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Based on observation and staff interview, the facility failed to provide doors with fire-rating labels on two openings in occupancy separation walls in accordance with NFPA 101 19.1.3.3, 8.3.3.1. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 195 on the day of survey.

Findings include

1. On 2/20/17 at 11:29 am, it was observed that the double doors in the 2-hr occupancy separation wall between the emergency department and the Ambulance Garage G09 did not have fire-rating labels. The doors are located adjacent to the Trauma Elevator Lobby G201 on the Garden Level.

2. On 2/20/17 at 11:29 am, it was observed that the single leaf door in the 3-hr occupancy separation wall between the Cardiovascular Institute and the Main Lobby 103 adjacent Stair #1 on the 1st Floor did not have a 3-hr fire-rating label.

The above deficiencies were confirmed by a concurrent observation and interview with the facilities supervisor (Staff LS5) and safety specialist (LS6).

Based on observation and staff interview, the River Woods Ambulatory Care Center (RWACC) facility did not provide and maintain the required construction type for existing structural members, in accordance with NFPA 101 (2012 edition), sections 19.1.6.2 through 19.1.6.7, 19.1.6.4, 19.1.6.5 & Table 19.1.6.1. The Building was originally built as a Type II (222) and has not been changed. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility.

FINDINGS INCLUDE:

1. On 3/2/2017 at 9:57 AM observation revealed on the 1st Floor in Elevator Lobby #1001 above ceiling, the lower steel flange of I-beam was missing fire protection. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

2. On 3/2/2017 at 11:23 AM observation revealed on the 1st Floor in Electrical Room #115.01 above the ceiling of the Surgery area, the lower steel flange of I-beam was missing fire protection. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

3. On 3/2/2017 at 1:34 PM observation revealed on the 2nd Floor in Clinical Lab Vestibule Room #243 above the ceiling, the lower steel flange of I-beam was missing fire protection. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

4. On 3/3/2017 at 2:35 PM observation revealed on the 2nd Floor in Soiled Utility Room #242 above the ceiling, six steel clamps attached to the steel I-beams were missing fire protection. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

5. On 3/3/2017 at 2:36 PM observation revealed on the 2nd Floor in Outpatient Room #208 above the ceiling, two steel clamps attached to the steel I-beam were missing fire protection. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

6. On 3/3/2017 at 2:58 PM observation revealed on the 2nd Floor in Room #253 above the ceiling, multiple steel clamps attached to the steel I-beam were missing fire protection. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

7. On 3/3/2017 at 3:12 PM observation revealed on the 2nd Floor in Corridor #2006 above the ceiling, multiple steel clamps attached to the steel I-beam were missing fire protection. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

8. On 3/3/2017 at 3:12 PM observation revealed on the 2nd Floor in Corridor #2006 above the ceiling, multiple steel clamps attached to the steel I-beam were missing fire protection. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

9. On 3/3/2017 at 3:14 PM observation revealed on the 2nd Floor in Corridor #2006 several feet down from the previous spot, above the ceiling, four steel clamps attached to the steel I-beam were missing fire protection. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

10. On 3/3/2017 at 3:29 PM observation revealed on the 1st Floor in Corridor #1002 above the ceiling, six steel clamps attached to the steel I-beam were missing fire protection. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).
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Based on observation and staff interview, the facility failed to maintain one means of egress free of obstruction due to the failure of one horizontal exit door to open in accordance with NFPA 101 19.2.1, 7.1.10.1. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 195 on the day of survey.

Findings include

On 2/22/17 at 9:05 am, it was observed that the 1 ½ hour fire-rated horizontal exit door at the bottom of the ramp of the Pedestrian Tunnel adjacent to the mechanical equipment room in the Garden level failed to open from the tunnel side to the main hospital side.

The above deficiency was confirmed by the concurrent observation and interview with the director of facilities management (Staff LS4), and facilities supervisor (Staff LS5).

Based on observation and staff interview, the River Woods Ambulatory Care Center (RWACC) facility did not provide and maintain the required egress at all doors with proper language to understand unique locking situations within the facility in a means of egress. These conditions were not in accordance with NFPA 101 (2012 edition), sections 19.2.2.2.4, 19.2.2.2.5.2, 7.2.1.6.1 & 7.2.1.6.3. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility.

FINDINGS INCLUDE:

1. On 3/2/2017 at 12:33 AM observation revealed on the 2nd Floor in Elevator Lobby next to Radiology Suite, the multiple doors were on a magnetic holding device at times. Radiology Waiting at 2nd Floor is within the 2-Story space. Elevator Lobby connects to Radiology Suite, Radiology Waiting and 2nd Floor Corridor. The elevator lobby doors will not release without pushing a red button on the side wall, when activated. Language was missing on the door for proper understanding to a un-suspecting occupant. Facility personnel were not sure if the door would release upon activation of the fire alarm system or sprinkler system. The door from Radiology Waiting area at 2nd Level of 2-Story space is a required exit access door in a fire emergency situation. The Monumental Stairs is not an exit from Radiology Waiting. This deficient practice was confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel) and staff LS7 (Mechanic 3 - Medxcel).
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Based on observation and staff interview, the facility failed to protect one hazardous area with automatic closing corridor doors in accordance with NFPA 101 19.2.2.2.7, NFPA 72 17.7.5.6.5.1. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 195 on the day of survey.

