. Both penetrated the two hour wall above the south exit access doors in the exit corridor. This was confirmed by Staff MM at the time of the observation on 03/20/14 at 5:00 PM.

40. Tour of the B floor of the South Tower conducted on 03/21/14 revealed a 1/2 inch gap above a 6 inch pneumatic tube penetrating the north two hour separation in the north corridor traveling east and west. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 8:15 AM.

41. Tour of the pharmacy on the B floor of the South Tower conducted on 03/21/14 revealed an 8 inch pipe penetrating the north two hour wall with a 3 inch gap above the pipe. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 8:34 AM.

42. Tour of the B floor of the South Tower conducted on 03/21/14 revealed a 5 inch by 5 inch hole in the one hour wall above the corridor doors in the west non-sterile corridor on the OR side of the corridor. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 8:40 AM.

43. Tour of the Radiology office waiting area on the C floor of the South Tower conducted on 03/21/14 revealed 3/4 inch flex conduit and 3/4 inch conduit penetrating the west two hour wall with opening around both conduits. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 9:40 AM.

44. Tour of the Radiology office "dark imaging reading room" on the C floor of the South Tower conducted on 03/21/14 revealed multiple penetrations of varying size from 2 feet to 6 inches with multiple pipes of varying size passing through. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 9:45 AM.

45. Tour of the South corridor below the lab on the C floor of the South Tower conducted on 03/21/14 revealed multiple penetrations of varying size above the west corridor doors. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 10:37 AM.

Based on observation and interview, the facility failed to maintain the rating assigned to each of its rated walls that formed a smoke compartment. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings include:
1. On 03/18/14 at 10:09 A.M. a tour was conducted of the eighth floor north and west wing with Staff AA and BB. At 10:25 A.M. observation above the drop down ceiling over the double doors leading to the wing revealed two one inch open conduits.
On 03/18/14 at 10:25 A.M. in an interview, Staff BB confirmed the observation.
2. On 03/18/14 at 11:48 A.M. the two hour rated barrier surrounding the lift room for the dumb waiters was observed to be penetrated by a sprinkler line and a one inch conduit with an annular space and the door was not rated.
On 03/18/14 at 11:48 A.M. in an interview Staff BB confirmed the observation.
3. On 03/18/14 at 2:05 P.M. a blue wire was observed to penetrate the one hour smoke barrier opposite room 8066 and next to kitchenette
On 03/18/14 at 2:05 P.M. in an interview, Staff BB confirmed the observation.
4. On 03/18/14 at 2:58 P.M. a tour was conducted of the seventh floor north and west wing with Staff AA and BB. At 4:27 P.M. room 7100, a room containing dumb waiters, was observed per schematic to be wrapped in two hour fire rated construction. However, at 4:27 P.M. the door was observed to be not rated and above the drop down ceiling an annular space was observed around a sprinkler line.
On 03/18/14 at 4:27 P.M. Staff BB confirmed the observation.
5. On 03/18/14 at 4:37 P.M. a tour was conducted of the 6th floor with Staff AA and BB. At 4:38 P.M. observation above the drop down ceiling in the chute room revealed the barrier with one one inch conduit with an annular space, and two flex conduits open to air.
On 03/19/14 at 4:38 P.M. in an interview, Staff BB confirmed the observation.
6. On 03/19/14 at 8:20 A.M. the tour of the 6th floor resumed with Staff AA and BB. At 9:04 A.M. observation above the double doors leading to the west wing clinical unit revealed a one inch conduit in an open junction box communicating through the barrier.
On 03/19/14 at 8:20 A.M. in an interview Staff BB confirmed the observation.
7. On 03/21/14 at 11:34 A.M. a tour was conducted of the C level of the west wing/courtyard building with Staff AA and BB. At 11:34 A.M., observation of the one hour rated wall above drop down ceiling over the double doors leading to the heart station area and near west wing stairwell 1, revealed three tubes with annular spaces and one conduit with a blue wire but open to air.
On 03/21/14 at 11:34 A.M. in an interview, Staff BB confirmed the observation.
8. On 03/21/14 at 11:48 A.M. observation of the two hour rated wall above the drop down ceiling near the double doors near the imaging library revealed an approximate one yard by one yard square opening.
On 03/21/14 at 11:48 A.M. in an interview, Staff BB confirmed the observation.
9. On 03/21/14 at 12:10 P.M. near the outpatient center 1 stairwell, observation above the drop ceiling of the one hour rated wall dividing an office space from the heart station suite, revealed an annular space around a sprinkler line.
On 03/21/14 at 12:10 P.M. in an interview, Staff BB confirmed the observation.
10. On 03/21/14 at 2:28 P.M. observation above the drop down ceiling of the one hour rated wall from the other side of room C361, revealed an unsealed one inch conduit and two one inch holes.
On 03/21/14 at 2:28 P.M. in an interview, Staff BB confirmed the observation.
11. At 3:10 P.M. observation of the one hour wall above the drop down ceiling surrounding data closet c370a revealed an open junction box with two communicating conduits open to air.
At 3:10 P.M. in an interview, Staff BB confirmed the observation.

