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Based on observation and interview, it was determined the facility failed to maintain the corridor smoke separation in one of six smoke zones.

Findings include:

Observation on June 26, 2014, at 9:00 am, revealed a ceiling tile was being held out of place by a zip tie to the ceiling grid system in the second floor West Laundry room.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the ceiling was not smoke tight.

Based on observation and interview, it was determined the facility failed to maintain the corridor separation to be smoke tight in one of three smoke compartments.

Findings include:

1. Observation on June 26, 2014, at 9:00 am, revealed that in the second floor housekeeping closet (near the roof access door), there was a five by five inch (5"x5") hole in the wall above the door. The hole is in a wall that abuts the corridor.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the penetration in the wall.

2. Observation on June 26, 2014, at 9:15 am, revealed in the second floor Library, room #206, there was a hole in the wall from where the thermostat had been relocated, approximately four feet up from the floor, to the left of the corridor door. There was also an opening in the wall around the new thermostat location. The holes are in a wall that abuts the corridor.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the penetrations in the wall.

Based on observation and interview, it was determined the facility failed to maintain the corridor doors to be able to close on a self closing device in one of six smoke zones.

Findings include:

Observation on June 26, 2014, at 10:30 am, revealed the door of the first floor east wing soiled linen room failed to close on the self-closing device when tested.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the door failed to close.

Based on observation and interview, it was determined the facility failed to ensure that corridor doors, in other than hazardous areas, are free of impediments to closing and latching in one of three smoke zones.

Findings Include:

Observation on June 26, 2014, at 9:03 am, revealed on the second floor, the door to the housekeeping closet was being held open by a wooden wedge. The wedge was removed by a member of the facility staff at the time of discovery.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed wooden wedge was holding the door open, and its subsequent removal by a member of the facility staff.

Based on observation and interview, it was determined the facility failed to maintain the floor/ceiling assembly in one of six smoke zones.

Findings include:

Observation on June 26, 2014, at 9:07 am, revealed an unsealed data wire sleeve in the floor of the second floor west wing laundry room electrical closet.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed there was a penetration.

Based on observation and interview, it was determined the facility failed to maintain the fire rating of the smoke barriers in five of six smoke zones.

Findings include:

Observation on June 26, 2014, between 9:33 am and 10:20 am, revealed penetrations of the smoke barrier walls at the following locations:

a. 9:33 am, second floor, above the smoke barrier doors by the linen closet in the central core, there was a partially sealed bx armored cable penetration.
b. 10:10 am, first floor, above the smoke barrier doors outside the elevator machine room, there were two partially sealed data wire penetrations.
c. 10:20 am, first floor, above the smoke barrier doors to the east wing, at the Admin Assistant office, there was a partially sealed penetration of a copper pipe.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed there were penetrations.

Based on observation and interview, it was determined the facility failed to maintain the fire rating of the stair tower in one of three stair towers.

Findings include:

Observation on June 26, 2014, at 9:24 am, revealed a penetration of the second floor central stair tower corridor wall, above the ceiling, by a metal rod.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed there was a penetration.

Based on documentation review and interview, it was determined the facility failed to provide documentation for testing of emergency lighting throughout the facility.

Findings include:

Document review on June 26, 2014 at 11:30 am, revealed that the facility failed to provide documentation that battery-operated emergency lighting is being tested monthly for a minimum of thirty-seconds, and annually for ninety minutes.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the lack of documentation for emergency lighting testing.

Based on documentation review and interview, it was determined the facility failed to provide documentation of a monthly visual inspection of exit signage throughout the facility.

Findings include:

Document review on June 26, 2014 at 11:30 am, revealed that the facility failed to provide documentation that exit signs are being visually inspected on a monthly basis.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the lack of documentation for monthly exit signage inspection..

Based on documentation review and interview, it was determined the facility failed to provide documentation of a visual inspection of fire alarm components on a semi-annual basis throughout the facility.

Findings include:

Document review on June 26, 2014 at 11:30 am, revealed that the facility failed to provide documentation that fire alarm components undergo a visual inspection on a semi-annual basis.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the lack of documentation for the semi-annual fire alarm inspection.

Based on observation and interview, it was determined the facility failed to provide sprinkler coverage in one of six smoke zones.

Findings include:

Observation on June 26, 2014, at 9:07 am, revealed the electrical closet inside the second floor West Wing patient laundry room did not have a sprinkler head.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed there was no sprinkler head visible.

Based on observation, interview, and document review, it was determined that the facility failed to properly maintain smoke detecting devices throughout the component.

