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Based on observation and interview, the facility failed to maintain a 2- hour separation in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.1.3.5), 2012 Edition. This facility has a capacity of 342 and a census of 165.

Findings include:

Observation and interview on 04/04/18 at 1:45 p.m., revealed approximate 1/2 inch gaps around three penetrations in the 2-hour fire wall located above the lay-in ceiling tile at the Emergency Room Doors. The Engineering Manager and Safety Officer verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain minimum construction requirements in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.1.6), 2012 Edition. This facility has a capacity of 342 and a census of 165.

Findings include:

1. Observation and interview on 04/04/18 at 10:30 a.m., revealed the Upstairs Flannel Room at the Mercy Family Clinic Northwood off site location contained an approximate 1/4 inch gap around 2 vent pipes penetrations. This room also contained an approximate 4 inch by 4 inch hole next to the vent pipes.

2. Observation and interview on 04/04/18 at 10:45 a.m., revealed the Providers Office at the Mercy Physical Rehabilitation & Pain Services off site location contained numerous (approximate 1/2 inch) holes in the walls where shelving had been removed.

3. Observation and interview on 04/04/18 at 9:55 a.m., revealed the 5th Floor West North Hallway Electrical Closet contained an approximate 4 inch by 4 inch hole in the east wall.

4. Observation and interview on 04/04/18 at 10:52 a.m., revealed the 3rd Floor TIS Phone Room had several missing or broke lay-in ceiling tiles. The Engineering Manager and Safety Officer verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain unobstructed egress in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.5.1), 2012 Edition. This facility has a capacity of 342 and a census of 165.

Findings include:

1. Observation and interview on 04/02/18 at 2:00 p.m., revealed the path of egress from the Northeast exit door to the public way at the Mercy Family Clinic Forest Park off site location was snow covered. The cement pad directly outside the door had been cleared.

2. Observation and interview on 04/04/18 at 9:17 a.m., revealed the path of egress from the Hall A exit door to the public way at the Mercy Family Clinic Clear Lake off site location was snow covered.

3. Observation and interview on 04/04/18 at 9:17 a.m., revealed the path of egress from the Hall B exit door to the public way at the Mercy Family Clinic Clear Lake off site location was snow covered.

4. Observation and interview on 04/04/18 at 10:30 a.m., revealed the north exit door at the Mercy Family Clinic Northwood off site location would not open due to a buildup of ice. The Engineering Manager and Safety Officer verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to ensure that required self-closing doors are maintained in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.2.2.2.7), 2012 Edition. This facility has a capacity of 342 and a census of 165.

Findings include:

1. Observation and interview on 04/04/18 at 10:30 a.m., revealed the basement door at the Mercy Family Clinic Northwood off site location did not contain a self-closing device.

2. Observation and interview on 04/04/18 at 11:20 a.m., revealed the basement door at the Mercy Family Clinic Lake Mills off site location did not contain a self-closing device.

3. Observation and interview on 04/04/18 at 11:06 a.m., revealed the self-closing device for the Cytology Room/Lab door had been disconnected. This door was a 1 1/2 hour fire rated door and is required to be self-closing. The Engineering Manager and Safety Officer verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain emergency lighting fixtures in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.9), 2012 Edition. This facility has a capacity of 342 and a census of 165.

Findings include:

1. Observation and interview on 04/03/18 at 12:42 p.m., revealed the battery backup emergency light near the Main Entrance at the Mercy Family Clinic Greene off site location failed to illuminate when tested.

2. Observation and interview on 04/02/18 at 2:20 p.m., revealed the battery backup emergency light in the ED Penthouse failed to illuminate when tested.

3. Observation and interview on 04/04/18 at 10:50 a.m., revealed the battery backup emergency light in the 4th Floor Pharmacy failed to illuminate when tested.

4. Observation and interview on 04/04/18 2:09 p.m., revealed the battery backup emergency light in the Main Fire Pump Room in the Basement failed to illuminate when tested.

5. Observation and interview on 04/02/18 at 2:45 p.m., revealed the battery backup emergency light in the Think Big Room at the Mercy Cheslea Creek off site clinic failed to illuminate when tested.

The Engineering Manager and Safety Officer verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other areas in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.2.1.3), 2012 Edition. This facility has a capacity of 342 and a census of 165.