Based on observation and interview, the facility failed to ensure doors in each smoke barrier closed. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings include:
On 03/24/14 at 2:35 P.M. a tour was conducted of the B level of the Heart Center with Staff AA and BB and others. At 3:12 P.M. the double doors in the smoke barrier across from room B715 to B764 failed to close.
On 03/24/14 at 2:35 P.M. in an interview, Staff AA confirmed the observation.

Based on observation and interview, the facility failed to ensure each storage area with a rated wall maintained the rating to that wall. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings:
1. On 03/17/14 at 1:55 P.M. a tour was conducted of the 10th floor, west and north wing, with Staff AA, BB. At 2:26 P.M. observation above the drop down ceiling of storage/collection room 9914 revealed the west wall to have a one yard wide by one yard high penetration with steel conduits running through it.
On 03/17/14 at 2:26 P.M. Staff BB confirmed the finding.

2. At 2:45 P.M. observation above the drop down ceiling of supply room 9110 revealed two one inch open conduits in the east wall. At 2:48 P.M. observation above the drop down ceiling of the same room revealed two one inch conduits running from the wall to an open junction box, two one foot, insulated pipes with annular spaces, and a sprinkler line coming from the north wall with an annular space.
On 03/17/14 at 2:48 P.M. Staff BB confirmed the findings.

3. On 03/17/14 at 3:21 P.M., on the 9th floor of the north and west wing, in the biohazard room, observation above the drop down ceiling in the east wall an open one inch conduit was observed, in the north wall a water pipe with an annular space was observed, and in the south wall a one inch conduit traveling to an open conduit was observed.
On 03/17/14 at 3:21 P.M. in an interview Staff BB confirmed the finding.

4. On 03/24/14 at 2:35 P.M. a tour was conducted of the B level of the Heart Center with Staff AA and BB. At 2:42 P.M. observation above the drop down ceiling of the one hour rated wall around a storage area located on the southern end revealed a two inch pipe with an annular space.
On 03/24/14 at 2:42 P.M. in an interview, Staff BB confirmed the observation.

5. On 03/24/14 at 2:50 P.M. observation above the drop down ceiling of the one hour rated wall around clean storage room B754 revealed a three inch conduit holding a yellow and blue wire, open to air, and a one inch square penetration. Also at 2:50 P.M. the door to soiled utility room B757 was observed not to close shut because a cart in the room was stopping it from doing so.
On 03/24/14 at 2:50 P.M. in an interview, Staff BB and AA confirmed the observations

6. On 03/24/14 at 2:52 P.M. observation above the drop down ceiling of the one hour rated wall in biohazard room B757 revealed a sprinkler line with annular space and a heating, ventilation and cooling conduit with a gap underneath.
On 03/24/14 at 2:52 P.M. in an interview, Staff BB confirmed the observation.

