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Based on facility observation and staff confirmation, the facility failed to ensure that corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating. In non-sprinklered buildings, walls properly extend above the ceiling. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings include;

On 04/28/14 through 05/01/14 between the hours of 8:15 A.M. and 5:00 P.M. tour of the facility was conducted with Staff PP and QQ. The following observations were noted in corridors with no sprinkler system protection.

Fourth Floor:

1. Observation on 04/30/14 at 9:20 AM, above the ceiling tiles on the "4 Bridge" with Staff PP revealed the corridor wall between Room 476 and Room 484 had a 1 foot by 25 feet section that did not extend to the floor decking above.

Third Floor

2. Continued observations above the ceiling tiles on 04/30/14 at 11:00 AM, of the "3C Wing", revealed the south corridor wall between the Mercy Heart Center Administrative Director doors had a three fourths inch conduit with two data cables passing through and a one half inch conduit with open annular spaces.

3.At 11:20 A.M., observation above the ceiling tiles revealed multiple penetrations varying in size and shape in the north corridor wall from the EP lab programmer room past the Respiratory Care Director office. Additionally the wall did not extend to the floor decking above.

4. Continued observation on 04/30, at 1:50 PM, of the third floor, "3 Bridge area", revealed a one and one half foot by one foot penetration above the ceiling tiles at the corridor doors between "3 Bridge" and "3A Wing".

5. At 2:00 P.M., observation above ceiling tiles of the north corridor wall revealed two, one and a half inch chilled water pipes passing through the wall of the corridor with open annular space.

6. These findings were confirmed by Staff PP at the time of the observations.

Based on facility observation and staff confirmation, the facility failed to ensure that stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings include;

On 04/28/14 through 05/01/14 between the hours of 8:15 A.M. and 5:00 P.M. tour of the facility was conducted with Staff PP, QQ, SS and TT. The following observations of vertical openings were noted;

1. On 04/29/14 , observation on the ground floor of B-Wing back corridor, revealed stairwell B1. Observation of the exit door for the stairwell revealed no identifiable fire rating on the door. Staff TT confirmed the observation.

2. Observation of the 4th floor vascular lab completed on 04/29/14 at 9:20 AM, above the ceiling behind elevators 7 and 8, revealed four, 12 inch by 12 inch openings in a two hour rated wall at the floor deck. Two of the penetrations were wiring troughs passing through the fire rated shaft. This finding was confirmed by Staff PP at the time of the observation.

3. On 04/30/14 at 8:50 AM, observation of the fourth floor ,"4 Bridge" duct shaft, revealed 2 pink cables penetrating the two hour rated wall with open annular space. This finding was confirmed by Staff PP at the time of the observation.

4. On 05/01/14 observation of stairwell B on first floor revealed the door had no identifiable fire rating. Staff TT confirmed the door was to have a fire rating of at least one and one half hours. Staff TT stated the fire rating label on the door had been painted over.

5. On 05/01/14 observation of the exit door for stairwell M2 on the first floor, revealed no identifiable fire rating on the door. The door was noted to be attached to the frame by piano hinges. Staff TT stated the piano hinges probably covered the fire rating of the door. Staff TT confirmed no identifiable fire rating could be seen on the door.

6. On 05/01/14 at 2:21 P.M., observation of the second floor labor and delivery area revealed two 8 inch sleeves with five inch steel pipe extending through an opening between the pipe and sleeve through the two hour fire rated wall of the vertical chase in the middle corridor traveling from South to North. This finding was confirmed by Staff PP at the time of the observation.



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Based on facility observation and staff confirmation, the facility failed to ensure that any door in an exit passageway, stairway enclosure, horizontal exit or smoke barrier was held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of the required manual fire alarm system, local smoke detectors designed to detect smoke passing through the opening and or the automatic sprinkler system, if installed. 19.2.2.2.6, 7.2.1.8.2. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings include;

On 04/28/14 through 05/01/14 between the hours of 8:15 A.M. and 5:00 P.M. tour of the facility was conducted with Staff SS and TT. The following observations of two hour fire rated stairwells were noted;

1. On 04/29/14, observation on the ground floor of B-Wing back corridor, revealed stairwell B1. Observation of the exit door for the fire rated stairwell revealed no identifiable fire rating on the door. Staff TT confirmed the observation.

2. On 05/01/14 observation of stairwell B on first floor revealed the door had no identifiable fire rating. Staff TT confirmed the door was to have a fire rating of at least one and one half hours. Staff TT stated the fire rating label on the door had been painted over.

3. On 05/01/14 observation of the exit door for stairwell M2 on the first floor, revealed no identifiable fire rating on the door. The door was noted to be attached to the frame by piano hinges. Staff TT stated the piano hinges probably covered the fire rating of the door. Staff TT confirmed no identifiable fire rating could be seen on the door.

Based on facility observation and staff interview, the facility failed to ensure that any doors in an exit passageway, horizontal exit or smoke barrier wass held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of; the required manual fire alarm system; local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system and the automatic sprinkler system, if installed. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey.

Findings include;

1. On 05/01/14 between 3:30 P.M. and 4:00 P.M. observation was conducted with Staff TT and SS of the concourse exit corridor located on the first floor of the hospital at the main entrance. Observation of the exit corridor and the two hour fire rated doors located within the exit corridor revealed the doors to the emergency department did not positively latch when tested.

2. Further observation of the exit corridor door at the concourse revealed another set of two hour fire rated doors that could not close and latch due to a rug on the concourse floor. Staff TT and SS confirmed the fire rated doors were to close and positively latch but did not when tested.

Staff SS acted immediately to remove the rug that obstructed the second set of fire doors.

Based on facility observation and staff confirmation, the facility failed to ensure that access to exits was marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey.

Findings include;


1. On 04/28/14 at 4:30 PM. tour of the first floor corridor revealed a path of egress was not clear when entering the corridor from stairwell "D2". No directional exit sign was noted showing the path of egress at the corridor intersection. This finding was confirmed at the time of the observation by Staff PP.

2. On 05/01/14 between 8:30 A.M. and 12:00 P.M. tour of the first floor continued with Staff TT. Observation of the radiology corridor leading to the MRI unit revealed it was designated as a way out. Observation and following the exit signage revealed it lead to a second corridor . At the second corridor there was no directional exit sign to show the continuation of the pathway.

Staff TT present on the tour confirmed another directional sign was needed to show the way out of the area.

Based on facility observation and staff confirmation, the facility failed to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey.

Findings include;

On 04/28/14 through 05/01/14 between the hours of 8:15 A.M. and 5:00 P.M. tour of the facility was conducted with Staff PP, QQ, SS and TT. The following observations of smoke barrier walls revealed penetrations:

Ground Floor:

1. On 04/28/14 between 11:00 A.M. and 4:40 P.M. tour of the ground floor was conducted with Staff TT. Observation of the smoke barrier wall located in the hot water tank room revealed three penetrations. Two penetrations were pipe approximately three inches in diameter that went through the wall and the third was an eight inch pipe that also extended through the smoke barrier.

