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Based on observation and interview, the facility did not provide and maintain the required building construction type with support steel covered with rated fire proofing. This deficiency occurred in of the 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/12/2016 at 1:30 pm, observation revealed on the exit to the MRI truck that fire proofing was missing from the structural steel at the entrance 'canopy' which is attached to the building. In addition, the walls and roof were made of combustible material. The building is a (3,3,2) building. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.1.6.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide and maintain the required building construction type by having support steel covered with a rated fire proofing. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/11/2016 at 1:30 PM, observation revealed on the Basement floor in the Staff Gym, that fire proofing was missing from a beam clamp that was attached to the structural steel beam. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with smoke detection in spaces that are open to the corridor and louver-free corridor walls. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 10:31 am, observation revealed on the basement floor in the reception area, where surgery used to be performed, 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 a smoke detector and was not fully observable from a 24 hour occupied location. 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 H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

2. On 01/11/2016 at 10:32 am, observation revealed on the basement floor in the elevator equipment room, that a wall mounted air-transfer grill was installed in the corridor wall. Louvers, even if they contained a fire damper, are not permitted in a corridor wall. The grill was 12 inches by 12 inches. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

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 by having the required safe-guards and smoke detection in spaces that are open to the corridor. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/12/2016 at 3:20 PM, observation revealed on the 1st floor in the Linen Storage Alcove, 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 a smoke detector and was not fully observable from a 24 hour occupied location. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

2. On 01/12/2016 at 3:30 PM, observation revealed on the 1st floor in the Nurse Station, 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 a smoke detector and was not fully observable from a 24 hour occupied location. Staff X mentioned that this Nurse Station was not occupied for 24/7. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

Based on observation and interview, the facility did not provide corridor doors with positive-latching hardware and hinged doors in the egress path. This deficiency occurred in 2 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 11:43 am, observation revealed on the basement floor in the loading dock, room 0304, that the corridor door would not positively self-latch when pushed to a closed position. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance mechanic).

2. On 01/12/2016 at 9:00 am, observation revealed on the 1st floor in the corridor in front of the Emergency Department, that the door was installed in the path of egress access and was not side-hinged. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.4.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff I (CEO) and staff J (Director Support Services).


29942

Based on observation and interview, the facility did not provide corridor separation doors with corridor doors that would close when pushed or pulled. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/12/2016 at 3:25 PM, observation revealed on the 1st floor in the Reading Room, that the door to the corridor was held open with an waste basket. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.3.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction. This deficiency occurred in 2 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 1/12/2016 at 2:40 pm, observation revealed on the 1st floor in the back wall of prep recovery and PACU Suite, that the smoke barrier wall was not constructed to a 1-hour fire resistance rating. The medical gas outlets were not installed with a listed rated system for a one hour wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director Support Services).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls and sealed wall penetrations. This deficiency occurred in 2 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 10:30 am, observation revealed on the 4th floor in the smoke barrier wall over the smoke barrier door, that a penetration was not sealed according to an approved method. The deficiency included a 2 inch diameter pipe penetration with a bundle of wires without fire-stopping seal. 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 H (President and CEO) and staff I (Maintenance Mechanic 1).

2. On 01/11/2016 at 12:00 PM, observation revealed on the 2nd floor in the smoke barrier wall over the smoke barrier door, that a penetration was not sealed according to an approved method. The deficiency included a 1'-0"x 0'-6" cable tray penetration without a fire stop seal. Fire stop pillows were removed from the penetrated hole and were left near the hole. 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 H (President and CEO) and staff I (Maintenance Mechanic 1).

Based on observation and interview, the facility did not provide smoke compartments of the appropriate size and layout with compliant smoke compartments. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 1/12/2016 at 2:35 pm, observation revealed on the 1st floor floor in corridor 1613, that the smoke compartment was not compliant. The across corridor door between corridor 1613 and 1619 was locked. This limits the smoke zone 16 useable area for 'area of refuge' to the area of corridor 1613, vestibule 1614 and consult room 1615, if unlocked, which is about 675 square feet. This is not enough space for evacuation at 6 square foot per person and 30 square feet per inpatient for smoke zone 11, which is 16,704 sq. ft. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director Support Services).

Based on observation and interview, the facility did not provide smoke barrier doors with the required minimal width, window openings that were protected by fire-rated glazing or wired glass panels with properly sized doors. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/12/2016 at 3:05 pm, observation revealed on the 1st floor in the corridor 1613 to corridor 1141 (surgery waiting), that the smoke barrier door was not compliant. The smoke barrier door is a single door. The door separates two corridors and is required to be a double egress door, opposite swing with 41.5 inch clear width since inpatients are traveling through this area. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not enclose hazardous rooms with rated doors and rated wall construction. This deficiency occurred in 4 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 1:05 pm, observation revealed on the basement floor in the Morgue, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The door was rated for 20 minutes and the space was used as a new storage room. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 . This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

2. On 01/11/2016 at 3:25 pm, observation revealed on the basement floor in the storage room for dummies and other CPR material, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The door was rated for 20 minutes and the space was used as a new storage room. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 . This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

3. On 01/11/2016 at 2:57 pm, observation revealed on the basement floor in the new storage room in the former OR area, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The door was rated for 20 minutes and the space was used as a new storage room. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 . This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

4. On 01/11/2016 at 2:56 pm, observation revealed on the basement floor in the new storage room in the former OR area, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had a 15 by 30 inches electrical panel. The maximum size (without special treatment) is 100 square inches in 100 square feet of wall. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

5. On 01/12/2016 at 9:45 am, observation revealed on the 1st floor in the rehab storage area, that the enclosing wall was not constructed to a 1-hour fire resistance rating and the door was not rated. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

6. On 01/12/2016 at 9:50 am, observation revealed on the 1st floor in the lab storage room 1273, that the enclosing wall was not constructed to a 1-hour fire resistance rating and the door was not rated. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

7. On 01/12/2016 at 3:15 pm, observation revealed on the 1st floor in the clean utility room in new surgery, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

8. On 01/12/2016 at 4:25 pm, observation revealed on the 1st floor in the operating room 1702, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had med gas control panel approximately 2' x 2' in the rated wall of sterile supply displacing the drywall. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

9. On 01/12/2016 at 4:55 pm, observation revealed on the 1st floor in the decontamination room of the operating room area, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had a water outlet box that was not rated in the one hour rated wall. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic)

Based on observation and interview, the facility did not enclose hazardous rooms with a smoke-tight room enclosure in a sprinkled smoke zone. This deficiency occurred in 3 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 1:30 PM, observation revealed on the Basement floor in the Staff Gym-Storage Area, that a gap in the enclosure did not resist the passage of smoke. The wall between the Staff Gym and Storage was not continuous up to the deck above, so the whole Staff Gym was considered a big hazardous room. In the same location, there were three, 3 inch diameter and one 3" x 4" unsealed holes in the wall near the entrance door. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. 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 H (President and CEO) and staff I (Maintenance Mechanic 1).

