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Based on interview and observation, the facility failed to ensure each door protecting a corridor opening had suitable means to keep it closed.

Findings:

On 07/24/12 at 10:33 A.M. on the 6th floor of the H building the corridor door between the nurses lounge and the corridor was observed to not have a suitable means to keep it closed as tape had been applied to the latch to disable the latch.

On 07/24/12 at 10:33 A.M. Staff DD verified the finding.

On 07/25/12 at 3:45 P.M. on the 2nd floor of the H building the corridor door between room H2 240A and the corridor was observed to not have a suitable means to keep it closed as tape had been applied to the latch to disable the latch.

On 07/25/12 at 3:45 P.M. Staff DD verified the finding.

On 07/27/12 at 10:36 A.M. on the 9th floor of the Q building the corridor (Q9 0006) door on procedure room Q9 136, Q9 135, Q9 134, Q9 133, Q9 132, Q9 131, and Q9 130 was observed to lack positive latching hardware.

On 07/27/12 at 10:36 A.M. Staff DD confirmed the finding.

On 07/27/12 at 11:01 A.M. on the 9th floor of the Q building the corridor (Q9 0012) door on procedure room Q9 154 and Q9 151 was observed to lack positive latching hardware.

On 07/27/12 at 11:01 A.M. Staff DD verified the observation.

On 07/30/12 at 1:50 P.M. on the 4th floor of the Q building, the door on storage room Q4 224 opening on to corridor Q4 21 was observed to have positive latching hardware that did not latch.

On 07/30/12 at 1:50 P.M. in an interview Staff DD verified the observation.

On 07/30/12 at 2:26 P.M. on the 4th floor of the Q building, the door on housekeeping room Q4 201 opening onto corridor Q4 20 was observed to have positive latching hardware that did not latch.

On 07/30/12 at 2:26 P.M. in an interview Staff DD verified the observation.

On 07/30/12 at 3:03 P.M. on the 3rd floor of the Q building, where there are endoscopy procedures and recovery areas, door to room Q3 210 opening onto corridor Q3 16, was observed to have latching hardware that did not latch.

On 07/30/12 at 3:03 P.M. in an interview Staff DD verified the observation.





21957

Based on facility tour and staff verification it was determined this facility failed to ensure all corridor doors to patient rooms had no impediment to closing of the door. This had the potential to affect all those utilizing this area of the facility. The patient census was 1,113 at the beginning of the survey.

Findings include:

Facility tour took place on 07/27/12 with staff members BB, QQ, UU, and WW1. During tour of the fifth floor corridor identified as J5 2-54 observation was made of a patient room corridor which failed to close properly. This door was leading to patient room J5 2-16.

This finding was verified by all staff members present during tour on 07/23/12.

Based on facility observation and staff verification, the facility failed to ensure that stairways and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of Building One, which consisted on Buildings G, H, and M, was conducted on 07/23/12 through 07/26/12 between the hours of 9:00 A.M. and 4:30 P.M. with Staff BB, CC, DD, FF, PP, JJ, and QQ. The following locations were noted to have fire rated stair way doors in place.

1. Observation of the stair door on third floor of the M building, revealed the one hour fire rated door did not positively latch when the door was tested. Staff present on tour verified the observation.

Based on facility tour and staff verification it was determined this facility failed to ensure all vertical openings, specifically regarding stairwell doors, are enclosed with construction having a fire resistive rating of at least one hour. This had the potential to affect all those utilizing this area of the facility. The facility census was 1,113 at the time of the survey.

Findings include:

Facility tour took place on 08/01/12 with staff members BB, QQ, UU, and WW1. During tour of the second floor observation was made at stairwell T2-ST2 of dual entrance/exit doors located on the east and west side which failed to close and latch properly.
Additionally, observation was made at stairwell T2-ST1 of a single entrance/exit door which failed to close and latch shut.
These findings were verified by all staff members during tour on 07/25/12.

Based on facility observation and staff verification, the facility failed to ensure that doors in an exit passageway, stairway enclosure, horizontal exit or smoke barrier was held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of the required manual fire alarm system, a required smoke detection system, and the automatic sprinkler system, if installed. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of the S Building was conducted on 07/25/12 between the hours of 11:05 A.M. and 5:00 P.M. with Staff FF, II and WW1. The following fire rated doors did not securely latch when tested by releasing from the magnetic hold open device.

1. Located on the ninth floor, fire rated doors were noted to separate the north side of the floor from the south. The door was located near room S9-996. When released from the magnetic hold the fire rated door failed to securely latch in a closed position.

2. Located on the second floor, fire rated doors ( S2-206) were noted to separate the S Building from the T Building. Release of the two-hour fire rated doors from the magnetic hold open, revealed the doors failed to latch when in the closed position. Staff present on tour verified the findings.









21957


Findings include:

Facility tour of building T took place on 08/01/12 with staff members BB, QQ, UU, and WW1. During tour of the fifth floor mechanical room identified as T5-04, observation was made of a one hour fire rated wall separating this mechanical room from two adjacent mechanical rooms. Within the fire rated wall was a door equipped with a self-closing device which was ineffective due to the door being propped open with an approximate three foot long two by four piece of wood.


This finding was verified by all staff members during tour on 07/25/12.

Based on facility observation and staff verification, the facility failed to ensure that doors in an exit passageway, stairway enclosure, horizontal exit or smoke barrier were held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of the required manual fire alarm system, a required smoke detection system, and the automatic sprinkler system, if installed. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of the Crile Building was conducted on 07/31/12 between the hours of 9:05 A.M. and 5:00 P.M. and 08/01/12 between 8:30 A.M. and 4:20 P.M. with Staff FF, II and WW 1. Observation of the second floor revealed two hour fire rated doors located at the skyway entrance and the Crile Building. When manually released from the magnetic hold devices, the doors did not positively latch when in the closed position.

Observation of the door frame revealed the latching mechanism had been removed from the frame causing the doors not to latch. Staff present on tour verified the observations.

Based on observations and staff interviews, the facility failed to ensure two sets of horizontal exit doors closed and latched when released from the hold open device. Additionally, this facility failed to ensure any door in an exit passage was permitted to be held open only by devices arranged to automatically close upon activation of the required manual fire alarm system and its components and assuring doors in stairwells, smoke/fire barriers closed properly. This involved a set of fire doors on the sixth floor and on the fourth floors in the J building in which inpatient ongoing care was being provided by the facility. The total census during this visit was 1,113 patients.

Findings include:

During tour of the J building, on 07/27/12, at 12:47 PM, with Staff JJ, a set of 1 and 1/2 hour fire rated fire doors were observed located outside J6-628, between this building and the Glickman building. These doors were observed on an automatic hold open device. When released from the hold open device, during testing, the doors failed to close entirely and latch. This was verified with Staff JJ at the time the doors were tested.

On 07/26/12, at 2:40 PM, the set of fire doors J73-50 were observed on an automatic hold open device. During testing, these doors failed to latch when released from the hold open device. This was verified with Staff JJ during tour.


21957


Findings include:

Facility tour took place on 07/27/12 with staff members BB, QQ, UU, and WW1. During tour of the basement observation was made of two doors equipped with self-closing devices being propped open with unauthorized devices. Door to room JB-909 was propped open with three cases of computer paper. Door to room JB-124 was propped open with a brick.
Additionally, smoke/fire barrier doors JB-021 and 009283B (separation between S,M and J) failed to close properly when disengaged from the hold open device.

During tour of the fourth floor observation was made of five doors equipped with self-closing devices being propped open with unauthorized devices or failing to close and latch shut when tested. Observation was made of the door to stairwell J4 failing to latch shut. Door to room J4-605 failed to close and latch shut. The north door in room J4-604E was observed to have a wood wedge holding the door open and this caused the south door's closing device to fail to close the door properly. Two hour fire rated door number J4-82 failed to close and latch shut. Stairwell J4-ST6 failed to latch shut. Door J4-214 to a one hour fire rated enclosure failed to close properly.

This finding was verified by all staff members present during tour on 07/23/12.

On 07/24/12 at 9:28 A.M. the door to exit stairwell 4 on the 6th floor of the H building was observed to not completely shut and latch.

On 07/24/12 at 9:28 A.M. in an interview Staff DD verified the observation.

On 07/24/12 at 9:37 A.M. the double doors in the horizontal exit from the 6th floor of the H building to the M building was observed to not close and latch.

On 07/24/12 at 9:37 A.M. in an interview Staff DD verified the observation.

On 07/24/12 at 2:23 P.M. on the 2nd floor of the H building the double doors leading to exit stairwell 4 was observed not to completely close and latch.

On 07/24/12 at 2:23 P.M. in an interview Staff DD verified the observation.

On 07/25/12 at 3:45 P.M. on the 2nd floor of the H building the double doors in the horizontal exit to the M building was observed to not completely close and latch.

On 07/25/12 at 3:45 P.M. in an interview Staff DD verified the observation.

These findings were verified by all staff members present during tour on 07/23/12 to 07/25/12.









21957

Based on facility tour and staff verification it was determined this facility failed to ensure any door in an exit passage way was permitted to be held open only by devices arranged to automatically close upon activation of the required manual fire alarm system and its components. This had the potential to affect all those utilizing this area of the facility. The facility census was 1,113 at the beginning of the survey.

Findings include:

Facility tour took place on 07/23/12 with staff members BB, QQ, UU, and WW1. Observation was made of room G5-135 on the fifth floor having a door equipped with a self-closing device which was ineffective due to a rubber wedge placed under the bottom of the door to hold it in the open position.

Based on facility observation and staff interview and verification, the facility failed to ensure that access to exits was marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. The facility had a census of 1113 patients at the time of the survey.

Findings included:

On 07/30/12 between the hours of 1:30 P.M. and 4:00 P.M. tour of the Cole Eye Institute was conducted with Staff AA, FF and WW1. Tour of the first floor revealed the presence of an ambulatory surgical area with four operating rooms. Observation of the pre-operative and post-operative areas revealed there was no directional signs to show the way out of the area.

Interview of a staff nurse regarding how to locate the way out of the area, revealed the staff would show the patients the way out. Staff FF verified that directional exit signs were not in place to show the way out.

Based on observation and interview, the facility failed to ensure access to each exit was marked by an approved, readily visible exit sign.

Findings:

On 07/27/12 at 9:24 A.M. on the 10th floor in the Q building the evacuation plan posted near Stair #1-which was near a small waiting area--was reviewed. The plan showed a path of egress traveling west across lobby Q10 0000 through a door and into open office Q10 111. However, while standing at the stairwell, an exit sign could not be observed over said door communicating between the lobby and the open office.

On 07/27/12 at 9:24 A.M. in an interview Staff DD confirmed the evacuation plan showed a path of egress traveling west across lobby Q10 0000 through a door and into open office Q10 111 and confirmed an exit sign could not be observed over said door communicating between the lobby and the open office.

On 07/27/12 at 1:25 P.M. on the 7th floor of the Q building the evacuation posted near Stair #1-which was near a large patient waiting area-was reviewed. The plan showed the path of egress as traveling north through the waiting area and then turning west on to corridor Q07 0014. However, when standing at the stairwell, an exit sign directing people to turn west on to corridor Q07 0014 was not observed.

On 07/27/12 at 1:25 P.M. Staff DD confirmed the evacuation plan showed a path of egress traveling north through the waiting area and then turning west on to corridor Q07 0014 and that an exit sign directing people to turn west on to corridor Q07 0014 was not observed.

On 07/30 at 11:50 A.M. on the 4th floor of the Q building while standing on the western end of corridor Q04 011 an exit sign was not observed at the end directing people through a set of double doors and on to corridor Q04 010 and stair #2 for a path of egress.

On 07/30/12 at 11:50 A.M. Staff DD confirmed an exit sign could not be observed at the end of corridor Q04 011 directing people through a set of double doors and on to corridor Q04 010 and stair #2 for a path of egress.

On 07/23/12 at 2:10 P.M. on the 8th floor of the H building, while standing in the southern portion of corridor H80 53, an exit sign leading to northern exit staircase H 08 STM4 could not be observed.

On 07/23/12 at 2:10 P.M. Staff JJ verified the observation.

On 07/23/12 at 3:20 P.M. on the 7th floor of the H building, while standing in the southern portion of corridor H70 53, an exit sign leading to the horizontal exit to the M building could not be observed.

On 07/23/12 at 3:20 P.M Staff JJ verified the observation.

On 07/24/12 at 9:31 A.M. on the 6th floor of the H Building, while standing in the southern portion of corridor H60 112, an exit sign leading to the horizontal exit to the M building could not be observed.

On 07/24/12 at 9:31 A.M. in an interview, Staff DD verified the observation.

On 07/25/12 at 9:55 A.M. on the second floor of the H building, while standing in the western portion of corridor H2 279, an exit sign could not be observed on the other end to direct people on whether to travel north, south or either way to exit the building.

On 07/24/12 at 9:55 A.M. in an interview, Staff DD verified the observation.

On 07/24/12 at 2:45 P.M. on the second floor of the H building, no exit sign was observed while standing inside Suite #1.

On 07/24/12 at 2:45 P.M. in an interview Staff DD verified the observation.

On 07/24/12 at 3:02 P.M. on the second floor of the H building, no exit sign was observed while standing inside the suite containing nurses station H20 0000.

On 07/24/12 at 3:02 P.M. in an interview Staff DD verified the observation.