2. Observation of the smoke barrier wall located in the light bulb room revealed multiple penetrations in cement block. Three unsealed areas were noted to be approximately four inches in diameter that surrounded conduit.

3. Observation of the smoke barrier wall located near the volunteer office revealed two penetrations surrounding conduit and sprinkler pipe.

First Floor:

4. Observation on 04/30/14 at 1:55 P.M. of the two hour fire rated separation between the surgery center and C- wing near the St. Luke wall revealed a penetration approximately one inch in diameter surrounding cable wire.

Observation of the first floor smoke barrier wall on 05/01/14 between 8:30 A.M. and 2:00 P.M. with Staff TT revealed the following:

5. Observation of the smoke barrier located in the gastroentrology area revealed penetrations surrounding three flex conduits and three ridged conduits.

6. Observation of smoke barrier wall in the radiology to MRI/ Nuclear Med corridor revealed three penetrations surrounding cables that extended through the wall. One area was approximately six inches by two inches and another area was approximately one inch by two inches in diameter.

7. Observation of the smoke barrier wall in the radiology directors office revealed multiple penetrations that surrounded air ducts and two inch pipe.

Second Floor:

8. Observation on 05/01/14 at 2:21 P.M., of smoke barrier walls in the "Labor and Delivery area" revealed a four inch penetration in the South wall at the maternity nurses station.

9. Also noted in the labor and delivery unit, a three fourths inch conduit open on the end and an uncovered electrical junction box with one half inch conduit were penetrating the smoke partition above the corridor doors separating labor and delivery from the 2A wing.

Third Floor;

10. Observation on 05/01/14 above ceiling tiles of "3 Bridge Area" revealed a one half inch inch conduit penetrating the North wall smoke partition in CCU storage room.

These findings were confirmed by Staff PP at the time of the observations.

Based on facility observation, review of the faciltiy schematic and staff interview, the facility failed to ensure that smoke barriers were constructed to provide at least a one-hour fire resistance rating in accordance with 8.3. The facility had a census of 216 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings include;

On 05/01/14 between 1:30 P.M. and 4:00 P.M. observation of the one hour smoke barrier wall on the first floor was conducted with Staff TT. The following areas of the fire rated smoke barrier wall were noted to have penetrations.

1. Located behind the smaller waiting area in the hospital lobby, observation above the ceiling tiles revealed two, four inch pipes which extended through the smoke barrier wall into the construction area for the emergency department. The pipes were to be used as sleeves for wire. Light could be seen from the construction side of the barrier wall.

2. Following the same smoke barrier wall in the waiting/ registration corridor, observation above the ceiling tiles revealed penetration surrounding a two inch conduit.

3. Located in the women's bathroom, observation above the ceiling tiles revealed at least two penetrations. One penetration was approximately one inch wide and six inches long. The second penetration was surrounding a flex cable which extended through the barrier wall.

Staff TT confirmed the observation.

Observation of the construction site on the other side of the smoke barrier wall revealed stud walls. Workers were placing wire and cables, cutting pipe and placing gypsum board on some stud walls.

3A Wing

Observation of the 3A Wing was conducted on 04/30/14 between 1:40 P.M. and 4;00 P.M. wiht Staff PP. The following areas were observed to have pentrations in smoke barrier walls.

4. Observation of a onr hour fire rated wall located in the 3 bridge area smoke compartment across from elevators seven and eight, reveaeld a three inch pipe slleve wiht a chill water pipe passing through the sleeve. A half inch gap between the sleeve and the pipe was also noted. at 1:40 PM.


5. Observation above ceiling tiles at the corridor doors on the "3 bridge area" side of the one hour smoke barrier wall reveaeld a one and one half foot by one foot penetration.

6. Observation of a smoke barrier wall above the ceiling tiles in the "3A Wing" locker room revealed an eight inch by four inch penetration.

7. Observation of a two hour fire rated barrier on the 3A side of the bridge connecting to the 3B Wing. revealed a one and one half inch conduit and a one half inch conduit with multiple data cables passing through the barrier wall. The annualr space was not sealed wiht fire rated caulking. A second pentration three-fourths inch in diameter was also noted.

These findings were confirmed by Staff PP at the time of the observations.

Based on facility observation and staff confirmation, the facility failed to ensure that door openings in smoke barriers had at least a 20-minute fire protection rating. Doors were to be self-closing or automatic closing in accordance with 19.2.2.2.6. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey.

Findings include;

On 04/28/14 at 3:40 P.M. observation of the ground floor was condcuted wiht Staff SS and TT of the fire rated separation between the main high rise corridor and the link to the medical office building. Observation and testing of the fire rated doors located in the two hour fire rated barrier revealed they did not positively latch when in the closed position.

On 04/29/14 between 8:40 A.M. and 9:30 A.M. observation of the ground floor , B-wing corridor revealed fire rated doors located near the elevator lobby. The doors were located within a fire rated barrier wall. Testing of the fire rated doors revealed they failed to adequately close and securely latch.

Observation of a second set of fire rated doors in the B-Wing corridor, located between the high rise building and the B-Wing, revealed the fire rated doors failed to adequately close and securely latch when tested.

On 04/30/14 between 1:55 P.M. and 3:00 P.M. observation of the first floor was conducted with Staff TT. Observation of the fire rated doors located in the two hour fire rated barrier located in CSP to the clean supply room revealed the doors failed to close and securely latch. Further observation of a second set of fire rated doors located in the two hour fire rated barrier between CSP and the dirty area revealed the doors failed to close and securely latch.

Observation and testing of the fire rated doors was confirmed by Staff SS and TT.

Based on facility observation and staff interview and verification, the facility failed to ensure that one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. When the approved automatic fire extinguishing system option is used, the areas were to be separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey.

Findings include;

On 04/28/14 through 05/01/14 between the hours of 8:15 A.M. and 5:00 P.M. tour of the facility was conducted with Staff PP, QQ, SS and TT. The following observations of hazardous areas were noted:

Sub-Basement;

On 04/28/14 between 11:00 A.M. and 4:40 P.M. the following observations were completed of hazardous areas with Staff SS and TT.

1. Observation of the maintenance shop revealed there was no automatic sprinkler protection. A four inch white pipe was observed to penetrate through the floor decking above the room. The pipe was located near a column labeled F2.5. Further observation of the maintenance shop revealed the door to the room had no identifiable fire rating.

2. Observation of the food services storage area revealed there was no automatic sprinkler protection. Observation above the ceiling tiles in the rooms revealed penetrations surrounding two capped copper pipes. A disconnected duct had duct tape covering the open end of the pipe. The duct penetrated the wall of the storage room and lacked fire resisitant caulking surrounding the ductwork . A one and one half inch pipe was noted to penetrate the wall and was not sealed with fire resisitant caulking. A larger penetration was observed above the ceiling tiles at the door to the room. A penetration was observed to have a rotary style phone stuffed into the hole.