2. On 01/11/2016 at 3:30 PM, observation revealed on the Basement floor in the PACU vacant area, that the enclosure did not resist the passage of smoke by having a proper enclosure around a combustible storage area. The combustible storage area included 8 wooden crates stacked in the middle of the room. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. 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 H (President and CEO) and staff I (Maintenance Mechanic 1).

3. On 01/11/2016 at 4:00 PM, observation revealed on the Basement floor in the Hazardous Waste Room, that a hole in the enclosure did not resist the passage of smoke because of one or more unsealed holes. The holes included a 3" x 4" hole in the wall. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. 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 H (President and CEO) and staff I (Maintenance Mechanic 1).

Based on observation and interview, the facility did not provide egress paths at all times with doors that were unlockable in the egress path and egress without passing through intervening hazardous rooms. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 2:43 pm, observation revealed on the basement floor, in the hall that serves the maintenance suite, that the door was locked from the egress side. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.2.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

2. On 01/11/2016 at 1:56 pm, observation revealed on the basement floor, in the the mechanical room that opens up into the electrical room (of the maintenance suite), that an intervening room in the means of egress was hazardous. The intervening room is a electrical room without sprinklers and therefore enclosed in 2 hour walls. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide egress paths at all times with doors that were unlockable in the egress path and snow cleared from the egress path. This deficiency occurred in 3 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/12/2016 at 9:30 am, observation revealed on the 1st floor in the rehab suite that the door was locked from the egress side. In the rehab suite, traveling north, there is a locked door (magnetic lock) preventing the use of the second exit for the suite. Going south, the push to exit button is missing. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.2.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

2. On 01/12/2016 at 1:40 pm, observation revealed on the path to the MRI truck under the 'canopy', that outside the exterior exit door there was an accumulation of snow in the exit discharge path. The door at the end of the canopy to the MRI truck had a wood wedge that was frozen on the ground such that the door would not open. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.10.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

3. On 01/12/2016 at 3:20 pm, observation revealed on the 1st floor in the corridor outside of the PACU, that the door was locked from the egress side. An exit sign was placed across a double egress door that was locked with a magnetic lock. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.2.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 2 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/12/2016 at 3:00 pm observation revealed on the 1st floor in the corridor of the surgery waiting area, that the clear and unobstructed width was 6'4". This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.3. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). Corridors used only by others must be at least 44" wide. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

2. On 01/12/2016 at 9:01 am, observation revealed on the 1st floor in the corridor in front of the Emergency Department, that the clear and unobstructed width of the corridor was 4 feet because when the sliding door opens from the closed position, it only opens to a 4 foot opening. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.3. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). Corridors used only by others must be at least 44" wide.. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).


29942

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/12/2016 at 10:30 am, observation revealed on the 1st floor in the Emergency area corridor, that the clear and unobstructed width of the corridor was 7 feet. An ATM machine installed in the corridor reduced the corridor width. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.3.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

Based on observation and interview, the facility did not provide rooms, or patient sleeping suites, larger than 1,000 square feet with at least 2 remote exit access doors having at least two exits from large suites. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/11/2016 at 11:00 am, observation revealed on the basement floor in the shell space, room 0100, that the suite of rooms was 3,500 square feet from the exit access door to the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.5.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide rooms, or patient sleeping suites, larger than 1,000 square feet with at least 2 remote exit access doors. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/12/2016 at 9:55 am, observation revealed on the 1st floor in the lab suite, that the legal exits from the floor were not remotely located from each other because they were located 10 feet from each other with the diagonal of the room being 60 feet This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.5.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide all spaces that can be exited without the use of a key or locked as permitted by the code, such as delayed egress and compliant egress locks. This deficiency occurred in 2 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 11:15 am, observation revealed on the 3rd floor, at the stair number 2 door, that the egress lock was not compliant. The exit door was equipped with a delayed egress locking (DEL) system and did not have the required signage on the door. Signs shall be readily visible with durable sign in letters not less than 1 inch high and not less than 1/8" inch stroke width on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS above the words DOOR CAN BE OPENED IN 15 SECONDS. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

2. On 01/11/2016 at 11:10 am, observation revealed on the 3rd floor, at the stair number 1 door, that the egress lock was not compliant. The exit door was equipped with a delayed egress locking (DEL) system and did not have the required signage on the door. Signs shall be readily visible, durable sign in letters not less than 1 inch high and not less than 1/8" inch stroke width on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS above the words DOOR CAN BE OPENED IN 15 SECONDS. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

3. On 01/11/2016 at 11:00 am, observation revealed on the 3rd floor, in the cross corridor door leading to stair number 4, that the egress lock was not compliant. The exit door was equipped with a delayed egress locking (DEL) system and did not have the required signage on the door. Signs shall be readily visible, durable sign in letters not less than 1 inch high and not less than 1/8" inch stroke width on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS above the words DOOR CAN BE OPENED IN 15 SECONDS. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 with visual alarm notification. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/11/2016 at 11:20 am, observation revealed on the 3rd floor, in the Inpatient Rehab Room, that the facility did not install a visual fire alarm notification device. Private mode notification requires staff to be aware of all fire alarm situations. This observed situation was not compliant with NFPA 72 (1999 ed.), 4-5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

Based on interview, observation and a review of documents, the facility did not maintain the fire alarm system according to NFPA 72 requirements with pull stations free of obstructions and repair of identified problems. This deficiency occurred in 10 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 2:30 pm, observation revealed on the Basement floor, in the air handling room, that access to the manual pull station of the fire alarm system was obstructed and not accessible for operation because a lot of unused ceiling tiles were stored in front of the pull station. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4; NFPA 72 (1999 ed.), 2-8.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

2. On 01/11/2016 at 5:45 pm, during a review of facility documents deficiencies were found during the test/inspection, but no records were available to confirm that the problem was corrected. Simplex Grinnel report titled "Inspection summary" dated 12-11-2015 indicated that 26 chime strobe, 1 fire alarm panel, 8 heat detectors, 3 horn strobes and 5 pull stations failed to pass the tests. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7 and NFPA 72 (1999 ed.), Chapter 7-3.2This condition was confirmed at the time of discovery by a concurrent record review and interview with staff H (President and CEO) and staff J (Director of Support Services).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with non-sprinkled rooms that meet permitted exceptions with unobstructed water distribution and all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 1of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/11/2016 at 11:45 am, observation revealed on the basement floor in the 1325 electrical room that opens up into mechanical room 0302, that the room was not sprinkler protected, although the entire facility was required to be sprinkled. The facility did not meet all the requirements of the code to avoid sprinkling the space. The room was enclosed with 2-hour rated construction, but the following was not provided: The walls are required to be 2 hours but only one hour walls are supplied. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.1 (exception). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