On 07/25/12 at 10:00 A.M. on the first floor of the H building, the evacuation plan posted near the door the opens from a kitchen area to corridor H01 0013 listed the path from the kitchen area through said door to the corridor as a path of egress. However, when standing in the kitchen, an exit sign was not posted above the door.

On 07/25/12 at 10:00 A.M. in an interview Staff DD confirmed the path of egress on the evacuation plan and confirmed the lack of exit signage.

These findings were verified by all staff present during tour on 07/23/12 to 07/25/12.










21957

Based on facility tour and staff verification it was determined this facility failed to ensure all accesses to exits were marked appropriately to ensure all occupants would be able to reach an exit which was not readily apparent. This had the potential to affect all those who utilized these areas of the facility. The facility census was 1,113 at the beginning of the survey.

Findings include:

Facility tour took place on 07/23/12 with staff members BB, QQ, UU, and WW1. Facing west within corridor G3-01 and at the smoke barrier doors by storage room G3-88, observation was made of an exit sign mounted at the end of the corridor outside of lounge G3-80. This exit sign was observed to have a directional arrow pointing flow to the left but failed to have the directional arrow also pointing to the right to a designated exit.

Based on facility tour and staff verification it was determined this facility failed to ensure all accesses to exits were marked appropriately to ensure all occupants would be able to reach an exit which was not readily apparent. This had the potential to affect all those who utilized these areas of the facility. The facility census was 1,113 at the beginning of the survey.

Findings include:

Facility tour took place on 08/01/12 with staff members BB, QQ, UU, and WW1. Within the basement outside general storage room TB-10 and above the door observation was made of an exit sign with directional arrows pointing occupants to the right and left. Facing the sign and looking to the right, observation was made of no visible exit signage. This writer followed the corridor for approximately 90 feet to an unsigned stairwell access on the right hand side. This stairwell was located in "S" building within corridor SB-14 and identified as stairwell SB-ST3.
Additionally, continuing down corridor SB-14 to the intersecting corridor SB-54 observation was made of no visible exit sign to the right directing occupants to the exit access in corridor SB-35.

These findings were verified by all staff members during tour on 07/25/12.

Based on facility observation and staff interview and verification, the facility failed to ensure door openings in smoke barriers had at least a 20-minute fire protection rating. Doors were to be self-closing or automatic closing in accordance with 19.2.2.2.6. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of Building One, which consisted of Buildings G, H, and M, was conducted on 07/23/12 through 07/26/12 between the hours of 9:00 A.M. and 4:30 P.M. with Staff BB, CC, DD, FF, PP, JJ, and QQ. The following locations were noted to have doors located in smoke barriers that did not close .

1. Observation of smoke barrier door located at 010431B was observed to fail to close when tested. Staff present on tour verified the observation.

Based on observations and staff interviews, the facility failed to ensure one set of smoke barrier doors closed when released from the hold open device. These smoke barrier doors were located in the corridor by the main entrance emergency waiting room. The total census during this visit was 1,113 patients.

Findings include:

During tour of the E building, on 07/31/12, at 2:50 P.M., with Staff JJ, a set of non-latching smoke barrier doors was located outside room the main emergency room waiting room by room E 01-0146. These doors were observed on an automatic hold open device. When released from the hold open device, during testing, the doors failed to close entirely, leaving a 2-3 inch gap. This was verified with Staff JJ at the time the doors were tested.

Based on facility observation and staff verification, the facility failed to ensure that one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. When the approved automatic fire extinguishing system option was used, the areas were separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of the Crile Building was conducted on 07/31/12 between the hours of 9:05 A.M. and 5:00 P.M. with Staff FF, II and WW1. The following findings were noted in storage areas:

1. Located on the twelfth floor, a dirty utility room was observed. Observation of the room revealed the door had no self-closing device in place.

2. Located on the seventh floor, room A7-116D was observed to be a medical supply storage room. No self-closing device was on the door to the room.

3. A storage room identified as A6-401 was observed. The storage area had no self-closing device on the door.

4. Room A6-508 identified as the apprentice copier room was noted to have storage of paper products. The door to the storage room did not have a self closing device in place.

5. Room A5-420 was noted to be a storage room for medical records and other combustible items. The door to the room did not have a self-closing device.

6. Room A 5-507 was identified as a storage room. The door to the room had no self closing device in place.

7. Rooms A2-209, an x-ray department soiled utility room, A2-539, a storage room, A2-533 a storage room and A2-117, a storage area for miscellaneous combustible items did not have self closing devices on the doors.

8. Room A3-153 a storage room in the adult endoscopy center was noted to have no closer on the door.

9. Two soiled utility rooms, A3-185 and A3-138, were observed to have no self closing devices on the doors.

10. Room A1-172, a soiled utility room was noted to have no self closing device on the door to the room.

Staff present on tour verified the observations.

Based on facility observation and staff verification, the facility failed to ensure that one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. When the approved automatic fire extinguishing system option was used, the areas were separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of the S Building was conducted on 07/25/12 between the hours of 11:05 A.M. and 5:00 P.M. with Staff FF, II and WW1. Located on the seventh floor, a storage area identified as S7-750, was noted to have no automatic sprinkler system protection. Observation and testing of the room door revealed there was no noted fire rating on the door to the room and the door failed to securely latch when in the closed position. Items stored in the room were combustible items in the form of office supplies.

Located on the third floor of the S Building was a storage area which contained notebooks, reading materials and cardboard. The room was not provided with automatic sprinkler protection. The door to the room was noted to be a sliding, wood, door with no identifiable fire rating. The door did not have a self closing device.

Located in the basement area, a room identified as the clinical engineering project room (SB-62) was observed. The room was noted to be very cluttered with card board boxes, various clinical equipment and many other items. There was no sprinkler system or smoke detection in the room. Ceiling tiles were missing from the room.

Staff present on tour verified the observations of the storage areas.


21957


Findings include:

Facility tour took place on 08/01/12 with staff members BB, QQ, UU, and WW1. During tour of the basement's two hour fire rated storage room identified as TB-20, observation was made of the east wall door not equipped with an automatic or self-closing device.
Additionally, observation was made of the west door within the same room which was part of a two hour fire rated building separation. This door failed to have a fire resistance rating and also failed to open and close properly due to the top right corner of the door rubbing against the door frame.

These findings were verified by all staff members during tour on 07/25/12.

Based on facility observation and staff interview and verification, the facility failed to ensure that hazardous areas are protected with doors which are equipped with self-closing or automatic closing devices which enables the door to close and latch properly. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of Building One, which consisted of Buildings G, H, and M, was conducted on 07/23/12 through 07/26/12 between the hours of 9:00 A.M. and 4:30 P.M. with Staff BB, CC, DD, FF, PP, JJ, and QQ. The following storage areas were noted to have doors in place that did not close as required.

1. Located in the M Building, on the third floor, a storage room was noted to have a door ( H3204) that failed to latch when in the closed position. Staff present on tour verified the observation.





21521

On 07/24/12 at 9:58 A.M. on the 6th floor, area B--designated as a hazard/clean utility area on the schematic--door H60 113A was observed to be on a self closer that did not latch.

On 07/24/12 at 9:58 A.M. in an interview Staff DD verified the findings.

On 07/24/12 at 2:43 P.M. on the 2nd floor, area L-designated as a hazard/storage area-door H20 022 was observed to be on a self closer that did not latch.

On 07/24/12 at 2:43 P.M. in an interview, Staff DD verified the observation.

On 07/24/12 at 3:10 P.M. the door H2 02B opening from an area designated as hazard I on a schematic and containing work supplies, was observed to be on a self closer that did not latch.

On 07/24/12 at 3:10 P.M. in an interview Staff DD verified the observation.

On 07/25/12 at 2:45 P.M. double doors to a hazard area enclosed with 2 hour walls and containing medical gases was observed to be on a coordinator that did not function to close the doors.

On 07/25/12 at 2:45 P.M. in an interview Staff DD verified the observation.

Staff present on tour verified the observation.

Based on facility observation and staff interview and verification, the facility failed to ensure that when the approved automatic fire extinguishing system option was used, the areas were separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door were permitted. The facility had a census of 1113 patients at the time of the survey.

Findings included:

On 07/30/12 between the hours of 9:30 A.M. and 12:00 P.M., tour of the R Building was conducted with Staff FF, TT and OO. Observation of a soiled utility room, R1-067, revealed there was no self closing device on the door to the room.

Located on the second floor was a storage room where chairs, desks and boxes were placed. Observation of the room revealed there was no self closing device on the door to the room.

Room R2-079 was identified as a storage room. Observation of the room revealed an arm of the self closing device was missing which would not allow the door to close.

Staff present on the tour verified the observation.

Based on facility observation and staff interview and verification, the facility failed to ensure exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of Building One, which consisted of Buildings G, H, and M, was conducted on 07/23/12 through 07/26/12 between the hours of 9:00 A.M. and 4:30 P.M. with Staff BB, CC, DD, FF, PP, JJ, and QQ.

Tour of the seventh floor revealed a large area for patient rehabilitation services. The area was identified as the gym. Tour inside the gym revealed the presence of three exit doors. Located near the center of the room was an exit sign which noted the way out to the exit corridor.

Following the sign toward the door revealed the exit door was blocked by a table with items stacked on it. Other items in the exit way was a chair and additional boxes . Staff present on tour verified the way out of that exit door was blocked and inaccessible.

On 07/30/12 from 2:41 P.M. to 4:00 P.M. a tour was conducted of the 3rd floor of the Q building. The tour and schematic revealed the floor contained three suites: a non-sleeping procedure suite of 5478 square feet (1), a non-sleeping prep/recovery suite of 5914 square feet (2), and a waiting area of 705 square feet (3). By observation and review of the schematic, Suite #1 had one exit into corridor Q03 16, and the other into Suite #2. By observation and review of the schematic, Suite #2 had one exit into corridor Q03 14, another into Suite #1, and two others into Suite #3. By observation and review of the schematic, Suite #3 had one exit into lobby Q03 116, and another into Suite #2.

On 07/30/12 during the tour from 2:41 P.M. to 4:00 P.M. in an interview Staff DD confirmed the findings.




21957

Based on facility tour and staff interview it was determined this facility failed to ensure any suite of rooms greater than 1,000 sq. ft. has at least two exit access doors remote from each other and the exit accesses may not exit through an intervening suite. This had the potential to affect all those utilizing this area of the facility. The facility census at the beginning of the survey was 1,113.

Findings include:

Facility tour took place on 08/01/12 with staff members BB, QQ, UU, and WW1. During tour of the fifth floor post anesthesia care unit (PACU Suite) which had a total of 5,250 sq. ft., observation was made of three exit accesses, two of which had egress access through intervening suites. The floor plan was reviewed and verified this finding. Staff BB stated on 08/01/12 during tour of the PACU that they were aware of this and were planning on applying for a waiver after a citation was issued.

Based on observation the facility failed to comply with NFPA 110 5-3, referenced in NFPA 101 7.9, referenced in NFPA 101 19.2.9.1, by failing to have battery powered emergency lighting in the generator room in building rr.

Findings:

On 07/26/12 at 3:44 P.M. a tour was conducted of the generator room. The room was observed to have emergency lighting, but the lighting did not have battery power backup.

On 07/26/12 at 3:44 P.M. Staff DD confirmed the room did not have battery power back up and said the generators themselves would run the lights in the room if power was lost.

Based on facility observation and staff interview and verification, the facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition and was inspected periodically. This was with regards to continuous or non continuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that could prevent the pattern from fully developing. The facility had a census of 1113 patients at the time of the survey.

Findings included:

On 07/30/12 between the hours of 9:30 A.M. and 12:00 P.M., tour of the R Building was conducted with Staff FF, TT and OO. The following areas were noted to have items stored to that could cause obstructions to the sprinkler flow.

1. Observation of storage room R3-087 revealed card board boxes stored significantly less than 18 inches from sprinkler deflectors.

2. Observation of storage room R4-063 was noted to have metal shelving with items stacked significantly closer than 18 inches from sprinkler deflectors.

Staff present on the tour verified the observations.

Based on facility observation and staff interview and verification, the facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition and was inspected periodically. This was with regards to continuous or non continuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that could prevent the pattern from fully developing. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of the Cole Eye Building was conducted on 07/30/12 between the hours of 1:30 A.M. and 4:00 P.M. with Staff AA FF, and WW 1. Observation of a first floor storage room revealed the room was used to store medical files. The room was observed to have files and boxes placed significantly closer than 18 inches from the sprinkler deflector.

Staff present on tour observed the storage room and verified the finding.

Based on facility observation and staff interview and verification, the facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition and was inspected periodically. This was with regards to continuous or non continuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that could prevent the pattern from fully developing. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of the Crile Building was conducted on 07/31/12 between the hours of 9:05 A.M. and 5:00 P.M. with Staff FF, II and WW 1. The following areas were observed to have items stored within 18 inches of the sprinkler deflector.

1. Located on the fifth floor, storage area A5503 had boxes and paper products placed closer than 18 from the sprinkler defector.

2. Located on the fourth floor, at A 4-104 and A 4-106, cubicle partition were noted to extend significantly closer than 18 inches from the sprinkler deflector. The partitions could impede the spray pattern of the sprinkler.

3. At A 3-245, a cabinet with items stacked on top of the cabinet was closer than 18 inches from the sprinkler deflector.

Staff present on tour observed and verified the observations.

