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Based on observation the facility failed to provide proper corridor separation. The deficient practice could affect patients, staff and visitors from using a corridor during a fire emergency.

Findings include:

A. On 03/17/2015 at 9:10 AM, while accompanied by the Director of Plant Operations and Switchboard Supervisor, the surveyor observed an alcove (near the central monitoring room) stored with wheelchair and chairs, that lacks a smoke detector to comply with the NFPA 18.3.6.1 exception #1 subpart (c).

Based on observations the facility failed to maintain properly rated shaft enclosures. This deficient practice could affect patients, staff and visitor if smoke and fire were allowed to expand from other areas of the facility through deficient shaft enclosures.

Findings include:

A. On 03/17/15 at 2:00PM the surveyor, while accompanied by the Vice President of Operations, observed two access panels within the Second floor Prep/Recovery Soiled Utility room. These panels are located in a 2-hour fire rated shaft wall. The framed-in opening was incomplete allowing the cavity of the 2-hour wall to be exposed. This condition does not comply with 18.3.1 and 8.2.5.2 for a continuous enclosure of the shaft wall.

Based on observations, the facility failed to provide separation between hazardous areas and exit access corridors. This deficient practice could affect, patients, staff and visitors by allowing fire to spread beyond the hazardous areas with high fuel loads into patient areas and through corridors.

Findings include:

A. On 03/17/2015 at 2:40 PM while accompanied by the Vice President of Operations an observation determined that in the ground floor I.T. Computer area a Storage Room (containing cardboard and plastic combustibles in a quantity deemed hazardous) contained a door with a hold open device which does not comply with section 18.3.2.1 for a self closing door.

B. On 03/17/2015 at 2:44 PM while accompanied by the Vice President of Operations, the surveyor observed that a storage room (containing cardboard and plastic combustibles in a quantity deemed hazardous) located in the ground floor I.T. computer area contained a hole in the wall above the suspended ceiling and entry door. This condition does not comply with 18.3.2.1 for storage rooms larger than 100 square feet to have a minimum 1-hour fire rated enclosure.

C. On 03/16/2015 at 2:30pm while accompanied by the Vice President of Operations, the surveyor observed that the 5th floor means of egress corridors contained numerous alcoves used as storage for cushioned back chairs, cardboard boxes and beds with mattresses. This condition does not comply with 38.3.2.1, 8.4.1.2 and 8.2.4.1 for smoke proof enclosures with self closing doors.

D. On 03/16/2015 at 1:30pm while accompanied by the Vice President of Operations, the surveyor observed that a 5th floor means of egress corridor contained a 100 square foot space enclosed with partial height partitions being used as a pantry containing canned food, cardboard and plastic containers. This condition does not comply with 38.3.2.1, 8.4.1.2 and 8.2.4.1 for smoke proof enclosures with self closing doors.

Based on observation, not all means of egress are arranged so that exits are readily accessible at all times. This deficient practice affects all patients, staff, and visitors, by preventing those occupants from reaching an exit under fire conditions.

Findings include:

A. At 9:05AM on 03/17/2015,while accompanied by the Director of Plant Operations and Switchboard Supervisor, the surveyor observed on the Third Floor of the Med/Surg Unit, an exit sign above a pair of corridor doors 3480. The doors lead into the designated suite of rooms (identified as S1 on the facility ' s Life Safety Plan) which does not comply with 18.2.5.9 for corridor exiting without passing through a room.



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B At 2:20pm on 03/17/15 while accompanied by the Vice President of Operations the surveyor observed that the 1st floor Won door adjacent to Out Patient Entry marked as an available exit from the Public Waiting/Lobby was equipped with operating hardware ( push to open paddle). During a test of the fire alarm system it was observed that access to the operating hardware is obstructed by the balcony railing which does not comply with 7.2.1.5.1.

Based on observations the facility failed to provide a compliant components of a fire alarm system. This could affect patients, staff and visitors of the building if the fire alarm system does not operate during a fire emergency.