3. Observation of the medical records storage area revealed there were two large rooms. One room of the large two room area was not provided sprinkler protection. Observation of the room revealed the presence of numerous shelving units and storage of a significant amount of combustible patient medical records. Review of the facility schematic revealed the room was not separated by one our fire resisitant construction.

Staff present on tour confirmed the observations.

On 04/29/14 between 8:40 A.M. and 4:00 P.M. tour of the ground floor continued with Staff SS and TT. The following observations of hazardous storage areas were noted;

4. Observation of the "old " generator room, identified as an electrical room on the facility schematic revealed the area had no automatic sprinkler protection. Review of the facility schematic revealed it was identified as a hazardous area. The room contained live electrical panels, storage of boxes, a desk, microwave for workers and additional combustible items. Observation of the wall surrounding the room revealed a penetration where a pipe sleeve and wire went through the wall.

5. Observation of a mechanical room in the sub-basement area revealed the room was not provided sprinkler protection. Observation of the double doors leading to the room revealed there was no identifiable fire resistance rating on the doors.

6. Observation of a biohazard room located in the back corridor of the B-Wing, near the back door of the pharmacy, revealed the area had no sprinkler protection. Observation above the ceiling tiles revealed there was no one hour fire rated construction between the pharmacy storage room and the biohazard room. The biohazard room contained a significant amount of cardboard boxes and other combustible items.

Observations this day were confirmed by staff present on tour.

On 04/30/14 between 8:20 A.M. and 10:07 A.M. tour of the ground floor continued with Staff SS and TT. The following observations of hazardous storage areas were noted;

7. Observation of a soiled utility room located in the Breast Health area, revealed the room was provided sprinkler protection. The door to the room was noted to have no self-closing device in place.

8. Observation of a biohazard room in the radiation therapy area revealed the room was not provided automatic sprinkler protection. A penetration was observed in the monolithic ceiling of the room. Staff present confirmed the penetration was once duct work for a vent. The room was once a dark room for processing films and it's usage was changed to a biohazard room.

First floor

On 04/30/14 between 10:10 A.M. and 11:30 A.M. tour of the first floor OR area was conducted with Staff SS and TT. Interview of Staff TT revealed the facility practice was to maintain hazardous area walls beyond ceiling tiles to the decking above the area.

9. Observation of the sprinklered soiled utility room, shared with the operating room, above the ceiling tiles revealed the walls to the room extended to the floor decking above. Penetrations were observed surrounding three pipes which extended through the wall. A waste pipe was observed to extend through the floor decking above and was not sealed in the area surrounding the pipe.

The observation was confirmed by staff present on the tour.

Second Floor:

Observation of the second floor on 05/01/14 between 1:50 P.M. and 3:30 P.M. with Staff PP revealed penetrations in hazardous areas provided automatic sprinkler protection. Staff PP stated the facility maintained walls in hazardous areas to the decking above the area regardless of automatic sprinkler protection.

10. Located on 2A wing, in the south west corner of the "set up room", a two inch by three inch penetration was noted.

11. Observation in the soiled utility room, the south wall, revealed penetration two and one half inches in diameter.

12. Observation in the labor/ delivery / recovery area, of a soiled utility room in the special care nursery, a penetration was noted above an air duct measuring eight inches by 12 inches in the north wall of the room.

Third Floor

Observation of the "3B Wing" on 05/01/14 between 9:55 A.M. and 10:35 A.M. revealed penetrations in the following areas:

13. A large storage area for Regional Heart operating room had multiple penetrations in the walls of the storage room. Additionally more than one wall of the storage room that did not to the floor decking above.

14. The soiled utility room for Regional Heart operating room had more than one wall in the room that did not extend to the floor decking above the ceiling tiles.

15. The soiled utility room of the cath lab holding area had a one and one half foot space at the east and south walls between the top of the wall and the ceiling deck above.

16. The soiled utility room in the dialysis area was not protected by wall that extended to the deck above.

Fourth Floor

Observation of the fourth floor, "4 Bridge" area revealed the area was not provided automatic sprinkler protection.

17. Observation above the ceiling tiles of a storage room located beside an exit stairwell had a one foot by five foot opening in the east wall of the room.

18. Observation of room 484 revealed storage of multiple paper files on three shelving units. Observation above the ceiling tiles of the storage room revealed no fire rated wall separating the room. The wall present in the room did not extend to the decking above the room.

Based on facility observation and staff interview and confimration, the facility failed to ensure that hazardous areas were protected in accordance with 8.4. The areas were to be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows (in accordance with 8.4). Doors are self-closing or automatic closing in accordance with The facility had a census of 216 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings include;

On 04/30/14 between 1:30 P.M. and 3:50 P.M. tour of the "3A Wing smoke compartment" was conducted with Staff PP. The following pentrations were noted in hazardous areas;

1. Located in the the north hazardous storage room, southwest corner, a pentration one inch by two inch penetration was noted.

2. Located outside of a soiled utility room, observation above the ceiling tiles revealed a one fourth inch gap below the duct inside and above the room door.

3. Observation above the ceiling tiles of the soiled utility room revealed the west wall was not to the decking above.

These finding were confirmed by Staff PP at the time of the observation.

Based on observation and staff confirmation the facility failed to maintain protection of exit components from fire. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey. This has the potential to affect all patients, visitors, and staff in the facility.

Findings include:

1. On 05/01/14 between 8:30 A.M. and 12:00 P.M. tour of the first floor two hour fire rated exit corridor with Staff SS and TT revealed a set of cross corridor doors. Observation of the fire rated doors which lead to the radiology area revealed the doors were on hold-open devices connected to the fire alarm system. Testing of the fire rated doors revealed they failed to completely close and securely latch. The observation was verified by Staff TT and SS.

2. On 05/01/14 at 3:20 PM, tour of the second floor labor and delivery room #1 was conducted with Staff PP. Observation of a two hour fire rated stairwell wall revealed a five foot by five foot section of the stairwell wall with one layer of gypsum board and multiple penetrations. This finding was confirmed by Staff PP at the time of the observation.

Based on facility observation and staff confirmation the facility failed to have the releasing mechanism of an exit door less than 48 inches from the floor. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey. This has the potential to affect all patients, visitors, and staff that would use the exit.

Findings include:

1. Tour of the "3 Main CCU" completed on 05/01/14 revealed an exit access door with a releasing mechanism (door handle) approximately five and one half feet above the floor. This finding was confirmed by Staff PP at the time of the observation on 05/01/14 at 8:55 AM.

Based on facility observation and staff confirmation the facility failed to have two light sources at an exit discharge. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey. Potentially any patients, visitors, and staff that would use the exit discharge could be affected.

Findings include:

1. Tour of "4C Wing" completed on 04/30/14 revealed the exit discharge for stairwell C1 had one light source and no other light sources were visible. This observation was confirmed by Staff PP at the time of the observation on 04/30/14 at 8:20 AM.