1. On 2/22/17 at 9:55 am, it was observed that corridor door of the Surgery Receiving Room 4459, with combustible storage, was held open, but did not have an automatic release device to automatically close upon activation of the fire alarm system. The room was located adjacent to the Imaging Support Room 4461 on the 4th Floor.

2. On 2/22/17 at 10:40 am, it was observed that two ceiling-mounted smoke detectors installed to detect smoke passing through one cross-corridor smoke door opening were too close to a set of smoke doors, and not installed at least "d" distance away from the door, where "d" is the depth of the lintel above the smoke door opening. The depth "d" was estimated to be approximately 3 ft. The pair of cross-corridor smoke doors was located adjacent to the Exit Stair 4907 and the Surgery Control Desk 4447 on the 4th Floor.

The above deficiencies were confirmed by the concurrent observation and interview with manager of operation rooms (Staff MM), the director of facilities management (Staff LS4), and facilities supervisor (Staff LS5).

Based on observation and staff interview, the River Woods Ambulatory Care Center (RWACC) facility did not provide and maintain the required exit discharge to a public way free of slippery snow on a gravel hard surface, in accordance with NFPA 101 (2012 edition), sections 19.2.7, Chapter 7 and S&C 05-38. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility.

FINDINGS INCLUDE:
1. On 3/2/2017 at 10:00 AM observation revealed on the 1st Floor at the north side of the waiting area in the 2-Story space, exit discharge was covered in snow that had occurred several days ago. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).
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Based on observation and interview, the facility failed to provide illumination of the means of egress in accordance with the requirements of NFPA 101 (2012 edition), 7.8. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 195 on the day of survey.

Findings include:

On 2/20/17 at 2:38 pm, observation and interview revealed in operating suite OR #2 room #4300 that it did not provide emergency illumination. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff LS11 HVAC Tech - Medxcel and Staff LS16 Manager Medical Imaging.

Based on observation and interview, the facility failed to properly install exit signs in some locations to direct occupants to exits in accordance with NFPA 101 19.2.10.1, 7.10.1.4, and to install proper signs on doors that are likely to be mistaken as exit doors in five locations in accordance with NFPA 101 7.10.8.1. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 195 on the day of survey.

Findings include

1. On 2/20/17 at 3:10 pm, it was observed that one exit sign in the Corridor 1100 in the atrium on the 1st Floor was pointing to the Patient Resource Room 1108 and not to the exit access door out of the atrium.

2. On 2/20/17 at 3:15 pm, it was observed that "NOT AN EXIT" signs posted on five glass doors along the south exterior wall of the Corridor 1100 on the 1st Floor did not read as "NO EXIT" with proper size letters.

3. On 2/22/17 between 10:30 am and 11:10 am, it was observed that exit signs located in the south end of the Corridor 4568 on the 4th Floor and Corridor 3599 on the 3rd Floor were not visible from corridor locations adjacent to the IDF Rooms 4942 and 3942 due to exit signs blocked by ceiling hung blue signs.

These deficiencies were confirmed by concurrent observation and interview with the assistant regional director (Staff LS3), facilities supervisor (Staff LS5), and safety specialist (LS6), and by concurrent observation and interview with the director of facilities management (Staff LS4), and Staff LS5.

Based on observation and interview, the facility failed to protect hazardous areas, maintain the sprinkler system, and maintain the electrical system in accordance with the requirements of NFPA 101 (2012 edition), Chapter 39, 8.3, NFPA 25, and NFPA 70. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 45 on the day of survey.

Findings include:

1. On 2/22/17 at 9:15 am, observation in the Research Storage room that was approximately 300 square feet revealed a 6-inch pipe penetrating through the 2-hour side wall that was not fire stopped with a 1-inch annular gap. The top of the 2-hour rated wall did not have the drywall joints taped and finished and the wall was not continuous to the deck above.

2. On 2/22/17 at 9:50 am, observation in the lower level electrical room revealed two 6-inch by 8-inch holes in the 2-hour rated wall that were filled with fiberglass insulation.

3. On 2/22/17 at 10:00 am, observation in room 4015 revealed a two 8-inch by 12-inch air ducts that were not fire stopped leaving a 1-inch annular gap.

4. On 2/22/17 at 10:25 am, observation in the third floor electrical room by the elevators revealed four pipes penetrating the ceiling were not fire stopped leaving a 1-inch annular gap.

5. On 2/22/17 at 10:45 am, observation in the second floor electrical room by the elevators revealed four pipes penetrating the ceiling were not fire stopped leaving a 1-inch annular gap.

6. On 2/22/17 at 10:25 am, observation above the ceiling in the second floor corridor by room WT-2009 revealed five 1.5 inch electrical conduit pipes penetrating the wall that were not fire stopped leaving a 1/2-inch annular gap.

7. On 2/22/17 at 9:45 am, observation in the storage closet in the simulator room revealed cardboard boxes were being stored within 2-inches of the sprinkle.