Based on facility observation and staff interview and verification, the facility failed to ensure the automatic sprinkler system, was installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. This was with regards to continuous or non continuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that could prevent the pattern from fully developing. Additionally, the facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition specifically in regards to dirt, dust and debris on the sprinkler heads. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of Building One, which consisted of Buildings G, H, and M, was conducted on 07/23/12 through 07/26/12 between the hours of 9:00 A.M. and 4:30 P.M. with Staff BB, CC, DD, FF, PP, JJ, and QQ. Observation of storage areas revealed items placed significantly closer than 18 inches from the sprinkler defector.

Located in the M Building, on the fourth floor, was a room noted to be the Children Life storage room. The room was provided with sprinkler system protection. Storage of games, puzzles, crafts and additional combustible items were stacked to the ceiling. Staff present on tour verified the items in the room were too close to the sprinkler defectors. Staff in the area began to address the storage issue immediately.

Located on the second floor of the M Building was storage room M2-171. Observation of the left side of the room revealed stacked paper cups and paper products, placed less than 18 inches from the sprinkler deflector. Staff present on tour verified the findings.




21521

On 07/23/12 at 9:50 A.M. a tour of the 9th floor of the building was begun. Two sprinkler heads with dust obscuring the red fluid in the glass bulb were observed in the corridor 09 003, and on the east wall of the smoking room (09 003B) two additional sprinkler heads with dust obscuring the red fluid in the glass bulb were observed.

On 07/23/12 at 12:57 P.M. and at 1:05 P.M. in an interview Staff JJ confirmed the findings.

On 07/24/12 at 11:22 A.M. the sprinklers in the laundry and rubbish chutes on the 8th floor was observed to have dust in clumps surrounding the glass bulb.

On 07/24/12 at 11:22 A.M. in an interview, Staff DD confirmed the finding.

On 7/25/12 at 4:00 P.M. a tour of "The Well" restaurant area on the first floor of the building was conducted. Four sprinkler heads running north/south perpendicular to the cashier station were observed to have their glass bulbs covered in dust.

On 07/25/12 at 4:00 P.M. in an interview Staff DD confirmed the findings.

On 07/26/12 at 11:15 A.M. in the basement of the H building, room HB 84 was observed to have computer equipment and cardboard boxes within 18 inches of the ceiling.

On 07/26/12 at 11:15 A.M. in an interview, Staff DD confirmed the findings.





21957


Findings include:

Facility tour took place on 07/23/12 with staff members BB, QQ, UU, and WW1. Observation was made within each trash chute access from the first floor through the eleventh floor of the G building, the sprinkler heads being thickly coated with what appeared to be the contents of wet trash which had accumulated and dried over a long period of time. Staff BB had taken a picture of at least two sprinkler heads which were covered so much with this debris that it was almost impossible to identify them as sprinkler heads.

This finding was verified by all staff members present during tour on 07/23/12.

Based on facility tour and staff interview it was determined this facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition specifically in regards to storage stacked up beyond the 18 inch requirement so as not to impede the spray pattern of the sprinklers in the event of an emergency. Additionally, having ceiling tiles placed in a position such as to impede the spray pattern of the sprinklers.

Findings include:

Facility tour took place on 07/27/12 with staff members BB, QQ, UU, and WW1. During tour of the second floor corridor identified as J2-81 observation was made of storage closet J2-816 literally stuffed full of storage items in a manner which prevented this surveyor from being able to identify any sprinklers in the closet.

During tour of corridor J2-90 observation was made of two side by side storage closets housing the lead aprons for the radiology department. Within the closet this writer observed no sprinkler heads. Staff BB stated the sprinkler heads had been covered by the drop down ceiling. The ceiling tiles were removed and the sprinkler heads were able to be identified.

This finding was verified by all staff members present during tour on 07/23/12.

Based on facility tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were not mounted greater than five feet from the floor according to the National Fire Protection Association (NFPA) 10, Chapter 1-6.10.

Findings include:

Facility tour took place on 08/01/12 with staff members BB, QQ, UU, and WW1. During tour of the basement, specifically the pharmacy JB-122 and the radiochem room JB-124, two portable fire extinguishers, one in each room, was mounted higher than the five foot requirement.

This finding was verified by all staff members present during tour on 07/23/12.

Based on facility tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were not mounted greater than five feet from the floor according to the National Fire Protection Association (NFPA) 10, Chapter 1-6.10.

Findings include:

Facility tour took place on 08/01/12 with staff members BB, QQ, UU, and WW1. During tour of the second floor corridor T2-100, observation was made of two portable fire extinguishers mounted greater than five feet from the floor. They were located by room T2-8 and T2-15.
Additionally, another portable fire extinguisher located on the fifth floor in mechanical room T5-04 was mounted greater than five feet from the floor.

These findings were verified by all staff members during tour on 07/25/12.

Based on review of facility documentation and staff interview and verification, the facility failed to ensure that fire and smoke dampers complied with the provisions of NFPA 90A with regards to testing. The facility had a census of 1113 patients at the time of the survey.

Findings included:

On 07/27/12 between 8:30 A.M. and 2:00 P.M. review of facility documentation was completed with regards to fire and smoke damper testing. Present for documentation review was Staff DD1, GG,and ZZ4. Review of the fire/ smoke damper testing revealed that testing was completed between May 2008 and April 2012.

Review of the documented testing revealed that some dampers could not be tested due to obstructions or an accessibility issue that prevented testing. Building E was noted to have twenty-three dampers that could not be tested due to obstructions. Six of 23 dampers were located on the second floor and 17 dampers were located in the third floor.

Interview of staff present at the document review verified that obstructions due to construction had to be addressed before many of the dampers could be tested.

Based on review of facility documentation and staff interview and verification, the facility failed to ensure that fire and smoke dampers complied with the provisions of NFPA 90A with regards to testing. The facility had a census of 1113 patients at the time of the survey.

Findings included:

On 07/27/12 between 8:30 A.M. and 2:00 P.M. review of facility documentation was completed with regards to fire and smoke damper testing. Present for documentation review was Staff DD1, GG,and ZZ4. Review of the fire/ smoke damper testing revealed that testing was completed between May 2008 and April 2012.

Review of the documented testing revealed that some dampers could not be tested due to obstructions or an accessibility issue that prevented testing. The following dampers were not tested due to obstructions or accessibility on the floors of the buildings.

1. Located in the H Building, a total of 94 dampers were not tested between the H building basement and H9. Twenty -two of the 94 dampers the could not be tested were located on H3

2. Located in the M Building, a total of 14 dampers could not be tested,. The inaccessible dampers were located on the first, sixth, seventh and ninth floor of the M Building.

3. Located in the G Building , a total of 3 dampers could not be tested. Those dampers were located on the third and fifth floors.

Interview of staff present at the document review verified that obstructions due to construction had to be addressed before many of the dampers could be tested.

Based on facility observation and staff interview and verification the facility failed to ensure existing linen and trash chutes, including pneumatic rubbish and linen systems, that opens directly onto any corridor was sealed by fire resistive construction to prevent further use. Additionally, it was determined this facility failed to ensure all existing trash and linen chutes were equipped with a locking device in which a key is required to open the door. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of Building One, which consisted of Buildings G, H, and M, on 07/23/12 through 07/26/12 between the hours of 9:00 A.M. and 4:30 P.M. was conducted with Staff BB, CC, DD, FF, PP, JJ, and QQ. The following locations were noted to have trash or soiled linen chutes that were unlocked and accessible to the corridor.

1. On 07/23 between the hours of 12:45 P.M. and 4:40 P.M. and 07/24/12 between 9:00 A.M. and 4:00 P.M. tour of Building M was completed. The following floors of the M building were noted to have trash or linen chutes unlocked.;

1. Located on the sixth floor was an unlocked trash chute located in a corridor.

2. Located on the second floor was an unlocked room where trash and linen chutes were located. Both chute doors were observed to be unlocked. Staff present on tour verified the observations.


21521


Findings:

From 07/23/12 at 12:50 P.M. to 07/26/12 at 11:40 A.M., a tour of the H Building, also known as the Hospital Building, was completed. On floor 8, 7, 6, 5, 3, and 2 a chute room was observed on each floor. On each floor the door to the chute room was not locked. Each chute room was observed to have both a laundry and rubbish chute. Each chute room was observed to have neither door to each chute lock.

On 07/24/12 at 9:52 A.M. in an interview, Staff DD confirmed the door opening into the chute room did not lock, nor did the chute doors themselves.




21957


Findings include:

Facility tour took place on 07/23/12 with staff members BB, QQ, UU, and WW1. Observation was made on the first floor within the trash/linen chute room identified as G1-213 of both chute doors lacking a key lock. Additionally, the door to the trash/linen room was equipped with a door lock but was also not secured.

Observation was made on the second floor within the trash/linen chute room identified as G2-213 of both chute doors lacking a key lock. Additionally, the door to the trash/linen room was equipped with a door lock but was also not secured.

Observation was made on the fifth floor within the trash/linen chute room identified as G5-135 of the trash chute door lacking a key lock. It was also noted that the linen chute door was equipped with a key lock but was not secured. Additionally, the door to the trash/linen room was equipped with a door lock but was also not secured.

Observation was made on the seventh floor within the trash/linen chute room identified as G7-59 of both chute doors lacking a key lock. Additionally, the door to the trash/linen room was equipped with a door lock but was also not secured.


These findings were verified by all staff members present during tour on 07/23/12.

Based on observations and staff interviews, the facility failed to ensure chute rooms were used exclusively for accessing the chute openings in accordance with the code at 8.4, did not ensure chute rooms were separated from the service elevator with a one hour fire resistance rated barrier in accordance with the code at Section 18.5.4 and 9.5.1., and failed to ensure chute rooms were locked in accordance with NFPA 82, 3.2.4.3.2. This involved 8 of 8 floors in patient care areas. The facility had a total census of 1,113 at the time of the survey.

During tour of the facility, on 07/26/12 and 07/27/12, between 9:00 A.M. and 3:00 P.M., and on 07/31/12, between 9:00 A.M. and 11:00 A.M., with Staff JJ, QQ, and HH, a combination linen chute, trash chute, and service elevator room was observed on patient care floors 1 through floor 8. These rooms were located in the center of each floor between Units 1, 2, and 3. The room numbers for the sixth floor was J63-57, and for the seventh floor room J73-57. The eighth floor room was directly above these two rooms. Observations of these rooms revealed the linen chute, trash chute, and service elevator were located in the same room, without a one hour fire rated separation between the chutes and the elevator. The doors to the hallways were observed not locked during tour. There were no locking mechanisms observed on the gravity chute doors.

On 07/27/12, at 11:10 A.M., this chute/elevator room was observed with Staff JJ. This employee stated the chute rooms on floors 1 through 8 were set up the same, with the service elevator in the same room as trash and linen chutes, and verified the lack of a one hour fire rated separation between the chutes and the elevator. During the aforementioned tour, Staff QQ and HH also verified the construction of these rooms.

On 07/26/12 and 07/27/12, between 9:00 A.M. and 3:00 P.M., and on 07/31/12, between 9:00 A.M. and 11:00 A.M., the chute doors throughout floors 1 through 8 were observed with handles on the laundry and trash chute doors which lacked a key mechanism; therefore, the chute doors could not be locked. Although the doors to the hallway were equipped with a locking mechanism, these doors were not locked during tour.

Observations of these chute doors, and hallway corridor doors for these rooms, revealed the following:

a) The corridor doors to trash and linen chute rooms located in J4-623, J5-3116, J5-213, J5-640, J51-113 revealed the corridor doors were unlocked. This was verified with Staff BB and WW1 during tour on 07/31/12.

b) Chute rooms J63-116, J63-57, J6-631, J62-131, and J73-57 were observed with a laundry and/or trash chutes which were observed without a locking mechanism on the chute doors. The corridor door to these chute rooms were observed unlocked on tour. These chute rooms and doors were verified with Staff JJ during tour on 07/27/12 between 10:20 A.M. and 1:25 PM.

Based on facility observation and staff interview and verification, the facility failed to ensure that soiled linen or trash collection receptacles did not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space was to not exceed .5 gal/sq ft (20.4 L/sq m). A capacity of 32 gal (121 L) is not exceeded within any 64 sq ft (5.9-sq m) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) were to be located in a room protected as a hazardous area when not attended. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of the Cole Eye Building was conducted on 07/30/12 between the hours of 1:30 A.M. and 4:00 P.M. with Staff AA FF, and WW 1. Observation of a first floor surgical area revealed the presence of one soiled linen cart and two large trash receptacles sitting in a surgical area corridor. The three carts were large, wheeled receptacles verified by staff as being 16 cubic feet in size. Staff present from the surgical area verified the carts were kept in that area.

Staff present on tour observed the storage room and verified the finding.

Based on observations and staff interviews, the facility failed to ensure greater than 300 cubit feet (over 12 e-tanks) was stored in accordance with NFPA 99, 4.3.1.1.2. This involved two areas of the J building in patient care areas on the 6th floor. The total census during the survey was 1,113 patients.

Findings include:

During tour of the J building, with Staff JJ, oxygen exceeded 300 cubit feet in one smoke compartment and was not stored in a one hour fire rated separation which was vented to the outside. Ordinary electrical wall fixtures in this room were observed less than 5 ft above the floor.

a) On 07/27/12, at 11:35 AM, tour with Staff AA1 and JJ, the J6-1 smoke compartment was observed with 15 e-tanks of oxygen (360 cu. feet). It was verified with Staff JJ the amount of oxygen in this smoke compartment exceeded 300 cubit feet and was not stored in accordance with NFPA 99.

b) On 7/27/12, at 12:50 PM, room J6-621A was observed with 20 E tanks of oxygen. This room opened directly into the egress corridor. According to Staff JJ and BB1 (Manager of Respiratory Care for Heart Center), at the time of tour, this was an oxygen storage area for respiratory. The room was observed with electrical switches less than five feet above the floor. The room was verified not vented to the outside.