2. On 01/12/2016 at 1:45 pm, observation revealed on the 1st floor canopy (walkway) to the MRI truck, that the area under the canopy was not sprinkler protected, although the entire facility was required to be sprinkled. The facility did not meet all the requirements of the code to avoid sprinkling the space. The canopy is made of combusible material and since it is attached to the hospital it is required to be sprinklered. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.1 (exception). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with non-sprinkled rooms that meet permitted exceptions, unobstructed water distribution, and all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 3 of the 14 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 3:50 pm, observation revealed on the basement floor, in the former operating room (north of vacant endo room), that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item . The obstruction included a building column This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

2. On 01/11/2016 at 1:50 pm, observation revealed on the basement floor, in the unsprinklered electrical room (of the maintenance suite), that the room was not sprinkler protected, although the entire facility was required to be sprinkled to meet a construction exception. The facility did not meet all the requirements of the code to avoid sprinkling the space. The room was enclosed with 2-hour rated construction, but the following was not provided: pipes through the rated wall were not fire stopped with an approved UL designed system. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.5.1 (exception). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

3. On 01/11/2016 at 1:06 pm, observation revealed on the basement floor in the Morgue, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included storage piled up onto the morgue 'box'. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

4. On 01/11/2016 at 1:09 pm, observation revealed on the basement floor, in the toilet room of the shop area, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included the wing wall of the shower. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

5. On 01/11/2016 at 3:15 pm, observation revealed on the basement floor in the housekeeping next to the kitchen suite, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The corridor walls shall be one hour fire rated if the hospital is not sprinklered. 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 H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

6. On 01/11/2016 at 3:20 pm, observation revealed on the basement floor in stairs S-3, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included an air ventilation machine (4 inches down and 12 inches away). This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

7. On 01/12/2016 at 12:30 pm, observation revealed on the 1st floor in stairwell 1, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The single head does not have the throw to cover the distance in the stairwell. 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 H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).



29942


Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with unobstructed water distribution, all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 3 of the 10 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 11:30 am, observation revealed on the 2nd floor in the Telecom Room, that the discharge of sprinkler water was obstructed from reaching an unprotected area on the other side of a surface mounted light fixture. The light fixture was located 1'-3" away and 6 inch below the adjacent sprinkler deflector. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

2. On 01/11/2016 at 11:45 am, observation revealed on the 2nd floor in the UW Clinic Laboratory Room, that the top of the storage cabinet was located within 18" below a sprinkler deflector. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.6 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

3. On 01/11/2016 at 3:45 pm, observation revealed on the Basement floor in the Endo vacant room, that the room was not fully sprinkler protected. The room has sprinkler heads located 22 feet apart. Staff H or Staff I were unable to verify whether those sprinkler heads had extended spray pattern or not. 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 H (President and CEO) and staff I (Maintenance Mechanic 1).

4. On 01/11/2016 at 4:10 pm, observation revealed on the Basement floor in the stair number 4, that a sprinkler was not provided under the bottom of the stairs, leaving floor space that was not protected. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-13.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

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 the appropriate quantity of spare sprinklers. This deficiency occurred in all of the smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/11/2016 at 1:35 pm, observation revealed on the basement floor in the maintenance shop, that the cabinet of spare sprinklers did not contain two spare heads for the each type of sprinkler that were observed in the facility. Spare sprinklers were not provided for the dry heads. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-4.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).


29942


Based on interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. This deficiency occurred in 10 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/11/2016 at 5:00 PM, it was noted during a review of facility documents that the monthly wet sprinkler inspections were not performed as required by the code. There were no documents available to confirm that valves were inspected monthly. This situation was not compliant with NFPA 25 (1998 ed.), 2-2. and Table 2-1 This condition was confirmed at the time of discovery by a concurrent record review and interview with staff H (President and CEO) and staff J (Director of Support Services).

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 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/12/2016 at 11:30 am, observation revealed on the 1st floor in the CT Machine room, that there was one or more unsealed holes near the ceiling. The holes included a 7'-0" x 0'-4" and a 2'-0" x 0'- 4" hole in the ceiling. This hole 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 H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).


______________________________________

Based on observation and interview, the facility did not provide an adequate and reliable water supply that provided a verified reliable and adequate sprinkler water supply. This deficiency occurred in all of the smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/11/2016 at 1:30 pm, observation revealed on the basement floor in the boiler room, that the fire pump room was not constructed to satisfy code requirements. The fire pump was a) not enclosed with 1 hour fire rated walls (2-7.1), b) did not have lighting that was battery operated fixed light or flashlight (2-7.4); and c) did not have floors pitched away from pump & controller w/drain (2-7.6) per NFPA 20. This observed situation was not compliant with NFPA 20 (1999 ed.) 2-7. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

Based on record review and interview, the facility did not provide and maintain portable fire extinguishers as required by the codes with compliant fire extinguishers. This deficiency occurred in 1 of the 10 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/12/2016 at 11:00 am, during a review of Simplex Grinnel annual fire-extinguisher inspection document for 2015, it was discovered that the required five year hydrostatic test for the K-type wet chemical fire extinguisher was due, but no records were available to confirm that hydrostatic test was conducted. This situation was not compliant with NFPA 101 (2000 ed.), 19.3.5.6, 9.7.4.1 and NFPA 10 (1998 ed.) 5-2. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with compliant fire dampers, hard ducts and neutral airflow between the corridor and rooms. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 2:05 PM, observation revealed on the Basement floor in the Staff Gym-Storage area, that a fire damper was not installed in an air duct that penetrated the rated wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1 and NFPA 90A (1999 ed.), 3-3.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

2. On 01/11/2016 at 2:10 PM, observation revealed on the Basement floor in the Staff Gym-Storage room, that airflow between the corridor and the dining room was not neutral. The damper in the return air duct, located in the Staff Gym room, was left in a close position and the door between Staff Gym room and dining room was left open most of the time . This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1, section 9.2, and NFPA 90A (1999 ed.), 2-3.11.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

3. On 01/11/2016 at 2:00 pm, observation revealed on the Basement floor in the Staff-Gym-Storage Area, that a flexible duct (air connector) was installed through the rated wall of the space. This observed situation was not compliant with NFPA 90A (1999 ed.), 2-3.2.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