Based on facility observation and staff confirmation, the facility failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities with regards to oxygen storage locations of greater than 3,000 cu.ft. that were to be enclosed by a one-hour separation and were vented to the outside. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey.

Findings include;

1. On 04/28/14 between 11:00 A.M. and 1:00 P.M. tour of the sub-basement of the facility was conducted with Staff SS and TT. Observation of an medical gas storage location was noted in a central storage room. Observation of the medical gas storage room revealed the door to the room had no identifiable fire resistance rating. Staff TT confirmed the observation and verified the door did not have a fire resistance rating of at least one hour.

2. On 04/29/14 between 8:40 A.M. and 11:00 A.M. tour of the ground floor was conducted with Staff TT. Observation of an oxygen storage room revealed the location was within a large mechanical area. Observation of the oxygen storage room revealed there was no fire resistance rating on the door to the room. A light switch for the room and an electrical receptacle were placed less than five feet from the floor inside the storage room. Observation of the oxygen storage wall which separated the mechanical space revealed a vent which opened into the mechanical space.

Staff TT confirmed the observations

Based on facility observation and staff confirmation, the facility failed to ensure that areas used for general storage of combustible medical records was protected, by enclosure of the area with a fire barrier without windows that had a 1-hour fire resistance rating in accordance with Section 8.2. or protection of the area with automatic extinguishing systems in accordance with Section 9.7. There were no patients present at the time of the facility observation.

Findings included;

On 05/01/14 between 4:00 P.M. and 5:00 P.M. observation of the sleep center was conducted with Staff TT. Observation of the fourth floor location revealed there were six bedrooms for patient sleep studies. Located near the entrance of the sleep center was a storage room with multiple shelves of paper medical records. Staff TT confirmed the room was used by the sleep study staff to store patient medical record information.

Further observation of the storage room with a significant amount of combustible patient medical records revealed the room was not provided with automatic sprinkler system protection. Two wooden doors were present on each side of storage room. One door was a sliding pocket door. Both doors lacked self closing devices. Staff TT confirmed the storage room for the medical records was not constructed to provided one hour fire rated protection.

Based on facility observation and staff confirmation, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement is located in the National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey. This had the potential to affect all patients, staff and visitors utilizing the facility.


Findings include;

1. On 04/29/14 between 10:30 A.M. and 12:00 P.M., observation of the ground floor surgical storage area revealed a smoke detector within 18 inches of an air diffuser.

On 04/30/14 between 10:35 A.M. and 11:25 A..M. tour of the first floor operating rooms was conducted with Staff TT and VV. Observation of the operating rooms and the adjacent areas revealed the following list of smoke detectors that were placed in close proximity to air flow devices;

2. Located in the operating room waiting area, outside elevators 9 and 10, a smoke detectors was approximately 12 inches from an air flow device.

3. Located in OR 16, control room , a smoke detector was approximately 12 inches from a air diffuser.

4. Located outside OR 4 and 8 a smoke detector was approximately 12 inches from an air vent.

5. Located in the pod area for OR 3 and 4 a smoke detector was approximately 16 inches from an air vent.

6. On 05/01/14 between 8:30 A.M. and 12:00 P.M. tour of the first floor continued with Staff TT. Observation of the radiology area revealed a smoke detector in the fluoroscopy work area that was approximately 12 inches from an air diffuser.

Staff TT confirmed the observations and verified the locations of the smoke detectors were too close to air flow devices.

Based on observations and staff interview, the facility failed to ensure exit access doors in the facility were arranged so that the exits were readily accessible at all times in accordance with the code at 39.2.1.1 and 7.2.1.5.1, failed to ensure one exit discharge contained a hard surface to the public way in accordance with the code at 39.2.1.1 and 7.7.1, and failed to ensure ten exits discharges were arranged so that failure of any single lighting fixture (bulb) would not leave the area in darkness in accordance with the code at 39.2.1.1 and 7.8.1.4. This could potentially affect all patients in the facility. The census on the survey day was 216 patients.
Findings include:
A tour was conducted on 05/02/14 between 8:25AM and 9:25 AM with Staff K. L, and M.
1. During the tour, two exit access doors leading from the following pediatric therapy care areas and the corridor by the men and women ' s restrooms to the front lobby were observed with a door handle along with a deadbolt (which required a key to lock and unlock). The deadbolts were observed located approximately one foot above the door handles. Interview with the aforementioned staff during tour revealed the doors were locked by housekeeping at night to keep people from entering the areas. The code requires exit access doors to release with an obvious method of operation that is readily operated under all lighting conditions, and with not more than one releasing operation.
2. Ten of ten exit discharges observed during tour were equipped with either one single egress battery powered light, non-battery backup lights, or no lights outside the discharge. This was confirmed with Staff L during tour. These exits are as follows:
a) The exit discharge from the Pediatric therapy area of the lobby to the main parking lot (no battery powered lights). Although 5 recessed lights were observed in the overhead canopy outside the exit discharge, Staff L stated the lights would not work in the event of a power loss.
b) The exit discharge outside the small work/exercise gym
c) The exit discharge outside the health fitness gym leading from the hallway containing the Director ' s office
d) The exit discharge from the work health and safety area at the opposite end of the front lobby
e) The exit discharge from the STATCARE corridor at the opposite end of the front lobby
f) The exit discharge from the Diagnostic/CT scan corridor at the opposite end of the front lobby
g) The exit discharge from the Wellness Clinic lobby
f) The exit discharge from the main lobby near the Wellness clinic entrance, and
g) Two exit discharges from the main lobby on the west end of the building. These discharges were not equipped with any type of discharge lights.
Staff L stated confirmed the current discharge arrangement, stating the exit discharges either lacked lighting, or were equipped with lights that did not have battery back-up. This employee stated the facility did not have a generator to power the lights.

3. The exit discharge from the small work/exercise gym was observed with a pair of exit discharge doors. Immediately outside the exit, a concrete pad was observed. The concrete pad was confirmed as measuring approximately 10 feet in length and 4 feet wide, which was confirmed with Staff K and L. The area surrounding the concrete pad was grass, which extended greater than 100 feet in all directions before reaching the public way. Both staff confirmed this was an exit discharge which would be used in the event of an emergency exit from the facility.

Based on documentation review and staff interview the facility failed to perform an annual 90 minute emergency light lest on battery powered emergency lighting. This has the potential to affect all patient, staff, and visitors at the facility. The facility's census at the time of the survey was 70.

Findings include:

1. Review of facility documentation completed on 05/02/14 revealed no documented evidence a 90 minute emergency light test was completed on the battery powered emergency lighting.

Interview with Staff PP completed on 05/02/14 at 7:45 AM revealed the owner of the building was unable to provide the testing of the emergency lighting before the building changed ownership. Staff PP stated that the facility started doing the monthly testing themselves last month and plan on doing the 90 minute test next month.