8. On 2/22/17 at 10:05 am, observation in suite 406 in the closet by room 4 revealed cardboard boxes were being stored within 8-inches of the sprinkle.

9. On 2/22/17 at 9:35 am, observation in room WT-0120.1 revealed an electrical outlet was installed within 4-feet of a water source and was not protected by a GFCI outlet.

10. On 2/22/17 at 10:00 am, observation in room 196 revealed an electrical outlet was installed within 4-feet of a water source and was not protected by a GFCI outlet.

11. On 2/22/17 at 10:05 am, observation in room 198 revealed a power strip daisy chain condition where one power strip was plugged into another that was plugged into the wall outlet.

12. On 2/22/17 at 10:25 am, observation in room 156 revealed two electrical outlets were installed within 4-feet of a water source and were not protected by a GFCI outlet.

13. On 2/22/17 at 10:30 am, observation in the first floor Lab Draw Room revealed three electrical outlets were installed within 4-feet of a water source and were not protected by a GFCI outlet.

14. On 2/22/17 at 10:30 am, observation in the Infusion Bay revealed three electrical outlets were installed within 4-feet of a water source and were not protected by a GFCI outlet.

Based on observation and staff interview, the River Woods Ambulatory Care Center (RWACC) facility did not provide and maintain the required vertical shaft wall construction for a wall assembly where they occur in the existing ambulatory health care occupancy, in accordance with NFPA 101 (2012 edition), sections 19.3.1.1 through 19.3.1.6 and 8.6 Vertical Openings. The Building was originally built as a Type II (222) and has not been changed per interview with staff LS4. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility.

FINDINGS INCLUDE:

1. On 3/2/2017 at 10:30 AM observation revealed on the 1st Floor in the East wall next to the Elevator Lobby #1001 above the ceiling, near the top of the wall a pipe/conduit was missing the proper fire-sealant were the pipe penetrated the wall assembly. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

2. On 3/2/2017 at 10:34 AM observation revealed on the 1st Floor in South wall next to the Elevator Lobby #1001 above the ceiling, near the top of wall, two pipes were penetrating the wall assembly using non-compliant fire-sealant, fire penetration labeling was missing. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

3. On 3/2/2017 at 11:38 AM observation revealed on the 1st Floor in far Eastern smoke compartment next to Surgery Nurses Station, Elevator Equipment Room #114, the wall was not properly fire-stopped at penetrations through 2-hour fire barrier. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

4. On 3/2/2017 at 11:40 AM observation revealed on the 1st Floor in far Eastern smoke compartment next to Surgery Nurses Station, Elevator Equipment Room #114, a 2 inch diameter penetrating pipe through 2-hour fire barrier was not properly fire-stopped. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

5. On 3/3/2017 at 2:58 PM observation revealed on the 2nd Floor in Room #253. The top-of-wall, at the shaft assembly of South wall, did not reflect the requirement for proper deflection from snow load where a fire barrier exists. The owner could not find structural deflection drawings at time of survey. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

6. On 3/3/2017 at 2:59 PM observation revealed on the 2nd Floor in Room #253. The top-of-wall at shaft assembly of the North wall did not reflect the requirement for proper deflection from snow load where a fire barrier exists. The owner could not find structural deflection drawings at time of survey. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

7. On 3/3/2017 at 3:12 PM observation revealed on the 2nd Floor in Toilet Room #255A. The top-of-wall at the shaft assembly did not reflect the requirement for proper deflection from snow load where a fire barrier exists. The owner could not find structural deflection drawings at time of survey. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).
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Based on observation and staff interview, the facility failed to protect one hazardous area with properly maintained fire doors in accordance with NFPA 101 19.3.2.1. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 195 on the day of survey.

Findings include

1. On 2/20/17 at 11:29 am, it was observed that the 1 ½ hour fire-rated double doors of the Chemical Explosion Room G512 adjacent to the Materials Management area in the Garden Level failed to latch at the top of the door.

2. On 2/20/17 at 11:55 am, it was observed that the fire-rated double doors of the Soiled Linen Storage Room G519 adjacent to the loading dock area in the Garden Level failed to fully close and latch.

The above deficiencies were confirmed by the concurrent observation and interview with the facilities supervisor (Staff LS5) and safety specialist (Staff LS6).


30964

Based on observation and interview, the facility failed to protect hazardous areas in accordance with the requirements of NFPA 101 (2012 edition), 19.3.2, 8.3.3.1, 8.4.3.5. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 195 on the day of survey.

Findings include:

1. On 2/20/17 at 2:55 pm, observation of room 7265 revealed the room is approximately 56 square feet in area and was being used to store a large number of cardboard boxes of paper files. There was no indication of a fire rating on the room walls and the door did not have a fire rating. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff LS7 and LS9.

2. On 2/20/17 at 3:15 pm, observation of data room 7945 revealed there were two 6-inch pipes passing through the floor and ceiling that were not firestopped. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff LS7 and LS9.

3. On 2/21/17 at 10:30 am, observation of electrical room 6922 revealed a 2-feet by 7-feet steel plate covering a hole in the floor with electrical conduit pipes passing through that was not fire protected to meet the 2-hour rating requirement for the type of construction for floors. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff LS7.