7. On 03/24/14 at 3:05 P.M. observation above the drop down ceiling of the one hour rated wall around clean storage room B763 revealed on the east wall a penetration by a Garey wire and on the west wall a one inch open to air conduit with a blue wire.
On 03/24/14 at 3:05 P.M. in an interview, Staff BB confirmed the observation.

8. On 03/24/14 at 3:45 P.M. a tour was conducted of C floor of Heart Center with Staff AA and BB. At 4:05 P.M. observation above the drop down ceiling of the one hour rated wall in soiled utility room C760 revealed a one foot by one foot opening in the right corner of the room.
On 03/24/14 at 4:05 P.M. in an interview, Staff BB confirmed the observation.

9. On 03/24/14 at 4:13 P.M. observation above the drop down ceiling of the one hour rated wall in the room adjacent to room C760, entered from the most eastern corridor, revealed over the door an orange conduit holding a Garey wire open to air and an heating, ventilation and cooling conduit with a half inch gap underneath supported by a wooden triangle.
On 03/24/14 at 4:13 P.M. in an interview, Staff BB confirmed the observation.

10. On 03/24/14 at 3:45 P.M. a tour was conducted of C floor of Heart Center with Staff AA and BB. At 4:35 P.M. observation above the drop down ceiling of the one hour rated wall around soiled utility room C742 revealed over the door an orange sleeve open to air holding Garey wires.
On 03/24/14 at 4:35 P.M. in an interview, Staff BB confirmed the observation.




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11. Tour of the 7th floor of the South Tower conducted on 03/19/14 revealed a 1/2 inch conduit with gray cables penetrating the one hour west wall of the soiled utility room (7042) from the corridor side of the wall. This was confirmed by Staff MM at the time of the observation on 03/19/14 at 2:42 PM.

12. Tour of the 6th floor of the South Tower conducted on 03/20/14 revealed a 3/4 inch conduit open on end penetrating the one hour wall between the clean utility room and the East corridor. This was confirmed by Staff MM at the time of the observation on 03/20/14 at 8:50 AM.

13. Tour of the 5th floor of the South Tower conducted on 03/20/14 revealed a 2 inch sleeve open on both sides of the wall with gray and blue wiring passing through the one hour wall between the clean utility room (5043) and the East corridor. This was confirmed by Staff MM at the time of the observation on 03/20/14 at 9:45 AM.

14. Tour of the 3rd floor of the South Tower conducted on 03/20/14 revealed a 1/2 inch penetration of the East one hour wall of room 3038. This was confirmed by Staff MM at the time of the observation on 03/20/14 at 11:41 AM.

15. Tour of the Lab located on the C floor of the South Tower conducted on 03/21/14 revealed the door of the Southwest storage room (C025) with a one hour enclosure was propped open with 10 large boxes. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 10:05 AM.

16. Tour of the Lab located on the C floor of the South Tower conducted on 03/21/14 revealed a 1 inch conduit open on the end of both sides of the one hour West wall of room C013. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 10:15 AM.

17. Tour of the C floor of the South Tower conducted on 03/21/14 revealed multiple penetrations of varying size in all 4 walls of the one hour enclosure of room C014A in the South corridor. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 10:35 AM.

18. Tour of the C floor of the South Tower conducted on 03/21/14 revealed multiple penetrations varying in size on the North one hour wall of the south corridor between the Southwest lab storage room (C025) and the corridor. This was confirmed by Staff MM at the time of the observation on 03/24/14 at 11:55 AM.
This was verified by Staff MM on 03/24/14 at 11:55 AM.

