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Based on observation, interview, and a review of facility flame spread documents, the facility did not provide room finishes with rated wall finishes. This deficiency occurred in 2 of the 14 smoke compartments, and had the potential to affect 16 of the 73 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/07/2011 at 11:40 am surveyor #12187 observed in the North Patient smoke compartment on the 2nd floor in the P.T. closet, that there was peg board mounted on the wall as a secondary finish and the facility could not confirm the peg bard had the appropriate finish rating. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

2. On 02/07/2011 at 2:55 pm surveyor #12187 observed in the north patient smoke compartment on the 2nd floor in room 2156, that the facility could not confirm the wall had an appropriate rating . The room wall was finished with wood on the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

3. On 02/08/2011 at 5:44 pm surveyor #12187 observed in the Atrium smoke compartment on the 1st floor in the chapel, that the facility could not confirm the wall had an appropriate rating. The room wall was finished with wood paneling on the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide corridor separation doors with doors with positive-latching hardware. This deficiency occurred in 4 of the 14 smoke compartments, and had the potential to affect 15 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/09/2011 at 10:38 am surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in the air compressor room, that the corridor door would not remain fully closed if a force of 5 lbs were applied to the latch edge of the door. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

2. On 02/07/2011 at 12:23 pm surveyor #12187 observed in the North Patient smoke compartment on the 2nd floor in the anti room to the isolation room, that the corridor door would not remain fully closed if a force of 5 lbs were applied to the latch edge of the door. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

3. On 02/08/2011 at 1:55 pm surveyor #12187 observed in the PACU smoke compartment on the 1st floor in rooms 1418 and 1308, that the corridor door would not remain fully closed if a force of 5 lbs were applied to the latch edge of the door. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

4. On 02/07/2011 at 3:00 pm surveyor #12187 observed in the north patient smoke compartment on the 2nd floor at back of the nurse station, that the corridor door would not positively self-latch when pushed to a closed position. The door slides and did not latch when the door was broken away. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

5. On 02/08/2011 at 4:55 pm surveyor #12187 observed in the Day Surgery smoke compartment on the 1st floor in room 1300B, that the corridor door would not remain fully closed if a force of 5 lbs were applied to the latch edge of the door. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

6. On 02/08/2011 at 5:39 pm surveyor #12187 observed in the Atrium smoke compartment on the 1st floor in the chapel, that the corridor door would not remain fully closed if a force of 5 lbs were applied to the latch edge of the door. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with rated wall construction, and sealed wall penetrations and did not have the windows in an atrium properly protected with sprinklers. This deficiency occurred in 5 of the 14 smoke compartments, and had the potential to affect all of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/07/2011 at 2:00 pm surveyor #12187 observed that all the windows on the 2nd floor "patient wing side" of the atrium wall which includes 8 patient rooms and several support rooms has venetian blinds that prevent the water from the sprinklers by the windows from fully covering the window with water. In addition, the windows on the "garden" side of the atrium that are at the same level as the atrium ( 3 rooms on the north side and 2 rooms on the south side) do not have sprinklers protecting the windows. This deficiency was observed and verified by surveyor 12187 and Staff L Maintenance Coordinator and Staff M, VP of Finance.

2. On 02/07/2011 at 2:10 pm surveyor #12187 observed in the South Patient smoke compartment on the 2nd floor in the S. E. Stairs, that penetrations were not sealed according to approved listed testing agency designs. The deficiency included conduits that were not fire caulked. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

3. On 02/08/2011 at 1:22 pm surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the room 1702, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because the top of the wall was stuffed with mineral wool and the bottom of the wall had damage to the dry wall. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide hold-open devices on doors in rated walls that included an adjacent smoke detector. This deficiency occurred in 1 of the 14 smoke compartments, and had the potential to affect 2 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 02/08/2011 at 2:39 pm surveyor #12187 observed in the Surgery smoke compartment on the 1st floor in the soiled utility room 1411, that the fire barrier door was magnetically held open and did not have a smoke detector. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations, and rated wall construction. This deficiency occurred in 14 of the 14 smoke compartments, and had the potential to affect all of the 73 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors. In further discussions with staff K, L, and M it was revealed that smoke barrier walls throughout the hospital were sealed on one side only. The following are examples of locations were smoke barriers were not properly rated.

FINDINGS INCLUDE:
1. On 02/07/2011 at 1:50 pm surveyor #12187 observed in the North Patient and atrium smoke compartment on the 2nd floor in the staff lounge on the north side of the atrium, that penetrations were not sealed according to approved listed testing agency designs. The deficiency included wires that penetrated the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

2. On 02/07/2011 at 2:00 pm surveyor #12187 observed in the all smoke compartment on the 2nd floor in the atrium, that the smoke barrier wall was not constructed to a one hour/ fire resistance rating /atrium "wet window" exception because it could not be verified that the windows glass is tempered, wired or laminated glass held in place by a gasket system that allows the glass framing to deflect without breaking (loading) the glass before the sprinklers operates per NFPA 101 8.2.5.6 exception. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

3. On 02/07/2011 at 4:30 pm surveyor #12187 observed in the ED smoke compartment on the 1st floor in the ED security room, that the smoke barrier wall was not constructed to a one hour fire resistance rating because the wall was not taped, dry wall was missing on the ceiling, holes were in the drywall, the electrical outlet boxes and med gas alarm panels exceed the 100 square inches in a 100 square feet requirement This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

4. On 02/08/2011 at 9:03 am surveyor #12187 observed in the ED smoke compartment on the 1st floor in the room 1806, that the smoke barrier wall was not constructed to a 1 hour fire resistance rating because there was two 2" by 4" holes in the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not enclose hazardous rooms with sealed wall penetrations, rated wall construction, closers on all doors, rated wall construction, rated doors, and closers on all doors. This deficiency occurred in 7 of the 14 smoke compartments, and had the potential to affect 5 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/07/2011 at 2:20 pm surveyor #12187 observed in the South Patient smoke compartment on the 2nd floor in the room 2141, that the door would not self-close because the door did not have a closer on it. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

2. On 02/07/2011 at 3:58 pm surveyor #12187 observed in the ICU smoke compartment on the 1st floor in the room 1510, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. Items include a cart full of clean linens, cart full of items stored in plastic and other plastic items. The door did not have a closer. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

3. On 02/08/2011 at 9:25 am surveyor #12187 observed in the ED smoke compartment on the 1st floor in the clean room by 1807, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. Items in the room include a cart full of clean linens, cart full of items stored in plastic and a shredder. The door did not have a closer. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

4. On 02/08/2011 at 10:10 am surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the file room 1923, that penetrations were not sealed according to approved listed testing agency design. The deficiency included wires that penetrated the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

5. On 02/08/2011 at 11:00 am surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the soiled utility room 1926, that a penetration was not sealed according to approved listed testing agency design. The deficiency included electrical wire that penetrated the rated wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

6. On 02/08/2011 at 11:45 am surveyor #12187 observed in the Cardiac/Nuclear Med smoke compartment on the 1st floor in the respiratory therapy room 1717, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. Items include 6 shelving units full of plastics. The door did not have a closer. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

7. On 02/08/2011 at 1:45 pm surveyor #12187 observed in the PACU smoke compartment on the 1st floor in the soiled utility room of the PACU, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. There is no door closer. Two conduits are not fire caulked. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

8. On 02/08/2011 at 1:50 pm surveyor #12187 observed in the PACU smoke compartment on the 1st floor in the clean work room 1419, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had 3 electrical panels in the wall that exceed the 100 square inches allowed of electrical box openings per 100 square feet of wall area. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

9. On 02/08/2011 at 2:50 pm surveyor #12187 observed in the Surgery smoke compartment on the 1st floor in the equipment room 1409, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had a 4" by 4" hole. In addition, 2 wire penetrations were not fire caulked. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

10. On 02/08/2011 at 5:55 pm surveyor #12187 observed in the Atrium smoke compartment on the 1st floor in the gift shop storage room (Office), that the door would not self-close because the door did not have a closer on it. The room was full of combustibles scattered about. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 and 18.3.6.3.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

11. On 02/09/2011 at 9:30 am surveyor #12187 observed in the material management smoke compartment on the Lower Level floor in room 0109, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had mineral wool at the top of the wall that was not rated for a 1 hour wall. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

12. On 02/09/2011 at 11:00 am surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in the Big Storage Room, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had mud missing on the dry wall screws and PVC pipe penetrations were not fire caulked. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

13. On 02/09/2011 at 11:56 am surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in the room 0029, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had mud missing on the dry wall screws and mineral wool was not rated at the top of the wall. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

14. On 02/09/2011 at 3:20 pm surveyor #12187 observed in the Lab smoke compartment on the Lower Level floor in the air handler room 0801, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had opening between the air handler room and the boiler room. The doors are not rated. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility failed to remove an abandoned electrical conduit which passed into the exit enclosure. This deficiency occurred in 3 of the 14 smoke compartments, and had the potential to affect 5 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.