Based on observation, interview and record review, the facility did not provide a kitchen extinguishing system as required by NFPA 96 with extinguisher identification and range hoods cleaned semi-annually. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 3:10 PM, observation revealed on the Basement floor in the Kitchen, that a placard identification sign was not provided near the Type K fire extinguisher to identify its location. This observed situation was not compliant with NFPA 96 (1998 ed.), Section 7-2.1.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

2. On 01/11/2016 at 3:15 PM, observation revealed on the Basement floor in the Kitchen, that a label was installed on the surface of the hood in the kitchen by Summit Companies but did not show the date of the last cleaning, rather showed a future service date of February 2nd, 2016. This observed situation was not compliant with NFPA 96 (1998 ed.), 8-3.1.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

3. On 01/11/2016 at 5:50 PM, during a review of documents entitled "Badger Hood Cleaning-Service Report" dated 9/2/2015, it was discovered that the range hood and ducts were not inspected semi-annually for grease contamination, as required for systems serving moderate-volume cooking operations. The range hood was inspected and cleaned only once on 9-2-2015 within last one year. This situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.6; 9.2.3; and NFPA 96 (1998 ed.), 8-3.1. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff H (President and CEO) and staff J (Director of Support Services).

Based on observation and interview, the facility did not provide hanging drapes or curtains that met code requirements, such as sprinkler obstruction with cubical curtains that permit the designed distribution of sprinkler water. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/12/2016 at 11:10 am, observation revealed on the 1st floor floor in the Emergency Area Decontamination room, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the eye wash area. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.5.5 and NFPA 13 (1999 ed.) 5-6.5.2.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes by having properly sized storage containers for soiled/trash. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/12/2016 at 10:10 am, observation revealed on the 1st floor in the lab suite, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. The biohazard trash can is about 40 gallons in the lab. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.6. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide the safe storage and use of medical gases as required by NFPA 99 with sealed wall penetrations. This deficiency occurred in all of the smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/11/2016 at 11:34 am, observation revealed on the basement floor in the med gas room 0303, that penetration(s) were not sealed according to an approved method. The deficiency included a door that was not labeled. This room was used to store greater than 3,000 cubic feet of medical oxygen and was required to be enclosed with 1-hour rated construction. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.4 and NFPA 99 (1999 ed.), 8-3.1.11. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping . In addition, the facility did not provide and maintain combustibles (vehicles) at least 10 feet away from a bulk (liquid) oxygen system, and 50 feet away areas occupied by nonambulatory patients from the inner container pressure-relief device, discharging piping outlets, and from filing and vent connections. This deficiency could affect all smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On January 12, 2016, 2014 at 1:10 pm, surveyor observed that the bulk oxygen tank in the parking lot, had a MRI truck partially parked behind a 2 hour wall. The truck was in direct line of sight of the bulk oxygen system tanks and was within 10 feet of the bulk oxygen system. This observed situation was not compliant with NFPA 50 (1998 edition) section 2.2.12 and NFPA 99 section 4-3.1.1.2(a) 10 b.

2. On January 12, 2016, 2014 at 1:10 pm, surveyor observed that the bulk oxygen tank in the parking lot, had a MRI truck within 50 feet of the bulk oxygen system. The MRI truck contains non ambulatory patients. This observed situation was not compliant with NFPA 50 (1998 edition) section 2.2.12 and NFPA 99 section 4-3.1.1.2(a) 10 b. (Note: Section 2.2.14 of NFPA 50 does not apply (2 hour wall separation) to section 2.2.12.)

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide interior walls and partitions made of noncombustible or limited-combustible materials. This deficiency occurred in 2 of the 10 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/11/2016 at 11:05 am, observation revealed on the basement floor in the shell space, room 0200, that a wall was made with combustible materials, which is not permitted in non-combustible types of building construction. The wall was constructed with wood to support the drywall in a 1 hour rated wall in the former window opening. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.1.6.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with: compliant air distribution installation, hazardous rooms were not enclosed, a wrench was missing in the spare sprinkler cabinet, the electrical panels did not have complete directories, and closed electrical raceways.

FINDINGS INCLUDE:

1. On 01/12/2016 at 3:00 PM, observation revealed on the Basement floor in the Laundry Room, that a flexible duct (air connector) was installed through the rated wall space. Flexible duct was installed for a dryer vent. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.5.2 and NFPA 90A (1999 ed.), 2-3.2.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

2. On 01/12/2016 at 3:06 PM, observation revealed on the Basement floor in the Laundry Room, that a hole in the enclosure did not resist the passage of smoke because of one or more unsealed holes. The holes included a 3 inch diameter and a 2 inch diameter unsealed holes in the wall. The room was considered hazardous because it contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

3. On 01/12/2016 at 3:10 PM, observation revealed on the Basement floor in the House Keeping room, that a hole in the enclosure did not resist the passage of smoke because of one or more unsealed holes. The holes included a 3 inch diameter unsealed pipe penetration in the wall. The room was considered hazardous because it contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

4. On 01/11/2016 at 2:45 PM, observation revealed on the Basement floor in the Air Handling Room number 6, that electrical panel breakers were not labeled to identify the loads they fed. Circuit breakers 17,19,21, 23, 25 inside the panel Leg Room #6 were not identified for the loads they were feeding. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.5.1 and NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

5. On 01/11/2016 at 2:50 PM, observation revealed on the Basement floor in the Air Handling Room number 6, that a 4 x 4 electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.5.1 and NFPA 70 (1999 ed.), 517-12. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

6. On 01/11/2016 at 3:00 PM, observation revealed on the Basement floor in the Air Handling Room number 6, that the cabinet of spare sprinklers did not contain a wrench that would fit the heads in the cabinet. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-4.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

7. On 01/12/2016 at 12:00 PM, observation revealed on the 1st floor in the Vestibule Canopy area, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code by having electrical panels with complete directories, and non-compliance. This deficiency occurred in all smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 10:36 am, observation revealed on the basement floor in the elevator equipment room, that the electrical panel breaker(s) were not labeled to identify the loads they fed. The panel in the elevator equipment room did not have the circuit breaker labeled. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

2. On 01/11/2016 at 10:40 am, observation revealed on the basement floor in the elevator equipment room, that the electrical code was not followed. The panel in the elevator equipment room was labeled indicating that both the normal and emergency power entered the same electrical panel. The normal and electrical power are too be separated. This observed situation was not compliant with NFPA 70 (1999 ed.). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

