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Based on facility tour and staff verification it was determined this facility failed to ensure all doors protecting corridor openings were maintained in a manner in which there was no impediments to the closing of the door. This had the potential to affect all those who utilized this area of the facility. The patient census at the beginning of the survey was 329.

Findings included:

A facility tour of the main building took place on 10/29/12 through 10/31/12 with staff members A1, B2 and C3. During a tour of the ground floor, an observation was made of the door to room G615, which was equipped with a self-closing device, being propped open with a broom stick.

This finding was verified by the staff members during tour.

Based on facility tour and staff verification it was determined this facility failed to ensure all vertical openings were protected with at least a one hour fire rated construction. This had the potential to affect all those who utilized this area of the facility. The patient census at the beginning of the survey was 329.

Findings included:

Ground floor:
A facility tour of the main building took place on 10/29/12 through 10/31/12 with staff members A1, B2 and C3. During a tour of stair G located at the north end, observation was made that there was no fire rating tag located on the door.

First Floor:
*During a tour of stair K1 located at the northwest end, observation was made that there was no fire rating tag located on the door.
*During a tour of stair G1 located at the north end, observation was made that there was no fire rating tag located on the door.
*During a tour of stair D1 located in corridor 1028Z, observation was made that there was no fire rating tag located on the door.

Third Floor:
*During a tour of stair G3 located at the south end, observation was made that there was no fire rating tag located on the door.

These findings were verified by the staff members during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure all exits were marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. This had the potential to affect all those utilizing this facility. The patient census on the day of the survey was 329.

Findings include:

1. A facility tour of the main building took place on 10/29/12 through 10/31/12 with staff members A1, B2 and C3. During tour of the third floor surgical area and specifically in corridor 3601Z facing north towards stairwell J, this writer observed there was no exit directional sign directing occupants to stairwell J. From the far south end of the corridor neither this writer nor all staff present was aware of the stairwell exit access.
Additionally, from the north end of the corridor identified as 3004Z facing south, this writer observed an exit sign directing flow south in the corridor. Following the corridor south it came to a dead end and no exit access was available. This was verified by all staff present during tour of this area.

2. A tour of the sixth floor on 10/29/12 between 3:15 P.M. and 4:35 P.M. with Staff H8 revealed exit Stairway N. Following exit Stair N to the exit discharge revealed the area at the bottom of the stairway was poorly lit as the stair well light was burned out. Two doors were present and no exit signage was present to indicate which door was the way out.

Staff present on tour verified the observation.

3. A tour of the facility on 10/31/12 between 8:50 A.M. and 4:30 P.M. with Staff H8 and I9 revealed the presence of an EP lab on the third floor. The lab area had three procedure rooms. Observation of the exit corridor from the lab area revealed the exit light was not lit.

Located on the third floor was the cardiovascular intensive care unit located within a suite. The suite was observed to have three exit signs above the doors. When standing near the patient rooms which surrounded the nursing station, the doors were not visibile and there was no signage to note the way to the exits. The middle exit was located behind the nursing station and was difficult to see unless standing directly in front of it. Staff H8 verified that exit signage was not placed within the suite to show the way to the exit doors.

Based on facility observation and staff interview and verification, the facility filed to ensure that smoke barriers are constructed to provide at least a one-hour fire resistance rating in accordance with 8.3. There were no patients in the facility at the time of survey.

Findings included:

On 11/01/12 between 8:50 A.M. and 11:30 A.M. a tour of the facility was conducted with Staff H8, L12 and M13. Observation of the one and two hour fire rated smoke/fire barrier walls revealed the following penetrations;

* Observation above the ceiling tiles at the fire doors located at room 306 revealed area not sealed with fire stop material surrounding sprinkler system pipes.

* Observation above the ceiling tiles of the two hour fire rated wall inside room 1810, revealed an unsealed area surrounding two white heating pipes and one conduit.

* Observation above the ceiling tiles of the one hour fire rated barrier, inside conference room 2, far right corner, an area with no fire stop material was observed surrounding pipe.

* Observation above the ceiling tiles of the one hour fire rated wall in conference room 3 revealed three penetrations, one surrounding the sprinkler pipe and additional areas surrounding two conduits. Also in conference room 3, the south wall of the one hour fire rated barrier, observation revealed an area not sealed by fire stop material surrounding a wire and two uni-struts.

* Observation above the ceiling tiles of the one hour fire rated barrier in room 1412, the north wall, revealed area surrounding a 4 inch pipe not sealed with fire stop material.

*Observation above the ceiling tiles of the one hour fire rated wall in room 1409, revealed an unsealed area surrounding sprinkler pipe.

*Observation above the ceiling tiles of the one hour fire rated wall in the fire panel room revealed three areas not sealed with fire stop material surrounding three pipes.

Staff present on tour observed and verified the findings.

Based on facility tour and staff verification it was determined this facility failed to ensure all one hour fire rated smoke barriers were constructed to resist the passage of smoke. This had the potential to affect all those utilizing this facility. The patient census on the day of the survey was 40.

Findings include:

Facility tour took place on 10/31/12 with staff members A1, D4, and E5. During a tour of the one hour smoke barrier observation was made of penetrations located above the ceiling tiles in the following locations:

*Within the back room located in the northwest corner of the short corridor leading to the surgery department, observation was made of a one inch unsealed conduit with an orange wire passing through and a one half inch curved conduit with blue and white wires passing through.

*Heading east and within the nurse ' s station, observation was made of two unsealed conduits, an I-beam which was not sealed along the left side for approximately twelve inches, a two inch by two inch opening in the drywall and an approximate half inch by eighteen inch long opening in the drywall.

*Above the double doors leading to the surgery department, observation was made of three unsealed conduits.

*Within the physician's room located at the southeast section of the smoke barrier, observation was made of an unsealed steel structure approximately six inches by one inch.

These findings were verified by staff member D4 during the tour on 10/31/12.

Based on facility tour and staff verification it was determined this facility failed to ensure all one hour fire rated smoke barriers were constructed to resist the passage of smoke. This had the potential to affect all those utilizing this facility. The patient census on the day of the survey was 56.

Findings include:

A facility tour took place on 11/01/12 with staff members A1, D4, E5 and F6. During a tour of the one hour smoke barrier observation was made of penetrations located above the ceiling tiles in the following locations:

*Within the corridor at the northeast entrance adjacent to the waiting room, observation was made of a half inch silver conduit not sealed within the end of the conduit or around the annular space.

*At the back of treatment room # 3 and within the east west corridor, observation was made of a half inch silver conduit not sealed in at the end where wires pass through.

These findings were verified by staff members E5 and F6 during tour on 11/01/12.

Based on facility tour and staff verification it was determined this facility failed to ensure all smoke/fire barriers were constructed with at least a one hour fire rated construction in order to resist the passage of smoke. This had the potential to affect all those who utilized this area of the facility. The patient census at the beginning of the survey was 329.

Findings include:

A facility tour of the main building took place on 10/29/12 through 10/31/12 with staff members A1, B2 and C3. During the tour an observation was made of several penetrations within the one hour fire rated smoke/fire barriers above the ceiling tiles in the following locations:

Ground Floor:
*Adjacent to the auditorium and above the house phone area, observation was made of one three inch unsealed water line, an approximate ten inch by two inch rectangle opening, one unsealed steel bracket and two open end conduits.
*Above the south entrance door to the auditorium, observation was made of one open end conduit.
*Observation was made of the smoke barrier door to the telecommunications room 426 not having a fire rated tag.
*The smoke barrier at the telecommunications room G426 was observed to have one open end conduit with blue and white wires passing through and just above that, observation was made of a flex conduit not sealed around the annular space.
*Double smoke barrier doors between rooms G626 and G625 was observed to have a gap greater than one-eighth inch between the door leafs when in the closed position.
*Above the smoke barrier door G507, observation was made of an approximate ten inch by one-eighth inch gap located at the top of the drywall where it meets the upper deck.
*Within the two hour fire rated separation at room G428 and specifically above door G648E, observation was made of an approximate four inch by one-eighth inch gap located at the top of the drywall where it meets the upper deck. Additionally, the door G648E was rated for only forty-five minutes.
*Above the double doors near room G028 and at the east end of corridor G815Z, observation was made of one unsealed silver conduit and unsealed white wires passing through the drywall.
*At the west end of corridor G815Z and at the human resources annex exit, observation was made of the south side one hour fire barrier an approximate six inch by one-eighth inch gap located on the side of a duct.

First Floor:
*From within rooms 1870A and 1870D, facing the two hour fire rated wall observation was made of an approximate thirty foot section of unsealed drywall at the top where it meets the upper deck.
*Above the double doors 1205B entering the lab, observation was made of an approximate one and a half inch square hole.
*From within 1204B observation was made of five unsealed conduits and areas of drywall which were not sealed between the sections and an unsealed duct.
*Within room 1201, observation was made of three missing ceiling tiles and two conduits which had what appeared to be residential spray foam around the annular space.
*At the north end of corridor 1169Z and above the large wooden decoration, observation was made of an unsealed copper line.
*Just to the east of the wood decoration and above the double doors leading to oncology, observation was made of an unsealed silver conduit.
*Observation of the smoke barrier double doors by room 1110 revealed a gap greater than one-eighth inch between the door leafs when in the closed position. Additionally, above the doors observation was made of a penetration around wires.
*Within room 1114 and facing the smoke barrier, observation was made of a small gap between two black insulated lines.
*Within room 1119B, observation was made of penetrations around conduits, an approximate three inch hole and an unsealed section of drywall approximately one-eighth inch by twelve feet long at the top of the drywall where it meets the upper deck.
*At the double smoke barrier doors by room 1119A, observation was made of a gap greater than one-eighth inch between the door leafs when in the closed position.
*Within the nurses ' station room designated as 1145A, observation was made of three unsealed conduits.
*To the west of the cath lab extension doors, observation was made of two open end conduits and one unsealed flex conduit.
*At the far east end of the same corridor and the end of the smoke barrier, observation was made of two unsealed conduits.
*At room 1042F, observation was made of a three inch water line which had what appeared to be residential spray foam around the annular space.
*Across the corridor and to the right above the double doors heading west observation was made of an approximate two inch hole in the two hour fire barrier.
*At room 1417E by room 1401, observation was made of one unsealed flex conduit.
*At the double smoke barrier doors beside room 1401, observation was made of one unsealed black wire.
*Within the smoke barrier at room 1426, observation was made of an approximate two foot by five inch open area around insulated lines and conduits.