FINDINGS INCLUDE:
On February 7, 2011 at 14:30 PM, surveyor # 12187 observed in south patient smoke compartment on the second floor at the south stairs that an abandon conduit passed through the stair wall. This deficiency was observed and verified by surveyor 12187 and Staff L Maintenance Coordinator and Staff M, VP of Finance.

Based on observation and interview, the facility did not provide egress paths at all times with a properly swinging door, obstructions, non-level walking surface at doorways, doors that were unlockable in the egress path, and door hardware that did not operate with a single release motion, the facility did not provide the proper exit distance out of suites, and facility did not provide paths out of rooms without going through a hazardous intervening room.

This deficiency occurred in 8 of the 14 smoke compartments, and had the potential to affect 20 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/08/2011 at 9:18 am surveyor #12187 observed in the ED smoke compartment on the 1st floor in the room 1806, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a red button on the wall adjacent to the door to release the magnetic lock and then another motion to push the door open. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

2. On 02/09/2011 at 9:22 am surveyor #12187 observed in the material management smoke compartment on the Lower Level floor in the room 0111, clean storage, that one or more doors swung outward into the exit path and obstructed the path because a cart blocks the door form opening all the way. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

3. On 02/08/2011 at 10:48 am surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the patient restrooms, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a red button on the wall adjacent to the door to release the magnetic lock and then another motion to push the door open. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

4. On 02/08/2011 at 11:30 am surveyor #12187 observed in the Cardiac/Nuclear Med smoke compartment on the 1st floor in the Bathroom 1708, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a red button on the wall adjacent to the door to release the magnetic lock and then another motion to push the door open. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

5. On 02/09/2011 at 12:20 pm surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in the room 0029, that the door could be locked from the egress side, preventing egress. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

6. On 02/07/2011 at 12:30 pm surveyor #12187 observed in the North Patient smoke compartment on the 2nd floor at the outside patio, that the exit path into the building dropped 8 inches to the floor. The floor level on both sides of an exit door are to remain at the same level. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.3, exception 2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

7. On 02/07/2011 at 3:59 pm surveyor #12187 observed in the ICU smoke compartment on the 1st floor in the six ICU rooms, that the door in the path of egress would not swing open when the door was closed. There is no handle to grab.. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

8. On 02/08/2011 at 5:20 pm surveyor #12187 observed in the Day Surgery smoke compartment on the 1st floor in the endoscope bathroom, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a red button on the wall adjacent to the door to release the magnetic lock and then another motion to push the door open. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

9. On 02/08/2011 at 6:10 pm surveyor #12187 observed in the OB smoke compartment on the 1st floor in the OB north exit, that the door was locked from the egress side. When the magnetic lock is engaged, the panic hardware on the door does not unlock the door. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

10. On 02/08/2011 at 6:20 pm surveyor #12187 observed in the OB smoke compartment on the 1st floor in the on-call toilet rooms, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a red button on the wall adjacent to the door to release the magnetic lock and then another motion to push the door open. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

11. On February 8, 2011 at 1:09 pm surveyor #12187 observed in the surgery smoke compartment on the first floor at room 1418, that the magnetic lock out of the room 1418 did not have both a manual release device located within 5 feet of the door and a sensor to open the door when a person approaches the door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator ).

12. On 02/08/2011 at 2:25 PM, surveyor #12187 observed in the OR suite that exit from the ORs is through the intervening room which is being used as a storage room. In an alcove, there is 2 storage carts of clean linens, a cart of plastic objects and shelving full of plastic objects. The intervening room is consider a hazardous room. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services), and staff L (Maintenance Coordinator)

13. On 02/10/2011 at 3:16 PM surveyor #12187 observed that the exit from the air handler room 0801 is through the boiler room, which is a hazardous intervening room due to the flame producing boilers. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), and staff L (Maintenance Coordinator).


14. On 02/08/2011 at 10:00 am surveyor #12187 observed in the ED smoke compartment on the 1st floor in the EMS back room, that the travel distance of 54 feet through (2) intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.5.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

15. On 02/09/2011 at 12:30 pm surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in the room 0029, that the travel distance of 110 feet through one intervening room. This exceeded the exit distance of 100 feet through 1 intervening room. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.5.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

16. On 02/08/2011 at 2:10 pm surveyor #12187 observed in the Surgery smoke compartment on the 1st floor in the room 4012 (OR 4), that the travel distance of 50 feet through (2) intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 3 of the 14 smoke compartments, and had the potential to affect 1 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/08/2011 at 11:15 am surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the MRI corridor, that the clear and unobstructed width of the corridor was seven feet. This corridor is a required patient corridor since there is no legal horizontal exit into the MOB. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.3. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). Corridors used only by others must be at least 44" wide. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

2. On 02/10/2011 at 11:30 am surveyor #12187 observed in the atrium smoke compartment on the Lower Level floor by column E6, that the clear and unobstructed width of the corridor was 7' 6" This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.3. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). Corridors used only by others must be at least 44" wide.. The condition was confirmed at the time of discovery by review of a previous waiver.

3. On 02/09/2011 at 12:25 pm surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in the room 0029, that the clear and unobstructed width of the passage cannot be maintained at 44 inches because there are movable storage files. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not ensure corridor doors were side-hinged and were the required clear width with the proper width of doors. This deficiency occurred in 1 of the 14 smoke compartments, and had the potential to affect 2 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 02/07/2011 at 4:05 pm surveyor #12187 observed in the ICU smoke compartment on the 1st floor in the ICU, that the exit doors to the outside used by inpatients was narrower than the required 41.5" minimum clear width. Doors to the exit at the south end of ICU were non-compliant. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

Based on observation and interview, the facility did not provide all spaces that can be exited without the use of a key or locked as permitted by the code, such as delayed egress with locks that release in less than 15 seconds. This deficiency occurred in 1 of the 14 smoke compartments, and had the potential to affect 4 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 02/08/2011 at 6:00 pm surveyor #12187 observed in the OB smoke compartment on the 1st floor at the OB south exit, that a delayed egress lock (DEL) did not release within 15 seconds of activation. It took 18 seconds until the door opened. In addition, the delayed egress doors did not have the required signage on the door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide and maintain emergency illumination of exit and directional signs with compliant sized lettering on "no-exit" signs, and exit signs when the egress path is not readily apparent. This deficiency occurred in 2 of the 14 smoke compartments, and had the potential to affect 1 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/08/2011 at 11:15 am surveyor #12187 observed in the Radiology smoke compartment on the 1st floor at the "horizontal exit into MOB", that the layout and lettering on the no exit sign did not meet the code requirements. There was no sign. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

2. On 02/09/2011 at 1:49 pm surveyor #12187 observed in the Atrium smoke compartment on the Lower Level floor in the Conference room A and B, that the path of egress in the room was not readily apparent and an exit sign was not provided near the door between conference room A and B (in the room divider). This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not maintain a written evacuation plan that contained all the elements with staff trained on life safety procedures. This deficiency occurred in all of the 14 smoke compartments, and had the potential to affect all of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1) On 02/09/2011 at 2:55 pm surveyor #12187 observed in the Pharmacy smoke compartment on the Lower Level floor in the Kitchen, that staff HH, cook, was not familiar with their responsibilities in the event of a fire, including where the fire extinguisher is located and where the pull for the kitchen hood was located. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.1.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).
2) On 02/07/2011 at 2:25 pm surveyor #12187 observed in the north patient smoke compartment on the 2nd floor, that staff II and JJ did not know the procedure as to who and when the oxygen supply to the zone should be shut off. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.1.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M (VP of Finance) and staff L (Maintenance Coordinator)

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with unobstructed water distribution, non-sprinkled rooms that met permitted exceptions , and sprinklers free of obstructions near the ceiling. This deficiency occurred in 14 of the 14 smoke compartments, and had the potential to affect all of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/09/2011 at 10:15 am surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in room 0505 Maintenance shop, that the discharge of sprinkler water was obstructed from reaching an unprotected area on the other side of a surface mounted light fixture. The light fixture was located 6 inches below the adjacent sprinkler deflector. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

2. On 02/09/2011 at 10:30 am surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in the electrical vault room, that the room was not sprinkler protected, although the entire facility was required to be sprinkled to meet a construction exception. The facility did not meet all the requirements of the code to avoid sprinkling the space. The room was enclosed with 2-hour rated construction, but the following was not provided. The mineral wool at the top of the wall was not listed for 2 hour wall and there was a 3 inch gap between the drywall and the fire insulated beam. On the other side of the 2 hour wall in the equipment room 0803, there are three 4 inch pipes running 3 feet in distance that displaces the drywall. This assembly is not a listed assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5.1 (exception). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

3. On 02/09/2011 at 12:41 pm surveyor #12187 observed in the Pharmacy smoke compartment on the Lower Level floor in rooms 0606 and 600, pharmacy, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included shelving in the middle of the room. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

4. On 02/08/2011 at 1:30 pm surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the corridor by room 1518, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included the Insty Med Machine. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

5. On 02/09/2011 at 2:30 pm surveyor #12187 observed in the Pharmacy smoke compartment on the Lower Level floor in the dry storage, room 0407A, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included shelving in the middle of the room. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).