4. On 2/21/17 at 10:35 am, observation of the electrical data rooms 6944 and 6945 revealed there were several 6-inch pipes passing through the floor and ceilings that were not firestopped. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff LS7.

5. On 2/21/17 at 1:10 pm, observation of the 5th floor shell room of approximately 90-feet by 100-feet revealed large quantities of paper, cardboard, plastics, decorations, furniture, rolls of vinyl flooring, plywood, and styrofoam sheets were being stored in this room. The two sets of exit doors that appeared to be less than half the diagonal distance of the room apart were only rated at 20-minutes and had glass windows with no fire rating labels. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff LS7.

6. On 2/21/17 at 2:12 pm, observation of electrical room 5922 revealed a 2-feet by 7-feet steel plate covering a hole in the floor with electrical conduit pipes passing through that was not fire protected to meet the 2-hour rating requirement for the type of construction for floors. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff LS7.

Based on record review and interview, the Central Utility Plant(CUP ) facility failed to inspect the automatic fire alarm system for 5-Year Nuisance Alarms as required by NFPA 101 (2012 edition), Sections 19.3.4.1 General, 9.6 Fire Detection, Alarm, and Communications Systems, NFPA 72 (2010 edition) and NFPA 25 (2011 edition). This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility.

FINDINGS INCLUDE:

1. On 2/22/2017 at 2:45 PM, during review of the Annual Fire Alarm System, inspection records, it was discovered that the facility did not inspect for the 5-Year Nuisance Alarms within this building, within the last 24 Months. Staff LS8 (Mechanic 2 - Medxcel) stated they did not know to check for this component under the Smoke Detector Sensitivity Report. This deficient practice was confirmed by LS8 (Mechanic 2 - Medxcel) and LS4 (Dir. Fac Mgmt - Medxcel).
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Based on record review and interview, the Central Utility Plant (CUP) facility failed to include in the Fire Watch Policy for Fire Alarm - Out of Service, the required notification to the State of Wisconsin (WI) - Authority Having Jurisdiction (AHJ), with the Division of Quality Assurance (DQA) -State Fire Authority (SFA), as required by NFPA 101 (2012 edition), Sections 19.3.4.1 General, 9.6 Fire Detection, Alarm, and Communications Systems, 9.6.1.6, NFPA 72 (2010 edition) and NFPA 25 (2011 edition). This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility.

FINDINGS INCLUDE:

1. On 2/22/2017 at 2:00 PM, during review of the Fire Watch Policy for Fire Alarm - Out of Service, it was discovered that the facility did not include language for notification of the WI-AHJ, DQA-SFA. The Staff LS8 (Mechanic 2 - Medxcel) stated he did not know to check for this component under the Fire Watch Policy for Fire Alarm - Out of Service. This deficient practice was confirmed by LS8 (Mechanic 2 - Medxcel) and LS4 (Dir. Fac Mgmt - Medxcel).
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Based on observation and interview, the facility failed to maintain all smoke detectors as required by NFPA 101 - 2012 edition, Sections 19.3.4 and 9.6; as well as NFPA 72, 2010 Edition. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 195 on the day of survey.

Findings include:

On 2/21/17 at 2:40 pm, observation of the smoke detector in room 5265 revealed it was mounted 12-inches from the air diffuser within the air stream. This finding was confirmed by staff LS7 at the time of discovery.

Based on observation and staff interview, the River Woods Ambulatory Care Center (RWACC) facility did not provide and maintain the existing sprinkler system installed originally into the building, in accordance with NFPA 101 (2012 edition), sections 21.1.1.2 and 21.1.1.3.2 per Goals and Objectives for Existing Ambulatory Health Care Occupancies. This building has not changed occupancy (I-2) from its original completion per occupancy subclassification, section 21.1.1.4.2 (hospital to ambulatory health care occupancy). This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility.

FINDINGS INCLUDE:

1. On 3/2/2017 at 10:20 AM observation revealed on the 1st Floor in Security Office Room #101.06 near the Wheelchair Storage, the sprinkler head was missing. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).
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Based on observation and interview, the facility failed to properly maintain sprinkler system in accordance with NFPA 101 9.7.5, NFPA 25 due to dirty sprinkler heads. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 195 on the day of survey.

Findings include

1. On 2/20/17 at 10:55 am, it was observed that one sprinkler head in the corridor adjacent to the Conference Room G279 and Locker Room G202 on the Ground Floor was dirty and not free of foreign materials.

2. On 2/20/17 at 3:55 pm, it was observed that one sprinkler head in Room 1545 adjacent to the Gamma Room 1543 in the Heart Institute area on the 1st Floor was dirty and not free of foreign materials.

These deficiencies was confirmed by the concurrent observation and interview with the facilities supervisor (Staff LS5) and safety specialist (LS6), and the assistant regional director (Staff LS3).



18107

Based on record review and interview, the Main Hospital facility failed to inspect the Automatic Sprinkler System for Hydraulic Nameplate at Sprinkler System Risers, 'access' around valves, hose connections and pressure gauges of the sprinkler system, as required by NFPA 101 (2012 edition), Sections 19.3.5.3 Hospitals, 9.7 Automatic Sprinklers and NFPA 25 (2011 edition) Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 195 on the day of survey.