Second Floor:
*At the two hour fire barrier adjacent to room 2207C, observation was made of a three inch unsealed water line, one unsealed silver conduit and a small hole penetrating the fire barrier.
*Above the double smoke barrier doors located in corridor 2100Z beside room 2104, observation was made of a junction box missing the cover plate which exposed two unsealed flex conduits.
*Heading north in corridor 2100Z and at the double doors by the elevators, observation was made of multiple unsealed wires and conduits in the two hour fire rated barrier.
*Outside room 2322 and to the left, observation was made of an approximate four inch by one inch opening at the bottom of the drywall. Several feet to the left of this and above the newspaper stands, an irregular shaped hole approximately six inches in diameter was observed in the two hour fire barrier.
*Within the labor and delivery waiting area, specifically in the vending alcove, observation was made of three unsealed conduits.
*From within rest room 2837, the top of the drywall where it meets the upper deck was sealed with what appeared to be non-fire rated caulking.
*Outside the labor and deliver and special care waiting area and adjacent to the back of stairwell D, observation was made of one unsealed silver conduit.
*Across the corridor at room 2846, observation was made of a two inch by two inch hole and an approximate ten inch by ten inch metal data chase without an cover plate on the upper end.
*Within room 2800, observation was made of an approximate three inch by three inch hole in the two hour fire barrier.
*At the back of room 2100A and within the two hour fire barrier, observation was mad of approximately twenty-two feet of drywall which was sealed at the top with what appeared to be non-fire rated caulking. Additionally, one two-inch unsealed insulated line was observed.
*At the back of room 2843 and within the two hour fire barrier, observation was made of a two and a half inch open end conduit with wires and also unsealed around the annular space.
*At the double doors of the labor and delivery and by elevator # 3, observation was made of an approximate quarter inch hole within the two hour fire rated barrier.
*Within the one hour fire rated smoke barrier within room 2436, observation was made of one unsealed conduit and three small holes.
*Within the smoke barrier between rooms 2413 and 2414, observation was made of eight conduits sealed with what appeared to be residential spray foam.
* Within the smoke barrier and at the double doors located outside of rooms 2413 and 2414, observation was made of a duct which was sealed with what appeared to be residential spray foam and non-fire rated insulation.
*Within room 2427C, observation was made of data cables sealed with what appeared to be non-fire rated insulation.
*Within the smoke barrier at the nursery room identified as room 2444, observation was made of conduits and an approximate eight foot section of drywall sealed at the top with what appeared to be non-fire rated caulking and residential spray foam.
*Within the closet located west of the nursery between the double doors identified as A and F, observation was made of wires and conduits sealed with what appeared to be residential spray foam.
*Above the double doors identified as A, observation was made of one conduit and the edges of where the drywall meets, sealed with what appeared to be residential spray foam.

Third Floor:
*Smoke barrier between rooms 3405 and 3415A was observed to have an unsealed half inch silver conduit, a three inch unsealed sleeve with a conduit passing through and an approximate fourteen foot section of drywall not sealed at the top where it meets the upper deck.
*At the north end of the bridge to the POB, observation was made above the ceiling tiles of double smoke barrier doors of an approximate three inch hole and approximately eight foot of drywall not sealed where it meets the upper deck.
*At the south end of the bridge to the POB, observation was made above the ceiling tiles of double, two hour fire barrier doors. The penetrations included an approximate one inch by six inch opening around the pneumatic tube system, an approximate fourteen inch by four inch opening, two unsealed conduits on both sides and only one layer of five-eighths inch drywall on the POB side of the two hour fire rated wall.
* On 10/31/12 at 10:10 A.M., with Staff H8, observation of the family waiting room revealed windows within a two hour fire rated wall. The large windows located within the same two hour fire rated wall had no fire rated glazing or wired glass panels.
* An area of construction was observed near the surgery area. Observation of the two hour fire rated wall above the ceiling tiles from the corridor side of the hospital, revealed that two penetrations approximately 3 to 4 inches in diameter were present. The penetrations were completely through the two hour fire rated wall. Interview of the construction staff revealed the pipes had been removed days before.
* Observation on 10/31/12 at 9:15 A.M. with Staff H8, above the ceiling tiles at the fire doors near the 3200 to 3100 corridor revealed penetrations surrounding blue wires.
* Observation above the ceiling tiles of the two hour fire rated barrier in room 3254 revealed the wall was not sealed on the back wall at the floor decking.
*Observation above the ceiling tiles in the two hour fire rated barrier in the corridor of 3200 to the 800 building revealed open, unsealed area surrounding white pipes.
* Observation above the ceiling tiles in the corridor of the third floor maternity unit revealed two penetrations surrounding sprinkler pipe in the one hour fire rated smoke barrier.
Observation of the one hour smoke barrier wall in room 3123 revealed the presence of two penetrations in the barrier.

Fourth Floor:
*Tour of the fourth floor was on 10/30/12 between 1:40 P.M. and 4:20 P.M. with Staff H8 and J10.
*Observation above the ceiling tiles of the one hour smoke barrier wall which extended into room 4416 revealed unsealed area surrounding a cable tray that went through the smoke barrier wall.
* Observation on 10/30/12 at 2:20 P.M. above the ceiling tiles of the one hour fire rated smoke barrier wall in locker room 4301 revealed penetrations in the barrier wall. The penetrations included areas 10 inches by 12 inches, surrounding black pipe, an area 2 inches by 4 inches and an area 3 inches by 4 inches.
* Observation above the ceiling tiles at the fire doors between the 4100 and 4200 corridors in the two hour fire rated barrier, revealed a penetration approximately one half inch in diameter.
* Observation at room 4219 of the two hour fire rated wall, above the ceiling tiles revealed unsealed area at the roof deck.
Observations were observed and verified by staff present on the tour.

Fifth Floor:
* Tour of the fifth floor was on 10/30/12 between 10:00 A.M. and 1200 P.M. with Staff H8. The following observation of penetrations in fire rated barrier walls were observed;
* Observation above the ceiling tiles at the fire doors near room 5201 revealed the two hour fire rated wall was not sealed at the floor decking above.
* Observation at 1:40 P.M. above the smoke doors near room 5268 revealed a 3 inch penetration in the gypsum board of the smoke barrier wall.
* Observation above the ceiling tiles of the two hour fire rated barrier between room 5222 and 5220 revealed the barrier wall was unsealed at the roof decking above.
* Observed in the fire/smoke barrier wall in room 5269, penetrations surrounding four electrical conduits.

Eighth Floor:
* Observation of the eighth floor was conducted on 10/29/12 with Staff H8. Observation of room 8109 at 12:05 P.M., .revealed unsealed area surrounding green flex line in th one hour fire rated barrier.

The observations were verified by staff present on the tour

Based on facility tour and staff verification it was determined this facility failed to ensure all doors in smoke barriers were equipped with automatic or self-closing devices and were fire rated for at least a one hour fire resistance rating. This had the potential to affect all those who utilized this area of the facility. The patient census at the beginning of the survey was 329.

Findings include:

Ground Floor:
* Facility tour of the main building took place on 10/29/12 through 10/31/12 with staff members A1, B2 and C3. During tour of G wing observation was made of smoke barrier door G408 not being equipped with an automatic or self-closing device or having a fire resistance rating. G407 was observed to not be equipped with an automatic or self-closing device.

Second Floor:
*The metal back door at the special care nursery located between rooms 2842E and 2842D was observed lacking a fire rating tag.

Third floor:
*On 10/31/12 at 10:10 A.M., observation of the door to the family waiting room was noted to have no fire resistance rating. The doorway to the waiting area was within a two hour fire rated wall.

Fourth floor:
*Tour of the fourth floor was on 10/30/12 between 1:40 P.M. and 4:20 P.M. with Staff H8 and J10. Observation of the one hour smoke barrier in room 4313 revealed a doorway had been created in the room. There was no fire rated door in the created opening between rooms 4313 and 4312A.

Fifth Floor:
* Tour of the fifth floor was on 10/30/12 between 10:00 A.M. and 1200 P.M. with Staff H8. Observations revealed that at room 5201, a door located within the two hour fire barrier, had a fire rating of 20 minutes. The door was not equipped with a self closing device or any device to automatically close the door.

Staff present on tour observed and verified the observations.

Based on facility observation and staff interview and verification, 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 and without windows (in accordance with 8.4). Doors were to be self-closing or automatic closing.


Findings included:


On 11/01/12 between 8:50 A.M. and 11:30 A.M. a tour of the facility was conducted with Staff H8, L12 and M13. Observation of hazardous storage areas and a mechanical room revealed the following;

* In rooms 1409 and 1412, storage rooms, the one hour fire rated wall on the north side of the room 1412 had an area surrounding a four inch pipe that was not sealed with fire stop material. In addition the door to the room was not provided with self-closing or automatic closing devices. In room 1409, an area surrounding a sprinkler pipe was not sealed with fire stop material. The door to room 1409 was not provided with self-closing or automatic closing devices.

* Observation of room 1505, a biohazard storage room, revealed the door to the room had no self-closing or automatic closing devices.

* Observation above the ceiling tiles of the one hour fire rated wall surrounding the mechanical room revealed an area surrounding a pipe not sealed with fire stop material. The door to the mechanical room had no fire resistance rating.

Staff present on tour observed and verified the findings.

