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Based on observation and interview, it was determined that the facility failed to maintain the fire resistance rating of the building construction in one instance within this component.

Findings include:

Observation made on June 27, 2012, at 1:20 p.m., revealed that inside the first floor admission department ( patient belonging closet) back wall, had a horizontal structural steel beam which lacks fire proofing material on the bottom.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the missing required fire proofing.

Based on observation and interview, it was determined that the facility failed to ensure that corridor walls are properly inspected and maintained and are smoke tight and free from penetrations in two instance within this component.

Findings include:

Observations made on June 27, 2012 , between 11:07 a.m., and 11:22 a.m., revealed corridor walls that had penetrations of the drywall in the following locations:

a. 11:07 a.m., second floor inside the Detox Clinical coordinators office , hole in the wall by a detached telecom outlet; and
b. 11:22 a.m., ground floor electrical room by the smoke doors in the Acute care unit, holes in the wall where a electrical panel had being removed that penetrated to the nursing station side and missing rectangular cutout of the drywall where the panel had been.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the penetrations of the corridor walls.

Based on observation and interview, it was determined that the facility failed to ensure that corridor doors are properly inspected and maintained that they positively latch, smoke tight, and are free of impediments to closing in ten instances within this component.
Findings include:
1. Observations made on June 27, 2012, between 10:28 and 11:56 a.m., revealed corridor doors that had gaps greater that one half inch between the top of the door frame in the following locations:
a. 10:28 a.m., second floor room # 222;
b. 10:53 a.m., second floor room # 245;
c. 10:54 a.m., second floor room # 246;
d. 11;00 a.m., second floor room # 204; and
e. 11:56 a.m., first floor room # 103.
Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the doors where not smoke tight in the above named locations.


2. Observation made on June 27, 2012 , at 10:35 a.m., revealed that corridor door to the multi- purpose room on the second floor lacks latching hardware.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed that the door lacked latching hardware.


3. Observation made on June 27 , 2012 , at 10:44 a.m., revealed that on the second floor the door to the Fire Alarm control room had a self closer that had the arm disconnected from the self closure hardware.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed that the self closure was disconnected.


4. Observation made on June 27 , 2012, at 10:59 a.m., revealed that on the second floor west wing, the door to Room # 202 failed to positively latch when tested.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the the door failed to latch when tested.


5. Observation made on June 27, 2012, at 10:58 a.m., revealed that the first floor copy room corridor door was being held open by an authorized device (rubber wedge).

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the door was impeded from closing.


6. Observation made on June 27 , 2012, at 11:20 a.m., revealed that east wing 123, corridor door failed to positively latch into its door assembly.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed that the door requires an adjustment.

Based on observation and interview, it was determined that the facility failed to maintain smoke barriers in two instances within this facility.

Findings include:

Observation made on June 27, 2012, between 10:55 and 11:04 a.m., revealed that the following smoke barrier walls had unsealed horizontal penetrations:

a. 10:55 a.m., the first floor smoke barrier above the door at Room 136 was not complete to the ceiling above; and
b.11:04 a.m., inside first floor Room117 with data wiring.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the above unsealed penetrations in the smoke barrier wall.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating smoke barriers in four instance within this facility.

Findings include:

1.Observation made on June 27, 2012, between 1:20 p.m. and 1:50 p.m., revealed that the following smoke barrier walls had unsealed horizontal penetrations:

a. 1:20 p.m.,inside the first floor admission department ( patient belonging closet) had an unsealed horizontal penetration around white data wiring;
b. 1:30 p.m., first floor above smoke barrier doors between Rooms 103 and 107 with data wiring;
c. 1:45 p.m., first floor above smoke barrier doors between Rooms 146/147 with armored cable; and
d. 1:50 p.m., first floor inside Room 136 with data wiring.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the unsealed penetrations.

Based on observation and interview, it was determined that the facility failed to maintain a fire-resistance rated smoke barrier assembly in one instance within this component.

Findings include:

Observation made on June 27, 2012, at 11:05 a.m., revealed that first floor smoke barrier doors at copy room 136 had Plexiglass installed in lieu of wired/or approved glass in an approved frame.


Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the smoke barrier separation was not maintained properly.

