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Based on observation and interview, the facility did not provide a common separation wall that had sealed wall penetrations. This deficiency occurred in 4 of the 8 smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 9-13-2010 at 12:40 pm surveyor #12187 observed in the 1st smoke compartment on the lower level in the room L146-S, that penetrations were not sealed according to approved UL designs. The deficiency included four 2" pipes through a two hour building separation wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
2. On 9-14-2010 at 9:31 am surveyor #12187 observed in the 4 th smoke compartment on level one in room 247, that a penetration was not sealed according to approved UL designs. The deficiency included 3/4' conduit. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
3. On 9-14-2010 at 10:20 am surveyor #12187 observed in the 4th smoke compartment on level one in the corridor between clinic and hospital, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4 and 8.2.3.2.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
4. On 9-14-2010 at 10:30 am surveyor #12187 observed in the 4th smoke compartment on level one in the men's bathroom, room 003, that a penetration was not sealed according to approved UL designs. The deficiency included 3/4" conduit. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
5. On 9-14-2010 at 10:45 am surveyor #12187 observed in the 4th smoke compartment on level one in rooms 005 and 007, that the separation wall was not constructed to a 2-hour fire rating because a 6" by 6" area of missing drywall is located at the top of the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not provide and maintain the required building construction type that had support steel covered with rated fire proofing. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 9-13-2010 at 11:11 am surveyor #12187 observed in the 1st smoke compartment on the lower level in room L219, that fire proofing was missing from the structural steel at ceiling beam supporting the 2 hour floor. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.6.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces that had rooms open to the corridor with the required safe-guards. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 9-14-2010 at 2:45 pm surveyor #12187 observed in the 5th smoke compartment on the level one floor in room 112 , that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The reception area is open to the corridor and it does not have 24 hour observation nor does it have a smoke detector coverage. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.1 . The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
2. On 9-14-2010 at 1:05 pm surveyor #12187 observed in the 6th smoke compartment on the level one floor in room 412 , that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The former meds room is open to the corridor and it does not have 24 hour observation nor does it have a smoke detector coverage. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.1 . The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not provide corridor separation doors that had positive-latching dutch doors. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all of the imaging outpatients, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 9-14-2010 at 11:00 am surveyor #12187 observed in the 8 th smoke compartment on level one in the corridor door from imaging, that the door to the corridor was split in the middle to form a "dutch door". The upper door would not positively self-latch to the bottom door or the frame. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect PT and OT patients, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 9-13-2010 at 3:20 pm surveyor #12187 observed in the 2 and 3 smoke compartment on the lower level floor in the corridor near room L157, that penetrations were not sealed according to approved UL designs. The deficiency included holes for 2 set of 25 cables. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
2. On 9-13-2010 at 3:30 pm surveyor #12187 observed in the 2nd and 3rd smoke compartment on the lower level in the room L157, that penetrations were not sealed according to approved UL designs. The deficiency included behind the conduit box, there is an opening, a 3/4' conduit and behind the lintel there is an opening. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not enclose hazardous rooms that had sealed wall penetrations, and rated doors. This deficiency occurred in 4 of the 8 smoke compartments, and had the potential to affect all PT and OT patients, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 9-13-2010 at 11:21 am surveyor #12187 observed in the 1st smoke compartment on the lower level floor in the boiler room, that penetrations were not sealed according to approved UL designs. The deficiency included two 3/4" conduits and two 1/2' copper pipe. The boiler rooms contains flame producing appliances and is considered a hazardous room. This observed situation was not compliant with NFPA 101 (2000 edition), 17.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
2. On 9-13-2010 at 1:20 pm surveyor #12187 observed in the 2nd smoke compartment on the lower level floor in storage room L146S, that penetrations were not sealed according to approved UL designs. The deficiency included five pipes through a 1 hour wall. The room is hazardous because it contained 40 cardboard boxes of material. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
3. On 9-13-2010 at 10:33 am surveyor #12187 observed in the 2nd smoke compartment on the lower level floor in the laundry room, L148, that penetrations were not sealed according to approved UL designs. The deficiency included 4 pipes through a 1 hour fire rated wall. The room is hazardous because it a laundry room. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
4. On 9-13-2010 at 1:30 pm surveyor #12187 observed in the 2nd smoke compartment on the lower level floor in the PT Storage room L135, the fire barrier door could not be verified to have the required rating. The storage of combustible items for PT are stored in the room. There was no closer on the door. 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. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
5. On 9-13-2010 at 2:00 pm surveyor #12187 observed in the 2nd smoke compartment on the lower level floor in room L104M, that the fire barrier door could not be verified to have the required rating and the door did not have a door closer. The storage of combustible items such as Christmas decorations and plastic containers are stored in the room. 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. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
6. On 9-13-2010 at 2:50 pm surveyor #12187 surveyor #12187 observed in the 3rd smoke compartment on the lower level floor in room L155, a penetration was not sealed according to approved UL designs. The deficiency included 4" plastic pipe. Combustible medical records are stored in the room. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1.