Based on facility tour and staff verification it was determined this facility failed to ensure all hazardous areas were constructed with at least a one hour fire resistance rating or doors were self-closing when the approved automatic fire extinguishing system option was used. This had the potential to affect all those who utilized this area of the facility. The patient census at the beginning of the survey was 329.

Findings include:

Facility tour of the main building took place on 10/29/12 through 10/31/12 with staff members A1, B2 and C3. During a tour of room G402, on the ground floor, an observation noted the room was equipped with an automatic sprinkler system. The door to the room was lacking an automatic or self-closing device. This room had two large mobile recycle containers stored within it.

Observation of the fifth floor on 10/30/12 at 11:55 A.M. with Staff H8 revealed that room 5201 was a storage area for miscellaneous items. The storage room was provided with sprinkler system protection. Items stored in the room included old cabinets and medical supplies. Observation of the door to the room revealed there was no self closing or automatic closing device in place.

Observation of the sixth floor on 10/29/12 at 3:10 P.M. with Staff H8 revealed linen storage in room 6430. The room was provided with sprinkler system protection however the door to the room had no self closing or automatic closing device in place.

Staff present during the tour observed and verfied the findings.

Based on facility tour and staff verification it was determined this facility failed to ensure all exit accesses and discharges were arranged in a manner so as to provide a safe access for patients to a paved public way. This had the potential to affect all those utilizing this facility. The patient census on the day of the survey was 329.


Findings include:


A facility tour of the main building took place on 10/29/12 through 10/31/12 with staff members A1, B2 and C3. During a tour of the ground floor exit discharge behind room G507E, observation was made of approximately 45 feet of grassy area between the exit discharge door and a paved common way.

On 10/30/12 between 10:00 A.M. and 10:25 A.M. tour was conducted with Staff H8 of Stairwell C. Observation from the upper floors of the facility to exit discharge revealed the exit was near the heart vascular building. Exit discharge was observed to be onto grassy, uneven ground 30 to 40 feet from the paved public way. Staff present on tour verified the observation.

Based on facility tour and staff verification it was determined this facility failed to ensure all exit discharges were arranged in a manner so as to provide a safe access for occupants to a paved public way. This had the potential to affect all those utilizing this facility. The patient census on the day of the survey was 56.

Findings include:

A facility tour took place on 11/01/12 with staff members A1, D4, E5 and F6. Tour of exit corridor 1142 located at the west side of the facility revealed multiple items of cleaning equipment including scrubbers, buckets and accessories lining approximately 20 feet on both sides of the corridor up to and beyond the exit door. This left about a two to three foot wide area of corridor space to access the discharge door. Once this writer open the exit door, observation was made of an unpaved access to the public common way consisting of approximately 15 feet of grass.
Additionally, accessing the exit discharge from north corridor 1032, observation was made of an unpaved access to the public common way consisting of approximately 60 feet of grass. These findings were verified by staff A4 during tour on 11/01/12.

Based on facility observation and staff interview and verification, the facility failed to ensure that patient room doors were arranged so that the patients could open the door from inside without using a key. Potentially all patients on the unit could be affected. The facility had a census of 329 patients at the time of the survey.

Findings included:

On 10/29/12 at 2:40 P.M., tour of the sixth floor was initiated with Staff H8. The sixth floor was identified as a psychiatric care floor with two units. The 6100 unit was for crisis intervention and more acutely ill patients. The 6400 unit was for patients less acutely ill.

Observation of the patient bed rooms revealed the presence of dead bolt type locks on all patient room doors. When locked from the corridor side of the door, no one could get out of the room without a key. Interview of Staff K11 revealed the patient rooms were locked only when the rooms were cleaned and vacant, such as after discharge of a patient.

Interview of Staff K11 revealed the 6100 unit had 19 patients rooms with a capacity of 25 patients. The census was 15 patients as of the morning of 10/29/12. Staff K11 stated that unit 6400 had 15 patient rooms. Patient rooms 6416 and 6417 were four bed patient rooms. The census for the 6400 unit as of 10/29/12 was 15 patients.

Staff present on tour verified that all patient sleeping rooms on the unit had locks in place that prevented exit from the room, without a key, if the room was locked.

Based on observation during tour and staff verification it was determined this facility failed to ensure all patient room doors were arranged so that patients are able to open the door without the use of a key or under special circumstances all staff would carry a key to the locked patient room door for quick access in the event of an emergency. This had the potential to affect those utilizing this patient room. The patient census on the day of the tour was 40.

Findings include:

A facility tour took place on 10/31/12 with staff members A1, D4, and E5. During a tour of the patient rooms, observation was made of one patient room door which was equipped with a key lock which was noted to be keyed on both sides of the door. When the door was closed and locked, a patient from within the room was not able to open the door without a key. Staff A1 interviewed five facility nursing staff members and was told they do not carry a key to this door and the key to this door is stored in a cabinet. This interview verified this finding.

Based on observation during tour and staff verification it was determined this facility failed to ensure all patient room doors were arranged so that patients are able to open the door without the use of a key or under special circumstances all staff would carry a key to the locked patient room door for quick access in the event of an emergency. This had the potential to affect those utilizing this patient room. The patient census on the day of the tour was 56.

Findings include:

A facility tour took place on 11/01/12 with staff members A1, D4, E5 and F6. During a tour of the patient rooms, observation was made of one patient room door which was equipped with a key lock which was noted to be keyed on the outer side of the door. When the door was closed and locked, a patient from within the room was not able to open the door. This writer interviewed staff G7 at approximately 10:50 AM and was told none of the staff carry a key to this door and the key to this door is stored in a cabinet and also one is with the physician. This interview verified this finding.

Based on observation during tour and staff verification it was determined this facility failed to ensure all sprinkler systems were continuously maintained in regards to sprinkler heads having dust and debris and ensuring they were equipped with escutcheon rings. This had the potential to affect all those utilizing this facility. The patient census on the day of the survey was 329.

Findings include:

A facility tour of the main building took place on 10/29/12 through 10/31/12 with staff members A1, B2 and C3. During tour an observation was made of several sprinkler heads coated with dust or debris in the following locations:

Ground Floor:
*In room G053A, central distribution observation was made of a sprinkler head missing the escutcheon ring.
*Dirty sprinkler heads were observed in the pharmacy department.
*Room G020, laundry room, one sprinkler head was missing an escutcheon ring.
*Dirty sprinkler head observed in the decontamination room.
*Dry storage in the kitchen area had a sprinkler head missing an escutcheon ring.
*Dirty sprinkler heads noted in the construction area for the new cafeteria.
*Women ' s restroom G535 had two dirty sprinkler heads.

First Floor:
*Within the holding area 1826 observation was made of dirty sprinkler heads.
*Within corridor 1801, two dirty sprinkler heads.
*Within the trash chute of room 1201, observation was made of a sprinkler head coated with debris. Additionally, the sprinkler head within the laundry chute was observed to have a piece of plastic attached to it.
*In the family waiting area 1100, dirty sprinkler heads were observed.
*Dirty sprinkler heads observed in rooms 1111, 1112 and 1113.
*Dirty sprinkler heads observed in heart and vascular waiting area.
*Dirty sprinkler heads observed within the women ' s locker room 1547.

Second Floor:
*Sprinkler head within the gift shop storage room had what appeared to be a coating of white paint.
*Dirty sprinkler heads observed in the petite café.
*Dirty sprinkler heads noted in the offices located adjacent to the chapel.
*Dirty sprinkler heads observed in the nursery room 2444.

These findings were verified by all staff present during tour of these areas.

Based on observation during tour and staff verification it was determined this facility failed to ensure the sprinkler system was maintained in such a manner that there were no impediments to the spray pattern of all sprinkler heads. This had the potential to affect all those utilizing this area of the facility. The facility census on the day of the survey was 40.

Findings include:

Facility tour took place on 10/31/12 with staff members A1, D4, and E5. During tour of the linen closet located near the entrance to the surgery department, observation was made of the top shelf located within a few inches of the sprinkler head. This shelf was observed to cover the entire sprinkler head and would have impeded the water spray pattern if activated. This finding was verified by staff members A1 and A4 during tour of the facility on 10/31/12.

Based on observation during tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were maintained and inspected according to the National Fire Protection Association 10. This had the potential to affect all those utilizing this area of the facility. The facility census on the day of the survey was 40.

Findings include:

Facility tour took place on 10/31/12 with staff members A1, D4, and E5. During tour within the front entrance area, observation was made of a child's wheelchair positioned directly in front of a fire extinguisher; located in a wall cabinet. The wheelchair was located in such a manner that it inhibited free access to the fire extinguisher.
Additionally, observation was made of another portable fire extinguisher located near the southeast double doors and by room E1036 which according to the inspection tag, was last inspected on 09/04/12.

This finding was verified by staff members A1 and A4 during tour of the facility on 10/31/12.

Based on review of facility documentation and staff interview and verification, the facility failed to ensure that fire and smoke dampers complied with the provisions of NFPA 90A with regards to testing. The facility had a census of 329 patients at the time of the survey.

Findings included:

On 11/02/12 between 8:30 A.M. and 10:00A.M. review of facility documentation was completed with regard to fire and smoke damper testing. Present for documentation review was Staff N14,and H8. Review of the fire/ smoke damper testing revealed that testing was completed in March 2009.

Review of the documented testing revealed that six dampers could not be tested due to inaccessibility or failed testing. Interview of Staff N14 regarding the six failed dampers revealed that since the facility was provided with an automatic sprinkler system that repair was not required. Staff N14 stated the same rational applied for the 18 dampers that could not be tested due to inaccessibility.

The 18 dampers not tested due to inaccessibility were located on the ground floor (3), third (2), fourth ( 6), fifth (3) and sixth floors( 4). The six failed dampers were located in the third (1), fourth (4) and sixth (1) floors.

Staff N14 verified the dampers were not repaired or tested due to Code referenced in NFPA 105, 2007 edition.


the floors of the buildings.