Based on facility observation and staff confirmation, the facility failed to ensure that corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating. In non-sprinklered buildings, walls properly extend above the ceiling. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings include;

On 04/28/14 through 05/01/14 between the hours of 8:15 A.M. and 5:00 P.M. tour of the facility was conducted with Staff PP and QQ. The following observations were noted in corridors with no sprinkler system protection.

Fourth Floor:

1. Observation on 04/30/14 at 9:20 AM, above the ceiling tiles on the "4 Bridge" with Staff PP revealed the corridor wall between Room 476 and Room 484 had a 1 foot by 25 feet section that did not extend to the floor decking above.

Third Floor

2. Continued observations above the ceiling tiles on 04/30/14 at 11:00 AM, of the "3C Wing", revealed the south corridor wall between the Mercy Heart Center Administrative Director doors had a three fourths inch conduit with two data cables passing through and a one half inch conduit with open annular spaces.

3.At 11:20 A.M., observation above the ceiling tiles revealed multiple penetrations varying in size and shape in the north corridor wall from the EP lab programmer room past the Respiratory Care Director office. Additionally the wall did not extend to the floor decking above.

4. Continued observation on 04/30, at 1:50 PM, of the third floor, "3 Bridge area", revealed a one and one half foot by one foot penetration above the ceiling tiles at the corridor doors between "3 Bridge" and "3A Wing".

5. At 2:00 P.M., observation above ceiling tiles of the north corridor wall revealed two, one and a half inch chilled water pipes passing through the wall of the corridor with open annular space.

6. These findings were confirmed by Staff PP at the time of the observations.

Based on facility observation and staff confirmation, the facility failed to ensure that stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings include;

On 04/28/14 through 05/01/14 between the hours of 8:15 A.M. and 5:00 P.M. tour of the facility was conducted with Staff PP, QQ, SS and TT. The following observations of vertical openings were noted;

1. On 04/29/14 , observation on the ground floor of B-Wing back corridor, revealed stairwell B1. Observation of the exit door for the stairwell revealed no identifiable fire rating on the door. Staff TT confirmed the observation.

2. Observation of the 4th floor vascular lab completed on 04/29/14 at 9:20 AM, above the ceiling behind elevators 7 and 8, revealed four, 12 inch by 12 inch openings in a two hour rated wall at the floor deck. Two of the penetrations were wiring troughs passing through the fire rated shaft. This finding was confirmed by Staff PP at the time of the observation.

3. On 04/30/14 at 8:50 AM, observation of the fourth floor ,"4 Bridge" duct shaft, revealed 2 pink cables penetrating the two hour rated wall with open annular space. This finding was confirmed by Staff PP at the time of the observation.

4. On 05/01/14 observation of stairwell B on first floor revealed the door had no identifiable fire rating. Staff TT confirmed the door was to have a fire rating of at least one and one half hours. Staff TT stated the fire rating label on the door had been painted over.

5. On 05/01/14 observation of the exit door for stairwell M2 on the first floor, revealed no identifiable fire rating on the door. The door was noted to be attached to the frame by piano hinges. Staff TT stated the piano hinges probably covered the fire rating of the door. Staff TT confirmed no identifiable fire rating could be seen on the door.

6. On 05/01/14 at 2:21 P.M., observation of the second floor labor and delivery area revealed two 8 inch sleeves with five inch steel pipe extending through an opening between the pipe and sleeve through the two hour fire rated wall of the vertical chase in the middle corridor traveling from South to North. This finding was confirmed by Staff PP at the time of the observation.



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Based on facility observation and staff confirmation, the facility failed to ensure that any door in an exit passageway, stairway enclosure, horizontal exit or smoke barrier was held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of the required manual fire alarm system, local smoke detectors designed to detect smoke passing through the opening and or the automatic sprinkler system, if installed. 19.2.2.2.6, 7.2.1.8.2. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings include;

On 04/28/14 through 05/01/14 between the hours of 8:15 A.M. and 5:00 P.M. tour of the facility was conducted with Staff SS and TT. The following observations of two hour fire rated stairwells were noted;

1. On 04/29/14, observation on the ground floor of B-Wing back corridor, revealed stairwell B1. Observation of the exit door for the fire rated stairwell revealed no identifiable fire rating on the door. Staff TT confirmed the observation.

2. On 05/01/14 observation of stairwell B on first floor revealed the door had no identifiable fire rating. Staff TT confirmed the door was to have a fire rating of at least one and one half hours. Staff TT stated the fire rating label on the door had been painted over.

3. On 05/01/14 observation of the exit door for stairwell M2 on the first floor, revealed no identifiable fire rating on the door. The door was noted to be attached to the frame by piano hinges. Staff TT stated the piano hinges probably covered the fire rating of the door. Staff TT confirmed no identifiable fire rating could be seen on the door.

Based on facility observation and staff interview, the facility failed to ensure that any doors in an exit passageway, horizontal exit or smoke barrier wass held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of; the required manual fire alarm system; local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system and the automatic sprinkler system, if installed. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey.

Findings include;

1. On 05/01/14 between 3:30 P.M. and 4:00 P.M. observation was conducted with Staff TT and SS of the concourse exit corridor located on the first floor of the hospital at the main entrance. Observation of the exit corridor and the two hour fire rated doors located within the exit corridor revealed the doors to the emergency department did not positively latch when tested.

2. Further observation of the exit corridor door at the concourse revealed another set of two hour fire rated doors that could not close and latch due to a rug on the concourse floor. Staff TT and SS confirmed the fire rated doors were to close and positively latch but did not when tested.

Staff SS acted immediately to remove the rug that obstructed the second set of fire doors.

Based on facility observation and staff confirmation, the facility failed to ensure that access to exits was marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey.

Findings include;


1. On 04/28/14 at 4:30 PM. tour of the first floor corridor revealed a path of egress was not clear when entering the corridor from stairwell "D2". No directional exit sign was noted showing the path of egress at the corridor intersection. This finding was confirmed at the time of the observation by Staff PP.

2. On 05/01/14 between 8:30 A.M. and 12:00 P.M. tour of the first floor continued with Staff TT. Observation of the radiology corridor leading to the MRI unit revealed it was designated as a way out. Observation and following the exit signage revealed it lead to a second corridor . At the second corridor there was no directional exit sign to show the continuation of the pathway.

Staff TT present on the tour confirmed another directional sign was needed to show the way out of the area.

Based on facility observation and staff confirmation, the facility failed to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey.

Findings include;

On 04/28/14 through 05/01/14 between the hours of 8:15 A.M. and 5:00 P.M. tour of the facility was conducted with Staff PP, QQ, SS and TT. The following observations of smoke barrier walls revealed penetrations:

Ground Floor:

1. On 04/28/14 between 11:00 A.M. and 4:40 P.M. tour of the ground floor was conducted with Staff TT. Observation of the smoke barrier wall located in the hot water tank room revealed three penetrations. Two penetrations were pipe approximately three inches in diameter that went through the wall and the third was an eight inch pipe that also extended through the smoke barrier.

