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Based on observations the facility failed to provide a proper separations between Buildings. This deficient practice could affect patients, staff and visitors if a fire was allowed to spread into the facility from the adjacent building.

Findings include:

A. On 6/13/17 at 2:02 PM, while accompanied by VPSP, it was determined that on the Ground floor, vestibule doors BA-1 and BA-2, separating buildings "F" and "A" did not latch to the frame when tested due to the air/pressure differential between these buildings. This does not comply with NFPA 101, 19.1.3.5.

B. On 6/13/17 at 1:11 PM, while accompanied by VPSP, it was determined that on the Ground floor, vestibule doors separating buildings "C" and "E" did not latch to the frame when tested due to the air/pressure differential between these buildings. This does not comply with NFPA 101, 19.1.3.5.

C. On 6/14/17 at 10:07 AM, while accompanied by VPSP, it was determined that on the 2nd floor, bridge to medical office building contains a door that does not latch to the frame when tested due to the air flow and pressurization issues across the threshold. This does not comply with NFPA 101, 19.1.3.5.

Based on observation during the survey walk-through, not all egress doors are installed or maintained to permit egress. These deficiencies could affect patients, staff and visitors if the room does not have access to the means of egress and becomes unavailable.

Findings include:

A. On 6/13/17 at 12:50 PM, while accompanied by the VPSP, it was determined that on the Ground floor, corridor to cafeteria, Dietitian offices, door to the exit corridor contained a keyed deadbolt from the corridor side but did not have a releasing device on the room side. This condition has the potential for someone to be locked in the room without the means of escape. This does not comply with the requirements of NFPA 101, 19.2.2.2.5.1.

B. On 6/13/17 at 12:51 PM, while accompanied by the VPSP, it was determined that on the Ground floor, corridor to cafeteria, training room, door to the exit corridor contained a keyed deadbolt from the corridor side but did not have a releasing device on the room side. This condition has the potential for someone to be locked in the room without the means of escape. This does not comply with the requirements of NFPA 101, 19.2.2.2.5.1.

C. On 6/13/17 at 1:21 PM, while accompanied by the VPSP, it was determined that on the Ground floor, Physical Therapy area, door to the exterior courtyard did not have hardware to allow for reentry back into the physical therapy area. This courtyard is enclosed without exit provisions. This condition has the potential for someone to be locked in the courtyard without the means of escape. This does not comply with the requirements of NFPA 101, 19.2.2.2.5.1.

D. On 6/14/17 at 10:42 AM, while accompanied by the VPSP, it was determined that on the 2nd floor, Respiratory Therapy area, Tech. room, door to the exit corridor contained a keyed deadbolt from the corridor side but did not have a releasing device on the room side. This condition has the potential for someone to be locked in the room without the means of escape. This does not comply with the requirements of NFPA 101, 19.2.2.2.5.1.

E. On 6/14/17 at 10:44 AM, while accompanied by the VPSP, it was determined that on the 2nd floor, Respiratory Therapy area, PFT room, door to the exit corridor contained a keyed deadbolt from the corridor side but did not have a releasing device on the room side. This condition has the potential for someone to be locked in the room without the means of escape. This does not comply with the requirements of NFPA 101, 19.2.2.2.5.1.

F. On 6/14/17 at 9:51 AM, while accompanied by the VPSP, it was determined that on the 1st floor, Emergency Department, Treatment room #4 door to the exit corridor contained a keyed deadbolt from the corridor side but did not have a releasing device on the room side. This condition has the potential for someone to be locked in the room without the means of escape. This does not comply with the requirements of NFPA 101, 19.2.2.2.5.1.

Based on record review and interview, it was determined that the emergency lighting is not maintained as required. This deficient practice could affect patients, staff and visitors in areas of the building under emergency conditions if Emergency Lights are not properly maintained.

Findings include:

On 6/14/17 at 2:00PM, during document review of the Battery-Pack Emergency Lights testing and interview with VPSP and FD, it was determined that the facility failed to conduct monthly 30 Seconds Test and 90 Minutes Annual Test, in accordance with Sections 7.9 and 19.2.9.1.

Based on observation during the survey walk-through and record review, not all exit signs are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if exit signs are not properly installed and maintained.