Based on facility tour and staff verification it was determined this facility failed to ensure all medical gas storage or in use locations were protected in accordance with the National Fire Protection Association (NFPA) 99 in regards to ensuring one hour fire rated barriers and proper location of electrical switches. This had the potential to affect all those utilizing this facility. The patient census on the day of the survey was 329.

Findings include:

A facility tour of the main building took place on 10/29/12 through 10/31/12 with staff members A1, B2 and C3. During a tour of the ground floor, observation was made of medical gas storage locations identified as rooms G802 and G804A. The rooms were equipped with a light switch mounted on the inner wall being less than five feet from the floor. Both rooms had a total of 90 full E-tanks of oxygen and carbon dioxide and 58 empty E-tanks of oxygen and carbon dioxide.

During a tour of the 800 machine room, observation was made of one unsecured H-tank of nitrogen.

During a tour of room G819, observation revealed the presence of a fire rated, yellow flammable liquid cabinet. The cabinet was labeled " Flammable Liquid Storage " and contained storage of gases rather than liquids. The gases stored in the cabinet included; 27, 16 oz. bottles of mapp gas, four 16 oz. bottles of propane, a 20 lb. bottle of propane, a D size tank of argon, two small bottles and three medium size bottles of oxygen and four small bottles of acetylene.

During a tour of the first floor and within medical gas storage room 1258C, observation was made of a total of six penetrations in the walls and ceiling measuring approximately one inch in diameter each. This room had a total of eight H-tanks of medical gas.

During a tour of the third floor and within medical gas storage room 3016, observation was made of the light switch mounted less than five foot from the floor. This room contained 24 H-tanks of nitrous oxide, 8 H-tanks of nitrogen, two large tanks of liquid nitrogen and one H-tank of oxygen.

Observation on 10/29/12 between 3:15 P.M. and 4:35 P.M. with Staff H8, revealed the presence of small oxygen storage location in the physical therapy treatment area. Observation of the small room revealed construction was with two hour fire rated walls. Observation above the ceiling tiles of the oxygen storage area revealed two, six inch air ducts that penetrated the fire rated wall. The two ducts were observed to have open, unsealed area surrounding them.

The observations and findings were verified by all staff present during tour of these areas.

*NFPA 101, 2000 Code, Chapter 7, Exits

7.1.10.1
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on facility tour and staff interview and verification, the facility failed to ensure the means of egress was continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. This could potentially affect all persons utilizing the facility;

Findings included:

On 10/31/12 between 2:10 P.M. and 4:25 P.M. a tour of the facility was conducted with Staff H8. Observations of the exit discharges from paths of egress revealed the following;

1. From Stairway C, the exit discharge required a step down which was approximately 14 inches to a grassy area. Travel to the paved, hard surface of the public way required travel across approximately 200 feet of uneven, grass covered ground.

2. From Stairway B, the exit discharge was observed to be onto a concrete pad, estimated by Staff H8 to be approximately 5 feet by 8 feet. Travel to the paved, hard surface of the public way required movement across an area estimated to be 4 feet of uneven, grassy ground.

Staff H8 present on tour observed and verified the findings.

7.10.1.2
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Based on facility tour and staff interview and verification, the facility failed to ensure the exits, other than main exterior exit doors that are obvious and clearly identifiable were marked readily visible from any direction of exit access.

Findings included:

On 10/31/12 between 2:10 P.M. and 4:25 P.M. tour of the facility was conducted with Staff H8. Observations of the exit signs leading to the way out of the facility revealed that on the fifth floor of the facility,one exit sign was not clearly visible.

The exit sign on the firth floor was located near an exit stairwell and was hidden by a sign hanging from the ceiling. The sign obstructing the view of the exit sign said "Department of Medicine".

Interview of Staff H8 verified the exit sign was hidden from clear view. Staff H8 stated the Department of Medicine sign had been recently hung at the location.


NFPA 101,
Chapter 21

Emergency illumination is provided in accordance with section 7.9.

Based on facility tour and staff interview and verification, the facility failed to ensure emergency lighting was provided for 11/2 hour at the emergency generator location.

Findings included:

1. On 10/31/12 between 2:10 P.M. and 4:25 P.M. tour of the facility was conducted with Staff H8. Observations of the emergency generator location revealed it was maintained inside the building. Observation of the room where the generator was located revealed there was no battery powered emergency illumination.

Interview of Staff H verified there was no battery powered emergency lighting in the generator location.

2. Observation during tour of the exit discharge for Stairwell A, revealed that at the exit discharge there was no emergency lighting provided. Staff H8 present on the tour, verified there was no lighting available once outside at the exit discharge for Stairway A.


39.3.2.1
Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

8.4.1.1*
Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.

8.4.1.3
Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

Based on facility tour and staff interview and verification, the facility failed to ensure that hazardous areas provided with sprinkler system protection were protected by doors with self-closing or automatic closing devices. Potentially all persons in the facility could be affected.

Findings included:

On 10/31/12 between 2:10 P.M. and 4:25 P.M. tour of the facility was conducted with Staff H8. Observations of the facility revealed the following storage areas that were provided with sprinkler protection but did not have self-closing or automatic closing devices on the doors;

1. Room 544 was observed to be a storage room with various supplies. The door to the room had no self-closing or automatic closing device.

2. Room 580, identified as a dirty utility room, had no door for the room.

3. Room 439, a linen storage area had a door with no self-closing or automatic closing device.

5. Room 449, a storage room that contained Christmas decorations, papers containing billing information and a fan had a door with no self-closing or automatic closing device.

6. Room 450, a room for miscellaneous items in storage had a door with no self-closing or automatic closing device.

7. Room 441, a medical records storage room, contained a large amount of combustible patient medical records, had a door at each end of the room. Both doors lacked self-closing or automatic closing devices.

8. Room 353, identified as a housekeeping closet had a door with no self-closing or automatic closing device.

9. Room 381, a miscellaneous storage room had a door with no self-closing or automatic closing device.

10. Room 121, located in the laboratory area, was a storage room with a door that had no self-closing or automatic closing device

11. Located in the breast health area on the first floor, a soiled linen room, that contained seven bags of soiled linen. The room had a door with no self-closing or automatic closing device.

Interview of Staff H8 verified there many storage rooms throughout the facility and that self-closing devices or automatic closing devices were not on the doors.


NFPA 99
Medical Gas Storage and Administration
Chapter 4
4.3.1.1.2
The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

Based on facility tour and staff interview and verification, the facility failed to ensure that electric wall switches and receptacles were installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage in medical gas storage areas.
Potentially all persons in the facility could be affected.

Findings included:

On 10/31/12 between 2:10 P.M. and 4:25 P.M. a tour of the facility was conducted with Staff H8. Observations of the facility revealed a medical gas storage area in the endoscopy procedure area of the ambulatory care center. Observation inside the medical gas storage room revealed a residential type light switch for the room placed lower than 5 feet from the floor. Staff H8, present on tour verified the observation.


NFPA 25
Chapter 2
2-2 Inspection.
2-2.1 Sprinklers.
2-2.1.1
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Based on facility tour and staff interview and verification, the facility failed to ensure that sprinklers were free of corrosion, foreign materials, paint, and physical damage and were installed in the proper orientation. Potentially all persons in the facility could be affected.

Findings included:

On 10/31/12 between 2:10 P.M. and 4:25 P.M. tour of the facility was conducted with Staff H8. Observations of the facility revealed the presence of an atrium. Automatic sprinkler protection was provided for the facility from the top of the atrium.

Observation from the fifth floor revealed the sprinkler heads and sprinkler pipe was covered with a thick layer of dusty debris. Interview of Staff H8 verified the sprinkler heads had not been cleaned for a significant time frame due to the height of the atrium and the location of the sprinkler heads.

Observation of the fourth floor office reception area revealed a sprinkler head with a missing escutcheon ring.

Staff H8 verified the finding.


NFPA 101
Chapter 20/21
20.1.2.1
Occupancy Separation
Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
(1) They are not intended to serve ambulatory health care occupants for purposes of treatment or customary access by patients incapable of self-preservation.
(2) They are separated from areas of ambulatory health care occupancies by construction having a fire resistance rating of not less than 1 hour.

Based on review of facility schematics, facility tour and staff interview and verification, the facility failed to ensure that sections of the ambulatory health care facilities was permitted to be classified as other occupancies provided that they were separated from areas of ambulatory health care occupancies by construction having a fire resistance rating of not less than 1 hour.
Potentially all persons in the facility could be affected.

Findings included:

On 10/31/12 between 2:10 P.M. and 4:25 P.M. a tour of the facility was conducted with Staff H8. Review of the facility schematic drawing revealed the endoscopy suite was located on the third floor of the building. Review of the schematic drawing revealed the endoscopy ambulatory care center was separated from the atrium of the facility by a one hour fire rated barrier.

Observations of the endoscopy suite area on the third floor revealed the presence of a waiting area located adjacent to the atrium. This waiting area was outside the one hour fire rated enclosure noted on the schematic.

Observation of the one hour fire rated enclosure revealed penetrations in the following locations of the one hour fire rated wall.

1. Located inside the soiled utility room was a shared wall that was the one hour fire rated barrier. Observation of the one hour fire rated wall revealed penetrations surrounding a black pipe and four conduits.

2. Observation of the one hour fire rated wall above bed 4, revealed a penetration approximately inch in diameter with a data line through it.

3. Observation of the one hour fire rated wall from the reception area revealed a penetration surrounding wire and pipe.

Staff present at the time of the tour verified the observations and findings.

Based on observation during tour and staff verification, 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. This had the potential to affect all patients, staff and visitors utilizing the facility. The patient census was 21 at the beginning of the survey.

Findings include:

Facility tour took place on 10/31/12 with staff members A1, D4, and E5. During tour the exit access corridors and checkout areas observation was made of smoke detectors located near air flow devices. Specific areas were observed as:

*Within the northwest corridor near the exit discharge.
*Within the center corridor on the east end and near the exit discharge.
*Within the PHC checkout area.

These findings were verified by all staff present during tour on 10/31/12.