2. Observation of the smoke barrier wall located in the light bulb room revealed multiple penetrations in cement block. Three unsealed areas were noted to be approximately four inches in diameter that surrounded conduit.

3. Observation of the smoke barrier wall located near the volunteer office revealed two penetrations surrounding conduit and sprinkler pipe.

First Floor:

4. Observation on 04/30/14 at 1:55 P.M. of the two hour fire rated separation between the surgery center and C- wing near the St. Luke wall revealed a penetration approximately one inch in diameter surrounding cable wire.

Observation of the first floor smoke barrier wall on 05/01/14 between 8:30 A.M. and 2:00 P.M. with Staff TT revealed the following:

5. Observation of the smoke barrier located in the gastroentrology area revealed penetrations surrounding three flex conduits and three ridged conduits.

6. Observation of smoke barrier wall in the radiology to MRI/ Nuclear Med corridor revealed three penetrations surrounding cables that extended through the wall. One area was approximately six inches by two inches and another area was approximately one inch by two inches in diameter.

7. Observation of the smoke barrier wall in the radiology directors office revealed multiple penetrations that surrounded air ducts and two inch pipe.

Second Floor:

8. Observation on 05/01/14 at 2:21 P.M., of smoke barrier walls in the "Labor and Delivery area" revealed a four inch penetration in the South wall at the maternity nurses station.

9. Also noted in the labor and delivery unit, a three fourths inch conduit open on the end and an uncovered electrical junction box with one half inch conduit were penetrating the smoke partition above the corridor doors separating labor and delivery from the 2A wing.

Third Floor;

10. Observation on 05/01/14 above ceiling tiles of "3 Bridge Area" revealed a one half inch inch conduit penetrating the North wall smoke partition in CCU storage room.

These findings were confirmed by Staff PP at the time of the observations.

Based on facility observation, review of the faciltiy schematic and staff interview, the facility failed to ensure that smoke barriers were constructed to provide at least a one-hour fire resistance rating in accordance with 8.3. The facility had a census of 216 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings include;

On 05/01/14 between 1:30 P.M. and 4:00 P.M. observation of the one hour smoke barrier wall on the first floor was conducted with Staff TT. The following areas of the fire rated smoke barrier wall were noted to have penetrations.

1. Located behind the smaller waiting area in the hospital lobby, observation above the ceiling tiles revealed two, four inch pipes which extended through the smoke barrier wall into the construction area for the emergency department. The pipes were to be used as sleeves for wire. Light could be seen from the construction side of the barrier wall.

2. Following the same smoke barrier wall in the waiting/ registration corridor, observation above the ceiling tiles revealed penetration surrounding a two inch conduit.

3. Located in the women's bathroom, observation above the ceiling tiles revealed at least two penetrations. One penetration was approximately one inch wide and six inches long. The second penetration was surrounding a flex cable which extended through the barrier wall.

Staff TT confirmed the observation.

Observation of the construction site on the other side of the smoke barrier wall revealed stud walls. Workers were placing wire and cables, cutting pipe and placing gypsum board on some stud walls.

3A Wing

Observation of the 3A Wing was conducted on 04/30/14 between 1:40 P.M. and 4;00 P.M. wiht Staff PP. The following areas were observed to have pentrations in smoke barrier walls.

4. Observation of a onr hour fire rated wall located in the 3 bridge area smoke compartment across from elevators seven and eight, reveaeld a three inch pipe slleve wiht a chill water pipe passing through the sleeve. A half inch gap between the sleeve and the pipe was also noted. at 1:40 PM.


5. Observation above ceiling tiles at the corridor doors on the "3 bridge area" side of the one hour smoke barrier wall reveaeld a one and one half foot by one foot penetration.

6. Observation of a smoke barrier wall above the ceiling tiles in the "3A Wing" locker room revealed an eight inch by four inch penetration.

7. Observation of a two hour fire rated barrier on the 3A side of the bridge connecting to the 3B Wing. revealed a one and one half inch conduit and a one half inch conduit with multiple data cables passing through the barrier wall. The annualr space was not sealed wiht fire rated caulking. A second pentration three-fourths inch in diameter was also noted.

These findings were confirmed by Staff PP at the time of the observations.

Based on facility observation and staff confirmation, the facility failed to ensure that door openings in smoke barriers had at least a 20-minute fire protection rating. Doors were to be self-closing or automatic closing in accordance with 19.2.2.2.6. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey.

Findings include;

On 04/28/14 at 3:40 P.M. observation of the ground floor was condcuted wiht Staff SS and TT of the fire rated separation between the main high rise corridor and the link to the medical office building. Observation and testing of the fire rated doors located in the two hour fire rated barrier revealed they did not positively latch when in the closed position.

On 04/29/14 between 8:40 A.M. and 9:30 A.M. observation of the ground floor , B-wing corridor revealed fire rated doors located near the elevator lobby. The doors were located within a fire rated barrier wall. Testing of the fire rated doors revealed they failed to adequately close and securely latch.

Observation of a second set of fire rated doors in the B-Wing corridor, located between the high rise building and the B-Wing, revealed the fire rated doors failed to adequately close and securely latch when tested.

On 04/30/14 between 1:55 P.M. and 3:00 P.M. observation of the first floor was conducted with Staff TT. Observation of the fire rated doors located in the two hour fire rated barrier located in CSP to the clean supply room revealed the doors failed to close and securely latch. Further observation of a second set of fire rated doors located in the two hour fire rated barrier between CSP and the dirty area revealed the doors failed to close and securely latch.

Observation and testing of the fire rated doors was confirmed by Staff SS and TT.

Based on facility observation and staff interview and verification, the facility failed to ensure that one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. When the approved automatic fire extinguishing system option is used, the areas were to be separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey.

Findings include;

On 04/28/14 through 05/01/14 between the hours of 8:15 A.M. and 5:00 P.M. tour of the facility was conducted with Staff PP, QQ, SS and TT. The following observations of hazardous areas were noted:

Sub-Basement;

On 04/28/14 between 11:00 A.M. and 4:40 P.M. the following observations were completed of hazardous areas with Staff SS and TT.

1. Observation of the maintenance shop revealed there was no automatic sprinkler protection. A four inch white pipe was observed to penetrate through the floor decking above the room. The pipe was located near a column labeled F2.5. Further observation of the maintenance shop revealed the door to the room had no identifiable fire rating.

2. Observation of the food services storage area revealed there was no automatic sprinkler protection. Observation above the ceiling tiles in the rooms revealed penetrations surrounding two capped copper pipes. A disconnected duct had duct tape covering the open end of the pipe. The duct penetrated the wall of the storage room and lacked fire resisitant caulking surrounding the ductwork . A one and one half inch pipe was noted to penetrate the wall and was not sealed with fire resisitant caulking. A larger penetration was observed above the ceiling tiles at the door to the room. A penetration was observed to have a rotary style phone stuffed into the hole.