7. On 9-13-2010 at 3:54 pm surveyor #12187 observed in the 3rd smoke compartment on the lower level floor in room L401S penetrations were not sealed according to approved UL designs. The deficiency included 3/4 " conduit. The fire door did not have a closer and there is a 1.5" diameter steel pipe located in the wall, dislocating the drywall and the fire rating. The room stored food located in combustible containers. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1.
8. On 9-14-2010 at 10:00 am surveyor #12187 observed in the 4th smoke compartment on the 1st level in the Emergency Department room 256U, penetrations were not sealed according to approved UL designs. The deficiency included two conduits, one hole in the wall to the corridor and 2 conduits running parallel to the rated wall for 2 feet, displacing the drywall. This is a soiled utility room which is a hazardous area. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1.

Based on observation and interview, the facility did not provide egress paths at all times that had doors that were unlockable in the egress path. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect emergency room patients, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 9-14-2010 at 2:58 pm surveyor #12187 observed in the 8th smoke compartment on level one in the court yard, that the door was locked from the egress side. The door from the court yard (which is the only exit out of the space) back into the building can be locked from inside the building and the person in the court yard is not able to exit. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
2. On 9-14-2010 at 9:15 am surveyor #12187 observed in the 4th smoke compartment on level one in the corridor to the ambulance garage, that the door in the path of egress did not swing . This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

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 2 of the 8 smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 9-13-2010 at 2:30 pm surveyor #12187 observed in the 2nd smoke compartment on the lower level in the corridor to PT area, that the clear and unobstructed width of the corridor was six feet. 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
2. On 9-14-2010 at 1:17 pm surveyor #12187 observed in the 7th smoke compartment on the level one in the patient corridor, that items were stored in the exit access pathway, including clean linen carts and 3 soiled linen carts. Forty minutes later at 1:57 pm, after surveyor 12187 mentioned the obstructions in the corridor, the carts were removed. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 (exception 6), and 19.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not maintain a written evacuation plan that contained all the elements that had staff trained on life safety procedures. This deficiency occurred in all of the 8 smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 9-14-2010 at 2:53 pm surveyor #12187 observed in all smoke compartment on the level one floor in the main reception area, that staff were not familiar with their responsibilities in the event of a fire, including Receptionists B and C who did not know to remove the chairs in the corridor that are obstructing the corridor in case of fire. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.1.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director), staff B (Receptionist), and staff C (Receptionist).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, that included all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 4 of the 8 smoke compartments, and had the potential to affect all 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 9-13-2010 at 3:05 pm surveyor #12187 observed in the 2nd smoke compartment on the lower level in the elevator equipment room, that there was no sprinkler or approved alternative suppression measures. The building was required to be fully sprinkled because the building type II (0,0,0) is not permitted unless the building is fully sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.1 (exception). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
2. On 9-13-2010 at 11:20 am surveyor #12187 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 in room L231 in smoke compartment #2. The obstruction included a partition that was located 8 inches below the sprinkler. 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. .
