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Based on observation the facility failed to ensure that building construction maintained appropriate fire resistance ratings.
The Findings Include:
On 8/29/2016 at approximately 12:33 PM it was observed in the OR Mechanical Room that fire-proofing was missing from sections of beams and that beam clamps were not appropriately over-packed with fire-proofing.
On 8/29/2016 at approximately 12:40 PM it was observed in the Door 6 Mechanical Room that beam clamps were not appropriately over-packed with fire-proofing.
On 8/29/2016 at approximately 12:43 PM it was observed in the Data Closet off of Door 6 Mechanical Room that beam clamps were not appropriately over-packed with fire-proofing.
On 8/29/2016 at approximately 12:55 PM it was observed in the Door 7 Electrical Room that fire-proofing was missing from sections of beams and that beam clamps were not appropriately over-packed with fire-proofing.
On 8/29/2016 at approximately 1:05 PM it was observed that the Water Heater/Water Softener Mechanical Room has metal lath and plaster ceiling assembly that appears to be part of the rated floor-ceiling assembly separating the mechanical room from the 1st floor above it. There are multiple holes in the ceiling assembly violating its integrity. The facility was not able to confirm how the fire separation between the mechanical room and the 1st floor was constructed.
On 8/29/2016 at approximately 1:15 PM it was observed in the Maintenance Shop that beam clamps were not appropriately over-packed with fire-proofing.

Based on observation it was determined that the facility failed to maintain its doors in rated assemblies.

The Finding includes:

On 8/29/2016 at approximately 11:11 AM it was observed that there was a fire rated access door in a hard ceiling of the corridor not latching in SDC at P2 conduit.

Based on observation the facility failed to properly maintain the integrity of its smoke barriers.

The Finding includes:

On 8/29/2016 at approximately 9:51 AM it was observed an unsealed penetrations in the 1 hour smoke barrier at top of wall at the seismic application located in the New ED in room 111 on the south wall.
On 8/29/2016 at approximately 9:51 AM it was observed an unsealed penetrations in the 1 hour smoke barrier at top of wall at the seismic application located in the New ED in room 111 on the east wall there is a conduit penetrating the Seismic application at top of wall.
On 8/29/2016 at approximately 10:06 AM it was observed an unsealed penetrations in the 1 hour smoke barrier at top of wall at the seismic application located in the New ED in room 107.
On 8/29/2016 at approximately 10:08 AM it was observed an unsealed penetrations in the 1 hour smoke barrier at top of wall at the seismic application located in the New ED in room 109.
On 8/29/2016 at approximately 10:08 AM it was observed an unsealed penetrations in the 1 hour smoke barrier there appears to be a box tubing structural member penetrating the smoke wall open on the end of tubing located in the New ED in room 116.
On 8/29/2016 at approximately 10:32 AM it was observed an unsealed penetrations in the 1 hour smoke barrier at top of wall at the seismic application located in the New ED in room 139.
On 8/29/2016 at approximately 11:00 AM it was observed an unsealed penetrations in the 1 hour smoke barrier around conduits at smoke damper 023.

On 8/29/2016 at approximately 12:50 PM it was observed an unsealed penetrations in the 1 hour smoke barrier located above doors by Fire smoke damper M-044 fire alarm conduit.