Based on observation and interview, the facility failed to ensure each of its stairways used as exits were in accordance with 7.1 of NFPA 101, 2000 edition. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings include:
1. On 03/18/14 at 10:09 A.M. a tour was conducted of the eighth floor north and west wing with Staff AA and BB and others. At 10:56 A.M. observation above the drop down ceiling near northwest stair one, near women ' s locker room number 8150 revealed a small penetration to the wall.
In an interview, on 03/18/14 at 10:56 A.M. Staff BB confirmed the observation.
2. On 03/18/14 at 10:58 A.M. observation of the wall above the drop down ceiling near the women's locker room and near northwest stairwell 1, revealed open wire mesh on one side of the wall and an open junction box with a one inch communicating conduit.
On 03/18/14 at 10:58 A.M. Staff BB confirmed the observation.
3. On 03/18/14 at 11:02 A.M. observation above the drop down ceiling near the women's bathroom door and northwest stair 2 revealed a one inch conduit with a blue wire with an annular space.
On 03/18/14 at 11:02 A.M. in an interview Staff BB confirmed the observation.
4. On 03/18/14 at 2:58 P.M. a tour was conducted of the west wing and north wing of the seventh floor with Staff AA and BB. Observation of the door of northwest stair 3, an exit stair, revealed the door did not fully open as wheelchairs were observed to be on the landing obstructing it.
On 03/18/14 at 2:58 P.M. in an interview, Staff AA confirmed the observation.
5. On 03/18/14 at 3:45 P.M. observation above the drop down ceiling in the three hour wall in locker room 7177 revealed a two inch conduit with an annular space
On 03/18/14 at 3:45 P.M. in an interview, Staff BB confirmed the observation.
6. On 03/19/14 at 8:20 A.M. a tour of the 6th floor north and west wing was conducted with Staff AA and BB. Observation of the fire stairway exit doors revealed at the northwest stairway 1 revealed the double doors to be unrated.
On 03/19/14 at 8:20 A.M. in an interview Staff AA confirmed the observation.
7. At 8:37 A.M. above the drop down ceiling in northwest stairway 1 observation revealed at the stairway itself, an open junction box with an open communicating one inch conduit.
On 03/19/14 at 8:37 A.M. in an interview Staff BB confirmed the observation.
8. On 03/19/14 at 8:38 A.M. observation above the drop down ceiling over the east doors of the stairway revealed an open junction box with a communicating two inch conduit.
On 03/19/14 at 8:38 A.M. in an interview Staff BB confirmed the observation.
9. At 9:45 A.M. the fire door at fire exit stairwell west wing 2 was observed to close and not latch.
On 03/19/14 at 9:45 A.M. in an interview Staff AA confirmed the observation.

Based on observation and interview, the facility failed to ensure each of its stairways used as exits were in accordance with 7.1 of NFPA 101, 2000 edition. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings include:
1. On 03/18/14 at 8:30 A.M. the tour of the ninth floor west and north wing resumed with Staff AA and BB. At 9:08 A.M. observation above the drop down ceiling over the double doors near north wing stair 1 and the women ' s locker room, revealed annular spaces around three conduits and one flex conduit.
On 03/18/14 at 9:08 A.M. in an interview, Staff BB confirmed the observation.

2. At 9:12 A.M. observation above the drop down ceiling over the double doors near the men ' s locker room revealed a two inch fiber duct that communicated through the two hour rated barrier and had been spliced open.
On 03/18/14 at 9:12 A.M. in an interview, Staff BB confirmed the observation.

3. On 03/19/14 at 11:02 A.M. a tour was conducted of the fifth floor of the west wing and north wing with Staff AA and BB. Observation of the double doors in the fire exit leading North West stairwell 1 revealed they were not rated and did not close because the coordinator did not work.
On 03/19/14 at 11:02 A.M. in an interview, Staff AA confirmed the observation.

4. At 11:05 A.M. observation of the door out of the respiratory storage room and into the northwest stairway 1, revealed the door was not rated.
On 03/19/14 at 11:05 A.M. in an interview Staff AA confirmed the observation.

5. On 03/19/14 at 1:45 P.M. a tour was conducted of the 4th floor north and west wing with Staff AA and BB. At 1:52 P.M. observation of the wall above the double doors in the corridor that lead to exit stairway northwest 1 revealed a fist sized opening near the heating, ventilation and cooling tube.
On 03/19/14 at 1:45 P.M. in an interview Staff BB confirmed the observation.