Findings include:

Observation, interview, and document review on June 26, 2014, at 11:45 am, revealed the Fire Alarm System Annual Test report, dated May 19, 2014, indicated there were six (6) smoke detectors that failed the sensitivity testing. The facility was unable to provide documentation that the failed detectors had been replaced.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed that six smoke detectors had failed the sensitivity testing.

Based on observation and interview, it was determined the facility failed to maintain the sprinkler heads to be in a smoke tight assembly in one of six smoke zones.

Findings include:

Observation on June 26, 2014, between 10:40 am and 10:42 am, revealed sprinkler head assemblies were not smoke tight at the following locations:

a. 10:40 am, first floor, East Wing, Therapist Office, was missing an escutcheon.
b. 10:42 am, first floor, East Wing, Therapist Office closet, was missing the ceiling tile around the sprinkler head.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the sprinkler heads were not in a smoke tight assembly.

Based on observation and interview, it was determined that the facility failed to ensure that the automatic sprinkler system is properly inspected and maintained, and that ceilings and partitions are smoke tight, in three of three smoke zones.
Findings include:
1. Observations on June 26, 2014, between 9:05 and 9:30 a.m., revealed missing and damaged ceiling tiles, and partitions that are not smoke tight in the following locations:

a. 9:05 am, second floor, Conference Room #209, three ceiling tiles that were sagging and not sitting tightly in the grid assembly.
b. 9:20 am, second floor, Library (room #206), in the Archives closet there were multiple missing and broken ceiling tiles.
c. 9:30 am, first floor, inside of Room #115, two holes in the wall, located at the rear right hand side of the room.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the non smoke tight ceilings and partitions at the above named locations.

2. Observation on June 26, 2014 at 10:00 a.m., revealed there was no signage for the sprinkler system Fire Department Connection (FDC) located at the exterior of the building.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the lack of signage for the sprinkler system Fire Department Connection.

Based on observation and interview, it was determined the facility failed to monitor the use of electric devices and maintain the junction boxes to be secured and covered in three of six smoke zones.

Findings include:

1. Observation on June 26, 2014, between 9:15 am and 9:54 am, revealed the unauthorized use of electrical devices in the following locations:

a. 9:15 am, second floor, West Wing Nurses Station, Doctor's Office room 212, there was an extension cord powering a surge protector.
b. 9:46 am, second floor, East Wing Nurses Lounge, there was a 3 way plug powering the appliances.
c. 9:54 am, second floor, East Wing Nurses Station, there was a surge protector plugged into a surge protector under the work space along the corridor wall.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the unauthorized use of electrical devices.


2. Observation on June 26, 2014, between 9:20 am and 9:35 am, revealed uncovered junction boxes at the following locations:

a. 9:20 am, second floor, west wing, above the ceiling at the smoke barrier in front of the central stair tower, there were two uncovered junction boxes.
b. 9:35 am, second floor, East Wing, above the ceiling at the smoke barrier by the linen closet, there was an uncovered junction box.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the junction boxes were not covered.

Based on observation and interview, it was determined the facility failed to monitor the use of electric devices, and ensure that electrical components are properly inspected and maintained in three of three smoke zones.

Findings include:

1. Observation on June 26, 2014, between 9:10 am and 10:15 am, revealed the unauthorized use of electrical devices in the following locations:

a. 9:10 am, second floor, Library (room #206), there were two instances where powerstrips were daisy-chained into another powerstrip. These powersrtips were powering computer and screen projector equipment.
b. 9:25 am, second floor, room #203, there was a white extension cord powering a microwave.
c. 9:35 am, first floor, inside the bedroom in room #113, there was a microwave and refrigerator plugged into a powerstrip.
d. 9:45 am, first floor, room #119, there was a refrigerator plugged into a powerstrip.
e. 10:15 am, first floor, Oxygen Storage Room (room #127), there was a blood pressure testing machine plugged into a powerstrip.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the unauthorized use of electrical devices.

2. Observation on June 26, 2014, at 10:15 am, revealed in the emergency generator room accessible from the exterior of the building, electrical circuit breaker panels labeled "OL" and "PP1A" were both missing two blank covers where circuit breakers were not installed.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the circuit breaker panels were missing blank covers.

3. Observation on June 26, 2014, at 10:20 am, revealed in the emergency generator room accessible from the exterior of the building, to the left of the door, there was a duplex electrical outlet that was missing the protective coverplate, exposing electrical wiring.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the electrical outlet as missing the protective coverplate.

Based on observation and interview, it was determined the facility failed to maintain the corridor smoke separation in one of six smoke zones.