6. On 02/08/2011 at 2:45 pm surveyor #12187 observed in the Surgery smoke compartment on the 1st floor in the equipment room 1409, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included racks in the middle of the room. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

7. On 02/08/2011 at 5:50 pm surveyor #12187 observed in the Atrium smoke compartment on the 1st floor in the gift shop, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included shelving in the middle of the room. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

8. On 02/09/2011 at 9:10 am surveyor #12187 observed in all smoke compartments on the Lower Level floor in the stairs, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side. The obstruction included the stairs. Water could not cover the entire floor area because the sprinkler was not at the same angle as the slanting stairs. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

9. On 02/09/2011 at 10:05 am surveyor #12187 observed in the Lab smoke compartment on the Lower Level floor in the Lab room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side. The obstruction included a column. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

10. On 02/08/2011 at 10:30 am surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the room 1901, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side. The obstruction included the fluoroscope. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide a proper ventilation system in accordance with manufacturer specifications and NFPA 90A. This deficiency occurred in 1 of the 14 smoke compartments, and had the potential to affect 2 of the 73 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 02/08/2011 at 11:25 am surveyor #12187 observed in the Cardiac/Nuclear Med smoke compartment on the 1st floor in the Injection room 1710, that airflow between the corridor and this room was not neutral because the injection room had only a supply grill and not a return or exhaust. This observed situation was not compliant with NFPA 101 (2000 edition), 18.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide a properly constructed kitchen extinguishing system as required by NFPA 96. This deficiency occurred in 1 of the 14 smoke compartments, and had the potential to affect none of the 73 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 02/09/2011 at 2:10 pm surveyor #12187 observed in the Pharmacy smoke compartment on the Lower Level floor in the Kitchen, that the kitchen hood did not have extinguisher nozzles above the grill and range. In addition, the grill and the plastic/fiberglass water softener were adjacent to each other. The natural gas shut off valve would not close due to the pipe blocking the handle. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.6, 9.2.3 and NFPA 96. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide and maintain properly sized linen/trash collection receptacles. This deficiency occurred in 5 of the 14 smoke compartments, and had the potential to affect 18 of the 73 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/07/2011 at 11:35 am surveyor #12187 observed in the North Patient smoke compartment on the 2nd floor in the patient room, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. In room 2008, there are two 32 gallon trash containers next to each other. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

2. On 02/08/2011 at 12:00 pm surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the decontamination room 1718 , that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. There are 2 sets of 32 gallon trash containers next to each other. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

3. On 02/07/2011 at 12:25 pm surveyor #12187 observed in the North Patient smoke compartment on the 2nd floor in the anti room to the isolation rooms, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. In the anti room, there are two 32 gallon trash containers next to each other. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

4. On 02/09/2011 at 12:45 pm surveyor #12187 observed in the Pharmacy smoke compartment on the Lower Level floor in the room 600, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. Two 32 gallon receptacles were located next to each other. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

5. On 02/09/2011 at 1:44 pm surveyor #12187 observed in the Atrium smoke compartment on the Lower Level floor in the Conference room A and B, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. Two sets of 32 gallon trash cans were next to each other at the exits of conference rooms A and B. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).

6. On 02/08/2011 at 2:23 pm surveyor #12187 observed in the Surgery smoke compartment on the 1st floor in the room 1404 (OR3) , that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. Two 40 gallon receptacles were located next to each other. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with separation of oxygen from combustibles. This deficiency occurred in 1 of the 14 smoke compartments, and had the potential to affect 2 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 02/08/2011 at 11:46 am surveyor #12187 observed in the Cardiac/Nuclear Med smoke compartment on the 1st floor in the respiratory therapy room 1717, that combustible materials were stored too close to the storage site of cylinders of oxygen. The 14 cylinders of oxygen were stored next to combustibles. This observed situation was not compliant with NFPA 99 (1999 edition), 4-3.1.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping. This deficiency occurred in 1 of the 14 smoke compartments, and had the potential to affect 15 of the 73 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 02/07/2011 at 2:45 pm surveyor #12187 observed in the north patient smoke compartment on the 2nd floor in the nurse station, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included the audio alarm did not sound when tested. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.4 and NFPA 99 (1999 edition), Chap 4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

Based on observation and interview, the facility failed to provide a critical branch receptacle in patient care areas who require life support and the facility did not provide the proper location of the emergency stop switch for the emergency generator. This deficiency occurred in all of the 14 smoke compartments, and had the potential to affect all of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
1. On 02/08/2011 at 10:20 am surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the 4 patient treatment rooms, other than MRI, that have patients with life support, that there was no critical branch electrical receptacle. This observed situation was not compliant with the code. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services), staff L (Maintenance Coordinator) and staff GG, Director of Radiology:
2. On 02/02/2011 at 4:47 PM surveyor #12187 observed in the Day Surgery Recovery rooms that there was no critical emergency power receptacles. This observed situation was not compliant with the code. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services), staff L (Maintenance Coordinator)

3. On 02/10/2011 at 11:20 am, surveyor #12187 observed that the emergency generator was not provided with a remote stop switch away from the generator. The remote stop switch was located inside of the enclosure. This observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

K130

Item #1
Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with sealed wall penetrations. This deficiency occurred in the medical office building and had the potential to affect an undetermined number of outpatients, inpatients, staff and visitors.

FINDINGS INCLUDE:
On 02/07/2011 at 11:30 am surveyor #12187 observed that penetrations in the Southwest stairwell of the medical office building at the 2nd floor were not sealed according to approved listed testing agency design. The deficiency included 4 conduits and 1 sprinkler pipe that was not fire caulked. In addition, drywall was missing such that the steel stud was visible. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

Item #2
Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with separation of oxygen from combustibles. This deficiency occurred in medical office building and had the potential to affect an undetermined number of outpatients, inpatients, staff and visitors.

FINDINGS INCLUDE:
On 02/10/2011 at 12:10 am surveyor #12187 observed that combustible materials were stored too close to the storage site of cylinders of oxygen. Ten cylinders of oxygen were stored next to cabinets full of combustibles in the rehab office off of the rehab gym. This observed situation was not compliant with NFPA 99 (1999 edition), 4-3.1.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).

Item #3
Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with the proper use of flexible cords. This deficiency occurred in the medical office building and had the potential to affect an undetermined number of outpatients, inpatients, staff and visitors.

FINDINGS INCLUDE:
a) On 02/10/2011 at 12:05 am surveyor #12187 observed that a flexible cord was used in a manner that is not permitted by the code. The cord was on the floor. A wheel chair was observed driving over the exposed cord. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).

b) On 02/10/2011 at 12:20 am surveyor #12187 observed that a flexible cord was used in a manner that is not permitted by the code. There is an extension cord to a light fixture in the audio booth instead of permanent wiring. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).

