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Based on observation and interview, the facility did not provide a common separation wall with closers on all doors. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 11/19/13 at 10:52 am, observation revealed on the 1st floor in the medical records room west door, that the separation door did not self-close because the closer was removed from the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff O (Director Building Operations).


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Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with rooms open to the corridor with the required safe-guards. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 11/18/13 at 3:33 pm, observation revealed on the 1st floor in the Woods Wing sub-waiting room, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have an electrically supervised smoke detector or was not located to allow direct supervision by the facility staff from a nursing station or similar 24- hour occupied space. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff O (Director Building Operations) and staff P (Building Operations Manager).


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Based on observation and interview, the facility did not provide all corridor separation doors with operational positive-latching hardware. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/19/13 at 12:37 pm, observation revealed on the 1st floor in the kitchen, that the corridor door would not positively self-latch. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The kitchen doors are equipped with electric strike plates that during daily operations are set to unlock until a timer automatically engages the latch, in the evening and on weekends. During normal daily operation the kitchen doors does not positively self-latch. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).


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Based on observation and interview, the facility did not provide all corridor separation doors with operational positive-latching hardware. This deficiency occurred in 4 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/18/13 at 2:30 pm, observation revealed on the 1st floor in the operating room suite, that the corridor door would not positively self-latch. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. Both sets of double doors to the operating room suite are equipped with electric strike plates that during daily operations are set to unlock, so unless a manual switch is thrown the suite doors do not positively self-latch. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff O (Director Building Operations) and staff P (Building Operations Manager).

2. On 11/18/13 at 2:38 pm, observation revealed on the 1st floor in the recovery room, that the corridor door would not positively self-latch. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The double doors to the recovery room are equipped with an electric strike plate that during daily operations are set to unlock, so unless a manual switch is thrown the door does not positively self-latch. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff O (Director Building Operations) and staff P (Building Operations Manager).

3. On 11/19/13 at 10:07 am, observation revealed on the 1st floor in the lab main entrance, that the corridor door would not positively self-latch. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The main entrance door to the lab is equipped with an electric strike plate that during daily operations is set to unlock until a timer automatically engages the latch, in the evening and on weekends. During normal daily operation the main lab room door does not positively self-latch. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).

4. On 11/19/13 at 10:12 am, observation revealed on the 1st floor in the lab east entrance, that the corridor door would not positively self-latch. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The east entrance door to the lab is equipped with an electric strike plate that during daily operations is set to unlock until a timer automatically engages the latch, in the evening and on weekends. During normal daily operation the east lab room door does not positively self-latch. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).


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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations. This deficiency occurred in 4 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/19/13 at 8:53 am, observation revealed on the 1st floor in the smoke barrier wall above the O.B. main entrance, that penetrations were not sealed according to an approved method. The deficiency included one 3/4"and two 1/2" conduits not plugged and five electrical conduits and a drywall cutout for the nurse call system not sealed. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).

2. On 11/19/13 at 9:02 am, observation revealed on the 1st floor in the smoke barrier wall above the O.B. supply closet, that a penetration was not sealed according to an approved method. The deficiency included a 3"x5" hole cut into the drywall for a sprinkler pipe to serve the closet behind the volunteer desk. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).

3. On 11/19/13 at 9:11 am, observation revealed on the 1st floor in the smoke barrier wall above the cross corridor doors to the woods wing, that a penetration was not sealed according to an approved method. The deficiency included one 3" conduit that was not plugged. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).

4. On 11/19/13 at 9:20 am, observation revealed on the 1st floor in the smoke barrier wall above the cross corridor doors located behind recovery, that a penetration was not sealed according to an approved method. The deficiency included one 2" conduit that was not plugged. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).

5. On 11/19/13 at 12:28 pm, observation revealed on the 1st floor in the smoke barrier wall between the pharmacy and corridor, that penetrations were not sealed according to an approved method. The deficiency included a 3" and 1/2" conduit with communication wires that were not plugged. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).


______________________________________

Based on observation and interview, the facility did not enclose all hazardous rooms with doors with operational positive-latching hardware. This deficiency occurred in 3 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/18/13 at 2:27 pm, observation revealed on the 1st floor in the O.R. clean corridor soiled linen room, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The door to the clean corridor is equipped with an electric strike plate that during daily operations is set to unlock, so unless a manual switch is thrown the hazardous room door does not positively self-latch. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff O (Director Building Operations) and staff P (Building Operations Manager).

2. On 11/18/13 at 2:40 pm, observation revealed on the 1st floor in the recovery soiled linen room, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The door to the recovery soiled linen room is equipped with an electric strike plate that during daily operations is set to unlock, so unless a manual switch is thrown the hazardous room door does not positively self-latch. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff O (Director Building Operations) and staff P (Building Operations Manager).


______________________________________

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/19/13 at 9:35 am, observation revealed on the 1st floor in patient delivery room #50, that the closet was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The building construction type is II(000) which requires automatic sprinkler protection in accordance with NFPA 100 (2000 ed.) 19.3.5.1 This observed situation was not compliant with NFPA 101 (2000 ed.)This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).

2. On 11/19/13 at 9:40 am, observation revealed on the 1st floor in patient delivery room #51, that the closet was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The building construction type is II(000) which requires automatic sprinkler protection in accordance with NFPA 100 (2000 ed.) 19.3.5.1 This observed situation was not compliant with NFPA 101 (2000 ed.)This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).


______________________________________

Based on observation and interview, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 11/19/13 at 10:00 am, observation revealed on the 1st floor in the business office server room, that there was one or more unsealed holes near the ceiling. The holes included 8 ceiling tiles that were missing. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).