Based on observation and interview, it was determined that the facility failed to ensure that smoke barrier doors are properly inspected maintain smoke tight resistance in one instance within this component.
Findings include:
1. Observation made on June 27 , 2012 , at 12:58 p.m., revealed that on the second floor the corridor first set of Auditorium double doors which are part of the smoke barrier failed to maintain smoke tight resistance when tested.
Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the doors failed to latch.


2. Observations made on June 27, at 1:11 p.m., revealed that on the second floor corridor from the atrium area, there was a lounge chair and recycling cans in front of the smoke barrier doors.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the corridor was obstructed and the subsequent correction of the deficiency during the time of the survey.

Based on observation and interview, it was determined that the facility failed to ensure that hazardous areas are properly inspected and maintained and that doors are free of impediments to closing in one instances within this component.
Findings include:
Observation made on June 27, 2012, at 1:05 p.m., on the second floor inside the medical records area, the door to file room # 202 was being held open by a rubber wedge. The door is on a self closure and the room contains combustible paper files.
Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the door was propped open.

Based on observation and interview, it was determined that the facility failed to ensure that the hazardous areas are properly inspected and maintained; are smoke tight in sprinklered locations, and that doors have self closures in two instances within this component.
Findings include:
1. Observations made on June 27, 2012, at 10:37 a.m., revealed that on the second floor East wing, the tub room is being used as storage room. The room door lacks a self closure and has a louvered grill on the bottom exposing the corridor. The room is greater than 50 square feet and contains combustible materials.
Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the tub room is being used as a storage room.


2. Observation made on June 27 ,2012 , at 12:00 p.m., revealed that on the ground floor Room # 107 storage room , the door lacks a self closure. The room is greater than 50 square feet and contains combustible materials.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed that the storage room lacks a self closure.

Based on observation and interview, it was determined that the facility failed to ensure that the exit stairways are properly inspected and maintained , that doors positively latch and that stairtower walls are free of storage in two instances within this component.

Findings include:

1. Observation made on June 27, 2012 , at 10:42 a.m., revealed that the second floor center stairtower door failed to positively latch when tested.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the stairtower door failed to positively latch.


2. Observation made on June 27 , 2012 , at 10:58 a.m., revealed that on the second floor west wing inside the stairtower, there were two picture frames being stored in the stairtower landing.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the storage within the stairtower.

Based on observation and interview, it was determined that the facility failed to ensure that exit access is free of impediments to instant use in one instance within this component.

Findings include:

Observation made on June 27, 2012 , at 1:16 p.m., revealed that on the second floor , the exit doors which lead to the exterior stairs, there were three vacuum cleaners that were being stored in the corridor in front of the exit doors.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the exit doors were obstructed.

Based on observation and interview, it was determined that the facility failed to ensure that exit access is readily available and free of obstructions in one instance within this component.

Findings include:

1. Observation made on June 27 , 2012 , at 10:31 a.m., revealed that on the second floor east wing corridor was obstructed by a housekeeping cart and scale on one side and a chair on the other side next to a fire extinguisher cabinet. The width was reduced to less than four feet in the middle of the corridor.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the obstructed corridor.


2. Observation made on June 27 2012 , at 11:38 a.m., revealed that the exit discharge path from the west wing stairtower was obstructed by a trash can and recycling cans and construction materials being stored in the pathway.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the obstructed exit discharge pathway.

Based on observation and interview it was determined that the facility failed to ensure that the automatic sprinkler system is properly inspected and maintained and that sprinkler heads are not obstructed and free of debris in two instances within this component.
Findings include:
1.Observation made on June 27, 2012 , at 1:15 p.m., revealed that on the second floor inside the storage closets that are on both sides of the small corridor that leads to the roof, there was storage within eighteen inches of the sprinkler heads in both closets.
Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the storage within eighteen inches of sprinkler heads.

2.Observation made on June 27, 2012 , at 1:40 p.m., revealed located at the first floor nurses station pendent sprinkler heads showed evidence of dust and debris load.


Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference,confirmed the sprinkler heads were not maintained free of debris.

Based on observation and interview, it was determined that the facility failed to ensure that the automatic sprinkler system is properly inspected and maintained; that sprinkler heads are not obstructed; and that ceilings are smoke tight in five instances within this component.
Findings include:
1. Observations made on June 27 , 2012, between 10:38 and 10:51 a.m., revealed missing and damaged ceiling tiles and escutcheon that are not smoke tight in the following locations:

a. 10:38 am, second floor east wing tube room, sprinkler head had become detached from the ceiling tile.
b. 10:46 am, second floor west wing in the case managers office which is across from the nurses station , missing ceiling tiles in the office and closet.
c. 10:51 a.m., second floor laundry room #243B, broken tiles and a gap around a grill for a supply vent.
d. 10:53 a.m., second floor west wing unit supply closet, the sprinkler head was not smoke tight around the escutcheon plate.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the non smoke conditions in the above named locations.