K130

The following items 1 through 7 affected all smoke compartments and all patients in the facility

Item #1
NFPA 101, 2000 edition, Chapter 8, Features of Fire Protection, 8.2.5.6 states "Unless prohibited by Chapters 12 through 42, an atrium shall be permitted, provided that the following conditions are met:
(1) In other than existing, previously approved atria, atriums are separated from the adjacent spaces by fire barriers with not less than a 1-hour fire resistance rating, with opening protectives for corridor walls. (See 8.2.3.2.3.1(2), exception No. 1)
..... Exception No. 2: Glass walls and inoperable windows, shall be permitted in lieu of the fire barriers where automatic sprinklers are spaced along both sides of the glass wall and the inoperable window at intervals not to exceed 6 ft (1.8 m). The automatic sprinklers shall be located at a distance from the glass not to exceed 1 ft. (0.3 m) and shall be arranged so that the entire surface of the glass is wet upon operation of the sprinklers. The glass shall be tempered, wired, or laminated glass held in place by a gasket system that allows the glass framing system to deflect without breaking (loading) the glass before the sprinklers operate. Automatic sprinklers shall not be required on the atrium side of the glass wall and the inoperable the windows where there is no walkway or other floor area on the atrium side above the main floor level. Doors in such walls shall be glass or other material that resists the passage of smoke. Doors shall be self-closing or automatic-closing upon the detection of smoke....."

Based on observation and interview, the facility did not have sprinkler coverage to wet the glass surfaces of the atrium windows.
FINDINGS INCLUDE:It was observed that all the windows on the 2nd floor "patient wing side" of the atrium wall which includes 8 patient rooms and several support rooms has venetian blinds that prevent the water from the sprinklers by the windows from fully covering the window with water. In addition, the windows on the "garden" side of the atrium that are at the same level as the atrium ( 3 rooms on the north side and 2 rooms on the south side) do not have sprinklers protecting the windows. This deficiency was observed and verified by surveyor 12187 and Staff L Maintenance Coordinator and Staff M, VP of Finance at 2:00 PM on February 7, 2011.

Item #2
NFPA 101, 2000 edition, Chapter 7, Means of Egress, 7.1.3.2.1 states "Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2.3 and the following. ... (e) penetrations into and openings through an exit enclosure assembly shall be prohibited except for the following: (1) Electrical conduit serving the stairway. ...."

Based on observation and interview, the facility failed to remove an abandoned electrical conduit which passed into the exit enclosure.

FINDINGS INCLUDE:
On February 7, 2011 at 14:30 PM, surveyor # 12187 observed in south patient smoke compartment on the second floor at the south stairs that an abandon conduit passed through the stair wall. This deficiency was observed and verified by surveyor 12187 and Staff L Maintenance Coordinator and Staff M, VP of Finance.


Item #3
NFPA 99, 1999 edition, Emergency Systems for 3-4.2.2.2(c) 3d "Selected acute nursing areas."; 3-4.2.2.2(c)8 "Postoperative recovery rooms (selected)"; and 3-4.2.2.2(c)9 "Additional task illumination, receptacles, and selected power circuits needed for effective facility operation."

Based on observation and interview, the facility failed to provide a critical branch receptacle in patient care areas who require life support.

Findings include:
a) On 02/08/2011 at 10:20 am surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the 4 patient treatment rooms, other than MRI, that have patients with life support, that there was no critical branch electrical receptacle. This observed situation was not compliant with the code. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services), staff L (Maintenance Coordinator) and staff GG, Director of Radiology:
b) On 02/02/2011 at 4:47 PM surveyor #12187 observed in the Day Surgery Recovery rooms that there was no critical emergency power receptacles. This observed situation was not compliant with the code. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services), staff L (Maintenance Coordinator)

Item #4
NFPA 101, 2000 edition, New Health Care 18.2.5.5 states "Intervening rooms shall not be hazardous areas as defined by 18.3.2.

Based on observation and interview, the facility did provided a path out of OR 1, OR 2, OR3 and OR 4 and air handler room 0801 without going through a hazardous intervening room.

Findings include:
a) On 02/08/2011 at 2:25 PM, surveyor #12187 observed in the OR suite that exit from the ORs is through the intervening room which is being used as a storage room. In an alcove, there is 2 storage carts of clean linens, a cart of plastic objects and shelving full of plastic objects. The intervening room is consider a hazardous room. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services), and staff L (Maintenance Coordinator)
b) On 02/10/2011 at 3:16 PM surveyor #12187 observed that the exit from the air handler room 0801 is through the boiler room, which is a hazardous intervening room due to the flame producing boilers. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), and staff L (Maintenance Coordinator).

Item #5
NFPA 14, 1996 edition, Installation of Standpipe and Hose Systems, 5-3.2 states "Class I Systems. Class I systems shall be provided with 2 1/2 inch (63.5-mm) hose connections in the following locations: ....
(b) On each side of the wall adjacent to the exit opening of horizontal exits.... "

Based on observation and interview, the facility did not provide 2 1/2 inch hose connections on each side of the wall adjacent to the exit opening of horizontal exits.

Findings include:
On 02/11/2011 at 10:30 AM, surveyor #12187 observed that the following horizontal exits did not have a 2 1/2 inch hose connection on each side of the horizontal exit: a) In the lower level, from the hospital to the MOB, b) 1st floor from hospital to the MOB by dialysis, and c) on the 2nd floor from the hospital to the MOB. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), and staff L (Maintenance Coordinator).

Item #6
NFPA 101, 2000 edition, new health care facilities, 18.2.5.8 states "Suites of rooms, other than patient sleeping rooms, shall be permitted to have one intervening room if the travel distance within the suite to the exit access door does not exceed 100 feet (30 m) and shall be permitted to have two intervening rooms where the travel distance within the suite to the exit access door does not exceed 50 ft (15 m).
Based on observation and interview, the facility did not provide the proper exit distance out of suites.

FINDINGS INCLUDE:
1. On 02/08/2011 at 10:00 am surveyor #12187 observed in the ED smoke compartment on the 1st floor in the EMS back room, that the travel distance of 54 feet through (2) intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.5.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

2. On 02/09/2011 at 12:30 pm surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in the room 0029, that the travel distance of 110 feet through one intervening room. This exceeded the exit distance of 100 feet through 1 intervening room. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.5.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

3. On 02/08/2011 at 2:10 pm surveyor #12187 observed in the Surgery smoke compartment on the 1st floor in the room 4012 (OR 4), that the travel distance of 50 feet through (2) intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Item #7
NFPA 110, 1999 edition, 3-5.5.6, states "All Level 1 and 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. "

Based on observation and interview, the facility did not provide the proper location of the emergency stop switch for the emergency generator.

FINDINGS INCLUDE:
On 02/10/2011 at 11:20 am, surveyor #12187 observed that the emergency generator was not provided with a remote stop switch away from the generator. The remote stop switch was located inside of the enclosure. This observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide liquid oxygen transfer space with rated doors. This deficiency occurred in 1 of the 14 smoke compartments, and had the potential to affect 15 of the 73 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 02/07/2011 at 12:10 pm surveyor #12187 observed in the North Patient smoke compartment on the 2nd floor in the P.T. closet, that the doors in the rated wall could not be verified of having at least a 45 minute rating. The room is used to transfer liquid oxygen from a 45 liter container to smaller containers on a average of at least once a day, according to staff LL. This observed situation was not compliant with NFPA 99 (1999 edition) 8-3.1.11.2(d) and 4-3.1.1.2(b)4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

Based on observation, interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes with derangement signals at a continuously monitored location. This deficiency occurred in all of the 14 smoke compartments, and had the potential to affect all of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 02/10/2011 at 11:00 am surveyor #12187 observed in all smoke compartments on the Lower Level floor in the outside generator, that audible and visual derangement signals were not located in continuously monitored location. The annunciator panel did not display the required alarms at the generator. This observed situation was not compliant with NFPA 99 (1999 edition), 3-4.1.1.15(b). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels, and fixed wiring rather than extension cords. This deficiency occurred in 4 of the 14 smoke compartments, and had the potential to affect 17 of the 73 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/09/2011 at 10:45 am surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in the air compress room, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a booster fan in the exhaust duct. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

2. On 02/08/2011 at 2:20 pm surveyor #12187 observed in the Surgery smoke compartment on the 1st floor in room 1404 (OR 3) and room 1412 (OR 4), that access to electrical panel was less than 3'-0" clearance. A cart was obstructing the access to the panel. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

3. On 02/07/2011 at 2:50 pm surveyor #12187 observed in the north patient smoke compartment on the 2nd floor in room 2152, that access to electrical panel was less than 3'-0" clearance. The Pixus machine blocked assess to the electrical panel. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

4. On 02/08/2011 at 3:07 pm surveyor #12187 observed in the Sterile Supply smoke compartment on the Lower Level floor in room 090, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to PCA pain machines This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

5. On 02/08/2011 at 5:00 pm surveyor #12187 observed in the Day Surgery smoke compartment on the 1st floor in the room 1324A, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to surgical clippers in staff work room. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation, interview, and a review of facility flame spread documents, the facility did not provide room finishes with rated wall finishes. This deficiency occurred in 2 of the 14 smoke compartments, and had the potential to affect 16 of the 73 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/07/2011 at 11:40 am surveyor #12187 observed in the North Patient smoke compartment on the 2nd floor in the P.T. closet, that there was peg board mounted on the wall as a secondary finish and the facility could not confirm the peg bard had the appropriate finish rating. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

