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Based on observation and interview, the facility failed to maintain 2-hour fire rating for separation between the health care occupancy and adjoining business occupancy.

NFPA 101 2012 Ed. 19.1.3.3*

The findings include:

Observation and interview with engineering staff on 8/21/17 between 3:00 PM and 4:00 PM revealed the following:
1. Ground floor by hyperbaric room: the 2-hour fire wall separating the health care from business occupancy has unsealed penetrations above ceiling of the fire doors which separated the two occupancy types.
2. Ground floor central supply: the doors that are in the 2-hour fire wall separating the business occupancy from health care occupancy are not fire rated doors and are not provided with positive latching hardware.

Engineering staff was present when the deficiencies were identified and acknowledged by administration during the exit conference on 8/23/17.

Based on observation, the facility failed to maintain the 1 hour fire rating of the exit stairwell.

NFPA 101 2012 Ed. 19.3.1.1, 8.6.2, Table 8.3.4.2

The findings include:

Observation on 8/21/17 - 8/22/17 at 9:45 AM and 1:20 PM revealed the following:
1. LL2 O.R. 1 hour exit stairwell between O.R. 6 & 7 has large unsealed penetration in the block wall.
2. LL1 Marion wing stairwell bottom floor stairwell door is not fire rated, not self-latching, and has louvered opening in the bottom of the door.

Engineering staff was present when the deficiencies were identified and acknowledged by administration during the exit conference on 8/23/17.

Based on observation and interview, the facility failed to maintain walls to hazardous area rooms.

NFPA 101 2012 Ed. 19.3.2.1.2*, 8.4, 8.4.2 (1), 8.4.4.1

The findings include:

Observation and interview with engineering staff on 8/21/17 and 8/22/17 between 10:30 AM and 3:00 PM confirmed the following hazardous room locations are not constructed and protected to resist the passage of smoke:
1. Women's Pavilion sterile storage room 3WP068 has multiple unsealed penetrations around conduits and blank openings.
2. Women's Pavilion storage room 3WP071 has multiple unsealed penetrations around penetrating items, the joints/seams of the sheetrock are not taped and mudded and sheetrock has detached from the wall.
3. Women's Pavilion soiled utility 3WP077 the head of wall is not sealed off by a fire stop system, joints/seams of the sheetrock are not taped and mudded and unsealed penetrations on the inside and outside of the room.
4. Women's Pavilion soiled utility room 3WP037 and clean utility room 3WP036 does not have a product that is capable of resisting the passage of smoke.
5. Women's Pavilion NICU clean utility room 2WP050 is not fire stopped around the column and the black cast iron pipe.
6. LL2 O.R. general and GYN instrument storage room has unsealed penetrations consisting of blank openings, metal pipe and conduit penetrating gypsum wall.
7. LL2 O.R. instrument storage room has sheetrock broken off the wall in the corner, sprinkler pipe is unsealed, and multiple unsealed penetrations throughout the gypsum walls in the room.
8. LL1 trash chute room 45-minute door has a non-rated protective plate that exceeds 48 inches from the bottom of the door.

Engineering staff was present when the deficiencies were identified and acknowledged by administration during the exit conference on 8/23/17.

Based on observation, the facility failed to maintain the kitchen hood exhaust system and appliances.

NFPA 101 2012 Ed. 19.3.2.5.1, 9.2.3
NFPA 96 2011 Ed. 11.6.1, 11.7.2

The findings include:

1. Observation on 8/22/17 at 10:00 AM revealed the kitchen hood exhaust has an excess amount of grease accumulation and carbon deposits behind the grease filters and plenum.
2. Observation on 8/22/17 at 10:00 AM revealed behind the deep fat fryers there is excessive accumulation of standing grease on the floor and back of the deep fat fryers.

Engineering staff was present when the deficiencies were identified and acknowledged by administration during the exit conference on 8/23/17.

Based on observation and interview, the facility failed to ensure dietary staff were properly trained. This deficiency affected one of fifteen smoke compartments.

NFPA 101, 9.2.3
NFPA 96, 10.5.7

The findings include:

Observation and interview with the maintenance director and two dietary staff on 8/21/17 at 9:00 AM revealed two of two dietary staff were unsure of what to do in the event of a hood fire, and which manual pull station went with the three hood suppression systems.