3. On 01/11/2016 at 1:52 pm, observation revealed on the basement floor in the unsprinklered electrical room (of the maintenance suite), that the electrical code was not followed. There is storage in the electrical room. This observed situation was not compliant with NFPA 70 (1999 ed.). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide and maintain the required building construction type with support steel covered with rated fire proofing. This deficiency occurred in of the 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/12/2016 at 1:30 pm, observation revealed on the exit to the MRI truck that fire proofing was missing from the structural steel at the entrance 'canopy' which is attached to the building. In addition, the walls and roof were made of combustible material. The building is a (3,3,2) building. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.1.6.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide and maintain the required building construction type by having support steel covered with a rated fire proofing. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/11/2016 at 1:30 PM, observation revealed on the Basement floor in the Staff Gym, that fire proofing was missing from a beam clamp that was attached to the structural steel beam. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with smoke detection in spaces that are open to the corridor and louver-free corridor walls. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 10:31 am, observation revealed on the basement floor in the reception area, where surgery used to be performed, 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 a smoke detector and was not fully observable from a 24 hour occupied location. 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 H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

2. On 01/11/2016 at 10:32 am, observation revealed on the basement floor in the elevator equipment room, that a wall mounted air-transfer grill was installed in the corridor wall. Louvers, even if they contained a fire damper, are not permitted in a corridor wall. The grill was 12 inches by 12 inches. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

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 by having the required safe-guards and smoke detection in spaces that are open to the corridor. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/12/2016 at 3:20 PM, observation revealed on the 1st floor in the Linen Storage Alcove, 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 a smoke detector and was not fully observable from a 24 hour occupied location. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

2. On 01/12/2016 at 3:30 PM, observation revealed on the 1st floor in the Nurse Station, 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 a smoke detector and was not fully observable from a 24 hour occupied location. Staff X mentioned that this Nurse Station was not occupied for 24/7. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

Based on observation and interview, the facility did not provide corridor doors with positive-latching hardware and hinged doors in the egress path. This deficiency occurred in 2 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 11:43 am, observation revealed on the basement floor in the loading dock, room 0304, that the corridor door would not positively self-latch when pushed to a closed position. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance mechanic).

2. On 01/12/2016 at 9:00 am, observation revealed on the 1st floor in the corridor in front of the Emergency Department, that the door was installed in the path of egress access and was not side-hinged. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.4.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff I (CEO) and staff J (Director Support Services).


29942

Based on observation and interview, the facility did not provide corridor separation doors with corridor doors that would close when pushed or pulled. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/12/2016 at 3:25 PM, observation revealed on the 1st floor in the Reading Room, that the door to the corridor was held open with an waste basket. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.3.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction. This deficiency occurred in 2 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 1/12/2016 at 2:40 pm, observation revealed on the 1st floor in the back wall of prep recovery and PACU Suite, that the smoke barrier wall was not constructed to a 1-hour fire resistance rating. The medical gas outlets were not installed with a listed rated system for a one hour wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director Support Services).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls and sealed wall penetrations. This deficiency occurred in 2 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 10:30 am, observation revealed on the 4th floor in the smoke barrier wall over the smoke barrier door, that a penetration was not sealed according to an approved method. The deficiency included a 2 inch diameter pipe penetration with a bundle of wires without fire-stopping seal. 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 H (President and CEO) and staff I (Maintenance Mechanic 1).

2. On 01/11/2016 at 12:00 PM, observation revealed on the 2nd floor in the smoke barrier wall over the smoke barrier door, that a penetration was not sealed according to an approved method. The deficiency included a 1'-0"x 0'-6" cable tray penetration without a fire stop seal. Fire stop pillows were removed from the penetrated hole and were left near the hole. 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 H (President and CEO) and staff I (Maintenance Mechanic 1).

Based on observation and interview, the facility did not provide smoke compartments of the appropriate size and layout with compliant smoke compartments. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 1/12/2016 at 2:35 pm, observation revealed on the 1st floor floor in corridor 1613, that the smoke compartment was not compliant. The across corridor door between corridor 1613 and 1619 was locked. This limits the smoke zone 16 useable area for 'area of refuge' to the area of corridor 1613, vestibule 1614 and consult room 1615, if unlocked, which is about 675 square feet. This is not enough space for evacuation at 6 square foot per person and 30 square feet per inpatient for smoke zone 11, which is 16,704 sq. ft. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director Support Services).

Based on observation and interview, the facility did not provide smoke barrier doors with the required minimal width, window openings that were protected by fire-rated glazing or wired glass panels with properly sized doors. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/12/2016 at 3:05 pm, observation revealed on the 1st floor in the corridor 1613 to corridor 1141 (surgery waiting), that the smoke barrier door was not compliant. The smoke barrier door is a single door. The door separates two corridors and is required to be a double egress door, opposite swing with 41.5 inch clear width since inpatients are traveling through this area. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not enclose hazardous rooms with rated doors and rated wall construction. This deficiency occurred in 4 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 1:05 pm, observation revealed on the basement floor in the Morgue, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The door was rated for 20 minutes and the space was used as a new storage room. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 . This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

2. On 01/11/2016 at 3:25 pm, observation revealed on the basement floor in the storage room for dummies and other CPR material, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The door was rated for 20 minutes and the space was used as a new storage room. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 . This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

3. On 01/11/2016 at 2:57 pm, observation revealed on the basement floor in the new storage room in the former OR area, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The door was rated for 20 minutes and the space was used as a new storage room. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 . This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

4. On 01/11/2016 at 2:56 pm, observation revealed on the basement floor in the new storage room in the former OR area, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had a 15 by 30 inches electrical panel. The maximum size (without special treatment) is 100 square inches in 100 square feet of wall. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

5. On 01/12/2016 at 9:45 am, observation revealed on the 1st floor in the rehab storage area, that the enclosing wall was not constructed to a 1-hour fire resistance rating and the door was not rated. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

6. On 01/12/2016 at 9:50 am, observation revealed on the 1st floor in the lab storage room 1273, that the enclosing wall was not constructed to a 1-hour fire resistance rating and the door was not rated. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

7. On 01/12/2016 at 3:15 pm, observation revealed on the 1st floor in the clean utility room in new surgery, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

8. On 01/12/2016 at 4:25 pm, observation revealed on the 1st floor in the operating room 1702, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had med gas control panel approximately 2' x 2' in the rated wall of sterile supply displacing the drywall. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

9. On 01/12/2016 at 4:55 pm, observation revealed on the 1st floor in the decontamination room of the operating room area, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had a water outlet box that was not rated in the one hour rated wall. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic)

Based on observation and interview, the facility did not enclose hazardous rooms with a smoke-tight room enclosure in a sprinkled smoke zone. This deficiency occurred in 3 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 1:30 PM, observation revealed on the Basement floor in the Staff Gym-Storage Area, that a gap in the enclosure did not resist the passage of smoke. The wall between the Staff Gym and Storage was not continuous up to the deck above, so the whole Staff Gym was considered a big hazardous room. In the same location, there were three, 3 inch diameter and one 3" x 4" unsealed holes in the wall near the entrance door. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. 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 H (President and CEO) and staff I (Maintenance Mechanic 1).

