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Based on observations and staff interviews, the facility did not ensure that the fire-rated corridors were maintained.

The findings were:

On the morning of 5/9/13 observations revealed that:

a) in the smoke partition wall located in the corridor between the Blood Lab and the Wellness Center there was 1 unsealed BX cable penetration found.

b) in the sheetrock located over the entrance to Labor and Delivery Suite there was a unsealed penetration in which 4 yellow cables passed through the wall and 1 partially sealed penetration.

The above mentioned observations were all concurrently confirmed by the Vice President of Operations, staff #16.

Based on observation and staff interview, the facility did not ensure that the fire-rated smoke barriers were maintained.

The finding was:

On the morning of 5/9/13 observation revealed that there were 2 unsealed penetrations were found in the smoke partition wall located in the vicinity of Room 2401.

The above mentioned observations were all concurrently confirmed by the Vice President of Operations, staff #16.

Based on observation and staff interview, the facility did not maintain the fire-rated exit walls.

The finding was:

On the morning of 5/9/13 observation in the vicinity of Room G-674 revealed that the sheetrock located over the double fire-rated doors had a large unsealed penetration in which there were multiple wires passing through the wall.

The above mentioned observations were all concurrently confirmed by the Vice President of Operations, staff #16.

Based on observation and staff interview, the facility did not ensure that the corridors were clear and unobstructed.

The finding was:

On the morning of 5/6/13, observation of an Emergency Department corridor in the vicinity of Triage Room 1 revealed that the there were four wheelchairs blocking the one of the fire-rated doors from closing.

The above mentioned observations were all concurrently confirmed by the Vice President of Operations, staff #16.

Based on observations and staff interviews, the facility did not ensure that the exit signage was displayed with section 7.10 with continuous illumination.

The findings were:

1) On the morning of 5/10/13 observation revealed that installed in the kitchen was a reflective exit sign. This sign did not have continuous illumination.

2) During the course of this survey from 5/6/13 to 5/10/13 observation of the facility revealed multiple locations that were missing required exit signage. Specifically this includes:
a) On the morning of 5/7/13 for both sides of the Maintenance Shop;
b) On the afternoon of 5/7/13 inside the Matenity OR Core;
c) On the morning of 5/8/13 inside the Central Sterile Linen Room;
d) On the afternoon of 5/8/13 inside the Decontamination Room.

The above mentioned observations were all concurrently confirmed by the Vice President of Operations, staff #16.

Based on observation and staff interview, the facility did not ensure that their required automatic sprinkler system was continuously maintained to function properly as per NFPA 13. Specifically, various supplies were stored less then 18" from the sprinkler heads.

The findings were:

1a) On the afternoon of 5/6/13 observation in both of the 3rd. Floor Medical/Surgical Medication Rooms revealed that various plastic containers, IV Tray, etc. were stored on top of the Omnicell Medication Dispensers, which were less then 18" from the sprinkler heads.

b) On the morning of 5/8/13 observation in the Basement Linen Room revealed that there were clean linens being stored on the top shelves, which were less then 18" from the sprinkler heads.

The above mentioned observations were all concurrently confirmed by the Vice President of Operations, staff #16.

Based on observations and staff interviews, the facility did not ensure that the fire-rated corridors were maintained.

The findings were:

On the morning of 5/9/13 observations revealed that:

a) in the smoke partition wall located in the corridor between the Blood Lab and the Wellness Center there was 1 unsealed BX cable penetration found.

b) in the sheetrock located over the entrance to Labor and Delivery Suite there was a unsealed penetration in which 4 yellow cables passed through the wall and 1 partially sealed penetration.

The above mentioned observations were all concurrently confirmed by the Vice President of Operations, staff #16.

Based on observation and staff interview, the facility did not ensure that the fire-rated smoke barriers were maintained.

The finding was:

On the morning of 5/9/13 observation revealed that there were 2 unsealed penetrations were found in the smoke partition wall located in the vicinity of Room 2401.

The above mentioned observations were all concurrently confirmed by the Vice President of Operations, staff #16.

Based on observation and staff interview, the facility did not maintain the fire-rated exit walls.

The finding was:

On the morning of 5/9/13 observation in the vicinity of Room G-674 revealed that the sheetrock located over the double fire-rated doors had a large unsealed penetration in which there were multiple wires passing through the wall.

The above mentioned observations were all concurrently confirmed by the Vice President of Operations, staff #16.

Based on observation and staff interview, the facility did not ensure that the corridors were clear and unobstructed.

The finding was:

On the morning of 5/6/13, observation of an Emergency Department corridor in the vicinity of Triage Room 1 revealed that the there were four wheelchairs blocking the one of the fire-rated doors from closing.

The above mentioned observations were all concurrently confirmed by the Vice President of Operations, staff #16.

Based on observations and staff interviews, the facility did not ensure that the exit signage was displayed with section 7.10 with continuous illumination.

The findings were:

1) On the morning of 5/10/13 observation revealed that installed in the kitchen was a reflective exit sign. This sign did not have continuous illumination.

2) During the course of this survey from 5/6/13 to 5/10/13 observation of the facility revealed multiple locations that were missing required exit signage. Specifically this includes:
a) On the morning of 5/7/13 for both sides of the Maintenance Shop;
b) On the afternoon of 5/7/13 inside the Matenity OR Core;
c) On the morning of 5/8/13 inside the Central Sterile Linen Room;
d) On the afternoon of 5/8/13 inside the Decontamination Room.

The above mentioned observations were all concurrently confirmed by the Vice President of Operations, staff #16.

Based on observation and staff interview, the facility did not ensure that their required automatic sprinkler system was continuously maintained to function properly as per NFPA 13. Specifically, various supplies were stored less then 18" from the sprinkler heads.

The findings were:

1a) On the afternoon of 5/6/13 observation in both of the 3rd. Floor Medical/Surgical Medication Rooms revealed that various plastic containers, IV Tray, etc. were stored on top of the Omnicell Medication Dispensers, which were less then 18" from the sprinkler heads.

b) On the morning of 5/8/13 observation in the Basement Linen Room revealed that there were clean linens being stored on the top shelves, which were less then 18" from the sprinkler heads.

The above mentioned observations were all concurrently confirmed by the Vice President of Operations, staff #16.