Findings include:

1. Observation and interview on 04/04/18 at 9:47 a.m., revealed the corridor doors to Room #'s 252, 253, and 254 at the Acute Rehabilitation Unit off site location did not contain self-closing devices. These rooms were greater than 50 square feet and were being used for storage.

2. Observation and interview on 04/04/18 at 10:40 a.m., revealed the corridor door to the Northwest Storage Room at the Mercy Pediatric & Adolescent Clinic off site location did not contain a self-closing device. This room was greater than 50 square feet and being used for storage.

3. Observation and interview on 04/04/18 at 1:29 p.m., revealed the corridor door to the 1st Floor North End Soiled Holding Room failed to fully self-close and positively latch within the door frame. The Engineering Manager and Safety Officer verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain smoke detectors in accordance with National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Section-17.7.4.1), 2010 Edition. This facility has a capacity of 342 and a census of 165.

Findings include:

1. Observation and interview on 04/02/18 at 2:00 p.m., revealed 2 smoke detectors installed within 3 feet of HVAC openings in the lobby of the Mercy Family Practice Center off site clinic.

2. Observation and interview on 04/02/18 at 2:18 p.m., revealed a smoke detector installed within 3 feet of an HVAC opening located in the corridor near the huddle board of the Mercy Heart Center and Vascular Institute off site clinic.

3. Observation and interview on 04/02/18 at 2:15 p.m., revealed a smoke detector installed within 3 feet of an HVAC opening located in the checkout hallway of the Mercy Obstetrics and Gynecology off site clinic.

4. Observation and interview on 04/02/18 at 2:19 p.m., revealed a smoke detector installed within 3 feet of an HVAC opening located in the Supply Room of the Mercy Obstetrics and Gynecology off site clinic.

5. Observation and interview on 04/04/18 at 1:20 p.m., revealed a smoke detector hanging by its wires located in the basement of the Mercy Family Clinic Rockford off site clinic.

6. Observation and interview on 04/04/18 at 9:47 a.m., revealed smoke detectors installed within 3 feet of HVAC openings in Room #248 and Room #249 located in the Acute Rehabilitation Unit off site clinic.

7. Observation and interview on 04/04/18 at 9:42 a.m., revealed a smoke detector installed within 3 feet of an HVAC opening located in the North Alcove of the CCU.

8. Observation and interview on 04/04/18 at 11:15 a.m., revealed a smoke detector installed within 3 feet of an HVAC opening located in the 1st floor CV & P Stress Test Room.

9. Observation and interview on 04/04/18 at 12:01 p.m., revealed a smoke detector installed within 3 feet of an HVAC opening located in Room #1 of the CV & P.

10. Observation and interview on 04/04/18 at 1:48 p.m., revealed a smoke detector installed within 3 feet of an HVAC opening located in the ED Storage Room near Family Room A.

11. Observation and interview on 04/04/18 at 1:59 p.m., revealed a smoke detector installed within 3 feet of an HVAC opening located in the Dock Corridor near the east exit doors.

12. Observation and interview on 04/04/18 at 9:46 a.m., revealed a smoke detector installed within 3 feet of an HVAC opening located at the Pyxis on the 6th Floor.

13. Observation and interview on 04/04/18 at 11:29 a.m., revealed a smoke detector installed within 3 feet of an HVAC opening located in the 2nd Floor South Corridor near the PRU.

14. Observation and interview on 04/04/18 at 1:27 p.m., revealed a smoke detector installed within 3 feet of an HVAC opening located in the CV & P 1st Floor Corridor near Room #3.

15. Observation and interview on 04/04/18 at 1:33 p.m., revealed a smoke detector installed within 3 feet of an HVAC opening located in the 1st Floor Lobby near the Northeast Fire Tower Stairs.

16. Observation and interview on 04/04/18 at 1:45 p.m., revealed a smoke detector installed within 3 feet of an HVAC opening located near the ED Triage Desk.

17. Observation and interview on 04/04/18 at 1:52 p.m., revealed a smoke detector installed within 3 feet of an HVAC opening located in the Dock Corridor near the Clean Linen Room.