______________________________________

Based on observation and interview, the facility did not provide a common separation wall with closers on all doors. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 11/19/13 at 10:52 am, observation revealed on the 1st floor in the medical records room west door, that the separation door did not self-close because the closer was removed from the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff O (Director Building Operations).


______________________________________

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with rooms open to the corridor with the required safe-guards. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 11/18/13 at 3:33 pm, observation revealed on the 1st floor in the Woods Wing sub-waiting room, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have an electrically supervised smoke detector or was not located to allow direct supervision by the facility staff from a nursing station or similar 24- hour occupied space. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff O (Director Building Operations) and staff P (Building Operations Manager).


______________________________________

Based on observation and interview, the facility did not provide all corridor separation doors with operational positive-latching hardware. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/19/13 at 12:37 pm, observation revealed on the 1st floor in the kitchen, that the corridor door would not positively self-latch. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The kitchen doors are equipped with electric strike plates that during daily operations are set to unlock until a timer automatically engages the latch, in the evening and on weekends. During normal daily operation the kitchen doors does not positively self-latch. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).


______________________________________

Based on observation and interview, the facility did not provide all corridor separation doors with operational positive-latching hardware. This deficiency occurred in 4 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/18/13 at 2:30 pm, observation revealed on the 1st floor in the operating room suite, that the corridor door would not positively self-latch. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. Both sets of double doors to the operating room suite are equipped with electric strike plates that during daily operations are set to unlock, so unless a manual switch is thrown the suite doors do not positively self-latch. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff O (Director Building Operations) and staff P (Building Operations Manager).

2. On 11/18/13 at 2:38 pm, observation revealed on the 1st floor in the recovery room, that the corridor door would not positively self-latch. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The double doors to the recovery room are equipped with an electric strike plate that during daily operations are set to unlock, so unless a manual switch is thrown the door does not positively self-latch. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff O (Director Building Operations) and staff P (Building Operations Manager).

3. On 11/19/13 at 10:07 am, observation revealed on the 1st floor in the lab main entrance, that the corridor door would not positively self-latch. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The main entrance door to the lab is equipped with an electric strike plate that during daily operations is set to unlock until a timer automatically engages the latch, in the evening and on weekends. During normal daily operation the main lab room door does not positively self-latch. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).

4. On 11/19/13 at 10:12 am, observation revealed on the 1st floor in the lab east entrance, that the corridor door would not positively self-latch. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The east entrance door to the lab is equipped with an electric strike plate that during daily operations is set to unlock until a timer automatically engages the latch, in the evening and on weekends. During normal daily operation the east lab room door does not positively self-latch. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).


______________________________________

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations. This deficiency occurred in 4 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/19/13 at 8:53 am, observation revealed on the 1st floor in the smoke barrier wall above the O.B. main entrance, that penetrations were not sealed according to an approved method. The deficiency included one 3/4"and two 1/2" conduits not plugged and five electrical conduits and a drywall cutout for the nurse call system not sealed. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).

2. On 11/19/13 at 9:02 am, observation revealed on the 1st floor in the smoke barrier wall above the O.B. supply closet, that a penetration was not sealed according to an approved method. The deficiency included a 3"x5" hole cut into the drywall for a sprinkler pipe to serve the closet behind the volunteer desk. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).

3. On 11/19/13 at 9:11 am, observation revealed on the 1st floor in the smoke barrier wall above the cross corridor doors to the woods wing, that a penetration was not sealed according to an approved method. The deficiency included one 3" conduit that was not plugged. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).

4. On 11/19/13 at 9:20 am, observation revealed on the 1st floor in the smoke barrier wall above the cross corridor doors located behind recovery, that a penetration was not sealed according to an approved method. The deficiency included one 2" conduit that was not plugged. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).

5. On 11/19/13 at 12:28 pm, observation revealed on the 1st floor in the smoke barrier wall between the pharmacy and corridor, that penetrations were not sealed according to an approved method. The deficiency included a 3" and 1/2" conduit with communication wires that were not plugged. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).


______________________________________

Based on observation and interview, the facility did not enclose all hazardous rooms with doors with operational positive-latching hardware. This deficiency occurred in 3 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/18/13 at 2:27 pm, observation revealed on the 1st floor in the O.R. clean corridor soiled linen room, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The door to the clean corridor is equipped with an electric strike plate that during daily operations is set to unlock, so unless a manual switch is thrown the hazardous room door does not positively self-latch. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff O (Director Building Operations) and staff P (Building Operations Manager).

2. On 11/18/13 at 2:40 pm, observation revealed on the 1st floor in the recovery soiled linen room, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The door to the recovery soiled linen room is equipped with an electric strike plate that during daily operations is set to unlock, so unless a manual switch is thrown the hazardous room door does not positively self-latch. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff O (Director Building Operations) and staff P (Building Operations Manager).


______________________________________

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/19/13 at 9:35 am, observation revealed on the 1st floor in patient delivery room #50, that the closet was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The building construction type is II(000) which requires automatic sprinkler protection in accordance with NFPA 100 (2000 ed.) 19.3.5.1 This observed situation was not compliant with NFPA 101 (2000 ed.)This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).

2. On 11/19/13 at 9:40 am, observation revealed on the 1st floor in patient delivery room #51, that the closet was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The building construction type is II(000) which requires automatic sprinkler protection in accordance with NFPA 100 (2000 ed.) 19.3.5.1 This observed situation was not compliant with NFPA 101 (2000 ed.)This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).


______________________________________

Based on observation and interview, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 11/19/13 at 10:00 am, observation revealed on the 1st floor in the business office server room, that there was one or more unsealed holes near the ceiling. The holes included 8 ceiling tiles that were missing. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Building Operations Manager).


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