Findings include:

Observation on June 26, 2014, at 9:00 am, revealed a ceiling tile was being held out of place by a zip tie to the ceiling grid system in the second floor West Laundry room.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the ceiling was not smoke tight.

Based on observation and interview, it was determined the facility failed to maintain the corridor separation to be smoke tight in one of three smoke compartments.

Findings include:

1. Observation on June 26, 2014, at 9:00 am, revealed that in the second floor housekeeping closet (near the roof access door), there was a five by five inch (5"x5") hole in the wall above the door. The hole is in a wall that abuts the corridor.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the penetration in the wall.

2. Observation on June 26, 2014, at 9:15 am, revealed in the second floor Library, room #206, there was a hole in the wall from where the thermostat had been relocated, approximately four feet up from the floor, to the left of the corridor door. There was also an opening in the wall around the new thermostat location. The holes are in a wall that abuts the corridor.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the penetrations in the wall.

Based on observation and interview, it was determined the facility failed to maintain the corridor doors to be able to close on a self closing device in one of six smoke zones.

Findings include:

Observation on June 26, 2014, at 10:30 am, revealed the door of the first floor east wing soiled linen room failed to close on the self-closing device when tested.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the door failed to close.

Based on observation and interview, it was determined the facility failed to ensure that corridor doors, in other than hazardous areas, are free of impediments to closing and latching in one of three smoke zones.

Findings Include:

Observation on June 26, 2014, at 9:03 am, revealed on the second floor, the door to the housekeeping closet was being held open by a wooden wedge. The wedge was removed by a member of the facility staff at the time of discovery.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed wooden wedge was holding the door open, and its subsequent removal by a member of the facility staff.

Based on observation and interview, it was determined the facility failed to maintain the floor/ceiling assembly in one of six smoke zones.

Findings include:

Observation on June 26, 2014, at 9:07 am, revealed an unsealed data wire sleeve in the floor of the second floor west wing laundry room electrical closet.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed there was a penetration.

Based on observation and interview, it was determined the facility failed to maintain the fire rating of the smoke barriers in five of six smoke zones.

Findings include:

Observation on June 26, 2014, between 9:33 am and 10:20 am, revealed penetrations of the smoke barrier walls at the following locations:

a. 9:33 am, second floor, above the smoke barrier doors by the linen closet in the central core, there was a partially sealed bx armored cable penetration.
b. 10:10 am, first floor, above the smoke barrier doors outside the elevator machine room, there were two partially sealed data wire penetrations.
c. 10:20 am, first floor, above the smoke barrier doors to the east wing, at the Admin Assistant office, there was a partially sealed penetration of a copper pipe.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed there were penetrations.

Based on observation and interview, it was determined the facility failed to maintain the fire rating of the stair tower in one of three stair towers.

Findings include:

Observation on June 26, 2014, at 9:24 am, revealed a penetration of the second floor central stair tower corridor wall, above the ceiling, by a metal rod.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed there was a penetration.

Based on documentation review and interview, it was determined the facility failed to provide documentation for testing of emergency lighting throughout the facility.

Findings include:

Document review on June 26, 2014 at 11:30 am, revealed that the facility failed to provide documentation that battery-operated emergency lighting is being tested monthly for a minimum of thirty-seconds, and annually for ninety minutes.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the lack of documentation for emergency lighting testing.

Based on documentation review and interview, it was determined the facility failed to provide documentation of a monthly visual inspection of exit signage throughout the facility.

Findings include:

Document review on June 26, 2014 at 11:30 am, revealed that the facility failed to provide documentation that exit signs are being visually inspected on a monthly basis.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the lack of documentation for monthly exit signage inspection..

Based on documentation review and interview, it was determined the facility failed to provide documentation of a visual inspection of fire alarm components on a semi-annual basis throughout the facility.

Findings include:

Document review on June 26, 2014 at 11:30 am, revealed that the facility failed to provide documentation that fire alarm components undergo a visual inspection on a semi-annual basis.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the lack of documentation for the semi-annual fire alarm inspection.

Based on observation and interview, it was determined the facility failed to provide sprinkler coverage in one of six smoke zones.

Findings include:

Observation on June 26, 2014, at 9:07 am, revealed the electrical closet inside the second floor West Wing patient laundry room did not have a sprinkler head.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed there was no sprinkler head visible.

Based on observation, interview, and document review, it was determined that the facility failed to properly maintain smoke detecting devices throughout the component.