2. Observation made on June 27 , 2012 at 10:38 a.m., revealed that on the second floor east wing tub room, there was storage within eighteen inches of the sprinkler head.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the storage within eighteen inches of the sprinkler head.

Based on observation and interview, it was determined that the facility failed to ensure that heating, air conditioning, and ventilating systems are installed properly and penetrations are protected in two instances within this component.

Findings include:

1. Observation made on June 27 , 2012 at 1:44 p.m., revealed that on the ground level mechanical room closet #1, there was a large gap where the duct work penetrates the exterior cinder block wall into the building which is not smoke tight and exposes the interior of the building areas.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the penetration of the wall by the ductwork.


2. Observation made on June 27, 2012, at 9:35 a.m., that the fire damper above the smoke barrier doors located on the second floor at Room 213, appears to be tied in the open position by the fusible link that is attached.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed that the fire damper was not maintained properly.

Based on observation and interview, it was determined that the facility failed to maintain illumination of generator set locations within this facility.

Findings Include:

Observation made on June 27, 2012, at 1:30 p.m., revealed that within the facility exterior mechanical/boiler room at emergency power transfer switch location lacked a battery powered emergency lighting fixture.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed that the generator was not properly maintained

Based on observation and interview, it was determined that the facility failed to maintain illumination of the generator location within this component.

Findings include:

Observation made on June 27 , 2012 , at 2:01 p.m., revealed that the exterior accessed basement generator room lacks an emergency battery back up light pack.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed that the generator room lacked a battery back up light.

Based on observation and interview, it was determined that the facility failed to ensure that electrical wiring and equipment is protected and secured, and that the unauthorized use of extension cords and powerstrips is prohibited in three instances within this component.
Findings include:
1. Observation made on June 27, 2012 , at 1:10 p.m., revealed that on the second floor computer room there was a powerstrip that had its cord running under floormats in the room.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed that the powerstrip cord was under the floor mat.


2. Observation made on June 27, 2012, at 1:30 p.m., revealed that on the first floor elevator control room by the elevator control box, there was an open electrical outlet box which had exposed wires.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the open outlet box in the elevator control room.


3. Observation made on June 27, 2012, at 1:34 p.m., revealed that on the first floor lab area inside the dark room, there was a ceiling mounted light fixture that had become detached from the ceiling tile.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the light fixture was detached from the ceiling.

Based on observation and interview, it was determined that the facility failed to ensure that electrical wiring and equipment is protected, are free from damage, and that the unauthorized use of extension cords and powerstrips is prohibited in seven instances within this component.
Findings include:
1. Observations made on June 27, 2012 , between 10:22 a.m., and 2:00 p.m., revealed electrical panels which had missing circuit breaker blank covers in the following locations:
a. 10:22 a.m., second floor, the first electrical panel by the east wing nurses station;
b.10:51 a.m., second floor laundry room # 243 B inside the double door closets, three electrical panels that were missing blank covers;
c. 11:22 a.m., ground floor in the Acute Care unit, the electrical room by the smoke barrier doors, panels EB and RC; and
d 2:00 p.m., ground floor exterior accessed basement generator room, electrical panel RA.
Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the missing circuit breaker blank covers in the above named locations.

2. Observation made on June 27, 2012 at 10:26 a.m., revealed that on the second floor East wing Room 230 (the windowside, bed side), there was a wall mounted electrical outlet that was damaged and coming loose from the wall.
Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the damaged outlet in the room.

3. Observations made on June 27, at 11:07 a.m., revealed that on the second floor inside the Detox Clinical Coordinator office, there was an extension cord that plugged into a powerstrip that was daisy chained into another powerstrip.
Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the unauthorized use of the extension cord and powerstrips.

4. Observation made on June 27, 2012 , at 1:44 p.m., revealed that in the ground floor exterior accessed basement mechanical/boiler room, there was an Armor cable which had exposed wires where the cable connects to a red colored jockey by boiler # 2.
Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the exposed wires from the Armor cable.