FINDINGS INCLUDE:

1. On 3/3/2017 at 2:25 PM, during review of the Monthly Sprinkler System inspection records, it was discovered that the facility did not inspect for the Monthly 'access' around the fire protection equipment and fire pump equipment for the sprinkler system, within this high-rise building or adjoining building housing the fire protection equipment. Staff LS8 (Mechanic 2 - Medxcel) stated they did not know to check for these components under the Monthly Sprinkler System - Visual Inspections. This deficient practice was confirmed by LS7 (Mechanic 3 - Medxcel), LS5 (Facilities Sprvsr - Medxcel) and LS4 (Dir. Fac Mgmt - Medxcel).

2. On 3/3/2017 at 2:32 PM, during review of the Quarterly Sprinkler System inspection records, it was discovered that the facility did not inspect for the Quarterly Hydraulic Nameplate at Sprinkler System Risers, within this high-rise building or adjoining building housing the fire protection equipment. Staff LS8 (Mechanic 2 - Medxcel) stated they did not know to check for these components under the Quarterly Sprinkler System - Visual Inspections. This deficient practice was confirmed by LS7 (Mechanic 3 - Medxcel), LS5 (Facilities Sprvsr - Medxcel) and LS4 (Dir. Fac Mgmt - Medxcel) .
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Based on observation and interview, the facility failed to maintain portable fire hose cabinets as required by NFPA 101 (2012 edition), Sections 19.3.5.12 and 9.7.4.1, and NFPA 10 (2010 edition) Sections 7.2.1, 7.2.1.2, 7.2.4.4 and 7.2.4.5. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility.

FINDINGS INCLUDE:
On 02/21/2017 at 9:14 am, surveyor observed on the Second Floor in Case Management that the fire hose cabinet also contained boxes, bags, and wiring.

This deficient practice was confirmed at the time of discovery by a concurrent observation and interview with staff LS4 (Director, Facilities Management Medxcel).

Based on observation and staff interview, the facility failed to provide doors in accordance with NFPA 101(2012 ed) 19.3.6.3. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility.

FINDINGS INCLUDE:
1. On 02/21/2017 at 2:11 pm observation revealed that on the First Floor the 2-hour fire rated corridor doors, near Elevator 12, had a gap greater than1/8th inch when closed.
These deficient practices were confirmed at the time of discovery by a concurrent observation and interview with staff LS4 (Director, Facilities Management Medxcel).

2. On 02/22/2017 at 9:48 am observation revealed that on the Fourth Floor the corridor door to Toilet Room E4630L had a door grille.
3. On 02/22/2017 at 10:00 am observation revealed that on the Fourth Floor the corridor door, near room E4643, had a corridor door labeled as 20 minute in a 1 hour corridor wall.

This deficient practice was confirmed at the time of discovery by a concurrent observation and interview with staff LS7 (Mechanic 3 Medxcel).

Based on observation and staff interview, the River Woods Ambulatory Care Center (RWACC) facility did not provide and maintain the required Smoke Barrier construction, in accordance with NFPA 101 (2012 edition), sections 19.3.7.3 and 8.5. Building was originally built as a Type II (222) and has not been changed. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility.

FINDINGS INCLUDE:

1. On 3/3/2017 at 2:34 PM observation revealed on the 2nd Floor in the Clean Utility Room #241, that the top-of-wall assembly did not reflect the requirement for proper deflection from snow load were a fire barrier exists. The owner could not find structural deflection drawings at time of survey. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

2. On 3/3/2017 at 2:36 PM observation revealed on the 2nd Floor in Patient Room #208, that the top-of-wall assembly did not reflect the requirement for proper deflection from snow load were a fire barrier exists. The owner could not find structural deflection drawings at time of survey. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

3. On 3/3/2017 at 2:50 PM observation revealed on the 2nd Floor in Office Room #251, that the top-of-wall assembly did not reflect the requirement for proper deflection from snow load were a fire barrier exists. The owner could not find structural deflection drawings at time of survey. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

4. On 3/3/2017 at 3:12 PM observation revealed on the 2nd Floor in Corridor #2006, that the top-of-wall assembly did not reflect the requirement for proper deflection from snow load were a fire barrier exists. The owner could not find structural deflection drawings at time of survey. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

5. On 3/3/2017 at 3:33 PM observation revealed on the 1st Floor in Materials Management Vestibule #106, that the top-of-wall assembly did not reflect the requirement for proper deflection from dead and live loads where a fire barrier exists. The owner could not find structural deflection drawings at time of survey. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

6. On 3/3/2017 at 3:36 PM observation revealed on the 1st Floor in Materials Management Storage Room #106.1,that the top-of-wall assembly at East, North and South walls did not reflect the requirement for proper deflection from dead and live loads where a fire barrier exists. The owner could not find structural deflection drawings at time of survey. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

7. On 3/3/2017 at 3:42 PM observation revealed on the 1st Floor in Urgent Care Supplies Room #103, that the top-of-wall assembly did not reflect the requirement for proper deflection from dead and live loads where a fire barrier exists. The owner could not find structural deflection drawings at time of survey. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).