21957


Findings include:

Facility tour took place on 08/01/12 with staff members BB, QQ, UU, and WW1. During tour of the fifth floor corridor identified as J 5-66 and specifically in the one hour fire rate room J5-635 observation was made of one H cylinders of medical air, 18 cylinders of medical air, two of which were not secured. Additionally, the room was observed to not have a medical gas sign posted outside the door, no dedicated ventilation system and the electrical light switch and outlets were not located above the required five foot or greater level. Also, the room was utilized to store medical equipment.

These findings were verified by all staff during tour of the facility on 08/01/12.

Based on observations and staff interviews, the facility failed to ensure greater than 300 cubit feet (over 12 e-tanks) was stored in accordance with NFPA 99, 4.3.1.1.2. This involved two of three smoke compartments in the operating room area of the E building on the second floor. The total census during the survey was 1,113 patients.

Findings include:

During tour of the E building, with Staff JJ, oxygen exceeded 300 cubit feet in two smoke compartments in the operating room area, and was not stored in a one hour fire rated separation which was mechanically vented to the outside. Ordinary electrical wall fixtures in these smoke compartments were observed less than 5 ft above the floor.

On 07/31/12, between 3:50 P.M. and 5:03 P.M., a tour was conducted with Staff JJ and Staff EE1 (Nurse Manager of Neurosurgery) on the second floor of the E building. This floor was observed with operating rooms suites which were divided into 3 different smoke compartments. The smoke compartment for operating rooms #19-25 was observed with 12 e-tanks of oxygen in a cart in the corner of the hallway. Operating room #22 was observed with 2 additional e-tanks of oxygen, for a total of 480 cubic feet of oxygen in this smoke compartment. Interview with Staff EE1, during this tour, revealed all operating rooms have at least one e-tank of oxygen.

The smoke compartment for operating rooms #7-18 were observed with 11 e-tanks of oxygen by room E2-44, in the main egress corridor. In addition, Staff EE1 verified each OR contained one e-tank of oxygen for a total of 23 e-tanks of oxygen in this smoke compartment. The total amount of oxygen stored in this smoke compartment was 552 cubit feet.

The aforementioned observations were verified with Staff JJ during tour.











'

Based on observation and interview, the facility failed to store medical gas in accordance with NFPA 99.
Findings:
On 07/25/12 at 3:00 P.M. on the 2nd floor of the H building, in the west side that contains 15 operating rooms, in the west end of corridor H02 0025, 3 250 cubic feet tanks of medical gas each chained to a dolly and aligned on the north side of the corridor were observed.

On 07/25/12 at 3:00 P.M. Staff DD confirmed the storage of the medical gas.

On 07/25/12 at 3:00 P.M. Staff FF1 in an interview said the gases were stored there for cases "across the street" because they lack the capability to have their own.

39.2.1.1
All means of egress shall be in accordance with Chapter 7 and this chapter.

7.1.10.2.1
No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Based on facility tour and staff interview and verification, the facility failed to ensure the facility exit egress was maintained in accordance with Chapter 7 with regards to furnishings and objects in an exit egress. The facility had a census of 1113 patients at the time of the survey.

Findings included:

On 07/30/12 between the hours of 9:30 A.M. and 12:00 P.M., tour of the R Building was conducted with Staff FF, TT and OO. Observation of the first floor revealed an exit corridor close to a pharmacy. A door was located at the end of the exit corridor. Review of the area revealed the exit corridor was used as a storage area.

The corridor contained a refrigerator, five steel shelves and boxes stored in the area. Passage through the corridor was narrowed to less than 36 inches. Staff from the pharmacy stated the corridor was shared with another business located across a hall. Both business used the corridor as storage.

Staff FF, present on tour, verified the corridor was not to be used as a storage area.

Based on observations, staff interview, and documentation of battery back-up lighting testing, the facility failed to test battery pack lights in accordance with the code at 7.9.3. This involves 5 of 5 battery back-up lights on the 3rd floor where the sleep center was located. The total census during the survey was 1,113 patients.

Findings include:

A tour was conducted on the third floor of the facility on 08/02/12, between 4:08 P.M. and 5:00 P.M., with Staff JJ. The third floor corridor was observed with 5 battery wall pack lights. When tested, during this visit, four of five battery packs illuminated; however, the battery wall pack located by Room 326 failed to work when the test button was pushed by Staff JJ.

On 07/23/12, a review of facility documentation for these battery packs revealed there was no 30 second every 30 day testing of the lights as required by the code. During this tour, this was verified per interview with Staff JJ, and per interview with the hotel manager, who stated there was no documented evidence of monthly testing of these battery back-up lights.

39.3.2.1
Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

Based on observation and interview, the facility failed to ensure 12 pallets holding multiple packages of paper, some stacked as high as four feet, were protected in accordance with Section 8.4.

Findings:

On 07/31/12 at 3:11 P.M. on the first floor 12 pallets holding multiple packages of paper, some stacked as high as four feet, were observed in common corridor C 01.

On 07/31/12 at 3:11 P.M. in an interview Staff EE confirmed the presence of the pallets of paper.

On 08/02/12 at 4:00 P.M. in an interview Staff FF confirmed the pallets of paper should not be kept in the corridor.


39.3.1.1
Any vertical opening shall be enclosed or protected in accordance with 8.2.5.

Based on observation and interview, the facility failed to ensure each exit stairway doors latched.

Findings:

On 07/31/12 at 2:48 P.M. on the first floor the fire door to common stair c 01 was observed to not latch.

On 07/31/12 at 2:48 P.M. in an interview Staff EE confirmed the finding.

On 07/31/12 at 3:52 P.M. on the second floor the fire door to common stair c 02 was observed to not latch.

On 07/31/12 at 3:52 P.M. in an interview Staff EE confirmed the finding.

39.2.1.1
All means of egress shall be in accordance with Chapter 7 and this chapter.

Based on observation and interview, the facility failed to ensure each means of egress was in accordance with chapter 7 in general, and 7.1.10 in particular.

Findings:

On 07/31/12 at 2:48 P.M. on the 1st floor near stair D in a kitchen area a 50 gallon rubbish receptacle was observed stationed in front of the door. In addition, a bag of charcoal and a bottle of lighter fluid were observed stored up against the wall shared with the stairwell.

On 07/31/12 at 2:48 P.M. in an interview Staff EE confirmed the finding.

Based on facility tour and staff verification it was determined this facility failed to ensure all doors in one hour fire rated room were held open only with self-closing or automatic closing devices and were arranged to automatically close upon activation of the device or arranged to be kept closed according to the National Fire Protection Association (NFPA) 101 Chapter 7.2.1.8.1.
This facility failed to ensure no smoking on a no smoking campus, specifically in regards to an area accessible to staff only. NFPA 101, Chapter 18.7.4
This facility failed to ensure all exit accesses were properly equipped with exit signs in order to provide occupants correct direction of egress according to NFPA 101, Chapter 7.10.1.4.
This facility failed to ensure corridor doors equipped with self-closing devices were not propped open according to NFPA 101, Chapter 19.3.6.
This facility failed to ensure storage in storage rooms were not placed within the 18 in requirement impeding the proper discharge of the sprinkler system according to NFPA 13, Chapter 5-5.5.2.1.
This facility failed to ensure all portable fire extinguishers were not mounted greater than five feet from the floor according to NFPA 10, Chapter 1-6.10.

This had the potential to affect all those utilizing this area of the facility.


Findings include:


Facility tour took place on 08/01/12 with staff members EE, NN, QQ, UU, and WW1. During tour of the first floor one hour fire rated storage room P1-210 observation was made of a wood wedge that was propping the door open. This fire rated door was equipped with a self-closing device.

Additionally, on the first floor in vestibule P1-100B and outside the delayed egress double doors, observation was made of an enclosed area which was limited to staff only. This area was observed to have several cigarette butts scattered within and around the enclosed area.

Heading south within the fourth floor corridor labeled P48-200, observation was made by this surveyor and staff members present of the inability to see the exit sign which was mounted opposite of a door header. This exit sign was only visible once this surveyor was within several feet from the door opening.

Additionally on the fourth floor and within corridor P4-100A at office P48-50, observation was made of a self closing device mounted to the door leading to this room. This door was propped open with a chair thus rendering the self-closing device ineffective. Staff QQ removed the chair and discussed this issue with the staff members present.

Additionally on the fourth floor, observation was made by this writer and the staff members present on tour within the storage room adjacent to vestibule P48-111 of combustible material stored to within a few inches of the ceiling.

Observation was made of one fire extinguisher mounted above the five foot requirement within room P9-3 located on the ninth floor.

These findings were verified by all staff members during tour on 07/25/12.

K-130

Based on facility tour and staff verification it was determined this facility failed to ensure all doors in fire barriers were held open only with self-closing or automatic closing devices and were arranged to automatically close upon activation of the device or arranged to be kept closed according to the National Fire Protection Association (NFPA) 101 Chapter 7.2.1.8.1.
Based on facility tour and staff verification it was determined this facility failed to ensure all mobile soiled linen or trash collection receptacles exceeding 32 gallons were located in a room protected as a hazardous area when not attended according to the National Fire Protection Association (NFPA) 101 Chapter 9.5
This had the potential to affect all those utilizing this area of the facility.

Findings include:

Facility tour took place on 08/01/12 with staff members EE, NN, QQ, UU, and WW1. During tour of the fourth floor one hour fire rated water pump room, observation was made of a fire rated door equipped with a self-closing device propped open with a small piece of metal conduit. Staff EE was observed to remove the section of conduit allowing the door to close and latch shut. Staff EE then verbalized to the staff present to not prop open doors equipped with self closing devices.

During tour of the first floor recycle room observation was made of greater than six mobile metal and plastic trash/linen containers located within a storage area which was determined to not have the one hour fire rated construction including doors, although it had a suppression system. This area was open to a short corridor which has additional rooms.
Observation was made of one metal trash bin filled with bio-hazard waste and a plastic bin partially filled with recycle waste products.

These findings were verified by all staff present during tour on 08/01/12.

K-130

Based on facility tour and staff verification it was determined this facility failed to ensure storage rooms considered as hazardous areas were constructed with at least a one hour fire resistance rating according to the National Fire Protection Association (NFPA) 101, Chapter 8.4.
This facility failed to ensure the 30 second monthly and 90 minute annual testing of the emergency battery operated egress lights according to NFPA 101, Chapter 7.9.3.
This facility failed to ensure that smoke detectors were sensitivity tested according to NFPA 72, Chapter 7-3.2.1.
This facility failed to ensure the monthly inspections of the portable fire extinguisher according to NFPA 10, Chapter 4-3.1.

Findings include:

Facility tour took place on 08/01/12 with staff members CC1, and FF. During tour of the storage room observation was made of several boxes, linen and miscellaneous items which were located on shelving and stacked to within a few inches of the ceiling.

During documentation review for the emergency battery operated egress lights took place on 08/01/12. Staff CC1 and FF stated there was no documentation available to verify the 30 second monthly or 90 minute annual inspections.

Documentation review for the smoke detectors took place on 08/01/12. Staff CC1 provided the fire alarm inspection reports which failed to include the sensitivity testing of the smoke detectors. Staff FF verified the sensitivity testing has not been performed since occupancy of the building in 2010.

During documentation review for the portable fire extinguisher took place on 08/01/12. Staff CC1 and FF stated there was no documentation available to verify monthly inspections. Visual inspection of the fire extinguisher tag reveals no signatures or dates documented.

These findings were verified during tour on 08/01/12.

Based on observation of the 5th, 6th, and 7th floor, and interview, the facility failed to ensure compliance with NFPA 70 in general, and NFPA 70, 110 3(b) and 400-7(b) in particular.

Findings:

On 07/23/12 at 3:00 P.M. on the 7th floor of the H building, in room H71 41 a power strip was observed with five devices and another power strip plugged into it. The second power strip had four appliances plugged into it.

On 07/23/12 at 3:00 P.M. Staff JJ confirmed the findings.

On 07/24/12 at 9:23 A.M. on the 6th floor of the H building, in room H60 117, a power strip was observed with six devices plugged into it, plus another power strip. The second power strip had two devices plugged into it.

On 07/24/12 at 9:23 A.M. in an interview Staff DD verified the observation.

On 07/24/12 at 10:57 A.M. on the 5th floor of the H building, in room H50 40, a coffee maker was observed plugged into an extension cord, which was then plugged into a power strip.

On 07/24/12 at 10:57 A.M. in an interview Staff DD verified the observation.

Based on observation of the 6th floor, and interview, the facility failed to ensure compliance with NFPA 70 in general, and NFPA 70 110 3(b) and 400-7(b) in particular.

Findings:

On 07/30/12 at 11:15 A.M. in an area designated the main laboratory in the Q building, and indicated as a hazard area on the schematic of the floor, three appliances rated (according to the tag on each cord) at 5.5 amps each (for a total of 16.5 amps) was observed to be plugged into an extension cord that, according to the tag on it, was rated at 15 amps.

On 07/30/12 at 11:15 A.M. staff DD in an interview confirmed the observation and arithmetic.