The engineering director was present when the deficiency was identified and was acknowledged by the administration during the exit conference on 8/22/17.

Based on observation and interview, the facility failed to ensure smoke detectors are 3 feet away from air flow per the requirements of:

NFPA 101, 2012 Edition 19.3.4.1, 9.6.1.3
NFPA 72, 2010 Edition 17.7.6.3.2

The deficiency affected 1 of 18 smoke compartments.

The findings include:

Observation and interview with the engineering staff, on 8/22/17 at 8:37 AM revealed smoke detectors located within 3 feet of air flow in Cath Lab 1 and Nuclear Medicine 2.

The engineering staff was present when the deficiency was identified and acknowledged by the administration during the exit conference on 8/22/17.

Based on observation, the facility failed to maintain the automatic sprinkler system.

NFPA 101 2012 Ed. 19.4.2.1, 9.7, 9.7.1.1*
NFPA 13 2010 Ed. 8.15.3.2.1, 8.15.3.2.3, 8.3.3.2, 8.6.5.1.2*, 9.1.1.7*

The findings include:

Observation on 8/21/17 - 8/22/17 between 10:00 AM and 3:30 PM revealed the following sprinkler deficiencies:
1. Stairwell 4C by 4C033 bottom landing is not provided with sprinkler protection and this area is being used for storage.
2. LL2 surgery corridor has mixed sprinkler heads of quick response and standard response sprinklers.
3. LL2 surgery above ceiling in front of anesthesia storage room has a bundle of wires that are being supported by the sprinkler system.
4. ICU has mixed sprinkler heads of quick response and standard response sprinklers.
5. 3C elevator lobby at corridor door has 1 standard response sprinkler head with of 12 quick response heads in the remainder of the compartment.
6. Kitchen has 3 of 4 walk in coolers that have a light fixture 1 foot away from the sprinkler head and has an obstructed spray pattern.

Engineering staff was present when the deficiencies were identified and acknowledged by administration during the exit conference on 8/23/17.

Based on observation and record review, the facility failed to maintain portable fire extinguishers per the requirements of:

NFPA 101, 2012 Edition 19.3.5.12
NFPA 10, 2010 Edition 8.3.1

The deficiency affected 1 of 18 smoke compartments.
The findings included:

Observation and record review with the engineering staff, on 8/22/17 at 12:45 PM, revealed the k-class fire extinguishers at the cafeteria serving line (1 of 1) and in the kitchen (1 of 1) failed to have the 5 year hydrostatic test performed.

The engineering staff was present when the deficiency was identified and acknowledged by the administration during the exit conference on 8/22/17.

Based on observation, the facility failed to maintain corridor doors.

NFPA 101 2012 Ed. 19.3.6.3.4

The findings include:

Observation on 8/21/17 at 10:55 AM revealed the LL1 arrhythmia response center corridor door L1C006 has an undercut greater than 1 inch.

Engineering staff was present when the deficiencies were identified and acknowledged by administration during the exit conference on 8/23/17.

Based on observation and interview, the facility failed to maintain the integrity of all smoke barrier walls.

NFPA 101 2012 Ed. 19.3.7.3, 8.5.2*, 8.5.6.3

The findings include:

Observation and interview with engineering staff on 8/21/17 and 8/22/17 between 10:00 AM and 4:00 PM revealed the following locations failed to maintain the integrity of the smoke barrier wall:
1. 1st floor central wing on staff side above corridor doors the smoke barrier wall has multiple conduits that are sealed with sheet rock mud and have mixed fire stopping within the same penetration.
2. 2nd central staff side lobby doors above corridor doors the smoke barrier wall has unsealed penetrations and mixed fire caulk in the same penetrations.
3. Women's Pavilion 3rd floor above corridor doors by patient room 012 the smoke barrier wall has electrical conduits that are sealed with sheetrock mud and not fire caulk and head of wall is not sealed with a material capable of ½ hour fire resistance rating.
4. Women's Pavilion 3rd floor in patient room 012 the smoke barrier wall has electrical conduits sealed with a material that is not capable of maintaining a ½ hour fire resistance rating.
5. 4th floor c wing 488 smoke barrier wall has 4 electrical conduits and head of wall are not sealed with a product capable of maintaining a ½ fire resistance rating.
6. 4th floor c wing 488 smoke barrier wall has electrical conduits that have a product that is not capable of maintaining a ½ fire resistance rating.