3. Observation of the medical records storage area revealed there were two large rooms. One room of the large two room area was not provided sprinkler protection. Observation of the room revealed the presence of numerous shelving units and storage of a significant amount of combustible patient medical records. Review of the facility schematic revealed the room was not separated by one our fire resisitant construction.

Staff present on tour confirmed the observations.

On 04/29/14 between 8:40 A.M. and 4:00 P.M. tour of the ground floor continued with Staff SS and TT. The following observations of hazardous storage areas were noted;

4. Observation of the "old " generator room, identified as an electrical room on the facility schematic revealed the area had no automatic sprinkler protection. Review of the facility schematic revealed it was identified as a hazardous area. The room contained live electrical panels, storage of boxes, a desk, microwave for workers and additional combustible items. Observation of the wall surrounding the room revealed a penetration where a pipe sleeve and wire went through the wall.

5. Observation of a mechanical room in the sub-basement area revealed the room was not provided sprinkler protection. Observation of the double doors leading to the room revealed there was no identifiable fire resistance rating on the doors.

6. Observation of a biohazard room located in the back corridor of the B-Wing, near the back door of the pharmacy, revealed the area had no sprinkler protection. Observation above the ceiling tiles revealed there was no one hour fire rated construction between the pharmacy storage room and the biohazard room. The biohazard room contained a significant amount of cardboard boxes and other combustible items.

Observations this day were confirmed by staff present on tour.

On 04/30/14 between 8:20 A.M. and 10:07 A.M. tour of the ground floor continued with Staff SS and TT. The following observations of hazardous storage areas were noted;

7. Observation of a soiled utility room located in the Breast Health area, revealed the room was provided sprinkler protection. The door to the room was noted to have no self-closing device in place.

8. Observation of a biohazard room in the radiation therapy area revealed the room was not provided automatic sprinkler protection. A penetration was observed in the monolithic ceiling of the room. Staff present confirmed the penetration was once duct work for a vent. The room was once a dark room for processing films and it's usage was changed to a biohazard room.

First floor

On 04/30/14 between 10:10 A.M. and 11:30 A.M. tour of the first floor OR area was conducted with Staff SS and TT. Interview of Staff TT revealed the facility practice was to maintain hazardous area walls beyond ceiling tiles to the decking above the area.

9. Observation of the sprinklered soiled utility room, shared with the operating room, above the ceiling tiles revealed the walls to the room extended to the floor decking above. Penetrations were observed surrounding three pipes which extended through the wall. A waste pipe was observed to extend through the floor decking above and was not sealed in the area surrounding the pipe.

The observation was confirmed by staff present on the tour.

Second Floor:

Observation of the second floor on 05/01/14 between 1:50 P.M. and 3:30 P.M. with Staff PP revealed penetrations in hazardous areas provided automatic sprinkler protection. Staff PP stated the facility maintained walls in hazardous areas to the decking above the area regardless of automatic sprinkler protection.

10. Located on 2A wing, in the south west corner of the "set up room", a two inch by three inch penetration was noted.

11. Observation in the soiled utility room, the south wall, revealed penetration two and one half inches in diameter.

12. Observation in the labor/ delivery / recovery area, of a soiled utility room in the special care nursery, a penetration was noted above an air duct measuring eight inches by 12 inches in the north wall of the room.

Third Floor

Observation of the "3B Wing" on 05/01/14 between 9:55 A.M. and 10:35 A.M. revealed penetrations in the following areas:

13. A large storage area for Regional Heart operating room had multiple penetrations in the walls of the storage room. Additionally more than one wall of the storage room that did not to the floor decking above.

14. The soiled utility room for Regional Heart operating room had more than one wall in the room that did not extend to the floor decking above the ceiling tiles.

15. The soiled utility room of the cath lab holding area had a one and one half foot space at the east and south walls between the top of the wall and the ceiling deck above.

16. The soiled utility room in the dialysis area was not protected by wall that extended to the deck above.

Fourth Floor

Observation of the fourth floor, "4 Bridge" area revealed the area was not provided automatic sprinkler protection.

17. Observation above the ceiling tiles of a storage room located beside an exit stairwell had a one foot by five foot opening in the east wall of the room.

18. Observation of room 484 revealed storage of multiple paper files on three shelving units. Observation above the ceiling tiles of the storage room revealed no fire rated wall separating the room. The wall present in the room did not extend to the decking above the room.

Based on facility observation and staff interview and confimration, the facility failed to ensure that hazardous areas were protected in accordance with 8.4. The areas were to be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows (in accordance with 8.4). Doors are self-closing or automatic closing in accordance with The facility had a census of 216 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings include;

On 04/30/14 between 1:30 P.M. and 3:50 P.M. tour of the "3A Wing smoke compartment" was conducted with Staff PP. The following pentrations were noted in hazardous areas;

1. Located in the the north hazardous storage room, southwest corner, a pentration one inch by two inch penetration was noted.

2. Located outside of a soiled utility room, observation above the ceiling tiles revealed a one fourth inch gap below the duct inside and above the room door.

3. Observation above the ceiling tiles of the soiled utility room revealed the west wall was not to the decking above.

These finding were confirmed by Staff PP at the time of the observation.

Based on observation and staff confirmation the facility failed to maintain protection of exit components from fire. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey. This has the potential to affect all patients, visitors, and staff in the facility.

Findings include:

1. On 05/01/14 between 8:30 A.M. and 12:00 P.M. tour of the first floor two hour fire rated exit corridor with Staff SS and TT revealed a set of cross corridor doors. Observation of the fire rated doors which lead to the radiology area revealed the doors were on hold-open devices connected to the fire alarm system. Testing of the fire rated doors revealed they failed to completely close and securely latch. The observation was verified by Staff TT and SS.

2. On 05/01/14 at 3:20 PM, tour of the second floor labor and delivery room #1 was conducted with Staff PP. Observation of a two hour fire rated stairwell wall revealed a five foot by five foot section of the stairwell wall with one layer of gypsum board and multiple penetrations. This finding was confirmed by Staff PP at the time of the observation.

Based on facility observation and staff confirmation the facility failed to have the releasing mechanism of an exit door less than 48 inches from the floor. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey. This has the potential to affect all patients, visitors, and staff that would use the exit.

Findings include:

1. Tour of the "3 Main CCU" completed on 05/01/14 revealed an exit access door with a releasing mechanism (door handle) approximately five and one half feet above the floor. This finding was confirmed by Staff PP at the time of the observation on 05/01/14 at 8:55 AM.

Based on facility observation and staff confirmation the facility failed to have two light sources at an exit discharge. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey. Potentially any patients, visitors, and staff that would use the exit discharge could be affected.

Findings include:

1. Tour of "4C Wing" completed on 04/30/14 revealed the exit discharge for stairwell C1 had one light source and no other light sources were visible. This observation was confirmed by Staff PP at the time of the observation on 04/30/14 at 8:20 AM.