Based on interview and observation, the facility failed to ensure each door protecting a corridor opening had suitable means to keep it closed.

Findings:

On 07/24/12 at 10:33 A.M. on the 6th floor of the H building the corridor door between the nurses lounge and the corridor was observed to not have a suitable means to keep it closed as tape had been applied to the latch to disable the latch.

On 07/24/12 at 10:33 A.M. Staff DD verified the finding.

On 07/25/12 at 3:45 P.M. on the 2nd floor of the H building the corridor door between room H2 240A and the corridor was observed to not have a suitable means to keep it closed as tape had been applied to the latch to disable the latch.

On 07/25/12 at 3:45 P.M. Staff DD verified the finding.

On 07/27/12 at 10:36 A.M. on the 9th floor of the Q building the corridor (Q9 0006) door on procedure room Q9 136, Q9 135, Q9 134, Q9 133, Q9 132, Q9 131, and Q9 130 was observed to lack positive latching hardware.

On 07/27/12 at 10:36 A.M. Staff DD confirmed the finding.

On 07/27/12 at 11:01 A.M. on the 9th floor of the Q building the corridor (Q9 0012) door on procedure room Q9 154 and Q9 151 was observed to lack positive latching hardware.

On 07/27/12 at 11:01 A.M. Staff DD verified the observation.

On 07/30/12 at 1:50 P.M. on the 4th floor of the Q building, the door on storage room Q4 224 opening on to corridor Q4 21 was observed to have positive latching hardware that did not latch.

On 07/30/12 at 1:50 P.M. in an interview Staff DD verified the observation.

On 07/30/12 at 2:26 P.M. on the 4th floor of the Q building, the door on housekeeping room Q4 201 opening onto corridor Q4 20 was observed to have positive latching hardware that did not latch.

On 07/30/12 at 2:26 P.M. in an interview Staff DD verified the observation.

On 07/30/12 at 3:03 P.M. on the 3rd floor of the Q building, where there are endoscopy procedures and recovery areas, door to room Q3 210 opening onto corridor Q3 16, was observed to have latching hardware that did not latch.

On 07/30/12 at 3:03 P.M. in an interview Staff DD verified the observation.





21957

Based on facility tour and staff verification it was determined this facility failed to ensure all corridor doors to patient rooms had no impediment to closing of the door. This had the potential to affect all those utilizing this area of the facility. The patient census was 1,113 at the beginning of the survey.

Findings include:

Facility tour took place on 07/27/12 with staff members BB, QQ, UU, and WW1. During tour of the fifth floor corridor identified as J5 2-54 observation was made of a patient room corridor which failed to close properly. This door was leading to patient room J5 2-16.

This finding was verified by all staff members present during tour on 07/23/12.

Based on facility observation and staff verification, the facility failed to ensure that stairways and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of Building One, which consisted on Buildings G, H, and M, was conducted on 07/23/12 through 07/26/12 between the hours of 9:00 A.M. and 4:30 P.M. with Staff BB, CC, DD, FF, PP, JJ, and QQ. The following locations were noted to have fire rated stair way doors in place.

1. Observation of the stair door on third floor of the M building, revealed the one hour fire rated door did not positively latch when the door was tested. Staff present on tour verified the observation.

Based on facility tour and staff verification it was determined this facility failed to ensure all vertical openings, specifically regarding stairwell doors, are enclosed with construction having a fire resistive rating of at least one hour. This had the potential to affect all those utilizing this area of the facility. The facility census was 1,113 at the time of the survey.

Findings include:

Facility tour took place on 08/01/12 with staff members BB, QQ, UU, and WW1. During tour of the second floor observation was made at stairwell T2-ST2 of dual entrance/exit doors located on the east and west side which failed to close and latch properly.
Additionally, observation was made at stairwell T2-ST1 of a single entrance/exit door which failed to close and latch shut.
These findings were verified by all staff members during tour on 07/25/12.

Based on facility observation and staff verification, the facility failed to ensure that doors in an exit passageway, stairway enclosure, horizontal exit or smoke barrier was held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of the required manual fire alarm system, a required smoke detection system, and the automatic sprinkler system, if installed. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of the S Building was conducted on 07/25/12 between the hours of 11:05 A.M. and 5:00 P.M. with Staff FF, II and WW1. The following fire rated doors did not securely latch when tested by releasing from the magnetic hold open device.

1. Located on the ninth floor, fire rated doors were noted to separate the north side of the floor from the south. The door was located near room S9-996. When released from the magnetic hold the fire rated door failed to securely latch in a closed position.

2. Located on the second floor, fire rated doors ( S2-206) were noted to separate the S Building from the T Building. Release of the two-hour fire rated doors from the magnetic hold open, revealed the doors failed to latch when in the closed position. Staff present on tour verified the findings.









21957


Findings include:

Facility tour of building T took place on 08/01/12 with staff members BB, QQ, UU, and WW1. During tour of the fifth floor mechanical room identified as T5-04, observation was made of a one hour fire rated wall separating this mechanical room from two adjacent mechanical rooms. Within the fire rated wall was a door equipped with a self-closing device which was ineffective due to the door being propped open with an approximate three foot long two by four piece of wood.


This finding was verified by all staff members during tour on 07/25/12.

Based on facility observation and staff verification, the facility failed to ensure that doors in an exit passageway, stairway enclosure, horizontal exit or smoke barrier were held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of the required manual fire alarm system, a required smoke detection system, and the automatic sprinkler system, if installed. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of the Crile Building was conducted on 07/31/12 between the hours of 9:05 A.M. and 5:00 P.M. and 08/01/12 between 8:30 A.M. and 4:20 P.M. with Staff FF, II and WW 1. Observation of the second floor revealed two hour fire rated doors located at the skyway entrance and the Crile Building. When manually released from the magnetic hold devices, the doors did not positively latch when in the closed position.

Observation of the door frame revealed the latching mechanism had been removed from the frame causing the doors not to latch. Staff present on tour verified the observations.

Based on observations and staff interviews, the facility failed to ensure two sets of horizontal exit doors closed and latched when released from the hold open device. Additionally, this facility failed to ensure any door in an exit passage was permitted to be held open only by devices arranged to automatically close upon activation of the required manual fire alarm system and its components and assuring doors in stairwells, smoke/fire barriers closed properly. This involved a set of fire doors on the sixth floor and on the fourth floors in the J building in which inpatient ongoing care was being provided by the facility. The total census during this visit was 1,113 patients.

Findings include:

During tour of the J building, on 07/27/12, at 12:47 PM, with Staff JJ, a set of 1 and 1/2 hour fire rated fire doors were observed located outside J6-628, between this building and the Glickman building. These doors were observed on an automatic hold open device. When released from the hold open device, during testing, the doors failed to close entirely and latch. This was verified with Staff JJ at the time the doors were tested.

On 07/26/12, at 2:40 PM, the set of fire doors J73-50 were observed on an automatic hold open device. During testing, these doors failed to latch when released from the hold open device. This was verified with Staff JJ during tour.


21957


Findings include:

Facility tour took place on 07/27/12 with staff members BB, QQ, UU, and WW1. During tour of the basement observation was made of two doors equipped with self-closing devices being propped open with unauthorized devices. Door to room JB-909 was propped open with three cases of computer paper. Door to room JB-124 was propped open with a brick.
Additionally, smoke/fire barrier doors JB-021 and 009283B (separation between S,M and J) failed to close properly when disengaged from the hold open device.

During tour of the fourth floor observation was made of five doors equipped with self-closing devices being propped open with unauthorized devices or failing to close and latch shut when tested. Observation was made of the door to stairwell J4 failing to latch shut. Door to room J4-605 failed to close and latch shut. The north door in room J4-604E was observed to have a wood wedge holding the door open and this caused the south door's closing device to fail to close the door properly. Two hour fire rated door number J4-82 failed to close and latch shut. Stairwell J4-ST6 failed to latch shut. Door J4-214 to a one hour fire rated enclosure failed to close properly.

This finding was verified by all staff members present during tour on 07/23/12.

On 07/24/12 at 9:28 A.M. the door to exit stairwell 4 on the 6th floor of the H building was observed to not completely shut and latch.

On 07/24/12 at 9:28 A.M. in an interview Staff DD verified the observation.

On 07/24/12 at 9:37 A.M. the double doors in the horizontal exit from the 6th floor of the H building to the M building was observed to not close and latch.

On 07/24/12 at 9:37 A.M. in an interview Staff DD verified the observation.

On 07/24/12 at 2:23 P.M. on the 2nd floor of the H building the double doors leading to exit stairwell 4 was observed not to completely close and latch.

On 07/24/12 at 2:23 P.M. in an interview Staff DD verified the observation.

On 07/25/12 at 3:45 P.M. on the 2nd floor of the H building the double doors in the horizontal exit to the M building was observed to not completely close and latch.

On 07/25/12 at 3:45 P.M. in an interview Staff DD verified the observation.

These findings were verified by all staff members present during tour on 07/23/12 to 07/25/12.









21957

Based on facility tour and staff verification it was determined this facility failed to ensure any door in an exit passage way was permitted to be held open only by devices arranged to automatically close upon activation of the required manual fire alarm system and its components. This had the potential to affect all those utilizing this area of the facility. The facility census was 1,113 at the beginning of the survey.

Findings include:

Facility tour took place on 07/23/12 with staff members BB, QQ, UU, and WW1. Observation was made of room G5-135 on the fifth floor having a door equipped with a self-closing device which was ineffective due to a rubber wedge placed under the bottom of the door to hold it in the open position.

Based on facility observation and staff interview and verification, the facility failed to ensure that access to exits was marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. The facility had a census of 1113 patients at the time of the survey.

Findings included:

On 07/30/12 between the hours of 1:30 P.M. and 4:00 P.M. tour of the Cole Eye Institute was conducted with Staff AA, FF and WW1. Tour of the first floor revealed the presence of an ambulatory surgical area with four operating rooms. Observation of the pre-operative and post-operative areas revealed there was no directional signs to show the way out of the area.

Interview of a staff nurse regarding how to locate the way out of the area, revealed the staff would show the patients the way out. Staff FF verified that directional exit signs were not in place to show the way out.

Based on observation and interview, the facility failed to ensure access to each exit was marked by an approved, readily visible exit sign.

Findings:

On 07/27/12 at 9:24 A.M. on the 10th floor in the Q building the evacuation plan posted near Stair #1-which was near a small waiting area--was reviewed. The plan showed a path of egress traveling west across lobby Q10 0000 through a door and into open office Q10 111. However, while standing at the stairwell, an exit sign could not be observed over said door communicating between the lobby and the open office.

On 07/27/12 at 9:24 A.M. in an interview Staff DD confirmed the evacuation plan showed a path of egress traveling west across lobby Q10 0000 through a door and into open office Q10 111 and confirmed an exit sign could not be observed over said door communicating between the lobby and the open office.

On 07/27/12 at 1:25 P.M. on the 7th floor of the Q building the evacuation posted near Stair #1-which was near a large patient waiting area-was reviewed. The plan showed the path of egress as traveling north through the waiting area and then turning west on to corridor Q07 0014. However, when standing at the stairwell, an exit sign directing people to turn west on to corridor Q07 0014 was not observed.

On 07/27/12 at 1:25 P.M. Staff DD confirmed the evacuation plan showed a path of egress traveling north through the waiting area and then turning west on to corridor Q07 0014 and that an exit sign directing people to turn west on to corridor Q07 0014 was not observed.

On 07/30 at 11:50 A.M. on the 4th floor of the Q building while standing on the western end of corridor Q04 011 an exit sign was not observed at the end directing people through a set of double doors and on to corridor Q04 010 and stair #2 for a path of egress.

On 07/30/12 at 11:50 A.M. Staff DD confirmed an exit sign could not be observed at the end of corridor Q04 011 directing people through a set of double doors and on to corridor Q04 010 and stair #2 for a path of egress.

On 07/23/12 at 2:10 P.M. on the 8th floor of the H building, while standing in the southern portion of corridor H80 53, an exit sign leading to northern exit staircase H 08 STM4 could not be observed.

On 07/23/12 at 2:10 P.M. Staff JJ verified the observation.

On 07/23/12 at 3:20 P.M. on the 7th floor of the H building, while standing in the southern portion of corridor H70 53, an exit sign leading to the horizontal exit to the M building could not be observed.

On 07/23/12 at 3:20 P.M Staff JJ verified the observation.

On 07/24/12 at 9:31 A.M. on the 6th floor of the H Building, while standing in the southern portion of corridor H60 112, an exit sign leading to the horizontal exit to the M building could not be observed.

On 07/24/12 at 9:31 A.M. in an interview, Staff DD verified the observation.

On 07/25/12 at 9:55 A.M. on the second floor of the H building, while standing in the western portion of corridor H2 279, an exit sign could not be observed on the other end to direct people on whether to travel north, south or either way to exit the building.

On 07/24/12 at 9:55 A.M. in an interview, Staff DD verified the observation.

On 07/24/12 at 2:45 P.M. on the second floor of the H building, no exit sign was observed while standing inside Suite #1.

On 07/24/12 at 2:45 P.M. in an interview Staff DD verified the observation.

On 07/24/12 at 3:02 P.M. on the second floor of the H building, no exit sign was observed while standing inside the suite containing nurses station H20 0000.

On 07/24/12 at 3:02 P.M. in an interview Staff DD verified the observation.