3. On 9-13-2010 at 2:11 pm surveyor #12187 observed in the 2nd smoke compartment on the lower level in the middle south and east stairs, that a sprinkler was located 1.5 feet from another sprinkler under the stairs. In addition, the sprinkler under the stairs was not at the angle of the stairs. Sprinklers cannot be closer to each other than the minimum required separation distance of 60" or closer to a wall than 4". This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
4. On 9-14-2010 at 1:30 pm surveyor #12187 observed in the 7th smoke compartment on level one in the chemo room, room 610-1, that the room was not sprinkled. All areas of new healthcare must be protected with sprinklers. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
5. On 9-13-2010 at 11:30 am surveyor #12187 observed in the 1st smoke compartment on lower level in room L234, medical records room, 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 6 movable medical records storage cabinets that was located 17 inches below the sprinkler. 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
6. On 9-13-2010 at 2:25 pm surveyor #12187 observed in the 2nd smoke compartment on the lower level in room 129T, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower area. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A. Fire dampers and fire damper access was missing. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 9-13-2010 at 12:31 pm surveyor #12187 observed in the 1st smoke compartment on the lower level in the L234, medical records room, that the space was not provided with fire damper in a transfer duct through a rated wall. It was observed that the transfer grill did not have a fire damper in the rated wall enclosing the medical record room. This observed situation was not compliant with NFPA 101 (2000 edition), 18.5.2.1 9.2 and NFPA 90A (1999 edition), 3-3.1.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
2. On 9-13-2010 at 11:15 am surveyor #12187 observed in the 1st smoke compartment on the lower level in the mechanical room L302, that access to fire dampers was not provided. It was observed that the there is no access panel to the fire dampers. This observed situation was not compliant with NFPA 101 (2000 edition), 18.5.2.1 9.2 and NFPA 90A, (1999 edition). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes that requires properly sized storage containers for soiled/trash. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all of the cardiac patients, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 9-14-2010 at 2:20 pm surveyor #12187 observed in the 5th smoke compartment on level one in the laboratory, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. There is one 32 gallon recycling container next to one plastic 32 gallon trash container in the middle of the room. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.5.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 that had separation of oxygen from combustibles. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all of the cardiac rehab patients, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 9-14-2010 at 2:30 pm surveyor #12187 observed in the 5th smoke compartment on level one in the cardiac rehab, room 155-4, that combustible materials were stored within 5' of a storage site of cylinders of oxygen. Stored within this distance was plastic covering the tanks and items in plastic storage. This observed situation was not compliant with NFPA 99 (1999 edition), 4.3.1.1.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not provide a common separation wall that had sealed wall penetrations. This deficiency occurred in 4 of the 8 smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 9-13-2010 at 12:40 pm surveyor #12187 observed in the 1st smoke compartment on the lower level in the room L146-S, that penetrations were not sealed according to approved UL designs. The deficiency included four 2" pipes through a two hour building separation wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
2. On 9-14-2010 at 9:31 am surveyor #12187 observed in the 4 th smoke compartment on level one in room 247, that a penetration was not sealed according to approved UL designs. The deficiency included 3/4' conduit. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
3. On 9-14-2010 at 10:20 am surveyor #12187 observed in the 4th smoke compartment on level one in the corridor between clinic and hospital, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4 and 8.2.3.2.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
4. On 9-14-2010 at 10:30 am surveyor #12187 observed in the 4th smoke compartment on level one in the men's bathroom, room 003, that a penetration was not sealed according to approved UL designs. The deficiency included 3/4" conduit. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
5. On 9-14-2010 at 10:45 am surveyor #12187 observed in the 4th smoke compartment on level one in rooms 005 and 007, that the separation wall was not constructed to a 2-hour fire rating because a 6" by 6" area of missing drywall is located at the top of the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not provide and maintain the required building construction type that had support steel covered with rated fire proofing. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 9-13-2010 at 11:11 am surveyor #12187 observed in the 1st smoke compartment on the lower level in room L219, that fire proofing was missing from the structural steel at ceiling beam supporting the 2 hour floor. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.6.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces that had rooms open to the corridor with the required safe-guards. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 9-14-2010 at 2:45 pm surveyor #12187 observed in the 5th smoke compartment on the level one floor in room 112 , that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The reception area is open to the corridor and it does not have 24 hour observation nor does it have a smoke detector coverage. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.1 . The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