On 8/29/2016 at approximately 9:57 AM it was observed an unsealed penetrations in the 1 hour smoke barrier located in the Manager of Communications/IS office around the IT cables and at the cable sleeve conduit along the south wall.
On 8/29/2016 at approximately 10:03 AM it was observed an unsealed penetrations in the 1 hour smoke barrier located in the Manager of Communications/IS office around the white and gray cables along the east wall.
On 8/29/2016 at approximately 10:14 AM it was observed an unsealed penetrations in the 1 hour smoke barrier wall located in the old gift shop above the entrance door.
On 8/29/2016 at approximately 10:14 AM it was observed an unsealed penetrations in the 1 hour smoke barrier wall located in the old gift shop at the conduit opening above the entrance door.
On 8/29/2016 at approximately 10:14 AM it was observed that a mixture of fire caulk was used to seal the top of the wall in the smoke barrier in the old gift shop above the entrance door.
On 8/29/2016 at approximately 10:23 AM it was observed that the fire caulk seal around the dry wall patch in the 1 hour smoke barrier wall located in the Cardiac Rehab Room was disconnected.
On 8/29/2016 at approximately 10:23 AM it was observed an unsealed penetration around the electrical conduit above the TV in the 1 hour smoke barrier wall located in the Cardiac Rehab Room.
On 8/29/2016 at approximately 10:39 AM it was observed an unsealed penetrations in the 1 hour smoke barrier located above the double fire doors to the old ED unit and lab hallway.
On 8/29/2016 at approximately 10:42 AM it was observed an unsealed penetrations in the 1 hour smoke barrier wall at the conduit opening located above the double fire doors to the old ED unit and lab hallway on the lab hallway side.
On 8/29/2016 at approximately 10:56 AM it was observed an unsealed penetrations above the exit sign in the 1 hour smoke barrier wall located above the double fire doors near the old x ray room on the main corridor side.
On 8/29/2016 at approximately 11:04 AM it was observed an unsealed penetrations and at the conduit opening with blue cables in the 1 hour smoke barrier wall located in the main corridor across from the ICU.
On 8/29/2016 at approximately 11:22 AM it was observed an unsealed penetrations in the smoke barrier wall located by Northwestern Community Services above the entry door on the office side.
On 8/29/2016 at approximately 12:40 PM it was observed that there was penetrations around the conduits and conduit openings in the smoke barrier wall located above the entrance doors to the old ED unit.
On 8/29/2016 at approximately 12:46 PM it was observed an unsealed penetrations around the conduits and conduit openings in the smoke barrier wall behind the reception desk in the old ED unit.
On 8/29/2016 at approximately 1:10 PM it was observed an unsealed penetrations in the fire barrier wall above the exit door on the left side near suite 108A.
On 8/29/2016 at approximately 1:53 PM an unsealed penetrations around the cluster of IT cables the Shenandoah Diagnostic side.

Based on observation the facility failed to ensure that hazardous areas were properly protected.

The Finding includes:

On 8/29/2016 at approximately 2:40 PM it was observed that the double 90 minute doors to the Central Storage Room behind OR 1 had a non-listed weather stripping between the meeting edges of the doors. Additionally on leaf had panic hardware installed rather than fire exit hardware.
On 8/29/2016 at approximately 2:44 PM it was observed the two wooden 90 minute doors between the two sides of the Central Storage room did not self close and latch properly.

Based on observation the facility faied to ensure that there are two identified exits from every area of the building.

The Finding includes:

It was observed on 8/29/2016 at 1:09 PM, the Ambulatory Surgery Unit had only one marked exit, all exit signs directed occupants to one exit door

Based on observation the facility failed to ensure that complete fire sprinkler coverage in accordance with NFPA 13 was provided throughout the building.

The Finding includes:

On 8/29/2016 at approximately 2:10 PM it was observed that the housekeeping closet across from OR 1 did not have a fire sprinkler installed in it.

Based on record review and observation the facility failed to ensure that its fire sprinkler system was properly maintained.

The Finding includes:

On 8/29/2016 at approximately 1:05 PM it was observed in the Water Heater/Water Softener Mechanical Room that the ceiling had multiple holes in it. These holes could affect the performance of the fire sprinkler system installed in the mechanical room.
On 8/29/2016 at approximately 1:40 PM it was observed in the old gift shop storage room that a fire sprinkler was missing its escutcheon.
On 8/29/2016 at approximately 10:08 AM it was observed that there was IT cables on the 3 inch sprinkler pipe in the server room near the Manager of Communications/IS office.
On 8/29/2016 at approximately 10:46 AM it was observed that there was cables on the sprinkler pipe in the lab hallway above the time clock.
On 8/29/2016 at approximately 1:05 PM it was observed that there was low voltage wiring wrapped around the sprinkler pipe in MOB2 hallway near suite 108A.
On 8/29/2016 at approximately 2:06 PM it was observed that there was cables and electrical conduit on the sprinkler pipe in the soiled utility room located in the Med Surg area.
On 8/29/2016 at approximately 2:28 PM it was observed that there was cables on the sprinkler pipe in front of the Medical Records entrance.