Based on facility tour and staff verification it was determined this facility failed to ensure all doors protecting corridor openings were maintained in a manner in which there was no impediments to the closing of the door. This had the potential to affect all those who utilized this area of the facility. The patient census at the beginning of the survey was 329.

Findings included:

A facility tour of the main building took place on 10/29/12 through 10/31/12 with staff members A1, B2 and C3. During a tour of the ground floor, an observation was made of the door to room G615, which was equipped with a self-closing device, being propped open with a broom stick.

This finding was verified by the staff members during tour.

Based on facility tour and staff verification it was determined this facility failed to ensure all vertical openings were protected with at least a one hour fire rated construction. This had the potential to affect all those who utilized this area of the facility. The patient census at the beginning of the survey was 329.

Findings included:

Ground floor:
A facility tour of the main building took place on 10/29/12 through 10/31/12 with staff members A1, B2 and C3. During a tour of stair G located at the north end, observation was made that there was no fire rating tag located on the door.

First Floor:
*During a tour of stair K1 located at the northwest end, observation was made that there was no fire rating tag located on the door.
*During a tour of stair G1 located at the north end, observation was made that there was no fire rating tag located on the door.
*During a tour of stair D1 located in corridor 1028Z, observation was made that there was no fire rating tag located on the door.

Third Floor:
*During a tour of stair G3 located at the south end, observation was made that there was no fire rating tag located on the door.

These findings were verified by the staff members during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure all exits were marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. This had the potential to affect all those utilizing this facility. The patient census on the day of the survey was 329.

Findings include:

1. A facility tour of the main building took place on 10/29/12 through 10/31/12 with staff members A1, B2 and C3. During tour of the third floor surgical area and specifically in corridor 3601Z facing north towards stairwell J, this writer observed there was no exit directional sign directing occupants to stairwell J. From the far south end of the corridor neither this writer nor all staff present was aware of the stairwell exit access.
Additionally, from the north end of the corridor identified as 3004Z facing south, this writer observed an exit sign directing flow south in the corridor. Following the corridor south it came to a dead end and no exit access was available. This was verified by all staff present during tour of this area.

2. A tour of the sixth floor on 10/29/12 between 3:15 P.M. and 4:35 P.M. with Staff H8 revealed exit Stairway N. Following exit Stair N to the exit discharge revealed the area at the bottom of the stairway was poorly lit as the stair well light was burned out. Two doors were present and no exit signage was present to indicate which door was the way out.

Staff present on tour verified the observation.

3. A tour of the facility on 10/31/12 between 8:50 A.M. and 4:30 P.M. with Staff H8 and I9 revealed the presence of an EP lab on the third floor. The lab area had three procedure rooms. Observation of the exit corridor from the lab area revealed the exit light was not lit.

Located on the third floor was the cardiovascular intensive care unit located within a suite. The suite was observed to have three exit signs above the doors. When standing near the patient rooms which surrounded the nursing station, the doors were not visibile and there was no signage to note the way to the exits. The middle exit was located behind the nursing station and was difficult to see unless standing directly in front of it. Staff H8 verified that exit signage was not placed within the suite to show the way to the exit doors.

Based on facility observation and staff interview and verification, the facility filed to ensure that smoke barriers are constructed to provide at least a one-hour fire resistance rating in accordance with 8.3. There were no patients in the facility at the time of survey.

Findings included:

On 11/01/12 between 8:50 A.M. and 11:30 A.M. a tour of the facility was conducted with Staff H8, L12 and M13. Observation of the one and two hour fire rated smoke/fire barrier walls revealed the following penetrations;

* Observation above the ceiling tiles at the fire doors located at room 306 revealed area not sealed with fire stop material surrounding sprinkler system pipes.

* Observation above the ceiling tiles of the two hour fire rated wall inside room 1810, revealed an unsealed area surrounding two white heating pipes and one conduit.

* Observation above the ceiling tiles of the one hour fire rated barrier, inside conference room 2, far right corner, an area with no fire stop material was observed surrounding pipe.

* Observation above the ceiling tiles of the one hour fire rated wall in conference room 3 revealed three penetrations, one surrounding the sprinkler pipe and additional areas surrounding two conduits. Also in conference room 3, the south wall of the one hour fire rated barrier, observation revealed an area not sealed by fire stop material surrounding a wire and two uni-struts.

* Observation above the ceiling tiles of the one hour fire rated barrier in room 1412, the north wall, revealed area surrounding a 4 inch pipe not sealed with fire stop material.

*Observation above the ceiling tiles of the one hour fire rated wall in room 1409, revealed an unsealed area surrounding sprinkler pipe.

*Observation above the ceiling tiles of the one hour fire rated wall in the fire panel room revealed three areas not sealed with fire stop material surrounding three pipes.

Staff present on tour observed and verified the findings.

Based on facility tour and staff verification it was determined this facility failed to ensure all one hour fire rated smoke barriers were constructed to resist the passage of smoke. This had the potential to affect all those utilizing this facility. The patient census on the day of the survey was 40.

Findings include:

Facility tour took place on 10/31/12 with staff members A1, D4, and E5. During a tour of the one hour smoke barrier observation was made of penetrations located above the ceiling tiles in the following locations:

*Within the back room located in the northwest corner of the short corridor leading to the surgery department, observation was made of a one inch unsealed conduit with an orange wire passing through and a one half inch curved conduit with blue and white wires passing through.

*Heading east and within the nurse ' s station, observation was made of two unsealed conduits, an I-beam which was not sealed along the left side for approximately twelve inches, a two inch by two inch opening in the drywall and an approximate half inch by eighteen inch long opening in the drywall.

*Above the double doors leading to the surgery department, observation was made of three unsealed conduits.

*Within the physician's room located at the southeast section of the smoke barrier, observation was made of an unsealed steel structure approximately six inches by one inch.

These findings were verified by staff member D4 during the tour on 10/31/12.

Based on facility tour and staff verification it was determined this facility failed to ensure all one hour fire rated smoke barriers were constructed to resist the passage of smoke. This had the potential to affect all those utilizing this facility. The patient census on the day of the survey was 56.

Findings include:

A facility tour took place on 11/01/12 with staff members A1, D4, E5 and F6. During a tour of the one hour smoke barrier observation was made of penetrations located above the ceiling tiles in the following locations:

*Within the corridor at the northeast entrance adjacent to the waiting room, observation was made of a half inch silver conduit not sealed within the end of the conduit or around the annular space.

*At the back of treatment room # 3 and within the east west corridor, observation was made of a half inch silver conduit not sealed in at the end where wires pass through.

These findings were verified by staff members E5 and F6 during tour on 11/01/12.

Based on facility tour and staff verification it was determined this facility failed to ensure all smoke/fire barriers were constructed with at least a one hour fire rated construction in order to resist the passage of smoke. This had the potential to affect all those who utilized this area of the facility. The patient census at the beginning of the survey was 329.

Findings include:

A facility tour of the main building took place on 10/29/12 through 10/31/12 with staff members A1, B2 and C3. During the tour an observation was made of several penetrations within the one hour fire rated smoke/fire barriers above the ceiling tiles in the following locations:

Ground Floor:
*Adjacent to the auditorium and above the house phone area, observation was made of one three inch unsealed water line, an approximate ten inch by two inch rectangle opening, one unsealed steel bracket and two open end conduits.
*Above the south entrance door to the auditorium, observation was made of one open end conduit.
*Observation was made of the smoke barrier door to the telecommunications room 426 not having a fire rated tag.
*The smoke barrier at the telecommunications room G426 was observed to have one open end conduit with blue and white wires passing through and just above that, observation was made of a flex conduit not sealed around the annular space.
*Double smoke barrier doors between rooms G626 and G625 was observed to have a gap greater than one-eighth inch between the door leafs when in the closed position.
*Above the smoke barrier door G507, observation was made of an approximate ten inch by one-eighth inch gap located at the top of the drywall where it meets the upper deck.
*Within the two hour fire rated separation at room G428 and specifically above door G648E, observation was made of an approximate four inch by one-eighth inch gap located at the top of the drywall where it meets the upper deck. Additionally, the door G648E was rated for only forty-five minutes.
*Above the double doors near room G028 and at the east end of corridor G815Z, observation was made of one unsealed silver conduit and unsealed white wires passing through the drywall.
*At the west end of corridor G815Z and at the human resources annex exit, observation was made of the south side one hour fire barrier an approximate six inch by one-eighth inch gap located on the side of a duct.

First Floor:
*From within rooms 1870A and 1870D, facing the two hour fire rated wall observation was made of an approximate thirty foot section of unsealed drywall at the top where it meets the upper deck.
*Above the double doors 1205B entering the lab, observation was made of an approximate one and a half inch square hole.
*From within 1204B observation was made of five unsealed conduits and areas of drywall which were not sealed between the sections and an unsealed duct.
*Within room 1201, observation was made of three missing ceiling tiles and two conduits which had what appeared to be residential spray foam around the annular space.
*At the north end of corridor 1169Z and above the large wooden decoration, observation was made of an unsealed copper line.
*Just to the east of the wood decoration and above the double doors leading to oncology, observation was made of an unsealed silver conduit.
*Observation of the smoke barrier double doors by room 1110 revealed a gap greater than one-eighth inch between the door leafs when in the closed position. Additionally, above the doors observation was made of a penetration around wires.
*Within room 1114 and facing the smoke barrier, observation was made of a small gap between two black insulated lines.
*Within room 1119B, observation was made of penetrations around conduits, an approximate three inch hole and an unsealed section of drywall approximately one-eighth inch by twelve feet long at the top of the drywall where it meets the upper deck.
*At the double smoke barrier doors by room 1119A, observation was made of a gap greater than one-eighth inch between the door leafs when in the closed position.
*Within the nurses ' station room designated as 1145A, observation was made of three unsealed conduits.
*To the west of the cath lab extension doors, observation was made of two open end conduits and one unsealed flex conduit.
*At the far east end of the same corridor and the end of the smoke barrier, observation was made of two unsealed conduits.
*At room 1042F, observation was made of a three inch water line which had what appeared to be residential spray foam around the annular space.
*Across the corridor and to the right above the double doors heading west observation was made of an approximate two inch hole in the two hour fire barrier.
*At room 1417E by room 1401, observation was made of one unsealed flex conduit.
*At the double smoke barrier doors beside room 1401, observation was made of one unsealed black wire.
*Within the smoke barrier at room 1426, observation was made of an approximate two foot by five inch open area around insulated lines and conduits.