Based on facility observation and staff confirmation, the facility failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities with regards to oxygen storage locations of greater than 3,000 cu.ft. that were to be enclosed by a one-hour separation and were vented to the outside. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey.

Findings include;

1. On 04/28/14 between 11:00 A.M. and 1:00 P.M. tour of the sub-basement of the facility was conducted with Staff SS and TT. Observation of an medical gas storage location was noted in a central storage room. Observation of the medical gas storage room revealed the door to the room had no identifiable fire resistance rating. Staff TT confirmed the observation and verified the door did not have a fire resistance rating of at least one hour.

2. On 04/29/14 between 8:40 A.M. and 11:00 A.M. tour of the ground floor was conducted with Staff TT. Observation of an oxygen storage room revealed the location was within a large mechanical area. Observation of the oxygen storage room revealed there was no fire resistance rating on the door to the room. A light switch for the room and an electrical receptacle were placed less than five feet from the floor inside the storage room. Observation of the oxygen storage wall which separated the mechanical space revealed a vent which opened into the mechanical space.

Staff TT confirmed the observations

Based on facility observation and staff confirmation, the facility failed to ensure that areas used for general storage of combustible medical records was protected, by enclosure of the area with a fire barrier without windows that had a 1-hour fire resistance rating in accordance with Section 8.2. or protection of the area with automatic extinguishing systems in accordance with Section 9.7. There were no patients present at the time of the facility observation.

Findings included;

On 05/01/14 between 4:00 P.M. and 5:00 P.M. observation of the sleep center was conducted with Staff TT. Observation of the fourth floor location revealed there were six bedrooms for patient sleep studies. Located near the entrance of the sleep center was a storage room with multiple shelves of paper medical records. Staff TT confirmed the room was used by the sleep study staff to store patient medical record information.

Further observation of the storage room with a significant amount of combustible patient medical records revealed the room was not provided with automatic sprinkler system protection. Two wooden doors were present on each side of storage room. One door was a sliding pocket door. Both doors lacked self closing devices. Staff TT confirmed the storage room for the medical records was not constructed to provided one hour fire rated protection.

Based on facility observation and staff confirmation, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement is located in the National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey. This had the potential to affect all patients, staff and visitors utilizing the facility.


Findings include;

1. On 04/29/14 between 10:30 A.M. and 12:00 P.M., observation of the ground floor surgical storage area revealed a smoke detector within 18 inches of an air diffuser.

On 04/30/14 between 10:35 A.M. and 11:25 A..M. tour of the first floor operating rooms was conducted with Staff TT and VV. Observation of the operating rooms and the adjacent areas revealed the following list of smoke detectors that were placed in close proximity to air flow devices;

2. Located in the operating room waiting area, outside elevators 9 and 10, a smoke detectors was approximately 12 inches from an air flow device.

3. Located in OR 16, control room , a smoke detector was approximately 12 inches from a air diffuser.

4. Located outside OR 4 and 8 a smoke detector was approximately 12 inches from an air vent.

5. Located in the pod area for OR 3 and 4 a smoke detector was approximately 16 inches from an air vent.

6. On 05/01/14 between 8:30 A.M. and 12:00 P.M. tour of the first floor continued with Staff TT. Observation of the radiology area revealed a smoke detector in the fluoroscopy work area that was approximately 12 inches from an air diffuser.

Staff TT confirmed the observations and verified the locations of the smoke detectors were too close to air flow devices.

Based on observations and staff interview, the facility failed to ensure exit access doors in the facility were arranged so that the exits were readily accessible at all times in accordance with the code at 39.2.1.1 and 7.2.1.5.1, failed to ensure one exit discharge contained a hard surface to the public way in accordance with the code at 39.2.1.1 and 7.7.1, and failed to ensure ten exits discharges were arranged so that failure of any single lighting fixture (bulb) would not leave the area in darkness in accordance with the code at 39.2.1.1 and 7.8.1.4. This could potentially affect all patients in the facility. The census on the survey day was 216 patients.
Findings include:
A tour was conducted on 05/02/14 between 8:25AM and 9:25 AM with Staff K. L, and M.
1. During the tour, two exit access doors leading from the following pediatric therapy care areas and the corridor by the men and women ' s restrooms to the front lobby were observed with a door handle along with a deadbolt (which required a key to lock and unlock). The deadbolts were observed located approximately one foot above the door handles. Interview with the aforementioned staff during tour revealed the doors were locked by housekeeping at night to keep people from entering the areas. The code requires exit access doors to release with an obvious method of operation that is readily operated under all lighting conditions, and with not more than one releasing operation.
2. Ten of ten exit discharges observed during tour were equipped with either one single egress battery powered light, non-battery backup lights, or no lights outside the discharge. This was confirmed with Staff L during tour. These exits are as follows:
a) The exit discharge from the Pediatric therapy area of the lobby to the main parking lot (no battery powered lights). Although 5 recessed lights were observed in the overhead canopy outside the exit discharge, Staff L stated the lights would not work in the event of a power loss.
b) The exit discharge outside the small work/exercise gym
c) The exit discharge outside the health fitness gym leading from the hallway containing the Director ' s office
d) The exit discharge from the work health and safety area at the opposite end of the front lobby
e) The exit discharge from the STATCARE corridor at the opposite end of the front lobby
f) The exit discharge from the Diagnostic/CT scan corridor at the opposite end of the front lobby
g) The exit discharge from the Wellness Clinic lobby
f) The exit discharge from the main lobby near the Wellness clinic entrance, and
g) Two exit discharges from the main lobby on the west end of the building. These discharges were not equipped with any type of discharge lights.
Staff L stated confirmed the current discharge arrangement, stating the exit discharges either lacked lighting, or were equipped with lights that did not have battery back-up. This employee stated the facility did not have a generator to power the lights.

3. The exit discharge from the small work/exercise gym was observed with a pair of exit discharge doors. Immediately outside the exit, a concrete pad was observed. The concrete pad was confirmed as measuring approximately 10 feet in length and 4 feet wide, which was confirmed with Staff K and L. The area surrounding the concrete pad was grass, which extended greater than 100 feet in all directions before reaching the public way. Both staff confirmed this was an exit discharge which would be used in the event of an emergency exit from the facility.

Based on documentation review and staff interview the facility failed to perform an annual 90 minute emergency light lest on battery powered emergency lighting. This has the potential to affect all patient, staff, and visitors at the facility. The facility's census at the time of the survey was 70.

Findings include:

1. Review of facility documentation completed on 05/02/14 revealed no documented evidence a 90 minute emergency light test was completed on the battery powered emergency lighting.

Interview with Staff PP completed on 05/02/14 at 7:45 AM revealed the owner of the building was unable to provide the testing of the emergency lighting before the building changed ownership. Staff PP stated that the facility started doing the monthly testing themselves last month and plan on doing the 90 minute test next month.