The Engineering Manager and Safety Officer verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain sprinkler systems in accordance with National Fire Protection Association (NFPA) 25, The Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition. This facility has a capacity of 342 and a census of 165.

Findings include:

1. Observation and interview on 04/02/18 at 2:00 p.m., revealed that 1 of 2 sprinklers in the Supply Closet near Room #18 at the Mercy Family Clinic Forest Park off site location did not contain an escutcheon ring.

2. Observation and interview on 04/02/18 at 2:00 p.m., revealed the Supply Closet at the Mercy Family Clinic Forest Park off site location contained boots that were being stored approximately 6 inches below the sprinkler.

3. Observation and interview on 04/02/18 at 2:17 p.m., revealed shelving approximately 5 inches below the sprinkler in the Doctors Pod at the Mercy Obstetrics and Gynecology Clinic off site location.

4. Observation and interview on 04/04/18 at 9:17 a.m., revealed no hydraulic name plate for the sprinkler system at the Mercy Family Clinic Clear Lake off site location.

5. Observation and interview on 04/04/18 at 9:17 a.m., revealed the pressure gauges for the sprinkler system at the Mercy Family Clinic Clear Lake off site location were not dated making it unable to determine if the gauges had been calibrated or replaced in the last 5 years.

6. Observation and interview on 04/04/18 at 10:32 a.m., revealed gray communication wires that were zip tied to the sprinkler piping in the 3rd Floor North Mechanical Room near AHU #28. The Engineering Manager and Safety Officer verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain portable fire extinguishers in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.7.4.1) and National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers, 2010 Edition. This facility has a capacity of 342 and a census of 165.

Findings include:

1. Observation and interview on 04/02/18 at 2:45 p.m., revealed that immediate access to the K type portable fire extinguisher in the Kitchen was obstructed by a refrigerator.

2. Observation and interview on 04/02/18 at 2:10 p.m., revealed the 10 & 11 Elevator Penthouse did not contain a portable fire extinguisher.

3. Observation and interview on 04/04/18 at 2:15 p.m., revealed the portable fire extinguisher in the corridor near the Break Room at the Mercy Family Clinic Sheffield off site location was installed with the top of the extinguisher at approximately 6 feet.

4. Observation and interview on 04/04/18 at 2:15 p.m., revealed the portable fire extinguisher in Room #3 at the Mercy Family Clinic Sheffield off site location was installed with the top of the extinguisher at approximately 6 feet. The Engineering Manager and Safety Officer verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain corridor doors in order to resist the passage of smoke in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.6.3.5), 2012 Edition. This facility has a capacity of 342 and a census of 165.

Findings include:

1. Observation and interview on 04/02/18 at 2:04 p.m., revealed the corridor door near the Scheduling Desk at the Mercy Heart Center & Vascular Institute off site clinic failed to close and positively latch within the door frame when tested.

2. Observation and interview on 04/04/18 at 2:53 p.m., revealed an approximate 1/2 inch gap along the top of the corridor door to Exam Room #2 at the Mercy Neurosurgery Forest Park Building off site clinic.

3. Observation and interview on 04/04/18 at 10:00 a.m., revealed an approximate 1/4 inch gap along the top of the corridor door to the Clinic Managers Office at the Mercy Diabetes, Kidney, & Weight Management off site clinic.

The Engineering Manger and Safety Officer verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to ensure that smoke barriers are free of penetrations which compromises the 1/2-hour fire resistance rating and prevents the passage of smoke to an adjacent smoke compartment in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-8.5.6), 2012 Edition. This facility has a capacity of 342 and a census of 165.

Findings include:

Observation and interview on 04/04/18 at 10:13 a.m., revealed the 4th Floor West Smoke Barrier contained an approximate 3/4 inch gap around a water pipe penetration located above the lay-in ceiling tile near Smoke Barrier Door #17908.

The Engineering Manager and Safety Officer verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain smoke barrier doors in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.7.8(1)), 2012 Edition. This facility has a capacity of 342 and a census of 165.

Findings include:

1. Observation and interview on 04/04/18 at 9:30 a.m., revealed that the 6th Floor West Smoke Barrier Door #17927 failed to fully self-close within the door frame when tested.