On 07/25/12 at 10:00 A.M. on the first floor of the H building, the evacuation plan posted near the door the opens from a kitchen area to corridor H01 0013 listed the path from the kitchen area through said door to the corridor as a path of egress. However, when standing in the kitchen, an exit sign was not posted above the door.

On 07/25/12 at 10:00 A.M. in an interview Staff DD confirmed the path of egress on the evacuation plan and confirmed the lack of exit signage.

These findings were verified by all staff present during tour on 07/23/12 to 07/25/12.










21957

Based on facility tour and staff verification it was determined this facility failed to ensure all accesses to exits were marked appropriately to ensure all occupants would be able to reach an exit which was not readily apparent. This had the potential to affect all those who utilized these areas of the facility. The facility census was 1,113 at the beginning of the survey.

Findings include:

Facility tour took place on 07/23/12 with staff members BB, QQ, UU, and WW1. Facing west within corridor G3-01 and at the smoke barrier doors by storage room G3-88, observation was made of an exit sign mounted at the end of the corridor outside of lounge G3-80. This exit sign was observed to have a directional arrow pointing flow to the left but failed to have the directional arrow also pointing to the right to a designated exit.

Based on facility tour and staff verification it was determined this facility failed to ensure all accesses to exits were marked appropriately to ensure all occupants would be able to reach an exit which was not readily apparent. This had the potential to affect all those who utilized these areas of the facility. The facility census was 1,113 at the beginning of the survey.

Findings include:

Facility tour took place on 08/01/12 with staff members BB, QQ, UU, and WW1. Within the basement outside general storage room TB-10 and above the door observation was made of an exit sign with directional arrows pointing occupants to the right and left. Facing the sign and looking to the right, observation was made of no visible exit signage. This writer followed the corridor for approximately 90 feet to an unsigned stairwell access on the right hand side. This stairwell was located in "S" building within corridor SB-14 and identified as stairwell SB-ST3.
Additionally, continuing down corridor SB-14 to the intersecting corridor SB-54 observation was made of no visible exit sign to the right directing occupants to the exit access in corridor SB-35.

These findings were verified by all staff members during tour on 07/25/12.

Based on facility observation and staff interview and verification, the facility failed to ensure door openings in smoke barriers had at least a 20-minute fire protection rating. Doors were to be self-closing or automatic closing in accordance with 19.2.2.2.6. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of Building One, which consisted of Buildings G, H, and M, was conducted on 07/23/12 through 07/26/12 between the hours of 9:00 A.M. and 4:30 P.M. with Staff BB, CC, DD, FF, PP, JJ, and QQ. The following locations were noted to have doors located in smoke barriers that did not close .

1. Observation of smoke barrier door located at 010431B was observed to fail to close when tested. Staff present on tour verified the observation.

Based on observations and staff interviews, the facility failed to ensure one set of smoke barrier doors closed when released from the hold open device. These smoke barrier doors were located in the corridor by the main entrance emergency waiting room. The total census during this visit was 1,113 patients.

Findings include:

During tour of the E building, on 07/31/12, at 2:50 P.M., with Staff JJ, a set of non-latching smoke barrier doors was located outside room the main emergency room waiting room by room E 01-0146. These doors were observed on an automatic hold open device. When released from the hold open device, during testing, the doors failed to close entirely, leaving a 2-3 inch gap. This was verified with Staff JJ at the time the doors were tested.

Based on facility observation and staff verification, the facility failed to ensure that one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. When the approved automatic fire extinguishing system option was used, the areas were separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of the Crile Building was conducted on 07/31/12 between the hours of 9:05 A.M. and 5:00 P.M. with Staff FF, II and WW1. The following findings were noted in storage areas:

1. Located on the twelfth floor, a dirty utility room was observed. Observation of the room revealed the door had no self-closing device in place.

2. Located on the seventh floor, room A7-116D was observed to be a medical supply storage room. No self-closing device was on the door to the room.

3. A storage room identified as A6-401 was observed. The storage area had no self-closing device on the door.

4. Room A6-508 identified as the apprentice copier room was noted to have storage of paper products. The door to the storage room did not have a self closing device in place.

5. Room A5-420 was noted to be a storage room for medical records and other combustible items. The door to the room did not have a self-closing device.

6. Room A 5-507 was identified as a storage room. The door to the room had no self closing device in place.

7. Rooms A2-209, an x-ray department soiled utility room, A2-539, a storage room, A2-533 a storage room and A2-117, a storage area for miscellaneous combustible items did not have self closing devices on the doors.

8. Room A3-153 a storage room in the adult endoscopy center was noted to have no closer on the door.

9. Two soiled utility rooms, A3-185 and A3-138, were observed to have no self closing devices on the doors.

10. Room A1-172, a soiled utility room was noted to have no self closing device on the door to the room.

Staff present on tour verified the observations.

Based on facility observation and staff verification, the facility failed to ensure that one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. When the approved automatic fire extinguishing system option was used, the areas were separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of the S Building was conducted on 07/25/12 between the hours of 11:05 A.M. and 5:00 P.M. with Staff FF, II and WW1. Located on the seventh floor, a storage area identified as S7-750, was noted to have no automatic sprinkler system protection. Observation and testing of the room door revealed there was no noted fire rating on the door to the room and the door failed to securely latch when in the closed position. Items stored in the room were combustible items in the form of office supplies.

Located on the third floor of the S Building was a storage area which contained notebooks, reading materials and cardboard. The room was not provided with automatic sprinkler protection. The door to the room was noted to be a sliding, wood, door with no identifiable fire rating. The door did not have a self closing device.

Located in the basement area, a room identified as the clinical engineering project room (SB-62) was observed. The room was noted to be very cluttered with card board boxes, various clinical equipment and many other items. There was no sprinkler system or smoke detection in the room. Ceiling tiles were missing from the room.

Staff present on tour verified the observations of the storage areas.


21957


Findings include:

Facility tour took place on 08/01/12 with staff members BB, QQ, UU, and WW1. During tour of the basement's two hour fire rated storage room identified as TB-20, observation was made of the east wall door not equipped with an automatic or self-closing device.
Additionally, observation was made of the west door within the same room which was part of a two hour fire rated building separation. This door failed to have a fire resistance rating and also failed to open and close properly due to the top right corner of the door rubbing against the door frame.

These findings were verified by all staff members during tour on 07/25/12.

Based on facility observation and staff interview and verification, the facility failed to ensure that hazardous areas are protected with doors which are equipped with self-closing or automatic closing devices which enables the door to close and latch properly. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of Building One, which consisted of Buildings G, H, and M, was conducted on 07/23/12 through 07/26/12 between the hours of 9:00 A.M. and 4:30 P.M. with Staff BB, CC, DD, FF, PP, JJ, and QQ. The following storage areas were noted to have doors in place that did not close as required.

1. Located in the M Building, on the third floor, a storage room was noted to have a door ( H3204) that failed to latch when in the closed position. Staff present on tour verified the observation.





21521

On 07/24/12 at 9:58 A.M. on the 6th floor, area B--designated as a hazard/clean utility area on the schematic--door H60 113A was observed to be on a self closer that did not latch.

On 07/24/12 at 9:58 A.M. in an interview Staff DD verified the findings.

On 07/24/12 at 2:43 P.M. on the 2nd floor, area L-designated as a hazard/storage area-door H20 022 was observed to be on a self closer that did not latch.

On 07/24/12 at 2:43 P.M. in an interview, Staff DD verified the observation.

On 07/24/12 at 3:10 P.M. the door H2 02B opening from an area designated as hazard I on a schematic and containing work supplies, was observed to be on a self closer that did not latch.

On 07/24/12 at 3:10 P.M. in an interview Staff DD verified the observation.

On 07/25/12 at 2:45 P.M. double doors to a hazard area enclosed with 2 hour walls and containing medical gases was observed to be on a coordinator that did not function to close the doors.

On 07/25/12 at 2:45 P.M. in an interview Staff DD verified the observation.

Staff present on tour verified the observation.

Based on facility observation and staff interview and verification, the facility failed to ensure that when the approved automatic fire extinguishing system option was used, the areas were separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door were permitted. The facility had a census of 1113 patients at the time of the survey.

Findings included:

On 07/30/12 between the hours of 9:30 A.M. and 12:00 P.M., tour of the R Building was conducted with Staff FF, TT and OO. Observation of a soiled utility room, R1-067, revealed there was no self closing device on the door to the room.

Located on the second floor was a storage room where chairs, desks and boxes were placed. Observation of the room revealed there was no self closing device on the door to the room.

Room R2-079 was identified as a storage room. Observation of the room revealed an arm of the self closing device was missing which would not allow the door to close.

Staff present on the tour verified the observation.

Based on facility observation and staff interview and verification, the facility failed to ensure exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of Building One, which consisted of Buildings G, H, and M, was conducted on 07/23/12 through 07/26/12 between the hours of 9:00 A.M. and 4:30 P.M. with Staff BB, CC, DD, FF, PP, JJ, and QQ.

Tour of the seventh floor revealed a large area for patient rehabilitation services. The area was identified as the gym. Tour inside the gym revealed the presence of three exit doors. Located near the center of the room was an exit sign which noted the way out to the exit corridor.

Following the sign toward the door revealed the exit door was blocked by a table with items stacked on it. Other items in the exit way was a chair and additional boxes . Staff present on tour verified the way out of that exit door was blocked and inaccessible.

On 07/30/12 from 2:41 P.M. to 4:00 P.M. a tour was conducted of the 3rd floor of the Q building. The tour and schematic revealed the floor contained three suites: a non-sleeping procedure suite of 5478 square feet (1), a non-sleeping prep/recovery suite of 5914 square feet (2), and a waiting area of 705 square feet (3). By observation and review of the schematic, Suite #1 had one exit into corridor Q03 16, and the other into Suite #2. By observation and review of the schematic, Suite #2 had one exit into corridor Q03 14, another into Suite #1, and two others into Suite #3. By observation and review of the schematic, Suite #3 had one exit into lobby Q03 116, and another into Suite #2.

On 07/30/12 during the tour from 2:41 P.M. to 4:00 P.M. in an interview Staff DD confirmed the findings.




21957

Based on facility tour and staff interview it was determined this facility failed to ensure any suite of rooms greater than 1,000 sq. ft. has at least two exit access doors remote from each other and the exit accesses may not exit through an intervening suite. This had the potential to affect all those utilizing this area of the facility. The facility census at the beginning of the survey was 1,113.

Findings include:

Facility tour took place on 08/01/12 with staff members BB, QQ, UU, and WW1. During tour of the fifth floor post anesthesia care unit (PACU Suite) which had a total of 5,250 sq. ft., observation was made of three exit accesses, two of which had egress access through intervening suites. The floor plan was reviewed and verified this finding. Staff BB stated on 08/01/12 during tour of the PACU that they were aware of this and were planning on applying for a waiver after a citation was issued.

Based on observation the facility failed to comply with NFPA 110 5-3, referenced in NFPA 101 7.9, referenced in NFPA 101 19.2.9.1, by failing to have battery powered emergency lighting in the generator room in building rr.

Findings:

On 07/26/12 at 3:44 P.M. a tour was conducted of the generator room. The room was observed to have emergency lighting, but the lighting did not have battery power backup.

On 07/26/12 at 3:44 P.M. Staff DD confirmed the room did not have battery power back up and said the generators themselves would run the lights in the room if power was lost.

Based on facility observation and staff interview and verification, the facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition and was inspected periodically. This was with regards to continuous or non continuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that could prevent the pattern from fully developing. The facility had a census of 1113 patients at the time of the survey.

Findings included:

On 07/30/12 between the hours of 9:30 A.M. and 12:00 P.M., tour of the R Building was conducted with Staff FF, TT and OO. The following areas were noted to have items stored to that could cause obstructions to the sprinkler flow.

1. Observation of storage room R3-087 revealed card board boxes stored significantly less than 18 inches from sprinkler deflectors.

2. Observation of storage room R4-063 was noted to have metal shelving with items stacked significantly closer than 18 inches from sprinkler deflectors.

Staff present on the tour verified the observations.

Based on facility observation and staff interview and verification, the facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition and was inspected periodically. This was with regards to continuous or non continuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that could prevent the pattern from fully developing. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of the Cole Eye Building was conducted on 07/30/12 between the hours of 1:30 A.M. and 4:00 P.M. with Staff AA FF, and WW 1. Observation of a first floor storage room revealed the room was used to store medical files. The room was observed to have files and boxes placed significantly closer than 18 inches from the sprinkler deflector.

Staff present on tour observed the storage room and verified the finding.

Based on facility observation and staff interview and verification, the facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition and was inspected periodically. This was with regards to continuous or non continuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that could prevent the pattern from fully developing. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of the Crile Building was conducted on 07/31/12 between the hours of 9:05 A.M. and 5:00 P.M. with Staff FF, II and WW 1. The following areas were observed to have items stored within 18 inches of the sprinkler deflector.

1. Located on the fifth floor, storage area A5503 had boxes and paper products placed closer than 18 from the sprinkler defector.

2. Located on the fourth floor, at A 4-104 and A 4-106, cubicle partition were noted to extend significantly closer than 18 inches from the sprinkler deflector. The partitions could impede the spray pattern of the sprinkler.

3. At A 3-245, a cabinet with items stacked on top of the cabinet was closer than 18 inches from the sprinkler deflector.

Staff present on tour observed and verified the observations.