2. On 01/11/2016 at 3:30 PM, observation revealed on the Basement floor in the PACU vacant area, that the enclosure did not resist the passage of smoke by having a proper enclosure around a combustible storage area. The combustible storage area included 8 wooden crates stacked in the middle of the room. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. 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 H (President and CEO) and staff I (Maintenance Mechanic 1).

3. On 01/11/2016 at 4:00 PM, observation revealed on the Basement floor in the Hazardous Waste Room, that a hole in the enclosure did not resist the passage of smoke because of one or more unsealed holes. The holes included a 3" x 4" hole in the wall. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. 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 H (President and CEO) and staff I (Maintenance Mechanic 1).

Based on observation and interview, the facility did not provide egress paths at all times with doors that were unlockable in the egress path and egress without passing through intervening hazardous rooms. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 2:43 pm, observation revealed on the basement floor, in the hall that serves the maintenance suite, that the door was locked from the egress side. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.2.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

2. On 01/11/2016 at 1:56 pm, observation revealed on the basement floor, in the the mechanical room that opens up into the electrical room (of the maintenance suite), that an intervening room in the means of egress was hazardous. The intervening room is a electrical room without sprinklers and therefore enclosed in 2 hour walls. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide egress paths at all times with doors that were unlockable in the egress path and snow cleared from the egress path. This deficiency occurred in 3 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/12/2016 at 9:30 am, observation revealed on the 1st floor in the rehab suite that the door was locked from the egress side. In the rehab suite, traveling north, there is a locked door (magnetic lock) preventing the use of the second exit for the suite. Going south, the push to exit button is missing. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.2.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

2. On 01/12/2016 at 1:40 pm, observation revealed on the path to the MRI truck under the 'canopy', that outside the exterior exit door there was an accumulation of snow in the exit discharge path. The door at the end of the canopy to the MRI truck had a wood wedge that was frozen on the ground such that the door would not open. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.10.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

3. On 01/12/2016 at 3:20 pm, observation revealed on the 1st floor in the corridor outside of the PACU, that the door was locked from the egress side. An exit sign was placed across a double egress door that was locked with a magnetic lock. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.2.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 2 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/12/2016 at 3:00 pm observation revealed on the 1st floor in the corridor of the surgery waiting area, that the clear and unobstructed width was 6'4". This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.3. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). Corridors used only by others must be at least 44" wide. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

2. On 01/12/2016 at 9:01 am, observation revealed on the 1st floor in the corridor in front of the Emergency Department, that the clear and unobstructed width of the corridor was 4 feet because when the sliding door opens from the closed position, it only opens to a 4 foot opening. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.3. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). Corridors used only by others must be at least 44" wide.. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).


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Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/12/2016 at 10:30 am, observation revealed on the 1st floor in the Emergency area corridor, that the clear and unobstructed width of the corridor was 7 feet. An ATM machine installed in the corridor reduced the corridor width. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.3.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

Based on observation and interview, the facility did not provide rooms, or patient sleeping suites, larger than 1,000 square feet with at least 2 remote exit access doors having at least two exits from large suites. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/11/2016 at 11:00 am, observation revealed on the basement floor in the shell space, room 0100, that the suite of rooms was 3,500 square feet from the exit access door to the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.5.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide rooms, or patient sleeping suites, larger than 1,000 square feet with at least 2 remote exit access doors. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/12/2016 at 9:55 am, observation revealed on the 1st floor in the lab suite, that the legal exits from the floor were not remotely located from each other because they were located 10 feet from each other with the diagonal of the room being 60 feet This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.5.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide all spaces that can be exited without the use of a key or locked as permitted by the code, such as delayed egress and compliant egress locks. This deficiency occurred in 2 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 11:15 am, observation revealed on the 3rd floor, at the stair number 2 door, that the egress lock was not compliant. The exit door was equipped with a delayed egress locking (DEL) system and did not have the required signage on the door. Signs shall be readily visible with durable sign in letters not less than 1 inch high and not less than 1/8" inch stroke width on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS above the words DOOR CAN BE OPENED IN 15 SECONDS. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

2. On 01/11/2016 at 11:10 am, observation revealed on the 3rd floor, at the stair number 1 door, that the egress lock was not compliant. The exit door was equipped with a delayed egress locking (DEL) system and did not have the required signage on the door. Signs shall be readily visible, durable sign in letters not less than 1 inch high and not less than 1/8" inch stroke width on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS above the words DOOR CAN BE OPENED IN 15 SECONDS. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

3. On 01/11/2016 at 11:00 am, observation revealed on the 3rd floor, in the cross corridor door leading to stair number 4, that the egress lock was not compliant. The exit door was equipped with a delayed egress locking (DEL) system and did not have the required signage on the door. Signs shall be readily visible, durable sign in letters not less than 1 inch high and not less than 1/8" inch stroke width on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS above the words DOOR CAN BE OPENED IN 15 SECONDS. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 with visual alarm notification. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/11/2016 at 11:20 am, observation revealed on the 3rd floor, in the Inpatient Rehab Room, that the facility did not install a visual fire alarm notification device. Private mode notification requires staff to be aware of all fire alarm situations. This observed situation was not compliant with NFPA 72 (1999 ed.), 4-5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

Based on interview, observation and a review of documents, the facility did not maintain the fire alarm system according to NFPA 72 requirements with pull stations free of obstructions and repair of identified problems. This deficiency occurred in 10 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 2:30 pm, observation revealed on the Basement floor, in the air handling room, that access to the manual pull station of the fire alarm system was obstructed and not accessible for operation because a lot of unused ceiling tiles were stored in front of the pull station. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4; NFPA 72 (1999 ed.), 2-8.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

2. On 01/11/2016 at 5:45 pm, during a review of facility documents deficiencies were found during the test/inspection, but no records were available to confirm that the problem was corrected. Simplex Grinnel report titled "Inspection summary" dated 12-11-2015 indicated that 26 chime strobe, 1 fire alarm panel, 8 heat detectors, 3 horn strobes and 5 pull stations failed to pass the tests. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7 and NFPA 72 (1999 ed.), Chapter 7-3.2This condition was confirmed at the time of discovery by a concurrent record review and interview with staff H (President and CEO) and staff J (Director of Support Services).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with non-sprinkled rooms that meet permitted exceptions with unobstructed water distribution and all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 1of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/11/2016 at 11:45 am, observation revealed on the basement floor in the 1325 electrical room that opens up into mechanical room 0302, that the room was not sprinkler protected, although the entire facility was required to be sprinkled. The facility did not meet all the requirements of the code to avoid sprinkling the space. The room was enclosed with 2-hour rated construction, but the following was not provided: The walls are required to be 2 hours but only one hour walls are supplied. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.1 (exception). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