2. On 02/07/2011 at 2:55 pm surveyor #12187 observed in the north patient smoke compartment on the 2nd floor in room 2156, that the facility could not confirm the wall had an appropriate rating . The room wall was finished with wood on the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

3. On 02/08/2011 at 5:44 pm surveyor #12187 observed in the Atrium smoke compartment on the 1st floor in the chapel, that the facility could not confirm the wall had an appropriate rating. The room wall was finished with wood paneling on the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide corridor separation doors with doors with positive-latching hardware. This deficiency occurred in 4 of the 14 smoke compartments, and had the potential to affect 15 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/09/2011 at 10:38 am surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in the air compressor room, that the corridor door would not remain fully closed if a force of 5 lbs were applied to the latch edge of the door. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

2. On 02/07/2011 at 12:23 pm surveyor #12187 observed in the North Patient smoke compartment on the 2nd floor in the anti room to the isolation room, that the corridor door would not remain fully closed if a force of 5 lbs were applied to the latch edge of the door. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

3. On 02/08/2011 at 1:55 pm surveyor #12187 observed in the PACU smoke compartment on the 1st floor in rooms 1418 and 1308, that the corridor door would not remain fully closed if a force of 5 lbs were applied to the latch edge of the door. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

4. On 02/07/2011 at 3:00 pm surveyor #12187 observed in the north patient smoke compartment on the 2nd floor at back of the nurse station, that the corridor door would not positively self-latch when pushed to a closed position. The door slides and did not latch when the door was broken away. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

5. On 02/08/2011 at 4:55 pm surveyor #12187 observed in the Day Surgery smoke compartment on the 1st floor in room 1300B, that the corridor door would not remain fully closed if a force of 5 lbs were applied to the latch edge of the door. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

6. On 02/08/2011 at 5:39 pm surveyor #12187 observed in the Atrium smoke compartment on the 1st floor in the chapel, that the corridor door would not remain fully closed if a force of 5 lbs were applied to the latch edge of the door. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with rated wall construction, and sealed wall penetrations and did not have the windows in an atrium properly protected with sprinklers. This deficiency occurred in 5 of the 14 smoke compartments, and had the potential to affect all of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/07/2011 at 2:00 pm surveyor #12187 observed that all the windows on the 2nd floor "patient wing side" of the atrium wall which includes 8 patient rooms and several support rooms has venetian blinds that prevent the water from the sprinklers by the windows from fully covering the window with water. In addition, the windows on the "garden" side of the atrium that are at the same level as the atrium ( 3 rooms on the north side and 2 rooms on the south side) do not have sprinklers protecting the windows. This deficiency was observed and verified by surveyor 12187 and Staff L Maintenance Coordinator and Staff M, VP of Finance.

2. On 02/07/2011 at 2:10 pm surveyor #12187 observed in the South Patient smoke compartment on the 2nd floor in the S. E. Stairs, that penetrations were not sealed according to approved listed testing agency designs. The deficiency included conduits that were not fire caulked. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

3. On 02/08/2011 at 1:22 pm surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the room 1702, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because the top of the wall was stuffed with mineral wool and the bottom of the wall had damage to the dry wall. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide hold-open devices on doors in rated walls that included an adjacent smoke detector. This deficiency occurred in 1 of the 14 smoke compartments, and had the potential to affect 2 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 02/08/2011 at 2:39 pm surveyor #12187 observed in the Surgery smoke compartment on the 1st floor in the soiled utility room 1411, that the fire barrier door was magnetically held open and did not have a smoke detector. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations, and rated wall construction. This deficiency occurred in 14 of the 14 smoke compartments, and had the potential to affect all of the 73 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors. In further discussions with staff K, L, and M it was revealed that smoke barrier walls throughout the hospital were sealed on one side only. The following are examples of locations were smoke barriers were not properly rated.

FINDINGS INCLUDE:
1. On 02/07/2011 at 1:50 pm surveyor #12187 observed in the North Patient and atrium smoke compartment on the 2nd floor in the staff lounge on the north side of the atrium, that penetrations were not sealed according to approved listed testing agency designs. The deficiency included wires that penetrated the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

2. On 02/07/2011 at 2:00 pm surveyor #12187 observed in the all smoke compartment on the 2nd floor in the atrium, that the smoke barrier wall was not constructed to a one hour/ fire resistance rating /atrium "wet window" exception because it could not be verified that the windows glass is tempered, wired or laminated glass held in place by a gasket system that allows the glass framing to deflect without breaking (loading) the glass before the sprinklers operates per NFPA 101 8.2.5.6 exception. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

3. On 02/07/2011 at 4:30 pm surveyor #12187 observed in the ED smoke compartment on the 1st floor in the ED security room, that the smoke barrier wall was not constructed to a one hour fire resistance rating because the wall was not taped, dry wall was missing on the ceiling, holes were in the drywall, the electrical outlet boxes and med gas alarm panels exceed the 100 square inches in a 100 square feet requirement This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

4. On 02/08/2011 at 9:03 am surveyor #12187 observed in the ED smoke compartment on the 1st floor in the room 1806, that the smoke barrier wall was not constructed to a 1 hour fire resistance rating because there was two 2" by 4" holes in the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not enclose hazardous rooms with sealed wall penetrations, rated wall construction, closers on all doors, rated wall construction, rated doors, and closers on all doors. This deficiency occurred in 7 of the 14 smoke compartments, and had the potential to affect 5 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/07/2011 at 2:20 pm surveyor #12187 observed in the South Patient smoke compartment on the 2nd floor in the room 2141, that the door would not self-close because the door did not have a closer on it. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

2. On 02/07/2011 at 3:58 pm surveyor #12187 observed in the ICU smoke compartment on the 1st floor in the room 1510, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. Items include a cart full of clean linens, cart full of items stored in plastic and other plastic items. The door did not have a closer. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

3. On 02/08/2011 at 9:25 am surveyor #12187 observed in the ED smoke compartment on the 1st floor in the clean room by 1807, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. Items in the room include a cart full of clean linens, cart full of items stored in plastic and a shredder. The door did not have a closer. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

4. On 02/08/2011 at 10:10 am surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the file room 1923, that penetrations were not sealed according to approved listed testing agency design. The deficiency included wires that penetrated the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

5. On 02/08/2011 at 11:00 am surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the soiled utility room 1926, that a penetration was not sealed according to approved listed testing agency design. The deficiency included electrical wire that penetrated the rated wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

6. On 02/08/2011 at 11:45 am surveyor #12187 observed in the Cardiac/Nuclear Med smoke compartment on the 1st floor in the respiratory therapy room 1717, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. Items include 6 shelving units full of plastics. The door did not have a closer. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

7. On 02/08/2011 at 1:45 pm surveyor #12187 observed in the PACU smoke compartment on the 1st floor in the soiled utility room of the PACU, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. There is no door closer. Two conduits are not fire caulked. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

8. On 02/08/2011 at 1:50 pm surveyor #12187 observed in the PACU smoke compartment on the 1st floor in the clean work room 1419, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had 3 electrical panels in the wall that exceed the 100 square inches allowed of electrical box openings per 100 square feet of wall area. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

9. On 02/08/2011 at 2:50 pm surveyor #12187 observed in the Surgery smoke compartment on the 1st floor in the equipment room 1409, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had a 4" by 4" hole. In addition, 2 wire penetrations were not fire caulked. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

10. On 02/08/2011 at 5:55 pm surveyor #12187 observed in the Atrium smoke compartment on the 1st floor in the gift shop storage room (Office), that the door would not self-close because the door did not have a closer on it. The room was full of combustibles scattered about. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 and 18.3.6.3.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

11. On 02/09/2011 at 9:30 am surveyor #12187 observed in the material management smoke compartment on the Lower Level floor in room 0109, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had mineral wool at the top of the wall that was not rated for a 1 hour wall. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

12. On 02/09/2011 at 11:00 am surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in the Big Storage Room, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had mud missing on the dry wall screws and PVC pipe penetrations were not fire caulked. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

13. On 02/09/2011 at 11:56 am surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in the room 0029, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had mud missing on the dry wall screws and mineral wool was not rated at the top of the wall. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

14. On 02/09/2011 at 3:20 pm surveyor #12187 observed in the Lab smoke compartment on the Lower Level floor in the air handler room 0801, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had opening between the air handler room and the boiler room. The doors are not rated. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility failed to remove an abandoned electrical conduit which passed into the exit enclosure. This deficiency occurred in 3 of the 14 smoke compartments, and had the potential to affect 5 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.