Based on facility observation and staff interview and verification, the facility failed to ensure the automatic sprinkler system, was installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. This was with regards to continuous or non continuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that could prevent the pattern from fully developing. Additionally, the facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition specifically in regards to dirt, dust and debris on the sprinkler heads. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of Building One, which consisted of Buildings G, H, and M, was conducted on 07/23/12 through 07/26/12 between the hours of 9:00 A.M. and 4:30 P.M. with Staff BB, CC, DD, FF, PP, JJ, and QQ. Observation of storage areas revealed items placed significantly closer than 18 inches from the sprinkler defector.

Located in the M Building, on the fourth floor, was a room noted to be the Children Life storage room. The room was provided with sprinkler system protection. Storage of games, puzzles, crafts and additional combustible items were stacked to the ceiling. Staff present on tour verified the items in the room were too close to the sprinkler defectors. Staff in the area began to address the storage issue immediately.

Located on the second floor of the M Building was storage room M2-171. Observation of the left side of the room revealed stacked paper cups and paper products, placed less than 18 inches from the sprinkler deflector. Staff present on tour verified the findings.




21521

On 07/23/12 at 9:50 A.M. a tour of the 9th floor of the building was begun. Two sprinkler heads with dust obscuring the red fluid in the glass bulb were observed in the corridor 09 003, and on the east wall of the smoking room (09 003B) two additional sprinkler heads with dust obscuring the red fluid in the glass bulb were observed.

On 07/23/12 at 12:57 P.M. and at 1:05 P.M. in an interview Staff JJ confirmed the findings.

On 07/24/12 at 11:22 A.M. the sprinklers in the laundry and rubbish chutes on the 8th floor was observed to have dust in clumps surrounding the glass bulb.

On 07/24/12 at 11:22 A.M. in an interview, Staff DD confirmed the finding.

On 7/25/12 at 4:00 P.M. a tour of "The Well" restaurant area on the first floor of the building was conducted. Four sprinkler heads running north/south perpendicular to the cashier station were observed to have their glass bulbs covered in dust.

On 07/25/12 at 4:00 P.M. in an interview Staff DD confirmed the findings.

On 07/26/12 at 11:15 A.M. in the basement of the H building, room HB 84 was observed to have computer equipment and cardboard boxes within 18 inches of the ceiling.

On 07/26/12 at 11:15 A.M. in an interview, Staff DD confirmed the findings.





21957


Findings include:

Facility tour took place on 07/23/12 with staff members BB, QQ, UU, and WW1. Observation was made within each trash chute access from the first floor through the eleventh floor of the G building, the sprinkler heads being thickly coated with what appeared to be the contents of wet trash which had accumulated and dried over a long period of time. Staff BB had taken a picture of at least two sprinkler heads which were covered so much with this debris that it was almost impossible to identify them as sprinkler heads.

This finding was verified by all staff members present during tour on 07/23/12.

Based on facility tour and staff interview it was determined this facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition specifically in regards to storage stacked up beyond the 18 inch requirement so as not to impede the spray pattern of the sprinklers in the event of an emergency. Additionally, having ceiling tiles placed in a position such as to impede the spray pattern of the sprinklers.

Findings include:

Facility tour took place on 07/27/12 with staff members BB, QQ, UU, and WW1. During tour of the second floor corridor identified as J2-81 observation was made of storage closet J2-816 literally stuffed full of storage items in a manner which prevented this surveyor from being able to identify any sprinklers in the closet.

During tour of corridor J2-90 observation was made of two side by side storage closets housing the lead aprons for the radiology department. Within the closet this writer observed no sprinkler heads. Staff BB stated the sprinkler heads had been covered by the drop down ceiling. The ceiling tiles were removed and the sprinkler heads were able to be identified.

This finding was verified by all staff members present during tour on 07/23/12.

Based on facility tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were not mounted greater than five feet from the floor according to the National Fire Protection Association (NFPA) 10, Chapter 1-6.10.

Findings include:

Facility tour took place on 08/01/12 with staff members BB, QQ, UU, and WW1. During tour of the basement, specifically the pharmacy JB-122 and the radiochem room JB-124, two portable fire extinguishers, one in each room, was mounted higher than the five foot requirement.

This finding was verified by all staff members present during tour on 07/23/12.

Based on facility tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were not mounted greater than five feet from the floor according to the National Fire Protection Association (NFPA) 10, Chapter 1-6.10.

Findings include:

Facility tour took place on 08/01/12 with staff members BB, QQ, UU, and WW1. During tour of the second floor corridor T2-100, observation was made of two portable fire extinguishers mounted greater than five feet from the floor. They were located by room T2-8 and T2-15.
Additionally, another portable fire extinguisher located on the fifth floor in mechanical room T5-04 was mounted greater than five feet from the floor.

These findings were verified by all staff members during tour on 07/25/12.

Based on review of facility documentation and staff interview and verification, the facility failed to ensure that fire and smoke dampers complied with the provisions of NFPA 90A with regards to testing. The facility had a census of 1113 patients at the time of the survey.

Findings included:

On 07/27/12 between 8:30 A.M. and 2:00 P.M. review of facility documentation was completed with regards to fire and smoke damper testing. Present for documentation review was Staff DD1, GG,and ZZ4. Review of the fire/ smoke damper testing revealed that testing was completed between May 2008 and April 2012.

Review of the documented testing revealed that some dampers could not be tested due to obstructions or an accessibility issue that prevented testing. Building E was noted to have twenty-three dampers that could not be tested due to obstructions. Six of 23 dampers were located on the second floor and 17 dampers were located in the third floor.

Interview of staff present at the document review verified that obstructions due to construction had to be addressed before many of the dampers could be tested.

Based on review of facility documentation and staff interview and verification, the facility failed to ensure that fire and smoke dampers complied with the provisions of NFPA 90A with regards to testing. The facility had a census of 1113 patients at the time of the survey.

Findings included:

On 07/27/12 between 8:30 A.M. and 2:00 P.M. review of facility documentation was completed with regards to fire and smoke damper testing. Present for documentation review was Staff DD1, GG,and ZZ4. Review of the fire/ smoke damper testing revealed that testing was completed between May 2008 and April 2012.

Review of the documented testing revealed that some dampers could not be tested due to obstructions or an accessibility issue that prevented testing. The following dampers were not tested due to obstructions or accessibility on the floors of the buildings.

1. Located in the H Building, a total of 94 dampers were not tested between the H building basement and H9. Twenty -two of the 94 dampers the could not be tested were located on H3

2. Located in the M Building, a total of 14 dampers could not be tested,. The inaccessible dampers were located on the first, sixth, seventh and ninth floor of the M Building.

3. Located in the G Building , a total of 3 dampers could not be tested. Those dampers were located on the third and fifth floors.

Interview of staff present at the document review verified that obstructions due to construction had to be addressed before many of the dampers could be tested.

Based on facility observation and staff interview and verification the facility failed to ensure existing linen and trash chutes, including pneumatic rubbish and linen systems, that opens directly onto any corridor was sealed by fire resistive construction to prevent further use. Additionally, it was determined this facility failed to ensure all existing trash and linen chutes were equipped with a locking device in which a key is required to open the door. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of Building One, which consisted of Buildings G, H, and M, on 07/23/12 through 07/26/12 between the hours of 9:00 A.M. and 4:30 P.M. was conducted with Staff BB, CC, DD, FF, PP, JJ, and QQ. The following locations were noted to have trash or soiled linen chutes that were unlocked and accessible to the corridor.

1. On 07/23 between the hours of 12:45 P.M. and 4:40 P.M. and 07/24/12 between 9:00 A.M. and 4:00 P.M. tour of Building M was completed. The following floors of the M building were noted to have trash or linen chutes unlocked.;

1. Located on the sixth floor was an unlocked trash chute located in a corridor.

2. Located on the second floor was an unlocked room where trash and linen chutes were located. Both chute doors were observed to be unlocked. Staff present on tour verified the observations.


21521


Findings:

From 07/23/12 at 12:50 P.M. to 07/26/12 at 11:40 A.M., a tour of the H Building, also known as the Hospital Building, was completed. On floor 8, 7, 6, 5, 3, and 2 a chute room was observed on each floor. On each floor the door to the chute room was not locked. Each chute room was observed to have both a laundry and rubbish chute. Each chute room was observed to have neither door to each chute lock.

On 07/24/12 at 9:52 A.M. in an interview, Staff DD confirmed the door opening into the chute room did not lock, nor did the chute doors themselves.




21957


Findings include:

Facility tour took place on 07/23/12 with staff members BB, QQ, UU, and WW1. Observation was made on the first floor within the trash/linen chute room identified as G1-213 of both chute doors lacking a key lock. Additionally, the door to the trash/linen room was equipped with a door lock but was also not secured.

Observation was made on the second floor within the trash/linen chute room identified as G2-213 of both chute doors lacking a key lock. Additionally, the door to the trash/linen room was equipped with a door lock but was also not secured.

Observation was made on the fifth floor within the trash/linen chute room identified as G5-135 of the trash chute door lacking a key lock. It was also noted that the linen chute door was equipped with a key lock but was not secured. Additionally, the door to the trash/linen room was equipped with a door lock but was also not secured.

Observation was made on the seventh floor within the trash/linen chute room identified as G7-59 of both chute doors lacking a key lock. Additionally, the door to the trash/linen room was equipped with a door lock but was also not secured.


These findings were verified by all staff members present during tour on 07/23/12.

Based on observations and staff interviews, the facility failed to ensure chute rooms were used exclusively for accessing the chute openings in accordance with the code at 8.4, did not ensure chute rooms were separated from the service elevator with a one hour fire resistance rated barrier in accordance with the code at Section 18.5.4 and 9.5.1., and failed to ensure chute rooms were locked in accordance with NFPA 82, 3.2.4.3.2. This involved 8 of 8 floors in patient care areas. The facility had a total census of 1,113 at the time of the survey.

During tour of the facility, on 07/26/12 and 07/27/12, between 9:00 A.M. and 3:00 P.M., and on 07/31/12, between 9:00 A.M. and 11:00 A.M., with Staff JJ, QQ, and HH, a combination linen chute, trash chute, and service elevator room was observed on patient care floors 1 through floor 8. These rooms were located in the center of each floor between Units 1, 2, and 3. The room numbers for the sixth floor was J63-57, and for the seventh floor room J73-57. The eighth floor room was directly above these two rooms. Observations of these rooms revealed the linen chute, trash chute, and service elevator were located in the same room, without a one hour fire rated separation between the chutes and the elevator. The doors to the hallways were observed not locked during tour. There were no locking mechanisms observed on the gravity chute doors.

On 07/27/12, at 11:10 A.M., this chute/elevator room was observed with Staff JJ. This employee stated the chute rooms on floors 1 through 8 were set up the same, with the service elevator in the same room as trash and linen chutes, and verified the lack of a one hour fire rated separation between the chutes and the elevator. During the aforementioned tour, Staff QQ and HH also verified the construction of these rooms.

On 07/26/12 and 07/27/12, between 9:00 A.M. and 3:00 P.M., and on 07/31/12, between 9:00 A.M. and 11:00 A.M., the chute doors throughout floors 1 through 8 were observed with handles on the laundry and trash chute doors which lacked a key mechanism; therefore, the chute doors could not be locked. Although the doors to the hallway were equipped with a locking mechanism, these doors were not locked during tour.

Observations of these chute doors, and hallway corridor doors for these rooms, revealed the following:

a) The corridor doors to trash and linen chute rooms located in J4-623, J5-3116, J5-213, J5-640, J51-113 revealed the corridor doors were unlocked. This was verified with Staff BB and WW1 during tour on 07/31/12.

b) Chute rooms J63-116, J63-57, J6-631, J62-131, and J73-57 were observed with a laundry and/or trash chutes which were observed without a locking mechanism on the chute doors. The corridor door to these chute rooms were observed unlocked on tour. These chute rooms and doors were verified with Staff JJ during tour on 07/27/12 between 10:20 A.M. and 1:25 PM.

Based on facility observation and staff interview and verification, the facility failed to ensure that soiled linen or trash collection receptacles did not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space was to not exceed .5 gal/sq ft (20.4 L/sq m). A capacity of 32 gal (121 L) is not exceeded within any 64 sq ft (5.9-sq m) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) were to be located in a room protected as a hazardous area when not attended. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of the Cole Eye Building was conducted on 07/30/12 between the hours of 1:30 A.M. and 4:00 P.M. with Staff AA FF, and WW 1. Observation of a first floor surgical area revealed the presence of one soiled linen cart and two large trash receptacles sitting in a surgical area corridor. The three carts were large, wheeled receptacles verified by staff as being 16 cubic feet in size. Staff present from the surgical area verified the carts were kept in that area.

Staff present on tour observed the storage room and verified the finding.

Based on observations and staff interviews, the facility failed to ensure greater than 300 cubit feet (over 12 e-tanks) was stored in accordance with NFPA 99, 4.3.1.1.2. This involved two areas of the J building in patient care areas on the 6th floor. The total census during the survey was 1,113 patients.

Findings include:

During tour of the J building, with Staff JJ, oxygen exceeded 300 cubit feet in one smoke compartment and was not stored in a one hour fire rated separation which was vented to the outside. Ordinary electrical wall fixtures in this room were observed less than 5 ft above the floor.

a) On 07/27/12, at 11:35 AM, tour with Staff AA1 and JJ, the J6-1 smoke compartment was observed with 15 e-tanks of oxygen (360 cu. feet). It was verified with Staff JJ the amount of oxygen in this smoke compartment exceeded 300 cubit feet and was not stored in accordance with NFPA 99.

b) On 7/27/12, at 12:50 PM, room J6-621A was observed with 20 E tanks of oxygen. This room opened directly into the egress corridor. According to Staff JJ and BB1 (Manager of Respiratory Care for Heart Center), at the time of tour, this was an oxygen storage area for respiratory. The room was observed with electrical switches less than five feet above the floor. The room was verified not vented to the outside.