Based on observation and interview, it was determined that the facility failed to maintain the fire resistance rating of the building construction in one instance within this component.

Findings include:

Observation made on June 27, 2012, at 1:20 p.m., revealed that inside the first floor admission department ( patient belonging closet) back wall, had a horizontal structural steel beam which lacks fire proofing material on the bottom.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the missing required fire proofing.

Based on observation and interview, it was determined that the facility failed to ensure that corridor walls are properly inspected and maintained and are smoke tight and free from penetrations in two instance within this component.

Findings include:

Observations made on June 27, 2012 , between 11:07 a.m., and 11:22 a.m., revealed corridor walls that had penetrations of the drywall in the following locations:

a. 11:07 a.m., second floor inside the Detox Clinical coordinators office , hole in the wall by a detached telecom outlet; and
b. 11:22 a.m., ground floor electrical room by the smoke doors in the Acute care unit, holes in the wall where a electrical panel had being removed that penetrated to the nursing station side and missing rectangular cutout of the drywall where the panel had been.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the penetrations of the corridor walls.

Based on observation and interview, it was determined that the facility failed to ensure that corridor doors are properly inspected and maintained that they positively latch, smoke tight, and are free of impediments to closing in ten instances within this component.
Findings include:
1. Observations made on June 27, 2012, between 10:28 and 11:56 a.m., revealed corridor doors that had gaps greater that one half inch between the top of the door frame in the following locations:
a. 10:28 a.m., second floor room # 222;
b. 10:53 a.m., second floor room # 245;
c. 10:54 a.m., second floor room # 246;
d. 11;00 a.m., second floor room # 204; and
e. 11:56 a.m., first floor room # 103.
Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the doors where not smoke tight in the above named locations.


2. Observation made on June 27, 2012 , at 10:35 a.m., revealed that corridor door to the multi- purpose room on the second floor lacks latching hardware.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed that the door lacked latching hardware.


3. Observation made on June 27 , 2012 , at 10:44 a.m., revealed that on the second floor the door to the Fire Alarm control room had a self closer that had the arm disconnected from the self closure hardware.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed that the self closure was disconnected.


4. Observation made on June 27 , 2012, at 10:59 a.m., revealed that on the second floor west wing, the door to Room # 202 failed to positively latch when tested.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the the door failed to latch when tested.


5. Observation made on June 27, 2012, at 10:58 a.m., revealed that the first floor copy room corridor door was being held open by an authorized device (rubber wedge).

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the door was impeded from closing.


6. Observation made on June 27 , 2012, at 11:20 a.m., revealed that east wing 123, corridor door failed to positively latch into its door assembly.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed that the door requires an adjustment.

Based on observation and interview, it was determined that the facility failed to maintain smoke barriers in two instances within this facility.

Findings include:

Observation made on June 27, 2012, between 10:55 and 11:04 a.m., revealed that the following smoke barrier walls had unsealed horizontal penetrations:

a. 10:55 a.m., the first floor smoke barrier above the door at Room 136 was not complete to the ceiling above; and
b.11:04 a.m., inside first floor Room117 with data wiring.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the above unsealed penetrations in the smoke barrier wall.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating smoke barriers in four instance within this facility.

Findings include:

1.Observation made on June 27, 2012, between 1:20 p.m. and 1:50 p.m., revealed that the following smoke barrier walls had unsealed horizontal penetrations:

a. 1:20 p.m.,inside the first floor admission department ( patient belonging closet) had an unsealed horizontal penetration around white data wiring;
b. 1:30 p.m., first floor above smoke barrier doors between Rooms 103 and 107 with data wiring;
c. 1:45 p.m., first floor above smoke barrier doors between Rooms 146/147 with armored cable; and
d. 1:50 p.m., first floor inside Room 136 with data wiring.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the unsealed penetrations.

Based on observation and interview, it was determined that the facility failed to maintain a fire-resistance rated smoke barrier assembly in one instance within this component.

Findings include:

Observation made on June 27, 2012, at 11:05 a.m., revealed that first floor smoke barrier doors at copy room 136 had Plexiglass installed in lieu of wired/or approved glass in an approved frame.


Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the smoke barrier separation was not maintained properly.