Second Floor:
*At the two hour fire barrier adjacent to room 2207C, observation was made of a three inch unsealed water line, one unsealed silver conduit and a small hole penetrating the fire barrier.
*Above the double smoke barrier doors located in corridor 2100Z beside room 2104, observation was made of a junction box missing the cover plate which exposed two unsealed flex conduits.
*Heading north in corridor 2100Z and at the double doors by the elevators, observation was made of multiple unsealed wires and conduits in the two hour fire rated barrier.
*Outside room 2322 and to the left, observation was made of an approximate four inch by one inch opening at the bottom of the drywall. Several feet to the left of this and above the newspaper stands, an irregular shaped hole approximately six inches in diameter was observed in the two hour fire barrier.
*Within the labor and delivery waiting area, specifically in the vending alcove, observation was made of three unsealed conduits.
*From within rest room 2837, the top of the drywall where it meets the upper deck was sealed with what appeared to be non-fire rated caulking.
*Outside the labor and deliver and special care waiting area and adjacent to the back of stairwell D, observation was made of one unsealed silver conduit.
*Across the corridor at room 2846, observation was made of a two inch by two inch hole and an approximate ten inch by ten inch metal data chase without an cover plate on the upper end.
*Within room 2800, observation was made of an approximate three inch by three inch hole in the two hour fire barrier.
*At the back of room 2100A and within the two hour fire barrier, observation was mad of approximately twenty-two feet of drywall which was sealed at the top with what appeared to be non-fire rated caulking. Additionally, one two-inch unsealed insulated line was observed.
*At the back of room 2843 and within the two hour fire barrier, observation was made of a two and a half inch open end conduit with wires and also unsealed around the annular space.
*At the double doors of the labor and delivery and by elevator # 3, observation was made of an approximate quarter inch hole within the two hour fire rated barrier.
*Within the one hour fire rated smoke barrier within room 2436, observation was made of one unsealed conduit and three small holes.
*Within the smoke barrier between rooms 2413 and 2414, observation was made of eight conduits sealed with what appeared to be residential spray foam.
* Within the smoke barrier and at the double doors located outside of rooms 2413 and 2414, observation was made of a duct which was sealed with what appeared to be residential spray foam and non-fire rated insulation.
*Within room 2427C, observation was made of data cables sealed with what appeared to be non-fire rated insulation.
*Within the smoke barrier at the nursery room identified as room 2444, observation was made of conduits and an approximate eight foot section of drywall sealed at the top with what appeared to be non-fire rated caulking and residential spray foam.
*Within the closet located west of the nursery between the double doors identified as A and F, observation was made of wires and conduits sealed with what appeared to be residential spray foam.
*Above the double doors identified as A, observation was made of one conduit and the edges of where the drywall meets, sealed with what appeared to be residential spray foam.

Third Floor:
*Smoke barrier between rooms 3405 and 3415A was observed to have an unsealed half inch silver conduit, a three inch unsealed sleeve with a conduit passing through and an approximate fourteen foot section of drywall not sealed at the top where it meets the upper deck.
*At the north end of the bridge to the POB, observation was made above the ceiling tiles of double smoke barrier doors of an approximate three inch hole and approximately eight foot of drywall not sealed where it meets the upper deck.
*At the south end of the bridge to the POB, observation was made above the ceiling tiles of double, two hour fire barrier doors. The penetrations included an approximate one inch by six inch opening around the pneumatic tube system, an approximate fourteen inch by four inch opening, two unsealed conduits on both sides and only one layer of five-eighths inch drywall on the POB side of the two hour fire rated wall.
* On 10/31/12 at 10:10 A.M., with Staff H8, observation of the family waiting room revealed windows within a two hour fire rated wall. The large windows located within the same two hour fire rated wall had no fire rated glazing or wired glass panels.
* An area of construction was observed near the surgery area. Observation of the two hour fire rated wall above the ceiling tiles from the corridor side of the hospital, revealed that two penetrations approximately 3 to 4 inches in diameter were present. The penetrations were completely through the two hour fire rated wall. Interview of the construction staff revealed the pipes had been removed days before.
* Observation on 10/31/12 at 9:15 A.M. with Staff H8, above the ceiling tiles at the fire doors near the 3200 to 3100 corridor revealed penetrations surrounding blue wires.
* Observation above the ceiling tiles of the two hour fire rated barrier in room 3254 revealed the wall was not sealed on the back wall at the floor decking.
*Observation above the ceiling tiles in the two hour fire rated barrier in the corridor of 3200 to the 800 building revealed open, unsealed area surrounding white pipes.
* Observation above the ceiling tiles in the corridor of the third floor maternity unit revealed two penetrations surrounding sprinkler pipe in the one hour fire rated smoke barrier.
Observation of the one hour smoke barrier wall in room 3123 revealed the presence of two penetrations in the barrier.

Fourth Floor:
*Tour of the fourth floor was on 10/30/12 between 1:40 P.M. and 4:20 P.M. with Staff H8 and J10.
*Observation above the ceiling tiles of the one hour smoke barrier wall which extended into room 4416 revealed unsealed area surrounding a cable tray that went through the smoke barrier wall.
* Observation on 10/30/12 at 2:20 P.M. above the ceiling tiles of the one hour fire rated smoke barrier wall in locker room 4301 revealed penetrations in the barrier wall. The penetrations included areas 10 inches by 12 inches, surrounding black pipe, an area 2 inches by 4 inches and an area 3 inches by 4 inches.
* Observation above the ceiling tiles at the fire doors between the 4100 and 4200 corridors in the two hour fire rated barrier, revealed a penetration approximately one half inch in diameter.
* Observation at room 4219 of the two hour fire rated wall, above the ceiling tiles revealed unsealed area at the roof deck.
Observations were observed and verified by staff present on the tour.

Fifth Floor:
* Tour of the fifth floor was on 10/30/12 between 10:00 A.M. and 1200 P.M. with Staff H8. The following observation of penetrations in fire rated barrier walls were observed;
* Observation above the ceiling tiles at the fire doors near room 5201 revealed the two hour fire rated wall was not sealed at the floor decking above.
* Observation at 1:40 P.M. above the smoke doors near room 5268 revealed a 3 inch penetration in the gypsum board of the smoke barrier wall.
* Observation above the ceiling tiles of the two hour fire rated barrier between room 5222 and 5220 revealed the barrier wall was unsealed at the roof decking above.
* Observed in the fire/smoke barrier wall in room 5269, penetrations surrounding four electrical conduits.

Eighth Floor:
* Observation of the eighth floor was conducted on 10/29/12 with Staff H8. Observation of room 8109 at 12:05 P.M., .revealed unsealed area surrounding green flex line in th one hour fire rated barrier.

The observations were verified by staff present on the tour

Based on facility tour and staff verification it was determined this facility failed to ensure all doors in smoke barriers were equipped with automatic or self-closing devices and were fire rated for at least a one hour fire resistance rating. This had the potential to affect all those who utilized this area of the facility. The patient census at the beginning of the survey was 329.

Findings include:

Ground Floor:
* Facility tour of the main building took place on 10/29/12 through 10/31/12 with staff members A1, B2 and C3. During tour of G wing observation was made of smoke barrier door G408 not being equipped with an automatic or self-closing device or having a fire resistance rating. G407 was observed to not be equipped with an automatic or self-closing device.

Second Floor:
*The metal back door at the special care nursery located between rooms 2842E and 2842D was observed lacking a fire rating tag.

Third floor:
*On 10/31/12 at 10:10 A.M., observation of the door to the family waiting room was noted to have no fire resistance rating. The doorway to the waiting area was within a two hour fire rated wall.

Fourth floor:
*Tour of the fourth floor was on 10/30/12 between 1:40 P.M. and 4:20 P.M. with Staff H8 and J10. Observation of the one hour smoke barrier in room 4313 revealed a doorway had been created in the room. There was no fire rated door in the created opening between rooms 4313 and 4312A.

Fifth Floor:
* Tour of the fifth floor was on 10/30/12 between 10:00 A.M. and 1200 P.M. with Staff H8. Observations revealed that at room 5201, a door located within the two hour fire barrier, had a fire rating of 20 minutes. The door was not equipped with a self closing device or any device to automatically close the door.

Staff present on tour observed and verified the observations.

Based on facility observation and staff interview and verification, 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 and without windows (in accordance with 8.4). Doors were to be self-closing or automatic closing.


Findings included:


On 11/01/12 between 8:50 A.M. and 11:30 A.M. a tour of the facility was conducted with Staff H8, L12 and M13. Observation of hazardous storage areas and a mechanical room revealed the following;

* In rooms 1409 and 1412, storage rooms, the one hour fire rated wall on the north side of the room 1412 had an area surrounding a four inch pipe that was not sealed with fire stop material. In addition the door to the room was not provided with self-closing or automatic closing devices. In room 1409, an area surrounding a sprinkler pipe was not sealed with fire stop material. The door to room 1409 was not provided with self-closing or automatic closing devices.

* Observation of room 1505, a biohazard storage room, revealed the door to the room had no self-closing or automatic closing devices.

* Observation above the ceiling tiles of the one hour fire rated wall surrounding the mechanical room revealed an area surrounding a pipe not sealed with fire stop material. The door to the mechanical room had no fire resistance rating.

Staff present on tour observed and verified the findings.