8. On 3/3/2017 at 3:47 PM observation revealed on the 1st Floor in Room #120, that a 3/4" diameter electrical conduit penetrated the smoke barrier wall and was not properly fire-sealed to preventt he passage of hot gases and smoke. This deficient practice was visually confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel), staff LS7 (Mechanic 3 - Medxcel) and staff MMM (CSM-Mgr. RWACC).
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Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to smoke doors not maintained/installed in accordance with NFPA 101 19.3.6.2.2. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 195 on the day of survey.

Findings include

1. On 2/20/17 at 10:36 am, it was observed that cross-corridor double smoke doors adjacent to Room G362 in the Emergency Department on the Garden Level did not fully close, and left a 3/8 inch gap at the meeting edge of the doors.

2. On 2/20/17 at 2:05 pm, it was observed that cross-corridor double smoke doors adjacent to the Exit Stair G903, Electrical Room G821, and the Central Sterile Processing Suite on the Garden Level had louver openings of approximately 15" x 15" on the top half of the doors. The doors would not stop the smoke transfer through the door opening in the 2-hr fire-rated smoke barrier wall, nor meet the requirements of a fire-resistance rated door.

3. On 2/21/17 at 11 am, it was observed that the north leaf of the cross-corridor double smoke doors adjacent to the minor procedure Room 3211 on the 3rd Floor had a delayed-egress locking arrangement, but did not open when tested; and the south leaf of the same pair of smoke doors with the delayed egress locking device did not have a 15-second sign posted on the door.

Item 1 was confirmed by concurrent observation and interview with the facilities supervisor (Staff LS5) and safety specialist (LS6), and Items 2 and 3 were confirmed by the concurrent observation and interview with Staff LS5, Staff LS6, and the assistant regional director (Staff LS3).

Based on observations and interview, the facility did not maintain electrical equipment in accordance with NFPA 101 (2012 edition), sections 19.5.1.1 and 9.1.2, and NFPA 70 - 2011 edition. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 195 on the day of survey.

Findings include:

1. On 2/20/17 at 1:40 pm, observation in room 7328 revealed an electrical outlet was within 2-feet of a water source and was not protected with a GFCI plug. This deficient practice was confirmed by staff LS7 and LS9 at the time of discovery.

2. On 2/20/17 at 2:10 pm, observation in room 7378 revealed an electrical outlet was within 2-feet of a water source and was not protected with a GFCI plug. This deficient practice was confirmed by staff LS7 and LS9 at the time of discovery.

3. On 2/20/17 at 2:35 pm, observation in room 7223 revealed an electrical outlet was within 2-feet of a water source and was not protected with a GFCI plug. This deficient practice was confirmed by staff LS7 and LS9 at the time of discovery.

4. On 2/21/17 at 9:20 am, observation in room 6328 revealed three electrical plug outlets were within 5-feet of a water source and were not protected with a GFCI plug. This deficient practice was confirmed by staff LS7 at the time of discovery.

5. On 2/21/17 at 10:00 am, observation in room 6106 revealed two electrical plug outlets were within 2-feet of a water source and were not protected with a GFCI plug. This deficient practice was confirmed by staff LS7 at the time of discovery.

6. On 2/21/17 at 10:05 am, observation in room 6223 revealed two electrical plug outlets were within 2-feet of a water source and were not protected with a GFCI plug. This deficient practice was confirmed by staff LS7 at the time of discovery.

7. On 2/21/17 at 11:00 am, observation in room 6277 revealed two electrical plug outlets were within 2-feet of a water source and were not protected with a GFCI plug. This deficient practice was confirmed by staff LS7 at the time of discovery.

8. On 2/21/17 at 11:43 am, observation in room 5338 revealed two electrical plug outlets were within 2-feet of a water source and were not protected with a GFCI plug. This deficient practice was confirmed by staff LS7 at the time of discovery.

9. On 2/21/17 at 1:40 pm, observation in the visitor lounge room 5106 revealed an electrical outlet was within 3-feet of a water source and was not protected with a GFCI plug. This deficient practice was confirmed by staff LS7 at the time of discovery.

10. On 2/21/17 at 1:55 pm, observation in room 5228 revealed two electrical plug outlets were within 2-feet of a water source and were not protected with a GFCI plug. This deficient practice was confirmed by staff LS7 at the time of discovery.

11. On 2/21/17 at 2:25 pm, observation in room 5261 revealed two electrical plug outlets were within 2-feet of a water source and were not protected with a GFCI plug. This deficient practice was confirmed by staff LS7 at the time of discovery.

Based on observation and staff interview, the River Woods Ambulatory Care Center (RWACC) facility did not provide and maintain the required pressure differential between negative pressure areas and positive pressure areas per NFPA 101 (2012 edition), sections 21.5.2.1, 9.2, NFPA 99 (2012 edition), section 9.1.3 existing construction or equipment shall be permitted to be continued in use when such use does not constitute a distinct hazard to life, section 9.3.7.5.3.1 mechanical exhaust and section 9.3.1.1 ASHRAE 170. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility.