6. On 03/19/14 at 3:15 P.M. a tour was conducted of the third floor north and west wing with Staff AA and BB. At 3:15 P.M. observation above drop down ceiling of the two hour fire barrier over the west double doors in the area leading to fire stairway northwest 1, revealed a one inch conduit open in the junction box that communicated from the barrier.
On 03/19/14 at 3:15 P.M. in an interview, Staff BB confirmed the observation.

7. On 03/19/14 at 3:35 P.M. a tour was conducted of the second floor north and west wing with Staff AA and BB. At 3:58 P.M. observation of the door to fire stairwell northwest 1 revealed it was not rated.
On 03/19/14 at 3:35 P.M. in an interview Staff AA confirmed the observation.

8. On 03/20/14 at 8:45 A.M. a tour was conducted of the first floor north and west wings with Staff AA and BB. At 9:21 A.M. observation above the drop down ceiling over the double doors that lead to the northwest stairwell area revealed one open electrical junction box and another junction box with an open one inch conduit.
On 03/20/14 at 8:45 A.M. in an interview, Staff BB confirmed the observation.

9. At 9:45 A.M. observation of the door at the northwest three fire stairwell revealed the door was not rated and did not close and latch.
On 03/20/14 at 9:45 A.M. in an interview Staff AA confirmed the observation.

10. On 03/20/14 at 10:45 A.M. a tour of the north and west wings of the A level was conducted with Staff AA and BB. At 11:11 A.M. the door to the fire exit stairwell west wing 2 was observed to not be rated.
On 03/20/14 at 10:45 A.M. in an interview Staff AA confirmed the observation.

11. At 1:59 P.M. the door of the fire exit stairwell west wing 2 was observed to have its label painted over.
On 03/20/14 at 1:59 P.M. in an interview, Staff AA confirmed the observation.

12. On 03/24/14 at 2:00 P.M. a tour was conducted of the A level of the Heart Center with Staff AA and BB. Observation of the door on fire exit stairwell heart center 1 revealed the label to be painted over and the rating indiscernible.
On 03/24/14 at 2:00 P.M. in an interview, Staff AA confirmed the observation.

13. At 2:12 P.M. observation of the door on fire stairwell exit heart center stair 2 revealed the label was painted over and the rating was not discernible.
On 03/24/14 at 2:12 P.M. in an interview, Staff AA confirmed the observation.

Based on observation and interview, the facility failed to ensure each path of egress was free of impediments. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings:
On 03/22/14 at 10:38 A.M. the tour of the C level of the west wing/courtyard building with Staff AA and BB and others was resumed. At 11:00 A.M. observation of the sliding doors on the path of egress out of the computed tomography suite revealed they were not of the breakaway type and did not unlock and release with the triggering of the fire alarm.
On 03/21/14 at 11:00 A.M. in an interview, Staff AA confirmed the observation.

Based on observation and staff confirmation the corridor was obstructed decreasing the corridor with to less than 4 feet. This has the potential to affect all patients, and visitors within this area of the facility. The census at the beginning of the survey was 362.

Findings include:

Tour of the corridor behind the operating room areas on B floor of South Tower completed on 03/21/14 revealed 3 pallets filled with boxes of various items located in the central corridor traveling east to west and boxes/equipment not being used immediately by staff was located the south east corridor traveling north and south both decreasing the size of the corridor to less than 4 feet. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 8:55 AM.

Based on observation, staff confirmation, and document review the facility failed to test emergency lighting in the exit stairwell. This has the potential to affect all patients, staff, and visitors that enter the facility.

Findings include:

Tour of the surgery center conducted on 03/24/14 revealed the emergency lights failed to illuminate when staff conducted a test during the survey. The areas in which the lights failed to illuminate was in the North Exit Stairwell between the basement and first floor and between the first and second floor. This was confirmed by Staff MM at the time of the observation on 03/24/14 at 1:45 PM.

Review of the Monthly emergency light and exit sign testing documentation completed on 03/25/14 revealed the emergency lights in the North Exit Stairwell are not tested by the facility. This was confirmed by Staff NN on 03/25/14 at 1:30 PM.