Findings include:

A. On 03/17/2015, at 2:30 PM during the fire alarm test the surveyor accompanied by the Assistant Director of Plant Operations, observed that the door operator on the cross corridor doors located at the entrance to OB did not drop out to a manual operation when the fire alarm system was activated to comply with section 7.2.1.9.1.

Based on observation components of the sprinkler system are not compliant. Failure to maintain the installation conditions can result in delayed response to a fire condition the sprinkler system is designed to control.

Findings include:

A. By direct observation at 9:00 a.m. on 3/17/15 while in the company of the Maintenance Technician, the surveyor finds the facility failed to install fire sprinkler protection in the 2nd floor phase 1 recovery (Bio-Hazard) Room 2174. (NFPA 13, 51, 1999, 5-1.1, (1).

B. By direct observation at 1:30pm on 3/17/15 while in the company of the Maintenance Technician, the surveyor finds the facility failed to install fire sprinkler protection under the first landing above the bottom of the stair shaft at the following location: (NFPA 13, 1999, 5-13.3.2)
Stairways #2, #3, #4, #5, & #6

Based on observation, the facility failed to keep the means of egress free of obstructions. This deficient practice could affect patients, staff, and visitors on the cited locations in the event of a fire emergency requiring egress or relocation.

Findings include:

A. At 10:30 AM on 03/17/2015, on the First floor, while accompanied by the switchboard supervisor the surveyor observed within the out patient prep/recovery, designated exit access corridors contain a patient weighing scale, a nurse computer and equipment being charged. These items partially block the required clear width of the corridors and do not comply with NFPA 101, Section 7.1.10.1.


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B. At 9:15AM on 03/17/2015, on the Second floor - prep/recovery, while accompanied by the director of plant operations, the surveyor observed designated exit access corridors which contain a patient weighing scale, and medical equipment plugged into the walls being charged, these items partially blocked the required clear width of the corridor and do not comply with 7.1.10.1.

Based on observation the facility failed to provide proper corridor separation. The deficient practice could affect patients, staff and visitors from using a corridor during a fire emergency.

Findings include:

A. On 03/17/2015 at 9:10 AM, while accompanied by the Director of Plant Operations and Switchboard Supervisor, the surveyor observed an alcove (near the central monitoring room) stored with wheelchair and chairs, that lacks a smoke detector to comply with the NFPA 18.3.6.1 exception #1 subpart (c).

Based on observations the facility failed to maintain properly rated shaft enclosures. This deficient practice could affect patients, staff and visitor if smoke and fire were allowed to expand from other areas of the facility through deficient shaft enclosures.

Findings include:

A. On 03/17/15 at 2:00PM the surveyor, while accompanied by the Vice President of Operations, observed two access panels within the Second floor Prep/Recovery Soiled Utility room. These panels are located in a 2-hour fire rated shaft wall. The framed-in opening was incomplete allowing the cavity of the 2-hour wall to be exposed. This condition does not comply with 18.3.1 and 8.2.5.2 for a continuous enclosure of the shaft wall.

Based on observations, the facility failed to provide separation between hazardous areas and exit access corridors. This deficient practice could affect, patients, staff and visitors by allowing fire to spread beyond the hazardous areas with high fuel loads into patient areas and through corridors.

Findings include:

A. On 03/17/2015 at 2:40 PM while accompanied by the Vice President of Operations an observation determined that in the ground floor I.T. Computer area a Storage Room (containing cardboard and plastic combustibles in a quantity deemed hazardous) contained a door with a hold open device which does not comply with section 18.3.2.1 for a self closing door.

B. On 03/17/2015 at 2:44 PM while accompanied by the Vice President of Operations, the surveyor observed that a storage room (containing cardboard and plastic combustibles in a quantity deemed hazardous) located in the ground floor I.T. computer area contained a hole in the wall above the suspended ceiling and entry door. This condition does not comply with 18.3.2.1 for storage rooms larger than 100 square feet to have a minimum 1-hour fire rated enclosure.