2. On 9-14-2010 at 1:05 pm surveyor #12187 observed in the 6th smoke compartment on the level one floor in room 412 , that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The former meds room is open to the corridor and it does not have 24 hour observation nor does it have a smoke detector coverage. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.1 . The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not provide corridor separation doors that had positive-latching dutch doors. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all of the imaging outpatients, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 9-14-2010 at 11:00 am surveyor #12187 observed in the 8 th smoke compartment on level one in the corridor door from imaging, that the door to the corridor was split in the middle to form a "dutch door". The upper door would not positively self-latch to the bottom door or the frame. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect PT and OT patients, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 9-13-2010 at 3:20 pm surveyor #12187 observed in the 2 and 3 smoke compartment on the lower level floor in the corridor near room L157, that penetrations were not sealed according to approved UL designs. The deficiency included holes for 2 set of 25 cables. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
2. On 9-13-2010 at 3:30 pm surveyor #12187 observed in the 2nd and 3rd smoke compartment on the lower level in the room L157, that penetrations were not sealed according to approved UL designs. The deficiency included behind the conduit box, there is an opening, a 3/4' conduit and behind the lintel there is an opening. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not enclose hazardous rooms that had sealed wall penetrations, and rated doors. This deficiency occurred in 4 of the 8 smoke compartments, and had the potential to affect all PT and OT patients, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 9-13-2010 at 11:21 am surveyor #12187 observed in the 1st smoke compartment on the lower level floor in the boiler room, that penetrations were not sealed according to approved UL designs. The deficiency included two 3/4" conduits and two 1/2' copper pipe. The boiler rooms contains flame producing appliances and is considered a hazardous room. This observed situation was not compliant with NFPA 101 (2000 edition), 17.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
2. On 9-13-2010 at 1:20 pm surveyor #12187 observed in the 2nd smoke compartment on the lower level floor in storage room L146S, that penetrations were not sealed according to approved UL designs. The deficiency included five pipes through a 1 hour wall. The room is hazardous because it contained 40 cardboard boxes of material. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
3. On 9-13-2010 at 10:33 am surveyor #12187 observed in the 2nd smoke compartment on the lower level floor in the laundry room, L148, that penetrations were not sealed according to approved UL designs. The deficiency included 4 pipes through a 1 hour fire rated wall. The room is hazardous because it a laundry room. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
4. On 9-13-2010 at 1:30 pm surveyor #12187 observed in the 2nd smoke compartment on the lower level floor in the PT Storage room L135, the fire barrier door could not be verified to have the required rating. The storage of combustible items for PT are stored in the room. There was no closer on the door. 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. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
5. On 9-13-2010 at 2:00 pm surveyor #12187 observed in the 2nd smoke compartment on the lower level floor in room L104M, that the fire barrier door could not be verified to have the required rating and the door did not have a door closer. The storage of combustible items such as Christmas decorations and plastic containers are stored in the room. 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. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
6. On 9-13-2010 at 2:50 pm surveyor #12187 surveyor #12187 observed in the 3rd smoke compartment on the lower level floor in room L155, a penetration was not sealed according to approved UL designs. The deficiency included 4" plastic pipe. Combustible medical records are stored in the room. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1.
7. On 9-13-2010 at 3:54 pm surveyor #12187 observed in the 3rd smoke compartment on the lower level floor in room L401S penetrations were not sealed according to approved UL designs. The deficiency included 3/4 " conduit. The fire door did not have a closer and there is a 1.5" diameter steel pipe located in the wall, dislocating the drywall and the fire rating. The room stored food located in combustible containers. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1.
8. On 9-14-2010 at 10:00 am surveyor #12187 observed in the 4th smoke compartment on the 1st level in the Emergency Department room 256U, penetrations were not sealed according to approved UL designs. The deficiency included two conduits, one hole in the wall to the corridor and 2 conduits running parallel to the rated wall for 2 feet, displacing the drywall. This is a soiled utility room which is a hazardous area. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1.