FINDINGS INCLUDE:
On February 7, 2011 at 14:30 PM, surveyor # 12187 observed in south patient smoke compartment on the second floor at the south stairs that an abandon conduit passed through the stair wall. This deficiency was observed and verified by surveyor 12187 and Staff L Maintenance Coordinator and Staff M, VP of Finance.

Based on observation and interview, the facility did not provide egress paths at all times with a properly swinging door, obstructions, non-level walking surface at doorways, doors that were unlockable in the egress path, and door hardware that did not operate with a single release motion, the facility did not provide the proper exit distance out of suites, and facility did not provide paths out of rooms without going through a hazardous intervening room.

This deficiency occurred in 8 of the 14 smoke compartments, and had the potential to affect 20 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/08/2011 at 9:18 am surveyor #12187 observed in the ED smoke compartment on the 1st floor in the room 1806, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a red button on the wall adjacent to the door to release the magnetic lock and then another motion to push the door open. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

2. On 02/09/2011 at 9:22 am surveyor #12187 observed in the material management smoke compartment on the Lower Level floor in the room 0111, clean storage, that one or more doors swung outward into the exit path and obstructed the path because a cart blocks the door form opening all the way. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

3. On 02/08/2011 at 10:48 am surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the patient restrooms, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a red button on the wall adjacent to the door to release the magnetic lock and then another motion to push the door open. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

4. On 02/08/2011 at 11:30 am surveyor #12187 observed in the Cardiac/Nuclear Med smoke compartment on the 1st floor in the Bathroom 1708, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a red button on the wall adjacent to the door to release the magnetic lock and then another motion to push the door open. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

5. On 02/09/2011 at 12:20 pm surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in the room 0029, that the door could be locked from the egress side, preventing egress. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

6. On 02/07/2011 at 12:30 pm surveyor #12187 observed in the North Patient smoke compartment on the 2nd floor at the outside patio, that the exit path into the building dropped 8 inches to the floor. The floor level on both sides of an exit door are to remain at the same level. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.3, exception 2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

7. On 02/07/2011 at 3:59 pm surveyor #12187 observed in the ICU smoke compartment on the 1st floor in the six ICU rooms, that the door in the path of egress would not swing open when the door was closed. There is no handle to grab.. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

8. On 02/08/2011 at 5:20 pm surveyor #12187 observed in the Day Surgery smoke compartment on the 1st floor in the endoscope bathroom, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a red button on the wall adjacent to the door to release the magnetic lock and then another motion to push the door open. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

9. On 02/08/2011 at 6:10 pm surveyor #12187 observed in the OB smoke compartment on the 1st floor in the OB north exit, that the door was locked from the egress side. When the magnetic lock is engaged, the panic hardware on the door does not unlock the door. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

10. On 02/08/2011 at 6:20 pm surveyor #12187 observed in the OB smoke compartment on the 1st floor in the on-call toilet rooms, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a red button on the wall adjacent to the door to release the magnetic lock and then another motion to push the door open. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

11. On February 8, 2011 at 1:09 pm surveyor #12187 observed in the surgery smoke compartment on the first floor at room 1418, that the magnetic lock out of the room 1418 did not have both a manual release device located within 5 feet of the door and a sensor to open the door when a person approaches the door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator ).

12. On 02/08/2011 at 2:25 PM, surveyor #12187 observed in the OR suite that exit from the ORs is through the intervening room which is being used as a storage room. In an alcove, there is 2 storage carts of clean linens, a cart of plastic objects and shelving full of plastic objects. The intervening room is consider a hazardous room. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services), and staff L (Maintenance Coordinator)

13. On 02/10/2011 at 3:16 PM surveyor #12187 observed that the exit from the air handler room 0801 is through the boiler room, which is a hazardous intervening room due to the flame producing boilers. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), and staff L (Maintenance Coordinator).


14. On 02/08/2011 at 10:00 am surveyor #12187 observed in the ED smoke compartment on the 1st floor in the EMS back room, that the travel distance of 54 feet through (2) intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.5.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

15. On 02/09/2011 at 12:30 pm surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in the room 0029, that the travel distance of 110 feet through one intervening room. This exceeded the exit distance of 100 feet through 1 intervening room. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.5.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

16. On 02/08/2011 at 2:10 pm surveyor #12187 observed in the Surgery smoke compartment on the 1st floor in the room 4012 (OR 4), that the travel distance of 50 feet through (2) intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 3 of the 14 smoke compartments, and had the potential to affect 1 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/08/2011 at 11:15 am surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the MRI corridor, that the clear and unobstructed width of the corridor was seven feet. This corridor is a required patient corridor since there is no legal horizontal exit into the MOB. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.3. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). Corridors used only by others must be at least 44" wide. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

2. On 02/10/2011 at 11:30 am surveyor #12187 observed in the atrium smoke compartment on the Lower Level floor by column E6, that the clear and unobstructed width of the corridor was 7' 6" This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.3. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). Corridors used only by others must be at least 44" wide.. The condition was confirmed at the time of discovery by review of a previous waiver.

3. On 02/09/2011 at 12:25 pm surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in the room 0029, that the clear and unobstructed width of the passage cannot be maintained at 44 inches because there are movable storage files. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not ensure corridor doors were side-hinged and were the required clear width with the proper width of doors. This deficiency occurred in 1 of the 14 smoke compartments, and had the potential to affect 2 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 02/07/2011 at 4:05 pm surveyor #12187 observed in the ICU smoke compartment on the 1st floor in the ICU, that the exit doors to the outside used by inpatients was narrower than the required 41.5" minimum clear width. Doors to the exit at the south end of ICU were non-compliant. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

Based on observation and interview, the facility did not provide all spaces that can be exited without the use of a key or locked as permitted by the code, such as delayed egress with locks that release in less than 15 seconds. This deficiency occurred in 1 of the 14 smoke compartments, and had the potential to affect 4 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 02/08/2011 at 6:00 pm surveyor #12187 observed in the OB smoke compartment on the 1st floor at the OB south exit, that a delayed egress lock (DEL) did not release within 15 seconds of activation. It took 18 seconds until the door opened. In addition, the delayed egress doors did not have the required signage on the door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide and maintain emergency illumination of exit and directional signs with compliant sized lettering on "no-exit" signs, and exit signs when the egress path is not readily apparent. This deficiency occurred in 2 of the 14 smoke compartments, and had the potential to affect 1 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/08/2011 at 11:15 am surveyor #12187 observed in the Radiology smoke compartment on the 1st floor at the "horizontal exit into MOB", that the layout and lettering on the no exit sign did not meet the code requirements. There was no sign. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

2. On 02/09/2011 at 1:49 pm surveyor #12187 observed in the Atrium smoke compartment on the Lower Level floor in the Conference room A and B, that the path of egress in the room was not readily apparent and an exit sign was not provided near the door between conference room A and B (in the room divider). This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not maintain a written evacuation plan that contained all the elements with staff trained on life safety procedures. This deficiency occurred in all of the 14 smoke compartments, and had the potential to affect all of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1) On 02/09/2011 at 2:55 pm surveyor #12187 observed in the Pharmacy smoke compartment on the Lower Level floor in the Kitchen, that staff HH, cook, was not familiar with their responsibilities in the event of a fire, including where the fire extinguisher is located and where the pull for the kitchen hood was located. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.1.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).
2) On 02/07/2011 at 2:25 pm surveyor #12187 observed in the north patient smoke compartment on the 2nd floor, that staff II and JJ did not know the procedure as to who and when the oxygen supply to the zone should be shut off. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.1.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M (VP of Finance) and staff L (Maintenance Coordinator)

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with unobstructed water distribution, non-sprinkled rooms that met permitted exceptions , and sprinklers free of obstructions near the ceiling. This deficiency occurred in 14 of the 14 smoke compartments, and had the potential to affect all of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/09/2011 at 10:15 am surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in room 0505 Maintenance shop, that the discharge of sprinkler water was obstructed from reaching an unprotected area on the other side of a surface mounted light fixture. The light fixture was located 6 inches below the adjacent sprinkler deflector. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

2. On 02/09/2011 at 10:30 am surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in the electrical vault room, that the room was not sprinkler protected, although the entire facility was required to be sprinkled to meet a construction exception. The facility did not meet all the requirements of the code to avoid sprinkling the space. The room was enclosed with 2-hour rated construction, but the following was not provided. The mineral wool at the top of the wall was not listed for 2 hour wall and there was a 3 inch gap between the drywall and the fire insulated beam. On the other side of the 2 hour wall in the equipment room 0803, there are three 4 inch pipes running 3 feet in distance that displaces the drywall. This assembly is not a listed assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5.1 (exception). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

3. On 02/09/2011 at 12:41 pm surveyor #12187 observed in the Pharmacy smoke compartment on the Lower Level floor in rooms 0606 and 600, pharmacy, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included shelving in the middle of the room. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

4. On 02/08/2011 at 1:30 pm surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the corridor by room 1518, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included the Insty Med Machine. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

5. On 02/09/2011 at 2:30 pm surveyor #12187 observed in the Pharmacy smoke compartment on the Lower Level floor in the dry storage, room 0407A, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included shelving in the middle of the room. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).