Findings include:

On 6/13/17 while accompanied by the FD, following locations were found to be missing EXIT signs with continuous illuminations, also served by emergency lighting system, not in accordance with the Sections 7.10 and 19.2.10.1:

1. At 12:50PM on 9th floor exit corridor bulk head by Room 927, Building "C".
2. At 11:05AM on 3rd floor exit corridor between Rooms 336/337, Building "D".

Based an observations during the survey walk-through, not all egress doors are installed or maintained to permit egress and provide protection of the exit enclosure. This deficiency could affect patients, staff and visitors if the exit access door did not provide the proper protection during a fire emergency.

Findings include:

On 6/13/17 at 12:50 PM, while accompanied by the VPSP, it was determined that on the Ground floor, Cafeteria, double doors to the exit stair contained door hardware that was loose and did not provide a proper seal to the fire rated door assembly. This does not comply with the requirements of NFPA 101, 19.3.1.7.

Based on observation during the survey walk-through, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass from the hazardous areas to the remainder of the building if the hazardous areas are not protected as required.

Findings include:

A. On 6/13/17 while accompanied by the FD, the following hazardous room locations contained doors that were not self-closing or automatic-closing to resist the passage of smoke into the exit corridor as required in accordance with Sections 19.3.2.1 and 8.4:

Locations include:

1. At 1:35PM, Office 631 on 6th floor was found storing combustible papers and boxes deemed in excess for an office, and the door was found open to the exit corridor and did not contain provisions for keeping the door closed. The room is classified as hazardous.

2. At 1:45PM, Mechanical Room door on 6th floor did not contain provisions for keeping the door closed.




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3. At 1:09 PM, Ground floor, Soiled Utility room adjacent to the sewing room did not contain provisions for keeping the door closed.

4. At 1:26 PM, Ground floor, Dialysis Storage area, double doors located on the exit corridor did not latch to the frame when tested.

5. At 1:55 PM, Ground floor, Storage room door located adjacent to the Fan Room S3 did not latch to the frame when tested.

6. At 2:10 PM, First floor, Medical Records area contains 1 door located on the northeast corner of the area and 1 door at the northwest corner that do not have provisions for keeping the door closed.

7. At 2:52 PM, First floor, Room 155, 1 south, doctor's office contained open storage of medical records that was open to the exit corridor and adjacent exam rooms. This area is considered hazardous and patients are prohibited from using this space to access other areas of the building. Provisions for medical records storage will need to be reviewed.

8. On 6/14/17 at 6:26 AM, First floor, Inpatient Pharmacy, double doors to exit corridor, inactive door leaf was installed with a manual flush bolt.

9. On 6/14/17 at 10:02 AM, First floor, Dock, Double doors located on the exit corridor are damaged and both door leafs and the installed hardware do not provide proper separation from the hazardous storage area at the dock to the exit corridor.

10. On 6/14/17 at 10:39 AM, 2nd floor, Lab area, door to Micro Sendout located on the exit corridor does not latch to the door frame when tested.

Based on review and interview, facility was unable to substantiate that the kitchen hood exhaust was inspected semi-annually. This deficient practice could affect staff and visitors if the fire spread to other areas of the facility due to non-maintenance of the kitchen hood exhaust.

Findings include:

On 6/14/17 at 2:10 PM, while accompanied with VPSP and FD, it was determined that the facility failed to produce documentation that the semi-annual kitchen hood exhaust inspection was conducted, in accordance with NFPA 96, Section 11.6.

Based on an observation during the survey walk-through, not all portions of the building's automatic sprinkler system are maintained in the required manner. This deficient practice could affect patients, staff, and visitors in the building if the sprinkler system failed to operate properly under fire conditions.

Findings include:

A. On 6/14/17 at 9:11 AM, while accompanied by VPSP, it was determined that on the First floor, Dialysis unit, Dietary office contained a sprinkler head that was missing an escutcheon ring. This does not comply with NFPA 13, 6.2.7.1.

B. On 6/13/17 at 1:57 PM, while accompanied by VPSP, it was determined that on the ground floor, Men's Locker room contained 4 sprinkler heads that were pain covered. This does not comply with NFPA 25, 5.2.1.1.1.