Based on observation and interview, the facility failed to ensure exit signage was placed in accordance with NFPA life safety code 101, 2000 edition. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings include:
1. On 03/18/14 at 10:09 A.M. a tour was conducted of the eighth floor of the west wing and north wing with Staff AA and BB and others. Observation of the corridor leading to the west wing revealed a "recovery and holding" sign occluding an exit sign on the path of egress from the waiting area.
On 03/18/14 at 10:09 A.M. Staff AA confirmed the finding.
2. At 12:00 P.M. observation of egress paths from the post anesthesia care unit did not reveal where they were marked with exit signs.
At 12:00 P.M. in an interview Staff AA confirmed the finding.

Based on observation, and staff confirmation the facility failed to have exit signs visible and displayed to mark the path of egress. This has the potential to affect all patients, visitors, and staff that enter the hospital. The patient census at the beginning of the survey was 362.

Findings include:

1. On 03/18/14 at 10:00 A.M. a tour was conducted of the c-section area of the ninth floor. Observation did not reveal an exit sign to a path of egress.
On 03/18/14 at 10:00 A.M. in an interview, Staff AA confirmed the observation.

2. On 03/20/14 at 8:45 A.M. a tour was conducted of the first floor north and south wings with Staff AA and BB. At 10:22 A.M. observation of exit signage at the west wing 2 stairwell revealed a sign was not in the line of sight of people entering the stairwell to direct them to go to the left.
On 03/20/14 at 8:45 A.M. in an interview, Staff AA and BB confirmed the observation.





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3. Observation of A floor in the administration corridor completed on 03/22/14 revealed two paths of egress: one going west in the corridor and then turning north, the other going east then turning north toward the exit corridor. The exit sign was not visible on the far west end of the corridor due to a directional sign showing where different departments were located was directly in front of the sign. The east exit was not marked with an exit sign showing the path of travel to the north exit corridor. This was confirmed by Staff MM at the time of the observation on 03/22/14 at 8:00 AM.

Based on review of the facility's fire drill documentation, fire response plan and interview, the facility failed to ensure fire drills were held under random, varying conditions, and that its fire response plan was followed. This has the potential to affect all patients, staff, and visitors to the facility. The patient census at the beginning of the survey was 362.
Findings include:
Review of the facility's fired drills for 2013 revealed a lack of variability. For each quarter of 2013, the third shift fire drill was held at 01:00 A.M., except for the summer quarter, when it was held at 01:05 A.M.
On 03/24/14 at 2:00 P.M. in an interview, Staff GG confirmed the observation.
In January 2014 a fire occurred in the operating room. Review of the facility's fire and safety documentation did not reveal who, if any, fire safety authority was notified.
On 03/20/14 at 2:35 P.M. in an interview with Staff GG, he/she said he/she knew nothing about the fire until Monday, 03/17/14, when he/she saw it mentioned in the paper work for the state ' s survey. He/she said if a flame has been extinguished, the fire department was to be called.
On 03/24/14 at 3:10 P.M. in an interview Staff FF confirmed a fire alarm was never triggered and the clinical staff alone made the decision the fire was satisfactorily extinguished using normal saline.
Review of the facility's Fire Response Plan, number 1.03.105, and effective on 10/2013 was completed on 03/24/14. Review of the aforementioned Fire Response Plan revealed: "Whomever discovers a fire should pull the nearest fire alarm box and/or dial"111" (Telecommunications Operator) and report the exact location of the fire; the Telecommunications Operator notified the (local) fire department of the fire alarm and location by telephone .....When the alarm is activated in the hospital, the fire system will announce within the building in alarm: 'code red' and the exact location....if it can be done safely, fight the fire using proper fire extinguishers...The (local) fire department will arrive, responding to a pre planned location. A safety/security officer will meet them and advise them of the situation...When the fire has been extinguished, the ALL CLEAR is given by the (local) fire department official in charge."

Based on document review and staff confirmation the facility failed to activate audible alarms during the fire drills conducted quarterly. This has the potential to affect all patients, visitors, and staff who enter the facility.