Based on observation and interview, the facility did not provide egress paths at all times that had doors that were unlockable in the egress path. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect emergency room patients, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 9-14-2010 at 2:58 pm surveyor #12187 observed in the 8th smoke compartment on level one in the court yard, that the door was locked from the egress side. The door from the court yard (which is the only exit out of the space) back into the building can be locked from inside the building and the person in the court yard is not able to exit. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
2. On 9-14-2010 at 9:15 am surveyor #12187 observed in the 4th smoke compartment on level one in the corridor to the ambulance garage, that the door in the path of egress did not swing . This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

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 2 of the 8 smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 9-13-2010 at 2:30 pm surveyor #12187 observed in the 2nd smoke compartment on the lower level in the corridor to PT area, that the clear and unobstructed width of the corridor was six feet. 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
2. On 9-14-2010 at 1:17 pm surveyor #12187 observed in the 7th smoke compartment on the level one in the patient corridor, that items were stored in the exit access pathway, including clean linen carts and 3 soiled linen carts. Forty minutes later at 1:57 pm, after surveyor 12187 mentioned the obstructions in the corridor, the carts were removed. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 (exception 6), and 19.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not maintain a written evacuation plan that contained all the elements that had staff trained on life safety procedures. This deficiency occurred in all of the 8 smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 9-14-2010 at 2:53 pm surveyor #12187 observed in all smoke compartment on the level one floor in the main reception area, that staff were not familiar with their responsibilities in the event of a fire, including Receptionists B and C who did not know to remove the chairs in the corridor that are obstructing the corridor in case of fire. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.1.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director), staff B (Receptionist), and staff C (Receptionist).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, that included all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 4 of the 8 smoke compartments, and had the potential to affect all 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 9-13-2010 at 3:05 pm surveyor #12187 observed in the 2nd smoke compartment on the lower level in the elevator equipment room, that there was no sprinkler or approved alternative suppression measures. The building was required to be fully sprinkled because the building type II (0,0,0) is not permitted unless the building is fully sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.1 (exception). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
2. On 9-13-2010 at 11:20 am surveyor #12187 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 in room L231 in smoke compartment #2. The obstruction included a partition that was located 8 inches below the sprinkler. 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. .
3. On 9-13-2010 at 2:11 pm surveyor #12187 observed in the 2nd smoke compartment on the lower level in the middle south and east stairs, that a sprinkler was located 1.5 feet from another sprinkler under the stairs. In addition, the sprinkler under the stairs was not at the angle of the stairs. Sprinklers cannot be closer to each other than the minimum required separation distance of 60" or closer to a wall than 4". This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
4. On 9-14-2010 at 1:30 pm surveyor #12187 observed in the 7th smoke compartment on level one in the chemo room, room 610-1, that the room was not sprinkled. All areas of new healthcare must be protected with sprinklers. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
5. On 9-13-2010 at 11:30 am surveyor #12187 observed in the 1st smoke compartment on lower level in room L234, medical records room, 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 6 movable medical records storage cabinets that was located 17 inches below the sprinkler. 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
6. On 9-13-2010 at 2:25 pm surveyor #12187 observed in the 2nd smoke compartment on the lower level in room 129T, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower area. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A. Fire dampers and fire damper access was missing. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 9-13-2010 at 12:31 pm surveyor #12187 observed in the 1st smoke compartment on the lower level in the L234, medical records room, that the space was not provided with fire damper in a transfer duct through a rated wall. It was observed that the transfer grill did not have a fire damper in the rated wall enclosing the medical record room. This observed situation was not compliant with NFPA 101 (2000 edition), 18.5.2.1 9.2 and NFPA 90A (1999 edition), 3-3.1.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).
2. On 9-13-2010 at 11:15 am surveyor #12187 observed in the 1st smoke compartment on the lower level in the mechanical room L302, that access to fire dampers was not provided. It was observed that the there is no access panel to the fire dampers. This observed situation was not compliant with NFPA 101 (2000 edition), 18.5.2.1 9.2 and NFPA 90A, (1999 edition). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes that requires properly sized storage containers for soiled/trash. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all of the cardiac patients, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 9-14-2010 at 2:20 pm surveyor #12187 observed in the 5th smoke compartment on level one in the laboratory, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. There is one 32 gallon recycling container next to one plastic 32 gallon trash container in the middle of the room. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.5.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 that had separation of oxygen from combustibles. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all of the cardiac rehab patients, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 9-14-2010 at 2:30 pm surveyor #12187 observed in the 5th smoke compartment on level one in the cardiac rehab, room 155-4, that combustible materials were stored within 5' of a storage site of cylinders of oxygen. Stored within this distance was plastic covering the tanks and items in plastic storage. This observed situation was not compliant with NFPA 99 (1999 edition), 4.3.1.1.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).