21957


Findings include:

Facility tour took place on 08/01/12 with staff members BB, QQ, UU, and WW1. During tour of the fifth floor corridor identified as J 5-66 and specifically in the one hour fire rate room J5-635 observation was made of one H cylinders of medical air, 18 cylinders of medical air, two of which were not secured. Additionally, the room was observed to not have a medical gas sign posted outside the door, no dedicated ventilation system and the electrical light switch and outlets were not located above the required five foot or greater level. Also, the room was utilized to store medical equipment.

These findings were verified by all staff during tour of the facility on 08/01/12.

Based on observations and staff interviews, the facility failed to ensure greater than 300 cubit feet (over 12 e-tanks) was stored in accordance with NFPA 99, 4.3.1.1.2. This involved two of three smoke compartments in the operating room area of the E building on the second floor. The total census during the survey was 1,113 patients.

Findings include:

During tour of the E building, with Staff JJ, oxygen exceeded 300 cubit feet in two smoke compartments in the operating room area, and was not stored in a one hour fire rated separation which was mechanically vented to the outside. Ordinary electrical wall fixtures in these smoke compartments were observed less than 5 ft above the floor.

On 07/31/12, between 3:50 P.M. and 5:03 P.M., a tour was conducted with Staff JJ and Staff EE1 (Nurse Manager of Neurosurgery) on the second floor of the E building. This floor was observed with operating rooms suites which were divided into 3 different smoke compartments. The smoke compartment for operating rooms #19-25 was observed with 12 e-tanks of oxygen in a cart in the corner of the hallway. Operating room #22 was observed with 2 additional e-tanks of oxygen, for a total of 480 cubic feet of oxygen in this smoke compartment. Interview with Staff EE1, during this tour, revealed all operating rooms have at least one e-tank of oxygen.

The smoke compartment for operating rooms #7-18 were observed with 11 e-tanks of oxygen by room E2-44, in the main egress corridor. In addition, Staff EE1 verified each OR contained one e-tank of oxygen for a total of 23 e-tanks of oxygen in this smoke compartment. The total amount of oxygen stored in this smoke compartment was 552 cubit feet.

The aforementioned observations were verified with Staff JJ during tour.











'

Based on observation and interview, the facility failed to store medical gas in accordance with NFPA 99.
Findings:
On 07/25/12 at 3:00 P.M. on the 2nd floor of the H building, in the west side that contains 15 operating rooms, in the west end of corridor H02 0025, 3 250 cubic feet tanks of medical gas each chained to a dolly and aligned on the north side of the corridor were observed.

On 07/25/12 at 3:00 P.M. Staff DD confirmed the storage of the medical gas.

On 07/25/12 at 3:00 P.M. Staff FF1 in an interview said the gases were stored there for cases "across the street" because they lack the capability to have their own.

39.2.1.1
All means of egress shall be in accordance with Chapter 7 and this chapter.

7.1.10.2.1
No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Based on facility tour and staff interview and verification, the facility failed to ensure the facility exit egress was maintained in accordance with Chapter 7 with regards to furnishings and objects in an exit egress. The facility had a census of 1113 patients at the time of the survey.

Findings included:

On 07/30/12 between the hours of 9:30 A.M. and 12:00 P.M., tour of the R Building was conducted with Staff FF, TT and OO. Observation of the first floor revealed an exit corridor close to a pharmacy. A door was located at the end of the exit corridor. Review of the area revealed the exit corridor was used as a storage area.

The corridor contained a refrigerator, five steel shelves and boxes stored in the area. Passage through the corridor was narrowed to less than 36 inches. Staff from the pharmacy stated the corridor was shared with another business located across a hall. Both business used the corridor as storage.

Staff FF, present on tour, verified the corridor was not to be used as a storage area.

Based on observations, staff interview, and documentation of battery back-up lighting testing, the facility failed to test battery pack lights in accordance with the code at 7.9.3. This involves 5 of 5 battery back-up lights on the 3rd floor where the sleep center was located. The total census during the survey was 1,113 patients.

Findings include:

A tour was conducted on the third floor of the facility on 08/02/12, between 4:08 P.M. and 5:00 P.M., with Staff JJ. The third floor corridor was observed with 5 battery wall pack lights. When tested, during this visit, four of five battery packs illuminated; however, the battery wall pack located by Room 326 failed to work when the test button was pushed by Staff JJ.

On 07/23/12, a review of facility documentation for these battery packs revealed there was no 30 second every 30 day testing of the lights as required by the code. During this tour, this was verified per interview with Staff JJ, and per interview with the hotel manager, who stated there was no documented evidence of monthly testing of these battery back-up lights.

39.3.2.1
Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

Based on observation and interview, the facility failed to ensure 12 pallets holding multiple packages of paper, some stacked as high as four feet, were protected in accordance with Section 8.4.

Findings:

On 07/31/12 at 3:11 P.M. on the first floor 12 pallets holding multiple packages of paper, some stacked as high as four feet, were observed in common corridor C 01.

On 07/31/12 at 3:11 P.M. in an interview Staff EE confirmed the presence of the pallets of paper.

On 08/02/12 at 4:00 P.M. in an interview Staff FF confirmed the pallets of paper should not be kept in the corridor.


39.3.1.1
Any vertical opening shall be enclosed or protected in accordance with 8.2.5.

Based on observation and interview, the facility failed to ensure each exit stairway doors latched.

Findings:

On 07/31/12 at 2:48 P.M. on the first floor the fire door to common stair c 01 was observed to not latch.

On 07/31/12 at 2:48 P.M. in an interview Staff EE confirmed the finding.

On 07/31/12 at 3:52 P.M. on the second floor the fire door to common stair c 02 was observed to not latch.

On 07/31/12 at 3:52 P.M. in an interview Staff EE confirmed the finding.

39.2.1.1
All means of egress shall be in accordance with Chapter 7 and this chapter.

Based on observation and interview, the facility failed to ensure each means of egress was in accordance with chapter 7 in general, and 7.1.10 in particular.

Findings:

On 07/31/12 at 2:48 P.M. on the 1st floor near stair D in a kitchen area a 50 gallon rubbish receptacle was observed stationed in front of the door. In addition, a bag of charcoal and a bottle of lighter fluid were observed stored up against the wall shared with the stairwell.

On 07/31/12 at 2:48 P.M. in an interview Staff EE confirmed the finding.

Based on facility tour and staff verification it was determined this facility failed to ensure all doors in one hour fire rated room were held open only with self-closing or automatic closing devices and were arranged to automatically close upon activation of the device or arranged to be kept closed according to the National Fire Protection Association (NFPA) 101 Chapter 7.2.1.8.1.
This facility failed to ensure no smoking on a no smoking campus, specifically in regards to an area accessible to staff only. NFPA 101, Chapter 18.7.4
This facility failed to ensure all exit accesses were properly equipped with exit signs in order to provide occupants correct direction of egress according to NFPA 101, Chapter 7.10.1.4.
This facility failed to ensure corridor doors equipped with self-closing devices were not propped open according to NFPA 101, Chapter 19.3.6.
This facility failed to ensure storage in storage rooms were not placed within the 18 in requirement impeding the proper discharge of the sprinkler system according to NFPA 13, Chapter 5-5.5.2.1.
This facility failed to ensure all portable fire extinguishers were not mounted greater than five feet from the floor according to NFPA 10, Chapter 1-6.10.

This had the potential to affect all those utilizing this area of the facility.


Findings include:


Facility tour took place on 08/01/12 with staff members EE, NN, QQ, UU, and WW1. During tour of the first floor one hour fire rated storage room P1-210 observation was made of a wood wedge that was propping the door open. This fire rated door was equipped with a self-closing device.

Additionally, on the first floor in vestibule P1-100B and outside the delayed egress double doors, observation was made of an enclosed area which was limited to staff only. This area was observed to have several cigarette butts scattered within and around the enclosed area.

Heading south within the fourth floor corridor labeled P48-200, observation was made by this surveyor and staff members present of the inability to see the exit sign which was mounted opposite of a door header. This exit sign was only visible once this surveyor was within several feet from the door opening.

Additionally on the fourth floor and within corridor P4-100A at office P48-50, observation was made of a self closing device mounted to the door leading to this room. This door was propped open with a chair thus rendering the self-closing device ineffective. Staff QQ removed the chair and discussed this issue with the staff members present.

Additionally on the fourth floor, observation was made by this writer and the staff members present on tour within the storage room adjacent to vestibule P48-111 of combustible material stored to within a few inches of the ceiling.

Observation was made of one fire extinguisher mounted above the five foot requirement within room P9-3 located on the ninth floor.

These findings were verified by all staff members during tour on 07/25/12.

K-130

Based on facility tour and staff verification it was determined this facility failed to ensure all doors in fire barriers were held open only with self-closing or automatic closing devices and were arranged to automatically close upon activation of the device or arranged to be kept closed according to the National Fire Protection Association (NFPA) 101 Chapter 7.2.1.8.1.
Based on facility tour and staff verification it was determined this facility failed to ensure all mobile soiled linen or trash collection receptacles exceeding 32 gallons were located in a room protected as a hazardous area when not attended according to the National Fire Protection Association (NFPA) 101 Chapter 9.5
This had the potential to affect all those utilizing this area of the facility.

Findings include:

Facility tour took place on 08/01/12 with staff members EE, NN, QQ, UU, and WW1. During tour of the fourth floor one hour fire rated water pump room, observation was made of a fire rated door equipped with a self-closing device propped open with a small piece of metal conduit. Staff EE was observed to remove the section of conduit allowing the door to close and latch shut. Staff EE then verbalized to the staff present to not prop open doors equipped with self closing devices.

During tour of the first floor recycle room observation was made of greater than six mobile metal and plastic trash/linen containers located within a storage area which was determined to not have the one hour fire rated construction including doors, although it had a suppression system. This area was open to a short corridor which has additional rooms.
Observation was made of one metal trash bin filled with bio-hazard waste and a plastic bin partially filled with recycle waste products.

These findings were verified by all staff present during tour on 08/01/12.

K-130

Based on facility tour and staff verification it was determined this facility failed to ensure storage rooms considered as hazardous areas were constructed with at least a one hour fire resistance rating according to the National Fire Protection Association (NFPA) 101, Chapter 8.4.
This facility failed to ensure the 30 second monthly and 90 minute annual testing of the emergency battery operated egress lights according to NFPA 101, Chapter 7.9.3.
This facility failed to ensure that smoke detectors were sensitivity tested according to NFPA 72, Chapter 7-3.2.1.
This facility failed to ensure the monthly inspections of the portable fire extinguisher according to NFPA 10, Chapter 4-3.1.

Findings include:

Facility tour took place on 08/01/12 with staff members CC1, and FF. During tour of the storage room observation was made of several boxes, linen and miscellaneous items which were located on shelving and stacked to within a few inches of the ceiling.

During documentation review for the emergency battery operated egress lights took place on 08/01/12. Staff CC1 and FF stated there was no documentation available to verify the 30 second monthly or 90 minute annual inspections.

Documentation review for the smoke detectors took place on 08/01/12. Staff CC1 provided the fire alarm inspection reports which failed to include the sensitivity testing of the smoke detectors. Staff FF verified the sensitivity testing has not been performed since occupancy of the building in 2010.

During documentation review for the portable fire extinguisher took place on 08/01/12. Staff CC1 and FF stated there was no documentation available to verify monthly inspections. Visual inspection of the fire extinguisher tag reveals no signatures or dates documented.

These findings were verified during tour on 08/01/12.

Based on observation of the 5th, 6th, and 7th floor, and interview, the facility failed to ensure compliance with NFPA 70 in general, and NFPA 70, 110 3(b) and 400-7(b) in particular.

Findings:

On 07/23/12 at 3:00 P.M. on the 7th floor of the H building, in room H71 41 a power strip was observed with five devices and another power strip plugged into it. The second power strip had four appliances plugged into it.

On 07/23/12 at 3:00 P.M. Staff JJ confirmed the findings.

On 07/24/12 at 9:23 A.M. on the 6th floor of the H building, in room H60 117, a power strip was observed with six devices plugged into it, plus another power strip. The second power strip had two devices plugged into it.

On 07/24/12 at 9:23 A.M. in an interview Staff DD verified the observation.

On 07/24/12 at 10:57 A.M. on the 5th floor of the H building, in room H50 40, a coffee maker was observed plugged into an extension cord, which was then plugged into a power strip.

On 07/24/12 at 10:57 A.M. in an interview Staff DD verified the observation.

Based on observation of the 6th floor, and interview, the facility failed to ensure compliance with NFPA 70 in general, and NFPA 70 110 3(b) and 400-7(b) in particular.

Findings:

On 07/30/12 at 11:15 A.M. in an area designated the main laboratory in the Q building, and indicated as a hazard area on the schematic of the floor, three appliances rated (according to the tag on each cord) at 5.5 amps each (for a total of 16.5 amps) was observed to be plugged into an extension cord that, according to the tag on it, was rated at 15 amps.

On 07/30/12 at 11:15 A.M. staff DD in an interview confirmed the observation and arithmetic.