FINDINGS INCLUDE:

1. On 3/2/2017 at 12:16 PM observation revealed on the 1st Floor in the Decontamination Room next to the Central Sterile Processing Room, using the 'tissue test' to determine air-flow across a surface or between glass panels of those two spaces, the air movement was moving from negative to positive, creating a distinct hazard to life. The HVAC Balance Report was produced 3/22/2016, almost a year ago. An outside mechanical HVAC company was in the ambulatory health care occupancy investigating the air-flow issue through-out the hospital, on day of investigation. No HVAC Report was given at time of survey exit. This deficient practice was confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel) and staff LS7 (Mechanic 3 - Medxcel).

2. On 3/2/2017 at 1:12 PM observation revealed on the 2nd Floor in Isolation Vestibule Room 219, the door would not latch to the frame, creating a cross-contamination air-flow between the isolation vestibule and corridor. The HVAC Balance Report was produced 3/22/2016, almost a year ago. An outside mechanical HVAC company was in the ambulatory health care occupancy investigating the air-flow issue through-out the hospital, on day of investigation. No HVAC Report was given at time of survey exit. This deficient practice was confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel) and staff LS7 (Mechanic 3 - Medxcel).
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Based on record review and staff interview, the River Woods Ambulatory Care Center (RWACC) facility did not provide and maintain the required Smoke Barrier construction, in accordance with NFPA 101 (2012 edition), sections 19.2.2, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3 and 8.5. The Building was originally built as a Type II (222) and has not been changed. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility.

FINDINGS INCLUDE:

1. On 3/3/2017 at 3:15 PM during record review, the CSM-Fire Safety Plan showed that the 'transmission of the signal' to the Glendale Fire Department was missing. The Report of Fire Alarm Annual Testing only identified sending signal to CSM-Central Station, but did not confirm signal went to Glendal Fire Department during the Annual Fire Alarm Test and notation within Quarterly Fire Drills. These record documentation reviews and staff interview were confirmed by staff LS4 (Dir, Fac. Mgmt. - Medxcel), staff LS5 (Fac. Sprvsr - Medxcel) and staff LS7 (Mechanic 3 - Medxcel).
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Based on observation and staff interview, the facility exceeded the 32 gallons capacity of trash or soiled linen containers within a 64 square foot area. This does not conform to NFPA 101 (2012 edition), 19.7.5.7.(2) This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility.

FINDINGS INCLUDE:
1. On 02/21/2017 at 2:30 pm, observation revealed on the First Floor in the Corridor near room E1612, that two 96 gallon trash containers and a 64 gallon trash container were next to each other, in an exit corridor and together they exceeded 32 gallons in a 64 square foot area.
2. On 02/21/2017 at 3:38 pm, observation revealed on the First Floor in the Corridor near room E1612, that two 96 gallon trash containers, a 64 gallon trash container, and a 55 gallon trash container were next to each other, in a reception area open to an exit corridor and together they exceeded 32 gallons in a 64 square foot area.

These deficient practices were confirmed at the time of discovery by a concurrent observation and interview with staff LS4 (Director, Facilities Management Medxcel).


3. On 02/22/2017 at 9:55 am, observation revealed on the Fourth Floor in a waiting space near Room E4634, that two 96 gallon trash containers, a 44 gallon trash container and 90 large folded cardboard boxes were next to each other, adjacent and open to an exit corridor and together they exceeded 32 gallons in a 64 square foot area.
4. On 02/22/2017 at 10:38 am, observation revealed on the Fifth Floor in the Corridor near the center stair, that a 96 gallon trash containers and a large shredder were next to each other, in an area open to an exit corridor and together they exceeded 32 gallons in a 64 square foot area.
5. On 02/22/2017 at 10:48 am, observation revealed on the Fifth Floor in the Corridor near the center stair, that a 96 gallon trash containers in an area open to an exit corridor and together they exceeded 32 gallons in a 64 square foot area.

This deficient practice was confirmed at the time of discovery by a concurrent observation and interview with staff LS7 (Mechanic 3 Medxcel).

Based on observation and interview, the facility failed to maintain proper pressure relationships in one air-borne infectious isolation room, and one procedure room in accordance with NFPA 99 (2012) 9.3.1.1, ASHRAE 170 Part 6, Table 7-1. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility.

Findings include

1. On 2/20/17 at 11:05 am, it was observed that the air-borne infectious isolation Room G315 adjacent to the Trauma Room G376 in the ED Department was not under negative pressure. The room was instead under positive pressure of a magnitude +0.02 in. of water column as displayed on the pressure monitor on the corridor wall of the room causing airflow in the wrong direction.

2. On 2/21/17 at 11:30 am, it was observed that the Endoscopy Procedure Room 3225 was not under positive pressure. Instead, the room was maintained under negative pressure relative to the adjacent spaces causing airflow in the wrong direction. Based on interview with the manager of GI Lab (Staff UU) on 2/22/17 at 11:30 am, the Room 3225 was previously used for a bronchoscopy procedure, but currently used as an endoscopy room. Review of the facility's life safety code plan, Sheet LS103, also showed the room as a bronchoscopy room.

Item 1 of the above deficiencies was confirmed by the concurrent observation and interview with the facilities supervisor (Staff LS5) and safety specialist (LS6), and Item 2 of the above deficiencies confirmed by the concurrent observation and interview with Staff LS5, Staff LS6, and Staff UU.