2. On 01/12/2016 at 1:45 pm, observation revealed on the 1st floor canopy (walkway) to the MRI truck, that the area under the canopy was not sprinkler protected, although the entire facility was required to be sprinkled. The facility did not meet all the requirements of the code to avoid sprinkling the space. The canopy is made of combusible material and since it is attached to the hospital it is required to be sprinklered. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.1 (exception). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with non-sprinkled rooms that meet permitted exceptions, unobstructed water distribution, and all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 3 of the 14 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 3:50 pm, observation revealed on the basement floor, in the former operating room (north of vacant endo room), that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item . The obstruction included a building column This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

2. On 01/11/2016 at 1:50 pm, observation revealed on the basement floor, in the unsprinklered electrical room (of the maintenance suite), that the room was not sprinkler protected, although the entire facility was required to be sprinkled to meet a construction exception. The facility did not meet all the requirements of the code to avoid sprinkling the space. The room was enclosed with 2-hour rated construction, but the following was not provided: pipes through the rated wall were not fire stopped with an approved UL designed system. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.5.1 (exception). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

3. On 01/11/2016 at 1:06 pm, observation revealed on the basement floor in the Morgue, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included storage piled up onto the morgue 'box'. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

4. On 01/11/2016 at 1:09 pm, observation revealed on the basement floor, in the toilet room of the shop area, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included the wing wall of the shower. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

5. On 01/11/2016 at 3:15 pm, observation revealed on the basement floor in the housekeeping next to the kitchen suite, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The corridor walls shall be one hour fire rated if the hospital is not sprinklered. 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 H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

6. On 01/11/2016 at 3:20 pm, observation revealed on the basement floor in stairs S-3, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included an air ventilation machine (4 inches down and 12 inches away). This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

7. On 01/12/2016 at 12:30 pm, observation revealed on the 1st floor in stairwell 1, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The single head does not have the throw to cover the distance in the stairwell. 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 H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).



29942


Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with unobstructed water distribution, all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 3 of the 10 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 11:30 am, observation revealed on the 2nd floor in the Telecom Room, that the discharge of sprinkler water was obstructed from reaching an unprotected area on the other side of a surface mounted light fixture. The light fixture was located 1'-3" away and 6 inch below the adjacent sprinkler deflector. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

2. On 01/11/2016 at 11:45 am, observation revealed on the 2nd floor in the UW Clinic Laboratory Room, that the top of the storage cabinet was located within 18" below a sprinkler deflector. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.6 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

3. On 01/11/2016 at 3:45 pm, observation revealed on the Basement floor in the Endo vacant room, that the room was not fully sprinkler protected. The room has sprinkler heads located 22 feet apart. Staff H or Staff I were unable to verify whether those sprinkler heads had extended spray pattern or not. 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 H (President and CEO) and staff I (Maintenance Mechanic 1).

4. On 01/11/2016 at 4:10 pm, observation revealed on the Basement floor in the stair number 4, that a sprinkler was not provided under the bottom of the stairs, leaving floor space that was not protected. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-13.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

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 the appropriate quantity of spare sprinklers. This deficiency occurred in all of the smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/11/2016 at 1:35 pm, observation revealed on the basement floor in the maintenance shop, that the cabinet of spare sprinklers did not contain two spare heads for the each type of sprinkler that were observed in the facility. Spare sprinklers were not provided for the dry heads. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-4.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).


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Based on interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. This deficiency occurred in 10 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/11/2016 at 5:00 PM, it was noted during a review of facility documents that the monthly wet sprinkler inspections were not performed as required by the code. There were no documents available to confirm that valves were inspected monthly. This situation was not compliant with NFPA 25 (1998 ed.), 2-2. and Table 2-1 This condition was confirmed at the time of discovery by a concurrent record review and interview with staff H (President and CEO) and staff J (Director of Support Services).

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 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/12/2016 at 11:30 am, observation revealed on the 1st floor in the CT Machine room, that there was one or more unsealed holes near the ceiling. The holes included a 7'-0" x 0'-4" and a 2'-0" x 0'- 4" hole in the ceiling. This hole 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 H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).


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Based on observation and interview, the facility did not provide an adequate and reliable water supply that provided a verified reliable and adequate sprinkler water supply. This deficiency occurred in all of the smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/11/2016 at 1:30 pm, observation revealed on the basement floor in the boiler room, that the fire pump room was not constructed to satisfy code requirements. The fire pump was a) not enclosed with 1 hour fire rated walls (2-7.1), b) did not have lighting that was battery operated fixed light or flashlight (2-7.4); and c) did not have floors pitched away from pump & controller w/drain (2-7.6) per NFPA 20. This observed situation was not compliant with NFPA 20 (1999 ed.) 2-7. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

Based on record review and interview, the facility did not provide and maintain portable fire extinguishers as required by the codes with compliant fire extinguishers. This deficiency occurred in 1 of the 10 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/12/2016 at 11:00 am, during a review of Simplex Grinnel annual fire-extinguisher inspection document for 2015, it was discovered that the required five year hydrostatic test for the K-type wet chemical fire extinguisher was due, but no records were available to confirm that hydrostatic test was conducted. This situation was not compliant with NFPA 101 (2000 ed.), 19.3.5.6, 9.7.4.1 and NFPA 10 (1998 ed.) 5-2. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with compliant fire dampers, hard ducts and neutral airflow between the corridor and rooms. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 2:05 PM, observation revealed on the Basement floor in the Staff Gym-Storage area, that a fire damper was not installed in an air duct that penetrated the rated wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1 and NFPA 90A (1999 ed.), 3-3.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

2. On 01/11/2016 at 2:10 PM, observation revealed on the Basement floor in the Staff Gym-Storage room, that airflow between the corridor and the dining room was not neutral. The damper in the return air duct, located in the Staff Gym room, was left in a close position and the door between Staff Gym room and dining room was left open most of the time . This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1, section 9.2, and NFPA 90A (1999 ed.), 2-3.11.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

3. On 01/11/2016 at 2:00 pm, observation revealed on the Basement floor in the Staff-Gym-Storage Area, that a flexible duct (air connector) was installed through the rated wall of the space. This observed situation was not compliant with NFPA 90A (1999 ed.), 2-3.2.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