Based on observation and interview, it was determined that the facility failed to ensure that smoke barrier doors are properly inspected maintain smoke tight resistance in one instance within this component.
Findings include:
1. Observation made on June 27 , 2012 , at 12:58 p.m., revealed that on the second floor the corridor first set of Auditorium double doors which are part of the smoke barrier failed to maintain smoke tight resistance when tested.
Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the doors failed to latch.


2. Observations made on June 27, at 1:11 p.m., revealed that on the second floor corridor from the atrium area, there was a lounge chair and recycling cans in front of the smoke barrier doors.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the corridor was obstructed and the subsequent correction of the deficiency during the time of the survey.

Based on observation and interview, it was determined that the facility failed to ensure that hazardous areas are properly inspected and maintained and that doors are free of impediments to closing in one instances within this component.
Findings include:
Observation made on June 27, 2012, at 1:05 p.m., on the second floor inside the medical records area, the door to file room # 202 was being held open by a rubber wedge. The door is on a self closure and the room contains combustible paper files.
Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the door was propped open.

Based on observation and interview, it was determined that the facility failed to ensure that the hazardous areas are properly inspected and maintained; are smoke tight in sprinklered locations, and that doors have self closures in two instances within this component.
Findings include:
1. Observations made on June 27, 2012, at 10:37 a.m., revealed that on the second floor East wing, the tub room is being used as storage room. The room door lacks a self closure and has a louvered grill on the bottom exposing the corridor. The room is greater than 50 square feet and contains combustible materials.
Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the tub room is being used as a storage room.


2. Observation made on June 27 ,2012 , at 12:00 p.m., revealed that on the ground floor Room # 107 storage room , the door lacks a self closure. The room is greater than 50 square feet and contains combustible materials.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed that the storage room lacks a self closure.

Based on observation and interview, it was determined that the facility failed to ensure that the exit stairways are properly inspected and maintained , that doors positively latch and that stairtower walls are free of storage in two instances within this component.

Findings include:

1. Observation made on June 27, 2012 , at 10:42 a.m., revealed that the second floor center stairtower door failed to positively latch when tested.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the stairtower door failed to positively latch.


2. Observation made on June 27 , 2012 , at 10:58 a.m., revealed that on the second floor west wing inside the stairtower, there were two picture frames being stored in the stairtower landing.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the storage within the stairtower.

Based on observation and interview, it was determined that the facility failed to ensure that exit access is free of impediments to instant use in one instance within this component.

Findings include:

Observation made on June 27, 2012 , at 1:16 p.m., revealed that on the second floor , the exit doors which lead to the exterior stairs, there were three vacuum cleaners that were being stored in the corridor in front of the exit doors.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the exit doors were obstructed.

Based on observation and interview, it was determined that the facility failed to ensure that exit access is readily available and free of obstructions in one instance within this component.

Findings include:

1. Observation made on June 27 , 2012 , at 10:31 a.m., revealed that on the second floor east wing corridor was obstructed by a housekeeping cart and scale on one side and a chair on the other side next to a fire extinguisher cabinet. The width was reduced to less than four feet in the middle of the corridor.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the obstructed corridor.


2. Observation made on June 27 2012 , at 11:38 a.m., revealed that the exit discharge path from the west wing stairtower was obstructed by a trash can and recycling cans and construction materials being stored in the pathway.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the obstructed exit discharge pathway.

Based on observation and interview it was determined that the facility failed to ensure that the automatic sprinkler system is properly inspected and maintained and that sprinkler heads are not obstructed and free of debris in two instances within this component.
Findings include:
1.Observation made on June 27, 2012 , at 1:15 p.m., revealed that on the second floor inside the storage closets that are on both sides of the small corridor that leads to the roof, there was storage within eighteen inches of the sprinkler heads in both closets.
Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the storage within eighteen inches of sprinkler heads.

2.Observation made on June 27, 2012 , at 1:40 p.m., revealed located at the first floor nurses station pendent sprinkler heads showed evidence of dust and debris load.


Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference,confirmed the sprinkler heads were not maintained free of debris.

Based on observation and interview, it was determined that the facility failed to ensure that the automatic sprinkler system is properly inspected and maintained; that sprinkler heads are not obstructed; and that ceilings are smoke tight in five instances within this component.
Findings include:
1. Observations made on June 27 , 2012, between 10:38 and 10:51 a.m., revealed missing and damaged ceiling tiles and escutcheon that are not smoke tight in the following locations:

a. 10:38 am, second floor east wing tube room, sprinkler head had become detached from the ceiling tile.
b. 10:46 am, second floor west wing in the case managers office which is across from the nurses station , missing ceiling tiles in the office and closet.
c. 10:51 a.m., second floor laundry room #243B, broken tiles and a gap around a grill for a supply vent.
d. 10:53 a.m., second floor west wing unit supply closet, the sprinkler head was not smoke tight around the escutcheon plate.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the non smoke conditions in the above named locations.