Based on observation the facility failed to ensure that its means of egress was maintained free of impediments and obstructions.

The Finding included:

On 8/29/2016 at approximately 12:55 PM it was observed that the exit push button located in the old ambulance entrance did not operate.

Based on observation the facility failed to store medical gases in accordance with the requirements of NFPA 99. This practice had the potential to affect approximately 50% of the residents.

The Finding includes:

On 8/29/2016 at approximately 12:30 PM it was observed in the medical gas manifold room that electrical receptacles and switches were located less than 5 feet above the finished floor. It was also observed that the door did not self close completely.
On 8/29/2016 at approximately 2:35 PM it was observed that the OR storage room had storage of greater than 300 cubic feet of medical gases (oxygen, nitrous oxide and carbon dioxide). The door to the room was not self closing and did not have positive latching hardware. Additionally electrical receptacles in the room were located less than 5 feet above the finished floor.
On 8/29/2016 at approximately 10:56 AM it was observed that 13 E cylinders of oxygen being store in the old x-ray equipment room. Light switches and electrical outlets was observed installed approximately 4 feet from the surface of the floor.

Based on observation and interview the facility failed to ensure that the medical air system being used for patient care provided air of the proper purity. This had the potential to adversely affect any patient using medical air.
The Findings Includes:
On 8/29/2016 at approximately 1:24 PM it was observed that the medical air compressor ' s carbon monoxide detector was in alarm. Maintenance staff indicated that it had been in alarm for 3 weeks and the alarm was due to a faulty part. Staff indicated that the replacement part had to be fabricated and then be installed by a contractor. The facility did not provide a back-up source of medical air and the facility has continued to use the medical air compressor for patient care without being able to monitor the level of carbon monoxide in the medical air.

Based on observation the facility failed to ensure the maintenance and identification of medical gas storage areas.

The finding includes:

On 8/29/2016 at approximately 2:35 PM it was observed that the OR storage room had storage of greater than 300 cubic feet of medical gases (oxygen, nitrous oxide and carbon dioxide). The door to the room did not have signage as required by NFPA 99.
On 8/29/2106 at approximately 2:00 PM it was observed in OR 2 that a power strip was plugged into an extension cord hanging from the ceiling mounted pedestal rather than being plugged directly into a permanently mounted receptacle.
On 8/29/2106 at approximately 2:20 PM it was observed in OR 1 that a power strips were plugged into extension cords rather than being plugged directly into permanently mounted receptacles. Additionally a power strip was plugged into the back of the anesthesia machine and an extension cord was being used to supply power to the anesthesia cart.
On 8/29/2106 at approximately 2:30 PM it was observed in OR 3 that a power strips were plugged into an extension cords rather than being plugged directly into permanently mounted receptacles. Additionally a power strip was plugged into the back of the anesthesia machine and a power strip (black) not listed for used with medical equipment was being used. Lastly, power strips were not properly supported and were hanging by their cords or the cords of equipment plugged into them; one power strip had cords plugged into it that were pulling out of the power strip exposing the conductors.

Based on observation the facility failed to ensure that its electrical system is fully maintained in a manner that reduces the risk of injury or fire.

The Finding includes:

On 8/29/2016 at approximately 1:05 PM it was observed in the Water Heater/Water Softener Mechanical Room that a large electrical pull box mounted near the ceiling did not have its cover installed.

On 8/29/2016 at approximately 11:18 AM it was observed that there was a Knock out missing from the smoke damper Junction box circuit #28 above doors SDC.

On 8/29/2016 at approximately 1:48 PM it was observed that there was an open Junction box above ceiling and the same J-box is missing Knock outs in the Medical Surgery Unit Managers office.

Based on observation the facility failed to ensure the proper mounting of alcohol based hand rub dispensers.