Based on observation and interview the facility did not provide and maintain an electrical installation compliant with NFPA 99, Chapter 6, Electrical Systems. This observed situation was not compliant with NFPA 70 (2011 edition), 400-8(1) and 517-18. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility.

FINDINGS INCLUDE:
1. On 02/20/2017 at 10:05 am, surveyor observed on the Basement Level in the EVS Locker Room, WB412, that a clock was off the wall, exposing conduit wires.
2. On 02/20/2017 at 10:07 am, surveyor observed on the Basement Level in an unassigned space in the Cart Cleaning Room, that electrical panels were blocked by equipment.
3. On 02/20/2017 at 10:55 am, the surveyor observed on the Basement Level, in the Mechanical Suite Tunnel, that a battery backup light did not turn on when tested.
4. On 02/20/2017 at 11:02 am, the surveyor observed on the Basement Level, in the Electrical Room, near W005, that several circuits in the electrical panel were labeled "unknown".
5. On 02/20/2017 at 11:45 am, the surveyor observed on the Basement Level, in the Locker Room, WB232, that one bulb in the exit sign was burnt out.

These deficient practices were confirmed at the time of discovery by a concurrent observation and interview with staff LS4 (Director, Facilities Management Medxcel).

Based on record review and interview, the Water Tower Medical Commons (WTMC) facility failed to have the proper three (3) electrical switchgear branches, when the Generator is providing power greater than 150 kVA (120 KW) continous load on any transfer switch, for a (Category 1) Electrical System as outlined in NFPA 99 (2012 edition), Section 6.4.2.2.1. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 45 on the day of survey.

FINDINGS INCLUDE:

1. On 2/20/2017 at 9:30 am, during review of the Water Tower Medical Commons (WTMC) Annual Emergency Generator Testing Report inspection records, it was discovered that the facility did not have the required three (3) branches including life safety branch, critical branch and equipment branch. What the facility had were two equipment branches and one life safety branch. At time of exiting, facility could not provide a complete listing of all functions on each electrical branch. The emergency generator for this facility was shared with another facility and was a 625 kVA, 3,180 Volts, diesel generator, by Katolight. A separate organization is currently providing maintenace on this facilty for regular on-going documentation. Staff LS8 (Mechanic 2 - Medxcel) stated they did not know to about this requirement under the NFPA 99 (2012 edition). This deficient practice was confirmed by LS8 (Mechanic 2 - Medxcel) and LS4 (Dir. Fac Mgmt - Medxcel).
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Based on observation and staff interview, the Central Utility Plant (CUP) facility did not provide and maintain the required electrcial system for a Type 1 Essential Electric System (EES) where secondary power is provided to the emergency loads, in accordance with NFPA 101 (2012 edition), sections 21.5.1.1 Utilities, 9.1.2 Electrical Systems, 6.4.4.1.2.1 Circuit Breakers and 700.10 (NFPA 70). Building was originally built as a Factory (F-1) Occupancy for large support equipment to two hospitals and two medical office buildings. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility.

FINDINGS INCLUDE:

1. On 2/22/2017 at 1:33 PM observation revealed on the 3rd Floor in the ATS Switchgear Room, Critical Branch-Electrical Panel identified Breaker as a Spare, but the switch was in a 'ON' position. This deficient practice was visually confirmed by staff LS8 (Mechanic 2 - Medxcel).

2. On 2/22/2017 at 1:37 PM observation revealed on the 3rd Floor in ATS Switchgear Room, Normal Branch-Electrical Panel identified Breaker as a Spare, but the switch was in a 'ON' position. This deficient practice was visually confirmed by staff LS8 (Mechanic 2 - Medxcel).
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Based on observations and staff interview, the facility did not provide fixed electrical wiring in accordance with NFPA 99 (2012 edition) and NFPA 70 (2011 edition). This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 195 on the day of survey.

Findings include:

On 2/20/17 at 1:11 pm, observation and interview revealed in office #6510 that a relocatable multiple outlet device was used to power multiple battery charging devices. This multiple outlet connection device is not listed for this purpose and is not in accordance with NFPA 70 (2011 edition), 400.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff LS11 HVAC Tech - Medxcel, Staff LS16 Manager Medical Imaging and Staff D Director of Labor and Delivery.

Based on observation and interview, the facility failed to install proper signage on the door of the gas cylinder storage room in accordance with NFPA 101 11.3.4.2. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 195 on the day of survey.

Findings include

On 2/20/17 at 1:15 pm, it was observed that the medical gas cylinder storage Room G509 had a sign "Medical Gases" installed on the door, which did not conform to the sign required by NFPA 99. The sign did not include the wording at a minimum CAUTION: OXIDIZING GASES STORED WITHIN NO SMOKING. Oxygen and Nitrous Oxide gas cylinders were stored in the Room G509 adjacent to the Materials Management on the Garden Level in addition to nitrogen and carbon dioxide system cylinders.

The above deficiency was confirmed by interview with the Area Vice President Medxcel (Staff LS1), the director of facilities management (LS4), facilities supervisor (Staff LS5) at the time of exit conference on 2/22/2017 at 3:30 pm.