2. Observation made on June 27 , 2012 at 10:38 a.m., revealed that on the second floor east wing tub room, there was storage within eighteen inches of the sprinkler head.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the storage within eighteen inches of the sprinkler head.

Based on observation and interview, it was determined that the facility failed to ensure that heating, air conditioning, and ventilating systems are installed properly and penetrations are protected in two instances within this component.

Findings include:

1. Observation made on June 27 , 2012 at 1:44 p.m., revealed that on the ground level mechanical room closet #1, there was a large gap where the duct work penetrates the exterior cinder block wall into the building which is not smoke tight and exposes the interior of the building areas.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the penetration of the wall by the ductwork.


2. Observation made on June 27, 2012, at 9:35 a.m., that the fire damper above the smoke barrier doors located on the second floor at Room 213, appears to be tied in the open position by the fusible link that is attached.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed that the fire damper was not maintained properly.

Based on observation and interview, it was determined that the facility failed to maintain illumination of generator set locations within this facility.

Findings Include:

Observation made on June 27, 2012, at 1:30 p.m., revealed that within the facility exterior mechanical/boiler room at emergency power transfer switch location lacked a battery powered emergency lighting fixture.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed that the generator was not properly maintained

Based on observation and interview, it was determined that the facility failed to maintain illumination of the generator location within this component.

Findings include:

Observation made on June 27 , 2012 , at 2:01 p.m., revealed that the exterior accessed basement generator room lacks an emergency battery back up light pack.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed that the generator room lacked a battery back up light.

Based on observation and interview, it was determined that the facility failed to ensure that electrical wiring and equipment is protected and secured, and that the unauthorized use of extension cords and powerstrips is prohibited in three instances within this component.
Findings include:
1. Observation made on June 27, 2012 , at 1:10 p.m., revealed that on the second floor computer room there was a powerstrip that had its cord running under floormats in the room.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed that the powerstrip cord was under the floor mat.


2. Observation made on June 27, 2012, at 1:30 p.m., revealed that on the first floor elevator control room by the elevator control box, there was an open electrical outlet box which had exposed wires.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the open outlet box in the elevator control room.


3. Observation made on June 27, 2012, at 1:34 p.m., revealed that on the first floor lab area inside the dark room, there was a ceiling mounted light fixture that had become detached from the ceiling tile.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the light fixture was detached from the ceiling.

Based on observation and interview, it was determined that the facility failed to ensure that electrical wiring and equipment is protected, are free from damage, and that the unauthorized use of extension cords and powerstrips is prohibited in seven instances within this component.
Findings include:
1. Observations made on June 27, 2012 , between 10:22 a.m., and 2:00 p.m., revealed electrical panels which had missing circuit breaker blank covers in the following locations:
a. 10:22 a.m., second floor, the first electrical panel by the east wing nurses station;
b.10:51 a.m., second floor laundry room # 243 B inside the double door closets, three electrical panels that were missing blank covers;
c. 11:22 a.m., ground floor in the Acute Care unit, the electrical room by the smoke barrier doors, panels EB and RC; and
d 2:00 p.m., ground floor exterior accessed basement generator room, electrical panel RA.
Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the missing circuit breaker blank covers in the above named locations.

2. Observation made on June 27, 2012 at 10:26 a.m., revealed that on the second floor East wing Room 230 (the windowside, bed side), there was a wall mounted electrical outlet that was damaged and coming loose from the wall.
Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the damaged outlet in the room.

3. Observations made on June 27, at 11:07 a.m., revealed that on the second floor inside the Detox Clinical Coordinator office, there was an extension cord that plugged into a powerstrip that was daisy chained into another powerstrip.
Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the unauthorized use of the extension cord and powerstrips.

4. Observation made on June 27, 2012 , at 1:44 p.m., revealed that in the ground floor exterior accessed basement mechanical/boiler room, there was an Armor cable which had exposed wires where the cable connects to a red colored jockey by boiler # 2.
Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the exposed wires from the Armor cable.