The Finding includes:

On 8/29/2016 at approximately 2:50 PM it was observed that the ABHR dispenser mounted across from the OR holding area was above an electrical receptacle.

Based on observation the facility failed to ensure that building construction maintained appropriate fire resistance ratings.
The Findings Include:
On 8/29/2016 at approximately 12:33 PM it was observed in the OR Mechanical Room that fire-proofing was missing from sections of beams and that beam clamps were not appropriately over-packed with fire-proofing.
On 8/29/2016 at approximately 12:40 PM it was observed in the Door 6 Mechanical Room that beam clamps were not appropriately over-packed with fire-proofing.
On 8/29/2016 at approximately 12:43 PM it was observed in the Data Closet off of Door 6 Mechanical Room that beam clamps were not appropriately over-packed with fire-proofing.
On 8/29/2016 at approximately 12:55 PM it was observed in the Door 7 Electrical Room that fire-proofing was missing from sections of beams and that beam clamps were not appropriately over-packed with fire-proofing.
On 8/29/2016 at approximately 1:05 PM it was observed that the Water Heater/Water Softener Mechanical Room has metal lath and plaster ceiling assembly that appears to be part of the rated floor-ceiling assembly separating the mechanical room from the 1st floor above it. There are multiple holes in the ceiling assembly violating its integrity. The facility was not able to confirm how the fire separation between the mechanical room and the 1st floor was constructed.
On 8/29/2016 at approximately 1:15 PM it was observed in the Maintenance Shop that beam clamps were not appropriately over-packed with fire-proofing.

Based on observation it was determined that the facility failed to maintain its doors in rated assemblies.

The Finding includes:

On 8/29/2016 at approximately 11:11 AM it was observed that there was a fire rated access door in a hard ceiling of the corridor not latching in SDC at P2 conduit.

Based on observation the facility failed to properly maintain the integrity of its smoke barriers.

The Finding includes:

On 8/29/2016 at approximately 9:51 AM it was observed an unsealed penetrations in the 1 hour smoke barrier at top of wall at the seismic application located in the New ED in room 111 on the south wall.
On 8/29/2016 at approximately 9:51 AM it was observed an unsealed penetrations in the 1 hour smoke barrier at top of wall at the seismic application located in the New ED in room 111 on the east wall there is a conduit penetrating the Seismic application at top of wall.
On 8/29/2016 at approximately 10:06 AM it was observed an unsealed penetrations in the 1 hour smoke barrier at top of wall at the seismic application located in the New ED in room 107.
On 8/29/2016 at approximately 10:08 AM it was observed an unsealed penetrations in the 1 hour smoke barrier at top of wall at the seismic application located in the New ED in room 109.
On 8/29/2016 at approximately 10:08 AM it was observed an unsealed penetrations in the 1 hour smoke barrier there appears to be a box tubing structural member penetrating the smoke wall open on the end of tubing located in the New ED in room 116.
On 8/29/2016 at approximately 10:32 AM it was observed an unsealed penetrations in the 1 hour smoke barrier at top of wall at the seismic application located in the New ED in room 139.
On 8/29/2016 at approximately 11:00 AM it was observed an unsealed penetrations in the 1 hour smoke barrier around conduits at smoke damper 023.

On 8/29/2016 at approximately 12:50 PM it was observed an unsealed penetrations in the 1 hour smoke barrier located above doors by Fire smoke damper M-044 fire alarm conduit.