Based on observation, interview and record review, the facility did not provide a kitchen extinguishing system as required by NFPA 96 with extinguisher identification and range hoods cleaned semi-annually. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 3:10 PM, observation revealed on the Basement floor in the Kitchen, that a placard identification sign was not provided near the Type K fire extinguisher to identify its location. This observed situation was not compliant with NFPA 96 (1998 ed.), Section 7-2.1.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

2. On 01/11/2016 at 3:15 PM, observation revealed on the Basement floor in the Kitchen, that a label was installed on the surface of the hood in the kitchen by Summit Companies but did not show the date of the last cleaning, rather showed a future service date of February 2nd, 2016. This observed situation was not compliant with NFPA 96 (1998 ed.), 8-3.1.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

3. On 01/11/2016 at 5:50 PM, during a review of documents entitled "Badger Hood Cleaning-Service Report" dated 9/2/2015, it was discovered that the range hood and ducts were not inspected semi-annually for grease contamination, as required for systems serving moderate-volume cooking operations. The range hood was inspected and cleaned only once on 9-2-2015 within last one year. This situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.6; 9.2.3; and NFPA 96 (1998 ed.), 8-3.1. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff H (President and CEO) and staff J (Director of Support Services).

Based on observation and interview, the facility did not provide hanging drapes or curtains that met code requirements, such as sprinkler obstruction with cubical curtains that permit the designed distribution of sprinkler water. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/12/2016 at 11:10 am, observation revealed on the 1st floor floor in the Emergency Area Decontamination room, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the eye wash area. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.5.5 and NFPA 13 (1999 ed.) 5-6.5.2.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes by having properly sized storage containers for soiled/trash. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/12/2016 at 10:10 am, observation revealed on the 1st floor in the lab suite, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. The biohazard trash can is about 40 gallons in the lab. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.6. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide the safe storage and use of medical gases as required by NFPA 99 with sealed wall penetrations. This deficiency occurred in all of the smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/11/2016 at 11:34 am, observation revealed on the basement floor in the med gas room 0303, that penetration(s) were not sealed according to an approved method. The deficiency included a door that was not labeled. This room was used to store greater than 3,000 cubic feet of medical oxygen and was required to be enclosed with 1-hour rated construction. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.4 and NFPA 99 (1999 ed.), 8-3.1.11. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping . In addition, the facility did not provide and maintain combustibles (vehicles) at least 10 feet away from a bulk (liquid) oxygen system, and 50 feet away areas occupied by nonambulatory patients from the inner container pressure-relief device, discharging piping outlets, and from filing and vent connections. This deficiency could affect all smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On January 12, 2016, 2014 at 1:10 pm, surveyor observed that the bulk oxygen tank in the parking lot, had a MRI truck partially parked behind a 2 hour wall. The truck was in direct line of sight of the bulk oxygen system tanks and was within 10 feet of the bulk oxygen system. This observed situation was not compliant with NFPA 50 (1998 edition) section 2.2.12 and NFPA 99 section 4-3.1.1.2(a) 10 b.

2. On January 12, 2016, 2014 at 1:10 pm, surveyor observed that the bulk oxygen tank in the parking lot, had a MRI truck within 50 feet of the bulk oxygen system. The MRI truck contains non ambulatory patients. This observed situation was not compliant with NFPA 50 (1998 edition) section 2.2.12 and NFPA 99 section 4-3.1.1.2(a) 10 b. (Note: Section 2.2.14 of NFPA 50 does not apply (2 hour wall separation) to section 2.2.12.)

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide interior walls and partitions made of noncombustible or limited-combustible materials. This deficiency occurred in 2 of the 10 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 01/11/2016 at 11:05 am, observation revealed on the basement floor in the shell space, room 0200, that a wall was made with combustible materials, which is not permitted in non-combustible types of building construction. The wall was constructed with wood to support the drywall in a 1 hour rated wall in the former window opening. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.1.6.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with: compliant air distribution installation, hazardous rooms were not enclosed, a wrench was missing in the spare sprinkler cabinet, the electrical panels did not have complete directories, and closed electrical raceways.

FINDINGS INCLUDE:

1. On 01/12/2016 at 3:00 PM, observation revealed on the Basement floor in the Laundry Room, that a flexible duct (air connector) was installed through the rated wall space. Flexible duct was installed for a dryer vent. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.5.2 and NFPA 90A (1999 ed.), 2-3.2.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

2. On 01/12/2016 at 3:06 PM, observation revealed on the Basement floor in the Laundry Room, that a hole in the enclosure did not resist the passage of smoke because of one or more unsealed holes. The holes included a 3 inch diameter and a 2 inch diameter unsealed holes in the wall. The room was considered hazardous because it contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

3. On 01/12/2016 at 3:10 PM, observation revealed on the Basement floor in the House Keeping room, that a hole in the enclosure did not resist the passage of smoke because of one or more unsealed holes. The holes included a 3 inch diameter unsealed pipe penetration in the wall. The room was considered hazardous because it contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

4. On 01/11/2016 at 2:45 PM, observation revealed on the Basement floor in the Air Handling Room number 6, that electrical panel breakers were not labeled to identify the loads they fed. Circuit breakers 17,19,21, 23, 25 inside the panel Leg Room #6 were not identified for the loads they were feeding. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.5.1 and NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

5. On 01/11/2016 at 2:50 PM, observation revealed on the Basement floor in the Air Handling Room number 6, that a 4 x 4 electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.5.1 and NFPA 70 (1999 ed.), 517-12. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

6. On 01/11/2016 at 3:00 PM, observation revealed on the Basement floor in the Air Handling Room number 6, that the cabinet of spare sprinklers did not contain a wrench that would fit the heads in the cabinet. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-4.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO) and staff I (Maintenance Mechanic 1).

7. On 01/12/2016 at 12:00 PM, observation revealed on the 1st floor in the Vestibule Canopy area, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code by having electrical panels with complete directories, and non-compliance. This deficiency occurred in all smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 10:36 am, observation revealed on the basement floor in the elevator equipment room, that the electrical panel breaker(s) were not labeled to identify the loads they fed. The panel in the elevator equipment room did not have the circuit breaker labeled. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

2. On 01/11/2016 at 10:40 am, observation revealed on the basement floor in the elevator equipment room, that the electrical code was not followed. The panel in the elevator equipment room was labeled indicating that both the normal and emergency power entered the same electrical panel. The normal and electrical power are too be separated. This observed situation was not compliant with NFPA 70 (1999 ed.). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

3. On 01/11/2016 at 1:52 pm, observation revealed on the basement floor in the unsprinklered electrical room (of the maintenance suite), that the electrical code was not followed. There is storage in the electrical room. This observed situation was not compliant with NFPA 70 (1999 ed.). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).