C. On 03/16/2015 at 2:30pm while accompanied by the Vice President of Operations, the surveyor observed that the 5th floor means of egress corridors contained numerous alcoves used as storage for cushioned back chairs, cardboard boxes and beds with mattresses. This condition does not comply with 38.3.2.1, 8.4.1.2 and 8.2.4.1 for smoke proof enclosures with self closing doors.

D. On 03/16/2015 at 1:30pm while accompanied by the Vice President of Operations, the surveyor observed that a 5th floor means of egress corridor contained a 100 square foot space enclosed with partial height partitions being used as a pantry containing canned food, cardboard and plastic containers. This condition does not comply with 38.3.2.1, 8.4.1.2 and 8.2.4.1 for smoke proof enclosures with self closing doors.

Based on observation, not all means of egress are arranged so that exits are readily accessible at all times. This deficient practice affects all patients, staff, and visitors, by preventing those occupants from reaching an exit under fire conditions.

Findings include:

A. At 9:05AM on 03/17/2015,while accompanied by the Director of Plant Operations and Switchboard Supervisor, the surveyor observed on the Third Floor of the Med/Surg Unit, an exit sign above a pair of corridor doors 3480. The doors lead into the designated suite of rooms (identified as S1 on the facility ' s Life Safety Plan) which does not comply with 18.2.5.9 for corridor exiting without passing through a room.



20224


B At 2:20pm on 03/17/15 while accompanied by the Vice President of Operations the surveyor observed that the 1st floor Won door adjacent to Out Patient Entry marked as an available exit from the Public Waiting/Lobby was equipped with operating hardware ( push to open paddle). During a test of the fire alarm system it was observed that access to the operating hardware is obstructed by the balcony railing which does not comply with 7.2.1.5.1.

Based on observations the facility failed to provide a compliant components of a fire alarm system. This could affect patients, staff and visitors of the building if the fire alarm system does not operate during a fire emergency.

Findings include:

A. On 03/17/2015, at 2:30 PM during the fire alarm test the surveyor accompanied by the Assistant Director of Plant Operations, observed that the door operator on the cross corridor doors located at the entrance to OB did not drop out to a manual operation when the fire alarm system was activated to comply with section 7.2.1.9.1.

Based on observation components of the sprinkler system are not compliant. Failure to maintain the installation conditions can result in delayed response to a fire condition the sprinkler system is designed to control.

Findings include:

A. By direct observation at 9:00 a.m. on 3/17/15 while in the company of the Maintenance Technician, the surveyor finds the facility failed to install fire sprinkler protection in the 2nd floor phase 1 recovery (Bio-Hazard) Room 2174. (NFPA 13, 51, 1999, 5-1.1, (1).

B. By direct observation at 1:30pm on 3/17/15 while in the company of the Maintenance Technician, the surveyor finds the facility failed to install fire sprinkler protection under the first landing above the bottom of the stair shaft at the following location: (NFPA 13, 1999, 5-13.3.2)
Stairways #2, #3, #4, #5, & #6

Based on observation, the facility failed to keep the means of egress free of obstructions. This deficient practice could affect patients, staff, and visitors on the cited locations in the event of a fire emergency requiring egress or relocation.

Findings include:

A. At 10:30 AM on 03/17/2015, on the First floor, while accompanied by the switchboard supervisor the surveyor observed within the out patient prep/recovery, designated exit access corridors contain a patient weighing scale, a nurse computer and equipment being charged. These items partially block the required clear width of the corridors and do not comply with NFPA 101, Section 7.1.10.1.


20224


B. At 9:15AM on 03/17/2015, on the Second floor - prep/recovery, while accompanied by the director of plant operations, the surveyor observed designated exit access corridors which contain a patient weighing scale, and medical equipment plugged into the walls being charged, these items partially blocked the required clear width of the corridor and do not comply with 7.1.10.1.