Findings include:

Observation, interview, and document review on June 26, 2014, at 11:45 am, revealed the Fire Alarm System Annual Test report, dated May 19, 2014, indicated there were six (6) smoke detectors that failed the sensitivity testing. The facility was unable to provide documentation that the failed detectors had been replaced.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed that six smoke detectors had failed the sensitivity testing.

Based on observation and interview, it was determined the facility failed to maintain the sprinkler heads to be in a smoke tight assembly in one of six smoke zones.

Findings include:

Observation on June 26, 2014, between 10:40 am and 10:42 am, revealed sprinkler head assemblies were not smoke tight at the following locations:

a. 10:40 am, first floor, East Wing, Therapist Office, was missing an escutcheon.
b. 10:42 am, first floor, East Wing, Therapist Office closet, was missing the ceiling tile around the sprinkler head.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the sprinkler heads were not in a smoke tight assembly.

Based on observation and interview, it was determined that the facility failed to ensure that the automatic sprinkler system is properly inspected and maintained, and that ceilings and partitions are smoke tight, in three of three smoke zones.
Findings include:
1. Observations on June 26, 2014, between 9:05 and 9:30 a.m., revealed missing and damaged ceiling tiles, and partitions that are not smoke tight in the following locations:

a. 9:05 am, second floor, Conference Room #209, three ceiling tiles that were sagging and not sitting tightly in the grid assembly.
b. 9:20 am, second floor, Library (room #206), in the Archives closet there were multiple missing and broken ceiling tiles.
c. 9:30 am, first floor, inside of Room #115, two holes in the wall, located at the rear right hand side of the room.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the non smoke tight ceilings and partitions at the above named locations.

2. Observation on June 26, 2014 at 10:00 a.m., revealed there was no signage for the sprinkler system Fire Department Connection (FDC) located at the exterior of the building.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the lack of signage for the sprinkler system Fire Department Connection.

Based on observation and interview, it was determined the facility failed to monitor the use of electric devices and maintain the junction boxes to be secured and covered in three of six smoke zones.

Findings include:

1. Observation on June 26, 2014, between 9:15 am and 9:54 am, revealed the unauthorized use of electrical devices in the following locations:

a. 9:15 am, second floor, West Wing Nurses Station, Doctor's Office room 212, there was an extension cord powering a surge protector.
b. 9:46 am, second floor, East Wing Nurses Lounge, there was a 3 way plug powering the appliances.
c. 9:54 am, second floor, East Wing Nurses Station, there was a surge protector plugged into a surge protector under the work space along the corridor wall.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the unauthorized use of electrical devices.


2. Observation on June 26, 2014, between 9:20 am and 9:35 am, revealed uncovered junction boxes at the following locations:

a. 9:20 am, second floor, west wing, above the ceiling at the smoke barrier in front of the central stair tower, there were two uncovered junction boxes.
b. 9:35 am, second floor, East Wing, above the ceiling at the smoke barrier by the linen closet, there was an uncovered junction box.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the junction boxes were not covered.

Based on observation and interview, it was determined the facility failed to monitor the use of electric devices, and ensure that electrical components are properly inspected and maintained in three of three smoke zones.

Findings include:

1. Observation on June 26, 2014, between 9:10 am and 10:15 am, revealed the unauthorized use of electrical devices in the following locations:

a. 9:10 am, second floor, Library (room #206), there were two instances where powerstrips were daisy-chained into another powerstrip. These powersrtips were powering computer and screen projector equipment.
b. 9:25 am, second floor, room #203, there was a white extension cord powering a microwave.
c. 9:35 am, first floor, inside the bedroom in room #113, there was a microwave and refrigerator plugged into a powerstrip.
d. 9:45 am, first floor, room #119, there was a refrigerator plugged into a powerstrip.
e. 10:15 am, first floor, Oxygen Storage Room (room #127), there was a blood pressure testing machine plugged into a powerstrip.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the unauthorized use of electrical devices.

2. Observation on June 26, 2014, at 10:15 am, revealed in the emergency generator room accessible from the exterior of the building, electrical circuit breaker panels labeled "OL" and "PP1A" were both missing two blank covers where circuit breakers were not installed.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the circuit breaker panels were missing blank covers.

3. Observation on June 26, 2014, at 10:20 am, revealed in the emergency generator room accessible from the exterior of the building, to the left of the door, there was a duplex electrical outlet that was missing the protective coverplate, exposing electrical wiring.

Interview at the exit conference with the Acting Quality Management Director and Director of Plant Operations on June 26, 2014 at 11:45 am, confirmed the electrical outlet as missing the protective coverplate.