Engineering staff was present when the deficiencies were identified and acknowledged by administration during the exit conference on 8/23/17.

Based on observation and interview, the facility failed to maintain smoke barriers.

NFPA 101, 19.3.7.3

The findings include:

Observation and interview with engineering staff on 8/22/17 between 2:52 PM and 3:12 PM revealed unsealed penetrations in the smoke barrier in the following locations;

1. Corridor 149 above the ceiling by the exit door had 3 conduit penetrations .
2. By the nurses station in the corridor above the ceiling two unsealed flex conduit penetrations.

The engineering staff was present when the deficiencies were identified and acknowledged by administration during the exit conference on 8/23/17.

Based on observation, the facility failed to maintain all electrical equipment.

NFPA 2012 Ed. 19.5.1.1, 9.1, 9.1.2
NFPA 70 2011 Ed. 110.12 (B)

The findings include:

Observation on 8/22/17 at 10:37 AM revealed the deep fat fryer sheathing to the electrical cord is damaged and has exposed the internal wiring that the sheathing is protecting.

Engineering staff was present when the deficiencies were identified and acknowledged by administration during the exit conference on 8/23/17.

Based on observation and testing, the facility failed to maintain the laundry chute fire door.

NFPA 101 2012 Ed. 19.5.4.1

The findings include:

Observation and testing on 8/22/17 at 3:15 PM revealed the ground floor environmental service room GW002 the wheels on the laundry chute door are bent and the door does close when tested.

Engineering staff was present when the deficiencies were identified and acknowledged by administration during the exit conference on 8/23/17

Based on staff interview and observation, the facility failed to ensure staff was trained so they are familiar with procedures in a kitchen fire per the requirements of:

NFPA 101, 2012 Edition Section 19.7.2.2(4)

The deficiency affected 1 of 18 smoke compartments.

The findings include:

Interview with a cook in the kitchen, on 8/21/17 at 12:47 PM revealed the cook was not trained to properly activate the suppression system if there is a fire under the kitchen hood.

The engineering staff was present when the deficiency was identified and acknowledged by the administration during the exit conference on 8/22/17.

Based on observation and interview, the facility failed to have medical gas shutoff valves placed where a wall intervenes between the valve and outlets/inlets that is controls per the requirements of:

NFPA 101, 2012 Edition 19.3.2.4
NFPA 99, 2012 Edition 5.1.4.8(3)

The deficiency affected 2 of 18 smoke compartments.

The findings include:

Observation and interview with the engineering staff, on 8/22/17 at 8:05 AM revealed the medical gas shutoff valves are located in the same area they serve in Pre-op and PACU Recovery with no intervening wall between the shutoff valve and the area it serves.

The engineering staff was present when the deficiency was identified and acknowledged by the administration during the exit conference on 8/22/17.

Based on observation, record review and interview the facility failed to ensure medical gas system was code compliant. This deficiency affected two of fifteen smoke compartments.

NFPA 101, 19.3.2.4
NFPA 99, 5.1.4.8(1)

The findings include:

1. Record review on 8/21/17 at 10:00 AM of the 5/22-24/17 Medical Gas Inspection report revealed two corridors where there is not an intervening wall between the zone valves and the outlets/inlets that they control.
2. Observation and interview with the engineering director on 8/21/17 at 10:30 AM verified that these two areas were non-compliant.

The engineering director was present when the deficiencies were identified and was acknowledged by the administration during the exit conference on 8/22/17.

Based on observation and interview, the facility failed to maintain oxygen storage areas.

NFPA 99, 11.3.2.3(2), 11.3.4.1, 11.3.4.2

The finding includes:

Observation and interview with the engineering staff on 8/22/17 at 3:26 PM revealed that the oxygen storage room did not have the required signage.
The engineering staff was present when the deficiencies were identified and acknowledged by administration during the exit conference on 8/23/17.