Findings include:

Review of the Fire Report/Evaluation completed on 03/25/14 revealed the fire alarm was not activated for the drills conducted on 01/28/13, 06/18/13, 08/27/13, and 02/25/14 due to other tenants in the building. This was confirmed by Staff NN on 03/25/14 at 12:15 PM.

Based on staff interview the facility failed to have fire drills at least every year. This has the potential to affect all patients served by the facility. The census was zero during the facility tour on 03/25/14.

Findings include:

Interview with Staff OO completed on 03/25/14 revealed no fire drills have been conducted for the facility.

Based on observation and interview, the facility failed to ensure its sprinkler system was in compliance with NFPA 25 and 13. This has the potential to affect all patients, staff, and visitors to the facility. The patient census at the beginning of the survey was 362.
Findings include:
1. On 03/17/14 at 3:02 P.M. a tour was conducted of the west wing and north wing of the ninth floor with Staff AA and BB. Observation of the side-mounted quick-response sprinkler head in room 9064 revealed it to cover in dust.
At 3:03 P.M. in an interview, Staff BB confirmed the observation.

2. At 3:30 P.M. in storage room 9104 boxes were observed stacked in the center room up to less than 18 inches from the ceiling.
On 03/17/14 at 3:30 P.M. in an interview Staff AA and BB confirmed the observation.

3. On 03/18/14 at 8:30 A.M. the tour of the ninth floor resumed with Staff AA and BB. At 8:30 A.M. in the men's locker room a dirty sprinkler head was observed near the air handler near the lockers.
On 03/18/14 at 8:30 A.M. in an interview Staff BB confirmed the findings.

4. On 03/18/14 at 8:41 A.M. in the women's locker room two dirty sprinkler heads were observed near the air handler in the back of the locker room.
On 03/18/14 at 8:41 A.M. Staff AA confirmed the observation in an interview.

5. On 03/19/14 at 11:36 A.M. treatment coordinator room 5090 had cubicle dividers less than 18 inches from the ceiling with sprinklers.
On 03/19/14 at 11:36 A.M. Staff AA confirmed the observation.

6. On 03/19/14 at 11:02 A.M. a tour was conducted of the fifth floor of the north wing and west wing with Staff AA and BB. At 11:51 A.M. in housekeeping room 5108 a sprinkler head was observed immediately next to a box light.
On 03/19/14 at 11:51 A.M. in an interview, Staff AA confirmed the observation.

7. At 12:04 P.M. in room 5103 was observed to have paper stacked less than 18 inches from a ceiling with sprinkler heads.
On 03/19/14 at 12:04 P.M. Staff AA confirmed the observation.

8. On 03/19/14 at 3:35 P.M. a tour was conducted of the second floor north and west wing with Staff AA and BB. At 4:41 P.M. in rooms 2093B, 2114, and 2100 sprinklers were observed to be missing their cover plates.
On 03/19/14 at 4:41 P.M. in an interview, Staff AA confirmed the observation.

9. On 03/20/14 at 10:45 A.M. a tour of the north and west wings of the A level was conducted with Staff AA and BB. At 11:02 A.M. observation in the office space near the eastern exit revealed a missing cover plate to a sprinkler head.
On 03/20/14 at 11:02 A.M. in an interview Staff BB confirmed the observation.

10. On 03/21/14 at 8:40 A.M. a tour was conducted of the central supply room of the B level with Staff AA and BB. At 8:55 A.M. a sign hanging from the ceiling grid work holding ceiling tiles in place and reading "carts B001-B017" was observed approximately less than 6 inches horizontally from a sprinkler head. Cart 42 was observed to have a height such that it extended to less than 18 inches from the ceiling, and had material on the top shelf.
At 8:55 A.M. Staff AA confirmed the observation.

11. On 03/21/14 at 9:40 A.M. a sprinkler head escutcheon ring was observed missing. The sprinkler was observed over the double doors leading to the post operative area.
On 03/21/14 at 9:40 A.M. in an interview Staff AA confirmed the observation.