6. On 02/08/2011 at 2:45 pm surveyor #12187 observed in the Surgery smoke compartment on the 1st floor in the equipment room 1409, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included racks in the middle of the room. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

7. On 02/08/2011 at 5:50 pm surveyor #12187 observed in the Atrium smoke compartment on the 1st floor in the gift shop, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included shelving in the middle of the room. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

8. On 02/09/2011 at 9:10 am surveyor #12187 observed in all smoke compartments on the Lower Level floor in the stairs, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side. The obstruction included the stairs. Water could not cover the entire floor area because the sprinkler was not at the same angle as the slanting stairs. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

9. On 02/09/2011 at 10:05 am surveyor #12187 observed in the Lab smoke compartment on the Lower Level floor in the Lab room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side. The obstruction included a column. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

10. On 02/08/2011 at 10:30 am surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the room 1901, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side. The obstruction included the fluoroscope. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide a proper ventilation system in accordance with manufacturer specifications and NFPA 90A. This deficiency occurred in 1 of the 14 smoke compartments, and had the potential to affect 2 of the 73 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 02/08/2011 at 11:25 am surveyor #12187 observed in the Cardiac/Nuclear Med smoke compartment on the 1st floor in the Injection room 1710, that airflow between the corridor and this room was not neutral because the injection room had only a supply grill and not a return or exhaust. This observed situation was not compliant with NFPA 101 (2000 edition), 18.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide a properly constructed kitchen extinguishing system as required by NFPA 96. This deficiency occurred in 1 of the 14 smoke compartments, and had the potential to affect none of the 73 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 02/09/2011 at 2:10 pm surveyor #12187 observed in the Pharmacy smoke compartment on the Lower Level floor in the Kitchen, that the kitchen hood did not have extinguisher nozzles above the grill and range. In addition, the grill and the plastic/fiberglass water softener were adjacent to each other. The natural gas shut off valve would not close due to the pipe blocking the handle. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.6, 9.2.3 and NFPA 96. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide and maintain properly sized linen/trash collection receptacles. This deficiency occurred in 5 of the 14 smoke compartments, and had the potential to affect 18 of the 73 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/07/2011 at 11:35 am surveyor #12187 observed in the North Patient smoke compartment on the 2nd floor in the patient room, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. In room 2008, there are two 32 gallon trash containers next to each other. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

2. On 02/08/2011 at 12:00 pm surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the decontamination room 1718 , that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. There are 2 sets of 32 gallon trash containers next to each other. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

3. On 02/07/2011 at 12:25 pm surveyor #12187 observed in the North Patient smoke compartment on the 2nd floor in the anti room to the isolation rooms, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. In the anti room, there are two 32 gallon trash containers next to each other. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

4. On 02/09/2011 at 12:45 pm surveyor #12187 observed in the Pharmacy smoke compartment on the Lower Level floor in the room 600, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. Two 32 gallon receptacles were located next to each other. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

5. On 02/09/2011 at 1:44 pm surveyor #12187 observed in the Atrium smoke compartment on the Lower Level floor in the Conference room A and B, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. Two sets of 32 gallon trash cans were next to each other at the exits of conference rooms A and B. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).

6. On 02/08/2011 at 2:23 pm surveyor #12187 observed in the Surgery smoke compartment on the 1st floor in the room 1404 (OR3) , that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. Two 40 gallon receptacles were located next to each other. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with separation of oxygen from combustibles. This deficiency occurred in 1 of the 14 smoke compartments, and had the potential to affect 2 of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 02/08/2011 at 11:46 am surveyor #12187 observed in the Cardiac/Nuclear Med smoke compartment on the 1st floor in the respiratory therapy room 1717, that combustible materials were stored too close to the storage site of cylinders of oxygen. The 14 cylinders of oxygen were stored next to combustibles. This observed situation was not compliant with NFPA 99 (1999 edition), 4-3.1.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping. This deficiency occurred in 1 of the 14 smoke compartments, and had the potential to affect 15 of the 73 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 02/07/2011 at 2:45 pm surveyor #12187 observed in the north patient smoke compartment on the 2nd floor in the nurse station, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included the audio alarm did not sound when tested. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.4 and NFPA 99 (1999 edition), Chap 4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

Based on observation and interview, the facility failed to provide a critical branch receptacle in patient care areas who require life support and the facility did not provide the proper location of the emergency stop switch for the emergency generator. This deficiency occurred in all of the 14 smoke compartments, and had the potential to affect all of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
1. On 02/08/2011 at 10:20 am surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the 4 patient treatment rooms, other than MRI, that have patients with life support, that there was no critical branch electrical receptacle. This observed situation was not compliant with the code. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services), staff L (Maintenance Coordinator) and staff GG, Director of Radiology:
2. On 02/02/2011 at 4:47 PM surveyor #12187 observed in the Day Surgery Recovery rooms that there was no critical emergency power receptacles. This observed situation was not compliant with the code. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services), staff L (Maintenance Coordinator)

3. On 02/10/2011 at 11:20 am, surveyor #12187 observed that the emergency generator was not provided with a remote stop switch away from the generator. The remote stop switch was located inside of the enclosure. This observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

K130

Item #1
Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with sealed wall penetrations. This deficiency occurred in the medical office building and had the potential to affect an undetermined number of outpatients, inpatients, staff and visitors.

FINDINGS INCLUDE:
On 02/07/2011 at 11:30 am surveyor #12187 observed that penetrations in the Southwest stairwell of the medical office building at the 2nd floor were not sealed according to approved listed testing agency design. The deficiency included 4 conduits and 1 sprinkler pipe that was not fire caulked. In addition, drywall was missing such that the steel stud was visible. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

Item #2
Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with separation of oxygen from combustibles. This deficiency occurred in medical office building and had the potential to affect an undetermined number of outpatients, inpatients, staff and visitors.

FINDINGS INCLUDE:
On 02/10/2011 at 12:10 am surveyor #12187 observed that combustible materials were stored too close to the storage site of cylinders of oxygen. Ten cylinders of oxygen were stored next to cabinets full of combustibles in the rehab office off of the rehab gym. This observed situation was not compliant with NFPA 99 (1999 edition), 4-3.1.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).

Item #3
Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with the proper use of flexible cords. This deficiency occurred in the medical office building and had the potential to affect an undetermined number of outpatients, inpatients, staff and visitors.

FINDINGS INCLUDE:
a) On 02/10/2011 at 12:05 am surveyor #12187 observed that a flexible cord was used in a manner that is not permitted by the code. The cord was on the floor. A wheel chair was observed driving over the exposed cord. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).

b) On 02/10/2011 at 12:20 am surveyor #12187 observed that a flexible cord was used in a manner that is not permitted by the code. There is an extension cord to a light fixture in the audio booth instead of permanent wiring. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).

K130

The following items 1 through 7 affected all smoke compartments and all patients in the facility

Item #1
NFPA 101, 2000 edition, Chapter 8, Features of Fire Protection, 8.2.5.6 states "Unless prohibited by Chapters 12 through 42, an atrium shall be permitted, provided that the following conditions are met:
(1) In other than existing, previously approved atria, atriums are separated from the adjacent spaces by fire barriers with not less than a 1-hour fire resistance rating, with opening protectives for corridor walls. (See 8.2.3.2.3.1(2), exception No. 1)
..... Exception No. 2: Glass walls and inoperable windows, shall be permitted in lieu of the fire barriers where automatic sprinklers are spaced along both sides of the glass wall and the inoperable window at intervals not to exceed 6 ft (1.8 m). The automatic sprinklers shall be located at a distance from the glass not to exceed 1 ft. (0.3 m) and shall be arranged so that the entire surface of the glass is wet upon operation of the sprinklers. The glass shall be tempered, wired, or laminated glass held in place by a gasket system that allows the glass framing system to deflect without breaking (loading) the glass before the sprinklers operate. Automatic sprinklers shall not be required on the atrium side of the glass wall and the inoperable the windows where there is no walkway or other floor area on the atrium side above the main floor level. Doors in such walls shall be glass or other material that resists the passage of smoke. Doors shall be self-closing or automatic-closing upon the detection of smoke....."