On 8/29/2016 at approximately 9:57 AM it was observed an unsealed penetrations in the 1 hour smoke barrier located in the Manager of Communications/IS office around the IT cables and at the cable sleeve conduit along the south wall.
On 8/29/2016 at approximately 10:03 AM it was observed an unsealed penetrations in the 1 hour smoke barrier located in the Manager of Communications/IS office around the white and gray cables along the east wall.
On 8/29/2016 at approximately 10:14 AM it was observed an unsealed penetrations in the 1 hour smoke barrier wall located in the old gift shop above the entrance door.
On 8/29/2016 at approximately 10:14 AM it was observed an unsealed penetrations in the 1 hour smoke barrier wall located in the old gift shop at the conduit opening above the entrance door.
On 8/29/2016 at approximately 10:14 AM it was observed that a mixture of fire caulk was used to seal the top of the wall in the smoke barrier in the old gift shop above the entrance door.
On 8/29/2016 at approximately 10:23 AM it was observed that the fire caulk seal around the dry wall patch in the 1 hour smoke barrier wall located in the Cardiac Rehab Room was disconnected.
On 8/29/2016 at approximately 10:23 AM it was observed an unsealed penetration around the electrical conduit above the TV in the 1 hour smoke barrier wall located in the Cardiac Rehab Room.
On 8/29/2016 at approximately 10:39 AM it was observed an unsealed penetrations in the 1 hour smoke barrier located above the double fire doors to the old ED unit and lab hallway.
On 8/29/2016 at approximately 10:42 AM it was observed an unsealed penetrations in the 1 hour smoke barrier wall at the conduit opening located above the double fire doors to the old ED unit and lab hallway on the lab hallway side.
On 8/29/2016 at approximately 10:56 AM it was observed an unsealed penetrations above the exit sign in the 1 hour smoke barrier wall located above the double fire doors near the old x ray room on the main corridor side.
On 8/29/2016 at approximately 11:04 AM it was observed an unsealed penetrations and at the conduit opening with blue cables in the 1 hour smoke barrier wall located in the main corridor across from the ICU.
On 8/29/2016 at approximately 11:22 AM it was observed an unsealed penetrations in the smoke barrier wall located by Northwestern Community Services above the entry door on the office side.
On 8/29/2016 at approximately 12:40 PM it was observed that there was penetrations around the conduits and conduit openings in the smoke barrier wall located above the entrance doors to the old ED unit.
On 8/29/2016 at approximately 12:46 PM it was observed an unsealed penetrations around the conduits and conduit openings in the smoke barrier wall behind the reception desk in the old ED unit.
On 8/29/2016 at approximately 1:10 PM it was observed an unsealed penetrations in the fire barrier wall above the exit door on the left side near suite 108A.
On 8/29/2016 at approximately 1:53 PM an unsealed penetrations around the cluster of IT cables the Shenandoah Diagnostic side.

Based on observation the facility failed to ensure that hazardous areas were properly protected.

The Finding includes:

On 8/29/2016 at approximately 2:40 PM it was observed that the double 90 minute doors to the Central Storage Room behind OR 1 had a non-listed weather stripping between the meeting edges of the doors. Additionally on leaf had panic hardware installed rather than fire exit hardware.
On 8/29/2016 at approximately 2:44 PM it was observed the two wooden 90 minute doors between the two sides of the Central Storage room did not self close and latch properly.

Based on observation the facility faied to ensure that there are two identified exits from every area of the building.

The Finding includes:

It was observed on 8/29/2016 at 1:09 PM, the Ambulatory Surgery Unit had only one marked exit, all exit signs directed occupants to one exit door

Based on observation the facility failed to ensure that complete fire sprinkler coverage in accordance with NFPA 13 was provided throughout the building.

The Finding includes:

On 8/29/2016 at approximately 2:10 PM it was observed that the housekeeping closet across from OR 1 did not have a fire sprinkler installed in it.

Based on record review and observation the facility failed to ensure that its fire sprinkler system was properly maintained.

The Finding includes:

On 8/29/2016 at approximately 1:05 PM it was observed in the Water Heater/Water Softener Mechanical Room that the ceiling had multiple holes in it. These holes could affect the performance of the fire sprinkler system installed in the mechanical room.
On 8/29/2016 at approximately 1:40 PM it was observed in the old gift shop storage room that a fire sprinkler was missing its escutcheon.
On 8/29/2016 at approximately 10:08 AM it was observed that there was IT cables on the 3 inch sprinkler pipe in the server room near the Manager of Communications/IS office.
On 8/29/2016 at approximately 10:46 AM it was observed that there was cables on the sprinkler pipe in the lab hallway above the time clock.
On 8/29/2016 at approximately 1:05 PM it was observed that there was low voltage wiring wrapped around the sprinkler pipe in MOB2 hallway near suite 108A.
On 8/29/2016 at approximately 2:06 PM it was observed that there was cables and electrical conduit on the sprinkler pipe in the soiled utility room located in the Med Surg area.
On 8/29/2016 at approximately 2:28 PM it was observed that there was cables on the sprinkler pipe in front of the Medical Records entrance.