12. On 03/24/14 at 11:20 A.M. a tour was conducted of the D level (with the exception of the south wing) with Staff AA and BB. At 12:16 P.M. in the men's locker room a sprinkler was missing the escutcheon ring.
On 03/24/14 at 12:16 P.M. in an interview, Staff AA confirmed the observation.





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13. Tour of the Lab located on the C floor of the South Tower conducted on 03/21/14 revealed boxes on middle shelves of the southwest storage room (C025) approximately 8 inches from the sprinkler heads potentially influencing changes in spray pattern. This was confirmed by Staff MM at the time of the observation on 03/21/14 at 10:05 AM.

Based on observation and interview, the facility failed to ensure space heaters were not kept in patient care areas. This has the potential to affect all patients, staff, and visitors to the facility. The census at the beginning of the survey was 362.
Findings include:
On 03/21/14 at 11:34 A.M. a tour was conducted of the C level of the west wing/courtyard building with Staff AA and BB and others. At 2:43 P.M. observation inside room c312, which was near a radiology patient treatment area, revealed a space heater plugged into a mechanical timer mechanism plugged into an extension cord, suggesting it could turn on without any supervision whatsoever.
On 03/21/14 at 11:34 A.M. Staff AA confirmed the observation.

Based on observation and interview, the facility failed to keep patient care areas free of space heaters. This had the potential to affect all patients, staff and visitors to the facility. The patient census was 362 at the beginning of the survey.

Findings include:

On 03/17/14 at 3:02 P.M. a tour was conducted of the north and west wing of the ninth floor with staff AA and BB. At 3:24 P.M. in room 9107 an office space within a smoke compartment shared by patients, a space heater was found.

Based on observation and interview, the facility failed to ensure trash collection receptacles with capacities greater than 32 gallons were located in a room protected as hazardous when not attended. This has the potential to affect all patients, staff, and visitors to the facility. The patient census at the beginning of the survey was 362.
Findings include:
1. On 03/20/14 at 10:45 A.M. a tour of the north and west wings of the A level was conducted with Staff AA and BB. At 11:50 A.M. in the north/south corridor of the north wing a waste receptacle of greater than 32 gallons was observed in the corridor for more than 30 minutes.
On 03/20/14 at 11:50 A.M. in an interview, Staff AA confirmed the observation.

2. On 03/24/14 at 11:20 A.M. a tour was conducted of the D level (with the exception of the south wing) with Staff AA and BB. At 12:10 P.M. a garbage receptacle of greater than 32 gallons was observed parked for more than 30 minutes on the path of egress to west wing 1 stairwell.
On 03/24/14 at 12:10 P.M. in an interview, Staff AA confirmed the observation.

Based on observation and staff conformation the facility failed to have extra sprinkler heads and a sprinkler head wrench at the sprinkler riser, as per NFPA 101 39.1.2.2 in accordance with 9.7.5 and NFPA 25 section 2-4.1.4. The patient census at the beginning of the survey was 15.

Findings include:

Tour of the facility completed on 03/24/14 revealed rapid sprinkler heads with red bulbs were installed throughout the physical therapy area and no spare rapid sprinkler heads with red bulbs were noted to be in the red sprinkler head box by the riser. No sprinkler head wrench was noted to be in or near the box as well. This was confirmed by Staff MM at the time of the observation on 03/24/14 at 11:55 AM.

Interview with the building maintenance person completed on 03/24/14 at 11:50 AM revealed that he/she did not know where the wrench was at but stated the company that works on the sprinkler system must keep it and bring it when it is needed. He/she also did not know of any other spare sprinkler heads in the building.

Based on observation the facility failed to provide safe access to public way, as per NFPA 101 section 38.2.7 in accordance with section 7.7.1. This has the potential to affect all patients that receive services from the facility. The census was zero during the facility tour on 03/25/14.

Findings include:

Tour of the facility conducted on 03/24/14 revealed an exit discharge at the Southeast stairwell that exited to a 4 feet by 4 feet concrete pad then to a grass covered area encompassing an approximate 20 foot distance to the nearest paved common way. This was presented to Staff MM on 03/24/14 at 11:00 AM.