C. On 6/13/17 at 1:59 PM, while accompanied by VPSP, it was determined that on the ground floor, Women's Locker room contained 3 sprinkler heads that were dust and dirt covered. This does not comply with NFPA 25, 5.2.1.1.1.

D. On 6/14/17 at 9:51 AM, while accompanied by VPSP, it was determined that on the 1st floor, Emergency Department, Treatment room #4 contained a 2 foot by 2 foot hole in the ceiling. This area is sprinkler protected and a sprinkler head is installed adjacent to the ceiling opening. This does not comply with NFPA 13, 8.5.4.1.

Based on observation during the survey walk through the facility lacks correct signage for the use of fire extinguishers in the cafeteria. This deficient practice could affect patients, staff and visitors during a kitchen cooking grease fire event.

Finding include:

On 6/13/17 at 1:10pm, while accompanied by the EGF, it was observed that the installed K fire extinguisher lack signage for the correct sequence and use of the K fire extinguisher located by the grease hood in the cafeteria. NFPA 96, 2008, 10.2.2

Based on observations during the survey walk-through, not all corridor doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass into corridors if the corridor doors are not installed in a compliant manner.

Findings include:

On 6/14/17 while accompanied with the facility representative "FD", the following patient room doors were found to not latch or having a gap of more than 1/4" at the jamb and door head. this is not in accordance with the Sections
19.3.6.3:

Locations include:

A. At 9:25AM Room # 436 on 4th: floor-Building "C".door not latching.
B. At 9:28AM Room # 439 on 4th: floor - Building "C" gap at the jamb/head.
C. At 9:35AM Large Dayroom pair of doors on 4th: floor - Building "D", was found damaged and the one door with door closure restrict the closing of the other door without opening the door with door closure to latch.
D. At 9:40AM Room # 444 on 4th: floor - Building "D" gap at the jamb/head.
E. At 9:43AM Room # 445 on 4th: floor - Building "D" gap at the jamb/head.
F. At 9:44AM Room # 446 on 4th: floor - Building "D" gap at the jamb/head.
G. At 9:50AM Room # 450 on 4th: floor - Building "D" gap at the jamb/head.
H. At 10:20AM Patient Room # 372 on 3rd: floor-Building "D"door not latching.
I. At 10:22AM Patient Room # 374 on 3rd: floor-Building "D"door not latching.
J. At 10:30AM Patient Room # 355 on 3rd: floor-Building "D"door not latching, due to damaged latching hardwarwe.
J. At 10:24AM Patient Room # 373 on 3rd: floor-Building "D"door not latching.
K. At 10:26AM Patient Room # 379 on 3rd: floor-Building "D"door not latching.
L. At 10:40AM Room # 371 on 3rd:: floor - Building "D" gap at the jamb/head.


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M. On 6/13/17 at 2:02 PM, while accompanied by VPSP, it was determined that in the Ground floor, back door to Ortho adjacent to "B" Pump room does not latch to the door frame when tested. This does not comply with NFPA 101 Section 19.3.6.3.

Based on an observation it was determined that the facility failed to properly manage and maintain the existing Air-conditioning and Ventilating Systems. This deficient practice could affect patients, staff and visitors if fire dampers are not installed in wall locations to limit the fire and smoke from a fire event in hazardous areas.

Findings Include:

On 6/14/17 at 1:26 AM, while accompanied by VPSP, it was determined that on the Ground floor, Elevator Machine room for Elevators 6 & 7 contained a supply duct that was not installed with a fire damper. This does not comply with NFPA 90A, 5.3.1.2.

Based on observations, the facility failed to provide proper electrical protections in electrical areas. This deficient practice could affect patients, staff and visitors if proper electrical wiring is not protected.

Findings include: On 6/13/17 at 2:00 PM, while accompanied by VPSP, it was determined that on the Ground floor, Electrical Room located adjacent to the Morgue contains 3 main electrical panels that are not installed with cover plates. This does not comply with the requirements of NFPA 70, 2011 edition, section 408.

Based on observation during the survey walk-through and staff interview, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.

Findings include:

On 6/14/17 at 10:38AM, while in the company of the FD it was observed that the electrical receptacle in the soiled utility rooms across from Patient Room 357, on the 3rd floor of Building "D" were installed within 6' on both sides of the sink and could not be verified to be GFCI protected to comply with NFPA 70-2011, 210.8(B)5.