2. Observation and interview on 04/04/18 at 10:05 a.m., revealed the 4th Floor West Smoke Barrier Door #17908 failed to fully self-close within the door frame. The Engineering Manager and Safety Officer verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain electrical systems in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.1.2), 2012 Edition and National Fire Protection Association (NFPA) 70, National Electrical Code, 2011 Edition. This facility has a capacity of 342 and a census of 165.

Findings include:

1. Observation and interview on 04/02/18, at approximately 2:08 p.m., revealed Exam Room #'s 1, 6, 9, 10, 11, 12, 13, 15, 17, 19, 20, 21 at the Mercy Heart Center and Vascular Institute off site clinic contained non-GFCI protected electrical receptacles that were located within 6 feet of sinks.

2. Observation and interview on 04/02/18 at 2:08 p.m., revealed a non-GFCI protected electrical receptacle located within 6 feet of the sink near Scheduling at the Mercy Heart Center and Vascular Institute off site clinic.

3. Observation and interview on 04/02/18 at 2:21 p.m., revealed a non-GFCI protected electrical receptacle located in the Public Restroom near Exam Room #11 at the Mercy Heart Center and Vascular Institute off site clinic.

4. Observation and interview on 04/02/18 at 12:30 p.m., revealed a non-GFCI protected electrical receptacle located within 6 feet of the sink in the Treatment Room at the Mercy Family Clinic Greene off site location.

5. Observation and interview on 04/02/18 at 2:17 p.m., revealed no designations for breaker #'s 78 and 80 in Panel R and breaker #26 in Panel L located in the Fleet Room at the Mercy Obstetrics and Gynecology off site clinic.

6. Observation and interview on 04/02/18 at 3:00 p.m., revealed no cover for the electrical receptacle near the X-Ray Computer Station at the Mercy Anticoagulation Clinic off site location.

7. Observation and interview on 04/04/18 at 9:45 a.m., revealed no designation for breaker #12 in Panel A at the Mercy Family Pediatric & Adolescent Clinic Clear Lake off site location.

8. Observation and interview on 04/04/18 at 2:15 p.m., revealed 6-plex electrical adapters being used along the south and west walls of the Clinic Managers Office at the Mercy Family Clinic Sheffield off site location.

9. Observation and interview on 04/04/18 at 10:00 a.m., revealed the 5th Floor West Soiled Utility Room contained a non-GFCI protected electrical receptacle located within 6 feet of a water source.

10. Observation and interview on 04/04/18 at 10:10 a.m., revealed the 4th Floor West Soiled Utility Room contained a non-GFCI protected electrical receptacle located within 6 feet of a water source.

11. Observation and interview on 04/04/18 at 9:40 a.m., revealed the 6th Floor South Side Mechanical Room contained an open junction box with exposed electrical wires along the wall near AHU #33.

12. Observation and interview on 04/04/18 at 2:23 p.m., revealed the Basement contained an open junction box with exposed electrical wires along the ceiling near AHU #27.

13. Observation and interview on 04/04/18 at 1:45 p.m., revealed an open junction box with exposed electrical wires located above the lay-in ceiling tile near the Central Emergency Room Doors. The Engineering Manager and Safety Officer verified these observations at the time of the survey process.

Based on observation and interview, the facility is not assuring that power strips are being used in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-10.2.3.6), 2012 Edition. This facility has a capacity of 342 and a census of 165.

Findings include:

1. Observation and interview on 04/02/18 at 2:40 p.m., revealed the Housekeeping Room near Treatment Room #11 at the Mercy Cheslea Clinic off site location contained a surge protector being used to supply power to an electric grinder and shop vac.

2. Observation and interview on 04/02/18 at 3:00 p.m., revealed the Lab Draw Room at the Mercy Family Clinic Regency off site location contained a plastic cased surge protector being used to supply power to an A1C blood test machine.

3. Observation and interview on 04/04/18 at 10:29 a.m., revealed the Coding Charge Entry Room at the Mercy Pediatric and Adolescent Clinic off site location contained a surge protector being used to supply power to a lamp.

4. Observation and interview on 04/04/18 at 10:15 a.m., revealed the Reception and Records Room at the Mercy Physical Rehabilitation & Pain Services off site clinic contained a surge protector being used to supply power to a fan. The Engineering Manager and Safety Officer verified these observations at the time of the survey process.