Based on observation the facility failed to ensure that its means of egress was maintained free of impediments and obstructions.

The Finding included:

On 8/29/2016 at approximately 12:55 PM it was observed that the exit push button located in the old ambulance entrance did not operate.

Based on observation the facility failed to store medical gases in accordance with the requirements of NFPA 99. This practice had the potential to affect approximately 50% of the residents.

The Finding includes:

On 8/29/2016 at approximately 12:30 PM it was observed in the medical gas manifold room that electrical receptacles and switches were located less than 5 feet above the finished floor. It was also observed that the door did not self close completely.
On 8/29/2016 at approximately 2:35 PM it was observed that the OR storage room had storage of greater than 300 cubic feet of medical gases (oxygen, nitrous oxide and carbon dioxide). The door to the room was not self closing and did not have positive latching hardware. Additionally electrical receptacles in the room were located less than 5 feet above the finished floor.
On 8/29/2016 at approximately 10:56 AM it was observed that 13 E cylinders of oxygen being store in the old x-ray equipment room. Light switches and electrical outlets was observed installed approximately 4 feet from the surface of the floor.

Based on observation and interview the facility failed to ensure that the medical air system being used for patient care provided air of the proper purity. This had the potential to adversely affect any patient using medical air.
The Findings Includes:
On 8/29/2016 at approximately 1:24 PM it was observed that the medical air compressor ' s carbon monoxide detector was in alarm. Maintenance staff indicated that it had been in alarm for 3 weeks and the alarm was due to a faulty part. Staff indicated that the replacement part had to be fabricated and then be installed by a contractor. The facility did not provide a back-up source of medical air and the facility has continued to use the medical air compressor for patient care without being able to monitor the level of carbon monoxide in the medical air.

Based on observation the facility failed to ensure the maintenance and identification of medical gas storage areas.

The finding includes:

On 8/29/2016 at approximately 2:35 PM it was observed that the OR storage room had storage of greater than 300 cubic feet of medical gases (oxygen, nitrous oxide and carbon dioxide). The door to the room did not have signage as required by NFPA 99.
On 8/29/2106 at approximately 2:00 PM it was observed in OR 2 that a power strip was plugged into an extension cord hanging from the ceiling mounted pedestal rather than being plugged directly into a permanently mounted receptacle.
On 8/29/2106 at approximately 2:20 PM it was observed in OR 1 that a power strips were plugged into extension cords rather than being plugged directly into permanently mounted receptacles. Additionally a power strip was plugged into the back of the anesthesia machine and an extension cord was being used to supply power to the anesthesia cart.
On 8/29/2106 at approximately 2:30 PM it was observed in OR 3 that a power strips were plugged into an extension cords rather than being plugged directly into permanently mounted receptacles. Additionally a power strip was plugged into the back of the anesthesia machine and a power strip (black) not listed for used with medical equipment was being used. Lastly, power strips were not properly supported and were hanging by their cords or the cords of equipment plugged into them; one power strip had cords plugged into it that were pulling out of the power strip exposing the conductors.

Based on observation the facility failed to ensure that its electrical system is fully maintained in a manner that reduces the risk of injury or fire.

The Finding includes:

On 8/29/2016 at approximately 1:05 PM it was observed in the Water Heater/Water Softener Mechanical Room that a large electrical pull box mounted near the ceiling did not have its cover installed.

On 8/29/2016 at approximately 11:18 AM it was observed that there was a Knock out missing from the smoke damper Junction box circuit #28 above doors SDC.

On 8/29/2016 at approximately 1:48 PM it was observed that there was an open Junction box above ceiling and the same J-box is missing Knock outs in the Medical Surgery Unit Managers office.