Based on facility tour and staff verification it was determined this facility failed to ensure all hazardous areas were constructed with at least a one hour fire resistance rating or doors were self-closing when the approved automatic fire extinguishing system option was used. This had the potential to affect all those who utilized this area of the facility. The patient census at the beginning of the survey was 329.

Findings include:

Facility tour of the main building took place on 10/29/12 through 10/31/12 with staff members A1, B2 and C3. During a tour of room G402, on the ground floor, an observation noted the room was equipped with an automatic sprinkler system. The door to the room was lacking an automatic or self-closing device. This room had two large mobile recycle containers stored within it.

Observation of the fifth floor on 10/30/12 at 11:55 A.M. with Staff H8 revealed that room 5201 was a storage area for miscellaneous items. The storage room was provided with sprinkler system protection. Items stored in the room included old cabinets and medical supplies. Observation of the door to the room revealed there was no self closing or automatic closing device in place.

Observation of the sixth floor on 10/29/12 at 3:10 P.M. with Staff H8 revealed linen storage in room 6430. The room was provided with sprinkler system protection however the door to the room had no self closing or automatic closing device in place.

Staff present during the tour observed and verfied the findings.

Based on facility tour and staff verification it was determined this facility failed to ensure all exit accesses and discharges were arranged in a manner so as to provide a safe access for patients to a paved public way. This had the potential to affect all those utilizing this facility. The patient census on the day of the survey was 329.


Findings include:


A facility tour of the main building took place on 10/29/12 through 10/31/12 with staff members A1, B2 and C3. During a tour of the ground floor exit discharge behind room G507E, observation was made of approximately 45 feet of grassy area between the exit discharge door and a paved common way.

On 10/30/12 between 10:00 A.M. and 10:25 A.M. tour was conducted with Staff H8 of Stairwell C. Observation from the upper floors of the facility to exit discharge revealed the exit was near the heart vascular building. Exit discharge was observed to be onto grassy, uneven ground 30 to 40 feet from the paved public way. Staff present on tour verified the observation.

Based on facility tour and staff verification it was determined this facility failed to ensure all exit discharges were arranged in a manner so as to provide a safe access for occupants to a paved public way. This had the potential to affect all those utilizing this facility. The patient census on the day of the survey was 56.

Findings include:

A facility tour took place on 11/01/12 with staff members A1, D4, E5 and F6. Tour of exit corridor 1142 located at the west side of the facility revealed multiple items of cleaning equipment including scrubbers, buckets and accessories lining approximately 20 feet on both sides of the corridor up to and beyond the exit door. This left about a two to three foot wide area of corridor space to access the discharge door. Once this writer open the exit door, observation was made of an unpaved access to the public common way consisting of approximately 15 feet of grass.
Additionally, accessing the exit discharge from north corridor 1032, observation was made of an unpaved access to the public common way consisting of approximately 60 feet of grass. These findings were verified by staff A4 during tour on 11/01/12.

Based on facility observation and staff interview and verification, the facility failed to ensure that patient room doors were arranged so that the patients could open the door from inside without using a key. Potentially all patients on the unit could be affected. The facility had a census of 329 patients at the time of the survey.

Findings included:

On 10/29/12 at 2:40 P.M., tour of the sixth floor was initiated with Staff H8. The sixth floor was identified as a psychiatric care floor with two units. The 6100 unit was for crisis intervention and more acutely ill patients. The 6400 unit was for patients less acutely ill.

Observation of the patient bed rooms revealed the presence of dead bolt type locks on all patient room doors. When locked from the corridor side of the door, no one could get out of the room without a key. Interview of Staff K11 revealed the patient rooms were locked only when the rooms were cleaned and vacant, such as after discharge of a patient.

Interview of Staff K11 revealed the 6100 unit had 19 patients rooms with a capacity of 25 patients. The census was 15 patients as of the morning of 10/29/12. Staff K11 stated that unit 6400 had 15 patient rooms. Patient rooms 6416 and 6417 were four bed patient rooms. The census for the 6400 unit as of 10/29/12 was 15 patients.

Staff present on tour verified that all patient sleeping rooms on the unit had locks in place that prevented exit from the room, without a key, if the room was locked.

Based on observation during tour and staff verification it was determined this facility failed to ensure all patient room doors were arranged so that patients are able to open the door without the use of a key or under special circumstances all staff would carry a key to the locked patient room door for quick access in the event of an emergency. This had the potential to affect those utilizing this patient room. The patient census on the day of the tour was 40.

Findings include:

A facility tour took place on 10/31/12 with staff members A1, D4, and E5. During a tour of the patient rooms, observation was made of one patient room door which was equipped with a key lock which was noted to be keyed on both sides of the door. When the door was closed and locked, a patient from within the room was not able to open the door without a key. Staff A1 interviewed five facility nursing staff members and was told they do not carry a key to this door and the key to this door is stored in a cabinet. This interview verified this finding.

Based on observation during tour and staff verification it was determined this facility failed to ensure all patient room doors were arranged so that patients are able to open the door without the use of a key or under special circumstances all staff would carry a key to the locked patient room door for quick access in the event of an emergency. This had the potential to affect those utilizing this patient room. The patient census on the day of the tour was 56.

Findings include:

A facility tour took place on 11/01/12 with staff members A1, D4, E5 and F6. During a tour of the patient rooms, observation was made of one patient room door which was equipped with a key lock which was noted to be keyed on the outer side of the door. When the door was closed and locked, a patient from within the room was not able to open the door. This writer interviewed staff G7 at approximately 10:50 AM and was told none of the staff carry a key to this door and the key to this door is stored in a cabinet and also one is with the physician. This interview verified this finding.

Based on observation during tour and staff verification it was determined this facility failed to ensure all sprinkler systems were continuously maintained in regards to sprinkler heads having dust and debris and ensuring they were equipped with escutcheon rings. This had the potential to affect all those utilizing this facility. The patient census on the day of the survey was 329.

Findings include:

A facility tour of the main building took place on 10/29/12 through 10/31/12 with staff members A1, B2 and C3. During tour an observation was made of several sprinkler heads coated with dust or debris in the following locations:

Ground Floor:
*In room G053A, central distribution observation was made of a sprinkler head missing the escutcheon ring.
*Dirty sprinkler heads were observed in the pharmacy department.
*Room G020, laundry room, one sprinkler head was missing an escutcheon ring.
*Dirty sprinkler head observed in the decontamination room.
*Dry storage in the kitchen area had a sprinkler head missing an escutcheon ring.
*Dirty sprinkler heads noted in the construction area for the new cafeteria.
*Women ' s restroom G535 had two dirty sprinkler heads.

First Floor:
*Within the holding area 1826 observation was made of dirty sprinkler heads.
*Within corridor 1801, two dirty sprinkler heads.
*Within the trash chute of room 1201, observation was made of a sprinkler head coated with debris. Additionally, the sprinkler head within the laundry chute was observed to have a piece of plastic attached to it.
*In the family waiting area 1100, dirty sprinkler heads were observed.
*Dirty sprinkler heads observed in rooms 1111, 1112 and 1113.
*Dirty sprinkler heads observed in heart and vascular waiting area.
*Dirty sprinkler heads observed within the women ' s locker room 1547.

Second Floor:
*Sprinkler head within the gift shop storage room had what appeared to be a coating of white paint.
*Dirty sprinkler heads observed in the petite café.
*Dirty sprinkler heads noted in the offices located adjacent to the chapel.
*Dirty sprinkler heads observed in the nursery room 2444.

These findings were verified by all staff present during tour of these areas.

Based on observation during tour and staff verification it was determined this facility failed to ensure the sprinkler system was maintained in such a manner that there were no impediments to the spray pattern of all sprinkler heads. This had the potential to affect all those utilizing this area of the facility. The facility census on the day of the survey was 40.

Findings include:

Facility tour took place on 10/31/12 with staff members A1, D4, and E5. During tour of the linen closet located near the entrance to the surgery department, observation was made of the top shelf located within a few inches of the sprinkler head. This shelf was observed to cover the entire sprinkler head and would have impeded the water spray pattern if activated. This finding was verified by staff members A1 and A4 during tour of the facility on 10/31/12.

Based on observation during tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were maintained and inspected according to the National Fire Protection Association 10. This had the potential to affect all those utilizing this area of the facility. The facility census on the day of the survey was 40.

Findings include:

Facility tour took place on 10/31/12 with staff members A1, D4, and E5. During tour within the front entrance area, observation was made of a child's wheelchair positioned directly in front of a fire extinguisher; located in a wall cabinet. The wheelchair was located in such a manner that it inhibited free access to the fire extinguisher.
Additionally, observation was made of another portable fire extinguisher located near the southeast double doors and by room E1036 which according to the inspection tag, was last inspected on 09/04/12.

This finding was verified by staff members A1 and A4 during tour of the facility on 10/31/12.

Based on review of facility documentation and staff interview and verification, the facility failed to ensure that fire and smoke dampers complied with the provisions of NFPA 90A with regards to testing. The facility had a census of 329 patients at the time of the survey.

Findings included:

On 11/02/12 between 8:30 A.M. and 10:00A.M. review of facility documentation was completed with regard to fire and smoke damper testing. Present for documentation review was Staff N14,and H8. Review of the fire/ smoke damper testing revealed that testing was completed in March 2009.

Review of the documented testing revealed that six dampers could not be tested due to inaccessibility or failed testing. Interview of Staff N14 regarding the six failed dampers revealed that since the facility was provided with an automatic sprinkler system that repair was not required. Staff N14 stated the same rational applied for the 18 dampers that could not be tested due to inaccessibility.

The 18 dampers not tested due to inaccessibility were located on the ground floor (3), third (2), fourth ( 6), fifth (3) and sixth floors( 4). The six failed dampers were located in the third (1), fourth (4) and sixth (1) floors.

Staff N14 verified the dampers were not repaired or tested due to Code referenced in NFPA 105, 2007 edition.


the floors of the buildings.