Based on observation and interview, the facility did not have sprinkler coverage to wet the glass surfaces of the atrium windows.
FINDINGS INCLUDE:It was observed that all the windows on the 2nd floor "patient wing side" of the atrium wall which includes 8 patient rooms and several support rooms has venetian blinds that prevent the water from the sprinklers by the windows from fully covering the window with water. In addition, the windows on the "garden" side of the atrium that are at the same level as the atrium ( 3 rooms on the north side and 2 rooms on the south side) do not have sprinklers protecting the windows. This deficiency was observed and verified by surveyor 12187 and Staff L Maintenance Coordinator and Staff M, VP of Finance at 2:00 PM on February 7, 2011.

Item #2
NFPA 101, 2000 edition, Chapter 7, Means of Egress, 7.1.3.2.1 states "Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2.3 and the following. ... (e) penetrations into and openings through an exit enclosure assembly shall be prohibited except for the following: (1) Electrical conduit serving the stairway. ...."

Based on observation and interview, the facility failed to remove an abandoned electrical conduit which passed into the exit enclosure.

FINDINGS INCLUDE:
On February 7, 2011 at 14:30 PM, surveyor # 12187 observed in south patient smoke compartment on the second floor at the south stairs that an abandon conduit passed through the stair wall. This deficiency was observed and verified by surveyor 12187 and Staff L Maintenance Coordinator and Staff M, VP of Finance.


Item #3
NFPA 99, 1999 edition, Emergency Systems for 3-4.2.2.2(c) 3d "Selected acute nursing areas."; 3-4.2.2.2(c)8 "Postoperative recovery rooms (selected)"; and 3-4.2.2.2(c)9 "Additional task illumination, receptacles, and selected power circuits needed for effective facility operation."

Based on observation and interview, the facility failed to provide a critical branch receptacle in patient care areas who require life support.

Findings include:
a) On 02/08/2011 at 10:20 am surveyor #12187 observed in the Radiology smoke compartment on the 1st floor in the 4 patient treatment rooms, other than MRI, that have patients with life support, that there was no critical branch electrical receptacle. This observed situation was not compliant with the code. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services), staff L (Maintenance Coordinator) and staff GG, Director of Radiology:
b) On 02/02/2011 at 4:47 PM surveyor #12187 observed in the Day Surgery Recovery rooms that there was no critical emergency power receptacles. This observed situation was not compliant with the code. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services), staff L (Maintenance Coordinator)

Item #4
NFPA 101, 2000 edition, New Health Care 18.2.5.5 states "Intervening rooms shall not be hazardous areas as defined by 18.3.2.

Based on observation and interview, the facility did provided a path out of OR 1, OR 2, OR3 and OR 4 and air handler room 0801 without going through a hazardous intervening room.

Findings include:
a) On 02/08/2011 at 2:25 PM, surveyor #12187 observed in the OR suite that exit from the ORs is through the intervening room which is being used as a storage room. In an alcove, there is 2 storage carts of clean linens, a cart of plastic objects and shelving full of plastic objects. The intervening room is consider a hazardous room. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services), and staff L (Maintenance Coordinator)
b) On 02/10/2011 at 3:16 PM surveyor #12187 observed that the exit from the air handler room 0801 is through the boiler room, which is a hazardous intervening room due to the flame producing boilers. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), and staff L (Maintenance Coordinator).

Item #5
NFPA 14, 1996 edition, Installation of Standpipe and Hose Systems, 5-3.2 states "Class I Systems. Class I systems shall be provided with 2 1/2 inch (63.5-mm) hose connections in the following locations: ....
(b) On each side of the wall adjacent to the exit opening of horizontal exits.... "

Based on observation and interview, the facility did not provide 2 1/2 inch hose connections on each side of the wall adjacent to the exit opening of horizontal exits.

Findings include:
On 02/11/2011 at 10:30 AM, surveyor #12187 observed that the following horizontal exits did not have a 2 1/2 inch hose connection on each side of the horizontal exit: a) In the lower level, from the hospital to the MOB, b) 1st floor from hospital to the MOB by dialysis, and c) on the 2nd floor from the hospital to the MOB. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), and staff L (Maintenance Coordinator).

Item #6
NFPA 101, 2000 edition, new health care facilities, 18.2.5.8 states "Suites of rooms, other than patient sleeping rooms, shall be permitted to have one intervening room if the travel distance within the suite to the exit access door does not exceed 100 feet (30 m) and shall be permitted to have two intervening rooms where the travel distance within the suite to the exit access door does not exceed 50 ft (15 m).
Based on observation and interview, the facility did not provide the proper exit distance out of suites.

FINDINGS INCLUDE:
1. On 02/08/2011 at 10:00 am surveyor #12187 observed in the ED smoke compartment on the 1st floor in the EMS back room, that the travel distance of 54 feet through (2) intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.5.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

2. On 02/09/2011 at 12:30 pm surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in the room 0029, that the travel distance of 110 feet through one intervening room. This exceeded the exit distance of 100 feet through 1 intervening room. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.5.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

3. On 02/08/2011 at 2:10 pm surveyor #12187 observed in the Surgery smoke compartment on the 1st floor in the room 4012 (OR 4), that the travel distance of 50 feet through (2) intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Item #7
NFPA 110, 1999 edition, 3-5.5.6, states "All Level 1 and 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. "

Based on observation and interview, the facility did not provide the proper location of the emergency stop switch for the emergency generator.

FINDINGS INCLUDE:
On 02/10/2011 at 11:20 am, surveyor #12187 observed that the emergency generator was not provided with a remote stop switch away from the generator. The remote stop switch was located inside of the enclosure. This observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide liquid oxygen transfer space with rated doors. This deficiency occurred in 1 of the 14 smoke compartments, and had the potential to affect 15 of the 73 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 02/07/2011 at 12:10 pm surveyor #12187 observed in the North Patient smoke compartment on the 2nd floor in the P.T. closet, that the doors in the rated wall could not be verified of having at least a 45 minute rating. The room is used to transfer liquid oxygen from a 45 liter container to smaller containers on a average of at least once a day, according to staff LL. This observed situation was not compliant with NFPA 99 (1999 edition) 8-3.1.11.2(d) and 4-3.1.1.2(b)4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

Based on observation, interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes with derangement signals at a continuously monitored location. This deficiency occurred in all of the 14 smoke compartments, and had the potential to affect all of the 73 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 02/10/2011 at 11:00 am surveyor #12187 observed in all smoke compartments on the Lower Level floor in the outside generator, that audible and visual derangement signals were not located in continuously monitored location. The annunciator panel did not display the required alarms at the generator. This observed situation was not compliant with NFPA 99 (1999 edition), 3-4.1.1.15(b). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator) and staff L (Maintenance Coordinator).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels, and fixed wiring rather than extension cords. This deficiency occurred in 4 of the 14 smoke compartments, and had the potential to affect 17 of the 73 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 02/09/2011 at 10:45 am surveyor #12187 observed in the Storage smoke compartment on the Lower Level floor in the air compress room, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a booster fan in the exhaust duct. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

2. On 02/08/2011 at 2:20 pm surveyor #12187 observed in the Surgery smoke compartment on the 1st floor in room 1404 (OR 3) and room 1412 (OR 4), that access to electrical panel was less than 3'-0" clearance. A cart was obstructing the access to the panel. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

3. On 02/07/2011 at 2:50 pm surveyor #12187 observed in the north patient smoke compartment on the 2nd floor in room 2152, that access to electrical panel was less than 3'-0" clearance. The Pixus machine blocked assess to the electrical panel. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).

4. On 02/08/2011 at 3:07 pm surveyor #12187 observed in the Sterile Supply smoke compartment on the Lower Level floor in room 090, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to PCA pain machines This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).

5. On 02/08/2011 at 5:00 pm surveyor #12187 observed in the Day Surgery smoke compartment on the 1st floor in the room 1324A, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to surgical clippers in staff work room. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Maintenance Coordinator), staff K (Director of Environmental Services) and staff L (Maintenance Coordinator).