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Based upon observations and staff interviews on 5/20/14 between approximately 0930 and 1700 hours the facility has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Sprinkler control rooms on the 8th, 7th, 6th and 5th floors were observed to have unprotected penetrations thru the rated floor/ceiling.
The 7th floor electrical room was observed to have a 4 inch conduit sealed with fire caulk.
The third floor clean utility had unprotected penetrations in the rated wall.

The above was discussed and acknowledged by the Facilities Safety Officer.

Based upon observations and staff interviews on 05/20/14 between approximately 0930 and 1200 hours the facility has failed to maintain draperies, curtains and other similar loosely hanging furnishings and decorations in accordance with NFPA 701. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
A quilt was observed to be hanging in the 8th floor staff restroom. When asked if the quilt was treated the Nurse on the floor said it was not treated. The nurse then removed the quilt.

The above was discussed and acknowledged by the Facilities Safety Officer.

Based upon observations and staff interviews on 5/20/14 between approximately 0930 and 1700 hours the facility has failed to maintain smoke barrier doors so that they would close and resist the passage of smoke. This could result in toxic products of combustion spreading throughout the entire building and would not provide for the opportunity to evacuate from one compartment to another which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:
The cross corridor smoke door by room 716 was observed to not close and latch properly.
The cross corridor smoke door 06 637 was observed to not close and latch properly.
Both doors were fixed while surveyor was on site.

The above was discussed and acknowledged by the Facilities Safety Officer.

Based upon observations and staff interviews on 05/20/14 between approximately 0930 and 1700 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
The electrical closet of the first floor 01-241 was observed to have the drop ceiling removed. The sprinkler head was located below the existing grid. There was no sprinkler head observed to be located at the top of the room.

The above was discussed and acknowledged by the Facilities Safety Officer.

Based upon observation, record review and staff interviews on 05/20/14 between approximately 0930 and 1700 hours the facility has failed to conduct testing of the hood and duct fire suppression equipment protecting the commercial cooking equipment in the kitchen. This could result in the failure of the system to operate properly which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
During the entrance conference with the Director of Facility and Technology Services he informed the surveyor that the kitchen hood was going to be replaced. This was due to a report that the duct was not continuously welded. The duct that is visible on the 8th floor was observed to be continuously welded. The new hood and duct will be installed by September. Per NFPA 96 4-7.2.2 ducts over four or more stories are to have not less than 2 hour protection. The exposed duct is not protected.

The above was discussed and acknowledged by the Facilities Safety Officer.

Based upon observations and staff interviews on 05/20/14 between approximately 0930 and 1700 hours the facility has failed to protect the electrical system. This could result in a fire from overheating of the electrical system endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
The 8th floor staff room was observed to have an unprotected power strip in use. The strip was provided by Telecom for charging the phones.
The 6th floor electrical room 06-653 was observed to be blocked by oxygen cylinders.
During the tour of the kitchen a fan was observed to be powered by an extension cord.
An extension cord was observed to be in use in the IS break room.
Empty and full wood spools for wire were observed to be stored in the FACP/Electrical room 609-00.

The above was discussed and acknowledged by the Facilities Safety Officer.

Based upon observations and staff interviews on 5/21/14 between approximately 0630 and 0730 hours the facility has failed to properly install alcohol based hand rub dispensers. Dispensers installed improperly could result in hand rub coming in contact with an electrical source resulting in a fire causing potential endanger to residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Three alcohol based hand rub dispensers were observed to be installed directly over electrical outlets in the the PACU.

The above was discussed and acknowledged by the Facilities Safety Officer.

Based upon observations and staff interviews on 5/20/14 between approximately 0930 and 1700 hours the facility has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Sprinkler control rooms on the 8th, 7th, 6th and 5th floors were observed to have unprotected penetrations thru the rated floor/ceiling.
The 7th floor electrical room was observed to have a 4 inch conduit sealed with fire caulk.
The third floor clean utility had unprotected penetrations in the rated wall.

The above was discussed and acknowledged by the Facilities Safety Officer.

Based upon observations and staff interviews on 05/20/14 between approximately 0930 and 1200 hours the facility has failed to maintain draperies, curtains and other similar loosely hanging furnishings and decorations in accordance with NFPA 701. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
A quilt was observed to be hanging in the 8th floor staff restroom. When asked if the quilt was treated the Nurse on the floor said it was not treated. The nurse then removed the quilt.

The above was discussed and acknowledged by the Facilities Safety Officer.

Based upon observations and staff interviews on 5/20/14 between approximately 0930 and 1700 hours the facility has failed to maintain smoke barrier doors so that they would close and resist the passage of smoke. This could result in toxic products of combustion spreading throughout the entire building and would not provide for the opportunity to evacuate from one compartment to another which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:
The cross corridor smoke door by room 716 was observed to not close and latch properly.
The cross corridor smoke door 06 637 was observed to not close and latch properly.
Both doors were fixed while surveyor was on site.

The above was discussed and acknowledged by the Facilities Safety Officer.

Based upon observations and staff interviews on 05/20/14 between approximately 0930 and 1700 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
The electrical closet of the first floor 01-241 was observed to have the drop ceiling removed. The sprinkler head was located below the existing grid. There was no sprinkler head observed to be located at the top of the room.

The above was discussed and acknowledged by the Facilities Safety Officer.

Based upon observation, record review and staff interviews on 05/20/14 between approximately 0930 and 1700 hours the facility has failed to conduct testing of the hood and duct fire suppression equipment protecting the commercial cooking equipment in the kitchen. This could result in the failure of the system to operate properly which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
During the entrance conference with the Director of Facility and Technology Services he informed the surveyor that the kitchen hood was going to be replaced. This was due to a report that the duct was not continuously welded. The duct that is visible on the 8th floor was observed to be continuously welded. The new hood and duct will be installed by September. Per NFPA 96 4-7.2.2 ducts over four or more stories are to have not less than 2 hour protection. The exposed duct is not protected.

The above was discussed and acknowledged by the Facilities Safety Officer.

Based upon observations and staff interviews on 05/20/14 between approximately 0930 and 1700 hours the facility has failed to protect the electrical system. This could result in a fire from overheating of the electrical system endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
The 8th floor staff room was observed to have an unprotected power strip in use. The strip was provided by Telecom for charging the phones.
The 6th floor electrical room 06-653 was observed to be blocked by oxygen cylinders.
During the tour of the kitchen a fan was observed to be powered by an extension cord.
An extension cord was observed to be in use in the IS break room.
Empty and full wood spools for wire were observed to be stored in the FACP/Electrical room 609-00.

The above was discussed and acknowledged by the Facilities Safety Officer.