Based on facility tour and staff verification it was determined this facility failed to ensure all medical gas storage or in use locations were protected in accordance with the National Fire Protection Association (NFPA) 99 in regards to ensuring one hour fire rated barriers and proper location of electrical switches. This had the potential to affect all those utilizing this facility. The patient census on the day of the survey was 329.

Findings include:

A facility tour of the main building took place on 10/29/12 through 10/31/12 with staff members A1, B2 and C3. During a tour of the ground floor, observation was made of medical gas storage locations identified as rooms G802 and G804A. The rooms were equipped with a light switch mounted on the inner wall being less than five feet from the floor. Both rooms had a total of 90 full E-tanks of oxygen and carbon dioxide and 58 empty E-tanks of oxygen and carbon dioxide.

During a tour of the 800 machine room, observation was made of one unsecured H-tank of nitrogen.

During a tour of room G819, observation revealed the presence of a fire rated, yellow flammable liquid cabinet. The cabinet was labeled " Flammable Liquid Storage " and contained storage of gases rather than liquids. The gases stored in the cabinet included; 27, 16 oz. bottles of mapp gas, four 16 oz. bottles of propane, a 20 lb. bottle of propane, a D size tank of argon, two small bottles and three medium size bottles of oxygen and four small bottles of acetylene.

During a tour of the first floor and within medical gas storage room 1258C, observation was made of a total of six penetrations in the walls and ceiling measuring approximately one inch in diameter each. This room had a total of eight H-tanks of medical gas.

During a tour of the third floor and within medical gas storage room 3016, observation was made of the light switch mounted less than five foot from the floor. This room contained 24 H-tanks of nitrous oxide, 8 H-tanks of nitrogen, two large tanks of liquid nitrogen and one H-tank of oxygen.

Observation on 10/29/12 between 3:15 P.M. and 4:35 P.M. with Staff H8, revealed the presence of small oxygen storage location in the physical therapy treatment area. Observation of the small room revealed construction was with two hour fire rated walls. Observation above the ceiling tiles of the oxygen storage area revealed two, six inch air ducts that penetrated the fire rated wall. The two ducts were observed to have open, unsealed area surrounding them.

The observations and findings were verified by all staff present during tour of these areas.

*NFPA 101, 2000 Code, Chapter 7, Exits

7.1.10.1
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on facility tour and staff interview and verification, the facility failed to ensure the means of egress was continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. This could potentially affect all persons utilizing the facility;

Findings included:

On 10/31/12 between 2:10 P.M. and 4:25 P.M. a tour of the facility was conducted with Staff H8. Observations of the exit discharges from paths of egress revealed the following;

1. From Stairway C, the exit discharge required a step down which was approximately 14 inches to a grassy area. Travel to the paved, hard surface of the public way required travel across approximately 200 feet of uneven, grass covered ground.

2. From Stairway B, the exit discharge was observed to be onto a concrete pad, estimated by Staff H8 to be approximately 5 feet by 8 feet. Travel to the paved, hard surface of the public way required movement across an area estimated to be 4 feet of uneven, grassy ground.

Staff H8 present on tour observed and verified the findings.

7.10.1.2
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Based on facility tour and staff interview and verification, the facility failed to ensure the exits, other than main exterior exit doors that are obvious and clearly identifiable were marked readily visible from any direction of exit access.

Findings included:

On 10/31/12 between 2:10 P.M. and 4:25 P.M. tour of the facility was conducted with Staff H8. Observations of the exit signs leading to the way out of the facility revealed that on the fifth floor of the facility,one exit sign was not clearly visible.

The exit sign on the firth floor was located near an exit stairwell and was hidden by a sign hanging from the ceiling. The sign obstructing the view of the exit sign said "Department of Medicine".

Interview of Staff H8 verified the exit sign was hidden from clear view. Staff H8 stated the Department of Medicine sign had been recently hung at the location.


NFPA 101,
Chapter 21

Emergency illumination is provided in accordance with section 7.9.

Based on facility tour and staff interview and verification, the facility failed to ensure emergency lighting was provided for 11/2 hour at the emergency generator location.

Findings included:

1. On 10/31/12 between 2:10 P.M. and 4:25 P.M. tour of the facility was conducted with Staff H8. Observations of the emergency generator location revealed it was maintained inside the building. Observation of the room where the generator was located revealed there was no battery powered emergency illumination.

Interview of Staff H verified there was no battery powered emergency lighting in the generator location.

2. Observation during tour of the exit discharge for Stairwell A, revealed that at the exit discharge there was no emergency lighting provided. Staff H8 present on the tour, verified there was no lighting available once outside at the exit discharge for Stairway A.


39.3.2.1
Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

8.4.1.1*
Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.

8.4.1.3
Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

Based on facility tour and staff interview and verification, the facility failed to ensure that hazardous areas provided with sprinkler system protection were protected by doors with self-closing or automatic closing devices. Potentially all persons in the facility could be affected.

Findings included:

On 10/31/12 between 2:10 P.M. and 4:25 P.M. tour of the facility was conducted with Staff H8. Observations of the facility revealed the following storage areas that were provided with sprinkler protection but did not have self-closing or automatic closing devices on the doors;

1. Room 544 was observed to be a storage room with various supplies. The door to the room had no self-closing or automatic closing device.

2. Room 580, identified as a dirty utility room, had no door for the room.

3. Room 439, a linen storage area had a door with no self-closing or automatic closing device.

5. Room 449, a storage room that contained Christmas decorations, papers containing billing information and a fan had a door with no self-closing or automatic closing device.

6. Room 450, a room for miscellaneous items in storage had a door with no self-closing or automatic closing device.

7. Room 441, a medical records storage room, contained a large amount of combustible patient medical records, had a door at each end of the room. Both doors lacked self-closing or automatic closing devices.

8. Room 353, identified as a housekeeping closet had a door with no self-closing or automatic closing device.

9. Room 381, a miscellaneous storage room had a door with no self-closing or automatic closing device.

10. Room 121, located in the laboratory area, was a storage room with a door that had no self-closing or automatic closing device

11. Located in the breast health area on the first floor, a soiled linen room, that contained seven bags of soiled linen. The room had a door with no self-closing or automatic closing device.

Interview of Staff H8 verified there many storage rooms throughout the facility and that self-closing devices or automatic closing devices were not on the doors.


NFPA 99
Medical Gas Storage and Administration
Chapter 4
4.3.1.1.2
The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

Based on facility tour and staff interview and verification, the facility failed to ensure that electric wall switches and receptacles were installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage in medical gas storage areas.
Potentially all persons in the facility could be affected.

Findings included:

On 10/31/12 between 2:10 P.M. and 4:25 P.M. a tour of the facility was conducted with Staff H8. Observations of the facility revealed a medical gas storage area in the endoscopy procedure area of the ambulatory care center. Observation inside the medical gas storage room revealed a residential type light switch for the room placed lower than 5 feet from the floor. Staff H8, present on tour verified the observation.


NFPA 25
Chapter 2
2-2 Inspection.
2-2.1 Sprinklers.
2-2.1.1
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Based on facility tour and staff interview and verification, the facility failed to ensure that sprinklers were free of corrosion, foreign materials, paint, and physical damage and were installed in the proper orientation. Potentially all persons in the facility could be affected.

Findings included:

On 10/31/12 between 2:10 P.M. and 4:25 P.M. tour of the facility was conducted with Staff H8. Observations of the facility revealed the presence of an atrium. Automatic sprinkler protection was provided for the facility from the top of the atrium.

Observation from the fifth floor revealed the sprinkler heads and sprinkler pipe was covered with a thick layer of dusty debris. Interview of Staff H8 verified the sprinkler heads had not been cleaned for a significant time frame due to the height of the atrium and the location of the sprinkler heads.

Observation of the fourth floor office reception area revealed a sprinkler head with a missing escutcheon ring.

Staff H8 verified the finding.


NFPA 101
Chapter 20/21
20.1.2.1
Occupancy Separation
Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
(1) They are not intended to serve ambulatory health care occupants for purposes of treatment or customary access by patients incapable of self-preservation.
(2) They are separated from areas of ambulatory health care occupancies by construction having a fire resistance rating of not less than 1 hour.

Based on review of facility schematics, facility tour and staff interview and verification, the facility failed to ensure that sections of the ambulatory health care facilities was permitted to be classified as other occupancies provided that they were separated from areas of ambulatory health care occupancies by construction having a fire resistance rating of not less than 1 hour.
Potentially all persons in the facility could be affected.

Findings included:

On 10/31/12 between 2:10 P.M. and 4:25 P.M. a tour of the facility was conducted with Staff H8. Review of the facility schematic drawing revealed the endoscopy suite was located on the third floor of the building. Review of the schematic drawing revealed the endoscopy ambulatory care center was separated from the atrium of the facility by a one hour fire rated barrier.

Observations of the endoscopy suite area on the third floor revealed the presence of a waiting area located adjacent to the atrium. This waiting area was outside the one hour fire rated enclosure noted on the schematic.

Observation of the one hour fire rated enclosure revealed penetrations in the following locations of the one hour fire rated wall.

1. Located inside the soiled utility room was a shared wall that was the one hour fire rated barrier. Observation of the one hour fire rated wall revealed penetrations surrounding a black pipe and four conduits.

2. Observation of the one hour fire rated wall above bed 4, revealed a penetration approximately inch in diameter with a data line through it.

3. Observation of the one hour fire rated wall from the reception area revealed a penetration surrounding wire and pipe.

Staff present at the time of the tour verified the observations and findings.

Based on observation during tour and staff verification, 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. This had the potential to affect all patients, staff and visitors utilizing the facility. The patient census was 21 at the beginning of the survey.

Findings include:

Facility tour took place on 10/31/12 with staff members A1, D4, and E5. During tour the exit access corridors and checkout areas observation was made of smoke detectors located near air flow devices. Specific areas were observed as:

*Within the northwest corridor near the exit discharge.
*Within the center corridor on the east end and near the exit discharge.
*Within the PHC checkout area.

These findings were verified by all staff present during tour on 10/31/12.